Will telehealth — which exploded during the pandemic — continue to boom?

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We know telehealth expanded a lot during the pandemic. Now we know how much. The Health and Human Services Office of Inspector General has pulled together data showing that in the first year (2020) more than 28 million Medicare beneficiaries received telehealth services. To find out more, the Federal Drive with Tom Temin talked with Andrew VanLandingham, the IG’s senior counselor for Medicaid policy.

Interview transcript:

Tom Temin: Andrew, good to have you back.

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Andrew VanLandingham: Thanks. I appreciate the opportunity to talk about our work.

Tom Temin: And so we knew that again that there was a lot of this going on and before we get into the details are these special provisions for the pandemic such as coverage by Medicare and Medicaid for telehealth still in place?

Andrew VanLandingham: All of the telehealth flexibilities that were sort of the subject of this report are still in place. To give your listeners sort of a feel for what those were pre-pandemic, Medicare only covered telehealth in certain situations. Primarily, it was restricted to Medicare patients who lived in rural areas. And you also couldn’t access telehealth at your home, you had to physically drive to a doctor’s office to then do a telehealth visit with another doctor who was further away. So those two main restrictions really limited telehealth utilization and Medicare pre-pandemic. But as you said, once the flexibilities were put into place, we saw that about two in five Medicare beneficiaries of close to 30 million. Were using telehealth during that first year of the pandemic. So those flexibilities really dramatically increased who was able to use telehealth. And then really, basically, through this report, we’re able to dive deeper about how they use telehealth.

Tom Temin: Yeah, so tell us more about first of all, who was primarily using it demographically? What did you find here?

Andrew VanLandingham: When you dive into the sort of demographic characteristics of the beneficiaries who use telehealth the most during this first year, and again, this is a unique year talking about the first year of the pandemic, many places have stay at home orders. But we do think that this sort of as a broader trend that policymakers now there should be aware of. And so for the most part, we’re seeing that beneficiaries in urban areas were more likely to use those in rural areas, about 45% of all beneficiaries who lived in urban areas were using telehealth versus if you look at the rural areas, about a third of beneficiaries who lived in rural areas were using telehealth. So that difference indicates that urban beneficiaries across both high affluent areas and lower income areas are using telehealth more frequently.

Tom Temin: Sure. And that one stands in contrast to the earlier policy of only rural people could use it if they could get to the nearest doctor, to hopscotch to another doctor. So that kind of shows that that policy might have been in need of revision, let’s say.

Andrew VanLandingham: Yeah, absolutely. I think as Congress and others think through what is the future of telehealth look like, this distinction is an important one, given that earlier restriction. And so if they really want to address access, Congress and others will have to think about what’s appropriate for Medicare beneficiaries in urban areas to access telehealth.

Tom Temin: All right, so urban versus rural. What else did you find about the people using?

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Andrew VanLandingham: Dual eligible beneficiaries, which is a special category of individuals who are typically sicker than your normal Medicare beneficiary, and they get covered both through Medicare and Medicaid. In large part, most of these folks have pretty serious significant cognitive or other functional impairments that require a lot of health care. And they were more likely to use telehealth compared to their peers, both in a demographic and geographic sense. When we controlled for those features, we still saw that these folks really took advantage of the telehealth flexibilities in a way that outpaced their peers again there. So that’s an interesting perspective, given that some of the policies across both Medicare and Medicaid may affect their telehealth access in the future. And it is an area that Congress and others wants to pay attention to, to make sure that those really medically needy individuals can continue that access in the future.

Tom Temin: And telehealth can take many forms, we tend to think of it as you know, being on your smartphone or your computer camera, but it can be a telephone call. And I guess those are the two main ones. What did you find with respect to what was the most used mode of telehealth?

Andrew VanLandingham: In a prior report, we did look at the differences between sort of modalities. And here the data is pretty limited. So we don’t have great views on what’s the largest modality. But in this report, what we did find is for about six services that we can tell, are always using a phone call. We call it an audio-only. Those beneficiaries who used it, there’s about 1/5 of beneficiaries who used audio only services, they tended to use just phone calls, almost exclusively. So if you are doing telehealth via phone, odds are you are doing all of your sort of telehealth visits via the phone. And that’s an important point, in part because there’s also another restriction in Medicare that required telehealth to be provided via a video call via an interactive communication and the telehealth flexibilities allowed from more services to be provided over the phone or through other audio-only mechanisms. And so again, as Congress and others think through, what does the future of telehealth look like, there is a significant part of the Medicare patient population that relies almost solely on audio-only and taking away access from those groups may impede future availability of services for them, including obsolete for folks in rural areas. There’s been other studies that rural beneficiaries really don’t have great access to things like broadband, or internet connectivity that supports that interactive video communication. So they tend to rely on audio-only. So again, another data point that we think stakeholders are going to have to really pay attention to as they think through what are the appropriate policies moving forward.

Tom Temin: We’re speaking with Andrew VanLandingham, senior counselor for Medicare policy in the Office of Inspector General at Health and Human Services. And that point about audio-only belies the trend that’s happening in telemedicine coming slowly. But that is the use of medical device peripherals that plug into smartphones that can give practitioners a close up view of what’s on your skin or your blood pressure, whatever the case might be. Not quite there yet, but that’s the trend, watches now do all of this. And so the audio-only people could be left behind in that trend.

Andrew VanLandingham: Yeah, I think it’s important to remember that when we’re talking about telehealth, it can mean a lot of different things based on what you’re talking about, and what use those sorts of devices are typically referred to as remote patient monitoring. And Medicare just started paying for those as a service in 2019. And there was a recent article in Health Affairs this week, that sort of dove into what’s the usage around remote patient monitoring look like. And I can say we’re still in the early innings, I think writ large in healthcare and understanding how that’s being used. But certainly there’s a place for it. HHS OIG wrote a rule a couple of years ago to help expand access to those types of technologies in certain situations. You can imagine where a doctor who’s helping a patient manage a chronic condition like diabetes, having something like a continuous glucose monitor is really going to help that patient and provider keep track of their insulin numbers, making sure that they’re being consistent to avoid spikes, which can lead to bad outcomes for diabetic patients. And that sort of care coordination model is something we’ve looked at for years. And so we’re actually getting ready to start an audit looking at remote patient monitoring devices in Medicare and look forward to sharing those results with you and your listeners, hopefully, in the future.

Tom Temin: Yeah, let’s hope the blood pressure remote is as accurate as a good old fashioned column of mercury, which I think is still the best. But you know, that’s me. Anyway, getting back to the report on telehealth, then, what are your main recommendations for Medicare, Medicaid for CMS?

Andrew VanLandingham: When you’re looking at the future of telehealth policy and payment policies, there’s lots of different areas that policymakers have to consider: cost, quality, access, health equity, program integrity. And this report really gets at that access angle policy. And so we recommend to CMS to really take steps to ensure that they can transition from the pandemic mode with these flexibilities to longer term policies that can improve access, but also consider those other factors at the same time. This is not a one dimension problem. And in fact, there’s going to be probably years and study necessary to get this right. But the access angle here I think is the most important because if those flexibilities turn off, you could see roughly 30 million beneficiaries lose pretty significant access to services that they took advantage of from their home and from elsewhere. And so that’s something that CMS is going to have to pay attention to closely. But it’s also going to require some congressional action as well. Most of these restrictions are done at the congressional or the statutory level. And so additional work is going to have to be done there. And the president’s budget in fiscal year 23 did include support for changing some of these flexibilities. But we are closely monitoring those efforts moving forward.

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Tom Temin: And this is really going in some ways, this whole complex of questions is even bigger than CMS, I imagine, say HHS Office of Civil Rights would come into play here for data privacy and so forth and also HRSA [Health Resources and Services Administration]. The whole quality question.

Andrew VanLandingham: Yeah, that’s right. HHS, writ large has a significant influence in the future of telehealth policy, as you mentioned, the Office of Civil Rights does have some privacy controls here related to how do you ensure the protection of data via telehealth and so I still think a lot of us are learning about that. They recently issued some additional guidance on how to protect conversations over the phone via telehealth. We’re doing some studies right now looking at the Office of Civil Rights and how they have used things like their security rules to maintain the sort of cybersecurity protections around telehealth And there’s lots of other governing bodies looking at that, including the National Institute of Science and Technology. So this is not just an HHS problem at all. This is something that a lots of different parts of the government insurance companies providers are going to be looking at for many years.

Tom Temin: Andrew VanLandingham is senior counselor for Medicaid policy in the Office of Inspector General of Health and Human Services. As always, thanks so much for joining me.

Andrew VanLandingham: Thanks, Tom. Pleasure to talk to you.

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