Telehealth

Issue: 

Telemedicine refers to the remote provision of clinical health services using information and communications technologies. Telehealth encompasses a broader set of activities, including not only telemedicine but also: 1) remote patient monitoring; 2) virtual patient education; and 3) store-and-forward technology, which transmits patient information (e.g., medical images or notes from health records) from one health care provider to another without the need for both parties to be present at the same time.  

Telehealth has advantages and disadvantages compared with in-person services. Potential advantages include: 
 

• Convenience. 

• Increased access to care, particularly in rural or underserved areas and for patients with limited mobility.  

• A reduction in the spread of infectious disease.  

• Lower spending.  

Potential disadvantages include: 

• Decreased continuity of care.  

• Weaker doctor-patient relationships. 

• Inappropriate use of telehealth due to poorly aligned incentives1 and other challenges, as discussed below. 

Impacts on spending vary. Although certain telehealth services may seem like they could save money, telemedicine visits might not actually lower overall spending. This is because of how different levels of health care services—like primary, specialty, and advanced care—interact in complex ways. If more people start using telemedicine with new providers and it weakens the quality of primary care from established providers, then people might end up needing more specialty and advanced care. This could lead to higher overall spending. 

The number of telehealth companies and services entering the market has increased dramatically since early 2020. Both patients and practitioners are much more comfortable with telehealth platforms and services, which suggests that the use of telehealth is likely to increase in the next several years.   

Background:  

Telehealth services in the U.S. date back to the 1960s. This is when the U.S. government, through agencies like the National Aeronautics and Space Administration (NASA) and the Department of Defense (DOD), began exploring the use of telemedicine to provide health care consultations to astronauts and military personnel stationed in remote locations. 

As technological advances continued over the decades, telehealth improved and expanded. By the 2000s, telehealth became more common in certain specialties, such as radiology, dermatology, and pathology. Throughout the 2010s, telehealth gained momentum with the proliferation of smartphones, high-speed internet, and mobile apps. As such, the use of telehealth began to expand beyond specialty care to include primary care, mental health services, and remote patient monitoring. Additionally, several states began implementing policies to support and regulate telehealth. 

Prior to the COVID-19 public health emergency (PHE) in early 2020, both the government and many private payers were reluctant to pay for telemedicine visits and other telehealth services. They were concerned that the ease of access provided by telehealth would increase health care utilization overall, which would likely increase spending. For years, Medicare payment for a telemedicine visit was about one-third less than the payment for a standard in-person visit. Medicare only covered telemedicine visits for a few select situations. Most other payers followed Medicare’s coverage and payment rules. Coverage and payment were restricted based on where the patient was located, where the physician was licensed, and the type of technology used. 

Changes to telehealth payment and coverage rules, starting in early 2020, aimed to limit the spread of infectious disease, expand access to health care, and ensure the solvency of medical practices. Changes implemented by private and public payers paved the way for dramatically higher use of telehealth services. Medicare coverage and payment rules were temporarily relaxed or removed; telemedicine visits were covered for all Medicare beneficiaries and paid at the same rate as in-person visits. Many states expanded coverage and availability of telehealth services by passing legislation and enacting regulations requiring coverage and payment parity for telehealth and allowing interstate licensure agreements. Some health care plans waived telehealth copays for the duration of the PHE. The NAIC tracked state actions in this area and other pandemic-related issues in its Coronavirus Resource Center. 

As health care continues to transition following the COVID-19 PHE, patients and providers have expressed interest in maintaining the increased availability of telehealth services. Health care spending and health insurance premiums could increase if the total number of physician visits or intensity of services increases due to the sustained uptake of telehealth services. 

While the potential benefits of increased telehealth have been well publicized, it is important to also consider the potential negative effects of these developments on patients and consumers, including: 

• Care coordination, continuity of care, doctor-patient relationship, and trust may deteriorate if telemedicine visits with new providers replace telemedicine or in-person visits with patients’ established providers. This concern is most important for primary care. Receiving primary care from one’s established primary caregiver is strongly associated with improved health and less use of more expensive care. The American Medical Association (AMA), American College of Physicians (ACP), and American Academy of Family Physicians (AAFP) have stated that responsible use of telemedicine should happen in consultation with a physician who has an established relationship with the patient. 

• Telehealth services aimed at direct-to-consumer marketing of prescription medications may leave patients confused and misinformed. It may also erode primary care coordination. In addition, telehealth companies must ensure robust ethical guidelines about prescribing procedures are in place for controlled substances and other medications that may cause harm or addiction.  

• Telehealth startups’ practices of sharing data with big tech companies may pose data security risks to patients.  

Physician membership organizations have expressed a strong desire for regulations and payments supporting telehealth to become permanent. Likewise, the telehealth market has grown dramatically. However, there are few studies that measure the impact of these changes on crucial health care outcomes like quality, usage, and costs. The Medicare Payment Advisory Commission (MedPAC) continues to urge caution about covering telehealth services broadly because of uncertainties about the impact on quality and spending. 

Status: 

The focus on telehealth has increased dramatically since the beginning of 2020, and many organizations—including the AMA, AAFP, and ACP—strongly urge that regulations and payments favorable to telehealth be made permanent. Telehealth startups and venture capital focused on telehealth opportunities have grown considerably.  

Telehealth use has declined and stabilized since its peak during the COVID-19 PHE. Use remains much higher than before the pandemic; telemedicine visits comprise roughly 15% of visits, compared with about 1% in February 2020. The portion of visits provided via telemedicine varies by specialty. By the last half of 2022, about half of behavioral health visits were provided virtually.   

The NAIC’s Health Insurance and Managed Care (B) Committee, its subcommittees and working groups, and state insurance regulators continue to closely monitor telehealth developments to protect consumers and promote equitable access to care. 

The Special (EX) Committee on Race and Insurance charged the Health Innovations (B) Working Group with evaluating mechanisms to reduce disparities through a few different means, including telehealth services and alternative payment models. Key findings of the research include that telehealth has the potential to bridge the gap in access to care by connecting isolated people with culturally competent health practitioners while reducing the need for transportation to receive such care.  

Whether telemedicine primary care visits are with patients’ established or new providers significantly impacts health outcomes in primary care and beyond. If increased telemedicine visits with new providers result in fewer visits with patients’ established primary care providers, it could negatively affect the doctor-patient relationship. This could potentially leave patients worse off.