Will the United States pass on telemedicine progress?

Abstract

Background

During the COVID-19 pandemic, federal and state health policies allowed temporary flexibilities for Medicare and Medicaid beneficiaries, leading to a sharp increase in telemedicine use. However, many of the flexibilities that enabled innovation and growth in telemedicine continue temporarily since the federal emergency declaration ended in May 2023, and the United States has not made permanent decisions about telemedicine policy. Analysts have raised concerns about increased spending, program integrity, safety, and equity, and recommend strengthening oversight.

Methods

Here, we argue that we must continue the flexibilities to better understand telemedicine’s quality, safety, and outcomes, and until the United States can develop an evidence-based digital health strategy. A premature regression to pre-pandemic telemedicine policies risks unintended consequences.

Conclusion

We must continue the current policy flexibilities, safeguard against fraud and abuse, and immediately prioritize research and evaluation of telemedicine’s quality, safety, and outcomes, to avoid unintended consequences and support more permanent policy decision-making.

President Biden announced an end to the COVID-19-related emergency declarations in May of 2023.¹ With the end of the emergency declarations came the end of the various waivers, exemptions, and flexibilities that enabled telemedicine use during the pandemic.² Fortunately, the regulatory flexibilities were largely extended. An extension approved by Congress in late 2022 allowed the continuation of telemedicine provisions for Medicaid patients until the end of 2024.^2,3 The Consolidated Appropriations Act of 2023 allowed extensions for Medicare recipients, Rural Health Clinics and Federally Qualified Health Centers until the end of 2024.⁴ However, these extensions are temporary in nature as stakeholders have persistent concerns about more permanent changes. While the evidence base related to telemedicine and telehealth has grown substantially since 2020, it will take time to synthesize the existing evidence, and where we lack sufficient evidence, to determine a focused research agenda that supports policy decisions. In the meantime, a regression from current telemedicine flexibilities could (1) exacerbate inequities of health care access, (2) stunt innovation, and (3) effectively discard the opportunity for research that is uniquely inclusive of vulnerable populations, and that can be conducted across health care settings, systems, and payment types.

Certainly, telemedicine existed long before the pandemic, as a promising approach to addressing barriers to healthcare. Early successes such as the US Department of Veterans Affairs’ large-scale telehealth program had already connected patients in underserved areas with specialty healthcare providers and helped patients overcome barriers of time or transportation in obtaining care.^5–9 Telemedicine held tremendous promise for overcoming barriers faced by persons with chronic disease and multi-morbidity, who require frequent office visits, ongoing monitoring, and disease management. However, telemedicine was not widely adopted or accepted. Most telemedicine services were not reimbursed, or the services were reimbursed at a lower rate. Consequently, the pre-pandemic adoption of telemedicine services often resulted in financial losses for healthcare organizations and providers.

The COVID-19 pandemic and its consequent public health measures abruptly changed this situation. In the face of the COVID-19 pandemic, healthcare providers were challenged to continue care delivery, while minimizing in-person interactions to control the spread of the virus, and so there was a sharp nationwide increase in the use of telemedicine during the early months of the pandemic.⁴ Doxy.me lnc., a free HIPAA-compliant telemedicine platform, witnessed a 29-fold increase in monthly minutes between February 2020 and March 2020.¹⁰ Federal and state health policy was responsive to the need for telemedicine services, allowing for temporary flexibilities during the public health emergency including expanded reimbursement for telemedicine services.¹¹ This enabled telemedicine access for everyone, including socially vulnerable populations served by an array of federal programs.

The collective experience of telemedicine adoption during the past 3 years, across diverse populations, has been remarkable. We learned that telemedicine could improve access to mental health care, help working people receive care without threatening their jobs and health, and help people in rural communities see difficult-to-find specialists.^12–17 We developed and implemented approaches for integrating telemedicine services into a hybrid system of healthcare, approaches that often worked very well. We also learned more about the digital divide, and how matters of digital access and digital literacy affect access to healthcare. This massive, nationwide adoption of telemedicine yielded tremendous insights into how telemedicine can improve healthcare and generated a number of questions about its capability to ameliorate—or worsen—health inequities.^18,19

While some private insurers have instituted ongoing reimbursement for telemedicine services, the ongoing reimbursement of services for Medicare and Medicaid beneficiaries remains in question. The delay in definitive decision-making stems from concerns in four areas, summarized in a report by the Government Accounting Office (GAO) in 2021: increased spending, program integrity, safety, and equity.^20,21 In short, there is concern that the widespread, post-pandemic availability of telemedicine will lead to increases in both legitimate and abusive utilization, with health care providers maximizing telemedicine service delivery to increase income. The GAO report also raised concerns about uncertain quality and safety, even fraud and abuse, and that telemedicine’s benefits may not be equitable. In a subsequent 2022 report, the GAO made specific recommendations to strengthen oversight of telemedicine.²²

Concern for potential fraud and abuse is appropriate. Indeed, some bad actors learned how telemedicine could be employed in fraud and abuse schemes.^23–25 However, if Medicare and Medicaid beneficiaries lose access to telemedicine services, we risk exacerbating existing health inequities through loss of services, before fully understanding their advantages and disadvantages relative to standard care. We would also lose the opportunity to conduct research that would allow us to better understand and address digital health inequities, and the opportunity to potentially improve outcomes for vulnerable populations. The appropriate response to a fear of fraud and abuse is not a return to pre-pandemic models of care or suppression of access to legitimate and much-needed health care services. Instead, we can and should implement safeguards, including billing surveillance as recommended by MedPAC²⁶ and the advancement of automated systems to detect fraud. We must also educate healthcare providers about telemedicine compliance; individual healthcare providers bear substantial liability for telemedicine fraud and should be prepared to recognize and address it in health care settings. Above all, we must continue to study telemedicine’s quality, safety, and outcomes and synthesize recent evidence, so that the knowledge base to support regulatory decisions is robust. Clearly, the loss of reimbursement for telemedicine and consequent loss of service to millions of Americans would be akin to “throwing out the baby with the bath water.”

We recommend that current telemedicine flexibilities be extended indefinitely, until we can adequately study telemedicine’s quality, safety, and outcomes, and until the United States determines a more enduring strategy for digital health that encompasses telehealth and telemedicine. We also recommend strengthened safeguards against fraud and abuse. Further, we strongly recommend a focused effort to synthesize evidence that emerged from the COVID-19 pandemic, and to invest now in research that will generate additional evidence to support policy decision-making. The COVID-19 pandemic caused a great deal of suffering worldwide, but it also pushed us to this incredible breakthrough in healthcare delivery, foundational to future progress in patient-centric, decentralized, and digitally enabled healthcare delivery.

The heartbreaking devastation of war and disease has repeatedly pushed the United States to impactful breakthroughs in science and medicine. Surgical amputations during the US Civil War led to advancements in prosthetic devices.²⁷ The crisis of the Spanish flu in the early 19th century led to research that pinpointed the influenza virus and enabled subsequent development of the world’s first influenza vaccine.²⁸ The need for antibiotics during World War II led to the development of systems for mass-producing antibiotics, which continued to meet needs long after the war’s end.²⁹ In painfully recent history, we experienced the COVID-19 pandemic. One of the most remarkable breakthroughs of the pandemic was the widespread adoption of telemedicine. It would be unthinkable for the United States to discard the progress realized.

Author contributions

All authors contributed to conceptualization, review, and editing. Mollie R. Cummins drafted the manuscript.

Funding

This manuscript was partially supported by the National Institute of Mental Health of the National Institutes of Health under Award Numbers R41MH126734, K23MH118482, and R42LM012547. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Conflicts of interest

B.M.W. is a shareholder, and all other authors are employees of Doxy.me, LLC, a commercial telemedicine company. The authors declare no other conflicts of interest.

Data availability

Not applicable.