For Medicare, telemedicine reimbursement and regulation has been about kicking the can down the road – more temporary extensions of COVID-era flexibilities. The current ones run out on September 30.
It’s April 2025 and healthcare still waits for a permanent solution from the government for telemedicine and Medicare – which tends to drive what Medicaid and private insurers do. Will October 1 find the industry with a permanent solution or another kick of the can down the road?
Dr. Ateev Mehrotra is chair of the department of health services, policy and practice at Brown University School of Public Health. He is an expert in telemedicine policy. Healthcare IT News sat down with him for a wide-ranging discussion on the future of telemedicine reimbursement and regulation.
Q. September 30 is the new deadline for more telemedicine flexibilities. Where do things stand, and what is your opinion of how this is going to shake out?
A. I often struggle to answer this question. On the one hand, it’s a very, very easy answer. There is broad bipartisan support for telehealth, and it’s very hard for me to find anyone who objects to a permanent expansion. In essence, it’s not the merits of telehealth, though there’s some nuances, but very minor, but generally people are enthusiastic. It’s really coming down to the money.
Expanding access to telehealth is going to take money. And where is that money coming from? To use the lingo within the Beltway, where is the pay-for? That is really the conversation. Short-term extensions are easier to pass because you don’t need to find a more substantial pay-for. So, in some ways, it seems easy because everyone loves this thing. Let’s keep it going.
On the other hand, what are you going to do to pay for it? That’s where the real controversy is, especially in the context of the Republican side trying to pass substantial tax cuts, which are very costly. Therefore, it’s not so easy to find how to pay for it. Anything that will increase healthcare spending or Medicare spending is seen as difficult. That’s where we stand right now.
Q. What will be the implications if the flexibilities are stopped? September 30 comes along, and Congress does not pass anything. Or, what will be the implications if the flexibilities are kicked down the road again?
A. If they’re stopped, this is going to be quite devastating for some patients who’ve come to depend on telehealth, either because of their life circumstances, difficulty with travel, distance to see their clinicians – and it’s going to decrease continuity of care in that context. And for clinicians who have become accustomed to providing this care.
Let’s be very clear: The average American and average clinician, while they see the strengths and weaknesses of telehealth, want it to be around and to be available. There’s going to be a lot of angry Americans.
What are the implications if we kick the can down the road again? These short-term extensions are very much undermining telehealth, even though they’re extended. What do I mean by that?
You run a cardiology practice in Illinois, and you have a patient in front of you today, and they say, “Hey, doc, I want to schedule my follow-up appointment in six months. Can we do it via telehealth?” Now you’re in a situation. You’re like, “I don’t know. Is Congress going to do it? Should I schedule it? No, let’s do an in-person visit.”
You’re undermining telehealth there. You are running a big health system or a practice. Should we invest in telehealth? I don’t know. What’s Congress going to do? Let’s not invest in telehealth. Should we open a hub so we can increase our telehealth? Not yet. We don’t know what Congress is going to do.
The constant short-term extensions are, in essence, undermining what everyone wants to happen, which is telehealth. That’s the real fear I have, because it is not like the healthcare system can turn on a dime.
These appointments for October already are being scheduled. You know what it’s like. I know what it’s like to get a follow-up appointment. You have to schedule things six, seven, eight months in advance. So right now, the uncertainty is the problem.
Q. You say, “Temporary interventions are stifling innovation.” Can you talk about that a bit?
A. If we want telehealth to be incorporated into routine care, then there needs to be changes in where health systems invest, how clinicians structure their weekly schedules, how the scheduling system works, the software we use, the contracts with the electronic health record vendors to implement and support telehealth.
All these things require investment and organization. Right now, no one’s willing to do it, or there’s less investment because of that. I also would say it’s stifling innovation in the private realm. There’s a lot of really interesting ideas out there for how we can make telehealth better.
To be a bit more concrete, when you ask the average American, “What do you think about telehealth?” They’re like, “Yeah, it’s really convenient. It’s really nice. But I don’t know about the physical exam. I’m not sure I’m getting the same care I would have if I went in person.”
Some companies are out there saying, “Well, what if we change that? What if we can introduce a device that you put on your chest and we can get your oxygen, we can see your heart rate, we can listen to your heart, and we can introduce a new device that patients at home can check their EKG or get a simple blood test and get the results immediately during the visit?
All of a sudden, I can add that critical piece of data that a doctor might need to try to make the best diagnosis and treatment plan. If you are one of those companies right now and you are investing in these devices, you’re trying to get VC funding. But people are like, “I don’t know. Do you guys have legs?”
Not right now, because maybe in October, the Congress won’t implement permanent telehealth extensions. All of a sudden this huge swath of people won’t be able to use telehealth, so your market size decreased.
Those companies are struggling right now. That’s just another example of where we’re stifling innovation by these short-term extensions. People need to know what the landscape is going to look like to make the investments they see fit.
Q. What, in your mind, is the solution to this challenge? And do you think the solution has a reasonable chance of being successfully implemented?
A. At the end of the day, I think it’s easy: Just take the word “temporary” and make it “permanent” and let’s move on with life. There are some nuances to that. I have advocated that the actual payment for telehealth visits be a little bit less than in-person visits. That way, the pay-for is a little bit less, so it’s more sustainable.
But that’s a nuance as opposed to a major issue. Do I think it has a reasonable chance of being implemented? When we’re talking about the big picture issues we’re facing right now, in terms of Medicaid cuts, tax cuts, increases to defense, all these larger issues, this expansion of telehealth and the pay-for, it’s teeny dollars.
In that sense, given the bipartisan support, as well as not being that much money, I hope we will come to that solution and we’ll move on from the conversation about whether telehealth is here to stay. Then we’ll move more toward, “How do we make telehealth better?”
Because there’s a lot of work to be done, still. How do we ensure everyone can access telehealth? How do we make sure it’s in rural areas? How do we improve the quality of telehealth visits? There’s a lot of work to be done, but we keep on pushing that down the road, and I’d love to start focusing on these questions now.
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