Coronavirus Disease 2019’s Shake-up of Telehealth Policy: Application of Kingdon’s Multiple Streams Framework

Abstract

Providing care by telehealth has been an aspiration for many health care practices. However, regulatory barriers often prevented its implementation. The emergence of the COVID-19 virus provided a window of opportunity for federal policy change in telehealth during a national state of emergency. Telehealth policy is examined using Kingdon’s multiple streams (policy) framework.

Highlights

• •Evidence suggests the effectiveness of telehealth for the delivery of health care.
• •Before coronavirus disease 2019 (COVID-19), widespread use of telehealth lagged related to reimbursement.
• •The COVID-19 pandemic provided a window of opportunity for federal policy change in telehealth reimbursement.

Telehealth as a strategy to improve access to care has slowly gained momentum in recent years. Yet, before the coronavirus disease 2019 (COVID-19) pandemic of 2020, office visits via telehealth were still fraught with restrictive rules and regulations. Telehealth also had lower than expected use on the part of patients, whereas many clinicians and health systems were reluctant to adopt telehealth because of reimbursement concerns.¹

The nursing profession advocates for broad access to health care.² Specifically, the American Nurses Association states “every single person . . . should have access to the highest quality and safest care.”² Enactment and passage of the Affordable Care Act in 2010 brought the United States closer to health care for all.³ Access to insurance coverage with the Affordable Care Act was an important first step toward improving access to care. However, it did not necessarily translate into improved access to care for all.

Social determinants of health factor into whether patients access health care.⁴ Some factors negatively affecting patient attendance at office visits include distance to the health care setting, copayments, childcare, reliable transportation, leave from work, and a patient’s cognitive or executive functioning to make and keep track of appointments.⁵ Nonattendance at appointments affects an organization’s financial viability and places stress on the productivity of a nurse practitioner (NP). Given the availability of mobile technology, moving to broader telehealth adoption makes sense as a strategy to reduce potential nonattendance factors and improve access to care if reimbursed in a fair manner.

NPs are the primary health care provider for many patients.⁶ Therefore, awareness of and interaction with health care policy affecting patient care are important to practicing NPs. The American Association of Nurse Practitioners encourages political activism on matters affecting the NP role and patient care.⁶ Reimbursement of services, including telehealth, would fall within this domain.

The purpose of this article is to discuss the window of opportunity for telehealth public policy change created by the COVID-19 pandemic. A common policy agenda-setting framework, Kingdon’s multiple streams framework,⁷ is used.

Background

Before the COVID-19 pandemic, telehealth was an aspiration for health systems, but implementation varied. Telehealth policies at the federal and many state levels including the Centers for Medicare and Medicaid Services had been highly restrictive. Almathami et al⁸ identified barriers influencing the uptake of telehealth. Based on this systematic review, 1 of the most prominent barriers was reimbursement from payers.⁸

Despite challenges to telehealth adoption in the pre–COVID-19 pandemic era, evidence in favor of telehealth is well-documented. Specialties with evidence demonstrating telehealth effectiveness include oncology, diabetology (including diabetes education services), cardiology, nephrology, psychiatry and addiction services, primary care, geriatrics, and women’s health.9, 10, 11, 12, 13, 14, 15, 16, 17, 18 For instance, DeNicola et al’s systematic review¹⁷ of telehealth interventions in women’s services found improvements in rates of perinatal smoking cessation, breastfeeding and scheduling of office visits, and obstetric outcomes. For the common chronic disease state of obesity, Huang et al’s systematic review¹⁸ found telemedicine visits to be an effective intervention in reducing body weight for patients with or without hypertension and diabetes. From a combined geriatric and financial perspective, Hale et al¹⁶ demonstrated cost savings by delivering subspecialty care to nursing home residents through telehealth in the Veteran’s Health Administration system.

Rules and Regulations Relating to Pre–COVID-19 Telehealth Office Visit Reimbursement

The federal government regulates Medicare, including telehealth for Medicare beneficiaries.¹⁹ Private health plans have separate regulations. Some private plans, but not all, follow Medicare. For the purposes of this article, Medicare is discussed.

Before the COVID-19 pandemic, Medicare reimbursed telehealth services at lower rates than traditional office visits, required a preexisting relationship with a provider, did not allow a traditional office visit from within a patient’s home, and required Health Insurance Portability and Accountability Act (HIPAA) compliance through the telehealth platform (for instance Zoom would not be allowed).²⁰

COVID-19 Pandemic Scenario

In March 2020, traditional outpatient office visits came to an abrupt halt because of the deadly COVID-19 pandemic. A national state of emergency was declared by President Trump on March 13, 2020.²¹ “Stay-at-home” orders were widespread across the US. Primary care and specialty office-based services all but stopped as individual states went into weeks of lockdown. Few medical offices were prepared to offer anything but in-person, face-to-face care. Two weeks after the state of emergency was declared, the Centers for Medicare and Medicaid Services announced temporary, sweeping regulatory changes in response to the virus’s impact on the health care system.²² Changes included regulatory waivers and new rules that allowed health systems to care for patients via telehealth directly from their place of residence, allowed new (previously unestablished) patients to be seen by telehealth, instituted payment parity (telehealth and in-person care reimbursed the same), and waived potential penalties for HIPAA violations for non–HIPAA-compliant telehealth platforms as long as patients were being served in good faith.²⁰ As a result, in effort to continue providing patient care, offices abruptly redesigned care delivery. Face-to-face office visits were replaced with telehealth.

Policy Agenda Setting

Policy starts with problem identification. Thomas Farley, MD,²³ nearly a decade ago suggested “the reason we have government is to solve problems collectively that we can’t solve individually.” The same thought can be extended to policy. Policy is needed when problems, such as an urgent need for access to telehealth, are not being solved locally.

Smith et al²⁴ lent further NP perspective on policy. They suggested that policy is “intimately tied to values and beliefs held by individuals and society at large.”^24(p761) Clinicians, individuals, and society at-large value and expect access to health care. NPs specifically value broad access to care as previously discussed. Anything that threatens that value around access to care, whether geographic, political, or biological, such as a deadly viral pandemic or any other threat, would be a problem for policy change.

Understanding the process of problem identification ultimately ending in policy change is important. This author has taught policy to graduate nursing students for several years and favors Kingdon’s multiple streams framework.⁷ Kingdon’s framework is a tool to help understand how and why some problems get addressed with policy change, whereas others do not. Additionally, Kingdon’s framework is easy to conceptualize with 3 main concepts, also known as streams.

Kingdon’s Multiple Streams Framework for Agenda Setting

A policy agenda, as described by Kingdon,⁷ is a list of problems being considered by government officials. The multiple streams framework has 3 streams that, although operating independently, eventually converge yielding a window of opportunity to push the agenda forward. Kingdon suggests that policy change, or the windows of opportunity “open infrequently and do not stay open long.”^7(p166) Therefore, timing is of critical importance. Each stream and application to the COVID-19 scenario follows.

Problem Stream

NPs identify problems every day. For policy change, clearly defining an urgent problem that decision makers with authority will notice and respond to is key. A stakeholder, or someone with an interest in a problem, provides alternative perspectives to fully define and understand a problem’s magnitude.

In the case of providing access to care using telehealth during a prolonged state of national emergency, the problem was clear. The need for health care did not stop despite stay home orders aimed at reducing the spread of COVID-19. For example, individuals still needed management of chronic disease, many experienced emotional stress, children still developed childhood illnesses, and pregnancies and acute illnesses continued to occur requiring care. Stakeholders were across all sectors of society, including health systems, independent medical offices, all patient support services, payers (including government), and potentially every person in the country. The magnitude of restricted access to community-based clinicians was like a deep, blunt dissection. Nonhospital care effectively stopped. Left unaddressed, a wider health crisis would ensue. The good news is that most people had access to telephone service and/or Internet, and the evidence basis for telehealth’s effectiveness was already in place. It was merely time to remove the regulatory red tape and translate the telehealth research into clinical practice.

Policy Stream

Kingdon’s policy stream can be summed up as the list of alternative strategies or solutions to the problem typically proposed by expert advisors.⁷ Ideas or proposals are tried out here by way of introducing bills into legislation, speeches, media exposure, and other means of persuasion.⁷

With the COVID-19 pandemic, there was little time for a drawn-out political process. Media coverage tallied scores of deaths daily, fueling the urgency for decisive action. It was discovered that vulnerable populations and the elderly did not always have access to video capability for telehealth. Tweaks were made to further broaden telehealth access to telephone including exact payment parity with video and in-person care.

Political Stream

The public or national mood conceptualizes the political stream in Kingdon’s framework.⁷ Changes in elected officials and administrations, along with ideological themes in the locality or nation, can exert a powerful effect on the policy agenda. Kingdon⁷ suggests that officials believe they can sense the mood or changes thereof around a problem based on media coverage, visits with individuals, or reports from trusted sources. The national mood has less to do with hard data and more to do with perceptions or interpretation of an issue.

In our COVID-19 scenario, the national, and even global, mood was that of fear and, in many cases, panic. Health care services in terms of hospital beds, ventilators, available nurses, physicians, and therapists were reaching epidemic shortages according to media reports. Although these severe and scary shortages were regional, they were in areas of the country with dense populations and high degrees of persuasion such as New York City. The pressure on elected officials to effectively address the problem was intense.

Window of Opportunity

What opens a window of opportunity? An external force is applied when opening any window, whether that be a household window or policy window. Kingdon’s framework⁷ suggests the opportunity for action on a given initiative will present itself but only stay open briefly. The opportunity specifically presents when all 3 streams (ie, problem, policy, and politics) align while an issue is urgent. Urgency is the force opening the window. Without urgency, Kingdon suggests stakeholders will cling to their individual positions rather than come to consensus. The more intense, widespread, and urgent the issue, the greater the chance the stakeholders will negotiate and reach a consensus.

Problem, policy, and politics all aligned in the spring of 2020 as COVID-19 gripped the country. Stakeholders across sectors cooperated and opened the window for truly accessible telehealth. This author’s analysis is that the staggering death toll and worry about access to care (problem stream) appropriately fueled public fear (political stream—mood), resulting in compliance with stay-at-home orders. These factors necessitated alternative methods to deliver health care where the people in need reside (policy stream).

Conclusion

The COVID-19 pandemic provided a window of opportunity as described by Kingdon⁷ for policy change concerning the provision and reimbursement of telehealth. Once restrictions were loosened, telehealth as an alternative to face-to-face office visits was experienced by both clinicians and patients. Evidence supports telehealth across many specialties whereby NPs deliver care. NPs should become familiar with and use Kingdon’s multiple streams framework to identify problems relating to the NP role or patient care amenable to policy change.

Biography

Karla K. Giese, DNP, FNP-BC, is an assistant professor at Liberty University in Lynchburg, VA, and a nurse practitioner with Lovelace Medical Group in Albuquerque, NM, and can be contacted at kkgiese@liberty.edu.