Statement of the American Hospital Association for the Subcommittee on Health of the Committee on Ways and Means of the U.S. House of Representatives “Charting the Path Forward on Telehealth”
April 28, 2021
On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners – including more than 270,000 affiliated physicians, 2 million nurses and other caregivers – and the 43,000 health care leaders who belong to our professional membership groups, the American Hospital Association (AHA) appreciates the opportunity to submit for the record our comments regarding the importance of the future of telehealth. During the COVID-19 pandemic, telehealth has provided a critical way for patients to continue accessing needed care. We greatly appreciate the flexibilities implemented during the public health emergency, as they have allowed hospitals and health systems to care for patients in the safety of their own homes.
The increased use of telehealth since the start of the public health emergency (PHE) is producing high-quality outcomes for patients, closing longstanding workforce gaps and those that arose as a result of an overwhelmed, hardworking provider workforce, and protecting access for patients too vulnerable to risk infection. This shift in care delivery could outlast the PHE if the appropriate statutory and regulatory framework is established. We urge Congress to consider how to ensure these flexibilities could remain in place for patients and health care providers beyond the PHE.
Delivery of Telehealth across the Nation
One of the most salient benefits of telehealth is the access to care it creates for broad patient populations. Telecommunications technology connects patients to vital health care services through videoconferencing, remote monitoring, electronic consults and wireless communications. It increases patients’ access to physicians, therapists and other practitioners. This is especially important in areas of the country where recruiting and retaining providers is challenging, such as in rural areas, and in areas where vulnerable populations often lack an entrance point to the health care system.
During the pandemic, hospitals and health systems have used critical flexibilities that the Centers for Medicare & Medicaid Services (CMS) established under waiver authority enacted by Congress to allow telehealth services to reach even more patients.
- Increased Access to Specialists: One example of the impact made by these flexibilities comes from a hospital member who reported a 10-fold increase in access to specialists while reaching 39% more ZIP codes in their state using telehealth. They also received extremely high patient satisfaction ratings; one such patient, a farmer, relayed how he conducted a visit with his physician via his smartphone while on his tractor, a process that would normally take three hours if in person.
- Avoided Hospitalizations: The COVID-19 pandemic spurred another hospital member to set up a virtual hospital with significant telehealth capabilities when the pandemic first hit. The program’s original objectives were to provide proactive management of COVID-19 patients across the care continuum, keep significant numbers of patients out of emergency departments (EDs) and hospitals, and preserve and increase inpatient bed capacity for those who needed it.
- These objectives were met with great success: nearly 18,000 patients were treated in the virtual hospital as of August 2020, with only 3% requiring transfer to a brick-and-mortar site. A significant number of hospitalizations were avoided, making the program very cost effective.
- The patients who were transferred often were able to bypass busy EDs, and by the time they arrived at the facility, the hospital already had their essential information due to their prior virtual care.
- Patients were extremely satisfied with the program, including the 97% of patients who remained at home and whose anxiety about this novel disease was very well-managed due to regular connection with a provider. Every patient discharged from the virtual hospital was set up with a follow-up appointment with a primary care provider, the majority of which were completed virtually. For many of these patients, that primary care visit was the jumping off point to ongoing access to care they never had before. This member is now expanding its virtual hospital beyond COVID-19 care to assist those with chronic conditions.
- Improved Outcomes: Many other AHA members also indicated they observed greatly improved health outcomes for patients who no longer cancelled or missed their appointments due to the ability to connect with their providers remotely.
Given these and the millions of other successful telehealth encounters that have occurred since COVID-19 first hit – and in the years prior – the AHA strongly urges Congress to consider the elimination of the 1834(m) geographic and originating site restrictions, which would allow all patients to receive telehealth services in their homes, residential facilities and other locations. The AHA has supported the Telehealth Modernization Act (S.368/H.R. 1332), which would accomplish this goal, along with other helpful changes that would improve access for patients. The AHA also appreciates the Protecting Access to Post-COVID-19 Telehealth Act of 2021 (H.R. 366), which would address geographic and originating site restrictions, and we look forward to working with the Committee on this issue going forward. Without this change, much of the progress that has been made over the past months to significantly increase patient access to care will disappear, since the status quo limits telehealth to rural areas of the country and requires patients to be at certain types of facilities to receive care. The PHE clearly demonstrated the need for access to telehealth in non-rural areas including in the safety of patients’ homes, and the importance of being able to reach patients who are completely removed from the health care system, such as homeless individuals in shelters.
While telehealth has great potential to increase access to care, any expansion of telehealth should be implemented with the explicit goal of addressing health equity and reducing health disparities, as challenges remain for the nation’s minority communities. As such, telehealth should be employed with supporting policies, such as access to broadband and end-user devices, to reach underserved populations.
Coverage and Reimbursement for Audio-only Services
One of the flexibilities allowed during the PHE is Medicare coverage and payment for audio-only services. During the PHE, CMS used waiver authority to establish separate payment for audio-only evaluation and management (E/M) services and temporarily waived the requirement that telehealth services be provided by two-way, audio/video communication technology, so as to add the audio-only E/M services to the Medicare telehealth list of services and permit other services on the list to be delivered via audio-only connection.
The AHA strongly supports coverage and reimbursement for audio-only services and encourages Congress to continue this flexibility for health care providers. This flexibility has enabled hospitals and health systems to maintain access to care for numerous patients who do not have access to broadband or video conferencing technology. It also has protected the continuity of care when a video connection fails. In those situations, if a provider and patient are connected via audio/video technology, and their video connection fails, they can default to an audio-only visit and pick up right where they left off. In addition, audio-only behavioral health services have become extremely popular with patients who are more comfortable without face-to-face visits.
State licensure laws for physicians and other health care professionals can be major obstacles for those facilities wanting to provide telehealth services to patients in other states because of the current lack of portability of health professional licenses. Every state and territory has laws in place that govern the practice of medicine. These laws require a person practicing medicine to obtain a full and unrestricted license authorizing that person to engage in the practice of medicine within that state or territory. The AHA has supported the Temporary Reciprocity to Ensure Access to Treatment Act (TREAT Act, S.168 and H.R. 708) that would allow for the temporary reciprocity for treatment by medical professionals licensed in one state to patients in other states. The legislation is limited in duration to the COVID-19 pandemic and only allows a health care professional to practice within their licensed scope of practice. It does not allow a health care professional to issue a prescription for a controlled substance without proper registration and in compliance with applicable regulations.
This legislation would provide flexibility for health care workers to cross state lines physically and virtually to provide care during the COVID-19 pandemic. We need as many of our health care providers as possible to provide care, regardless of their location.
Payment for Telehealth Services
For providers to be able to continue delivering high-quality patient care through telehealth and other virtual services, they need adequate reimbursement for the substantial upfront and ongoing costs of establishing and maintaining their virtual infrastructure, including secure platforms, licenses, IT support, scheduling, patient education and clinician training. Without adequate reimbursement of these costs, providers may be forced to decrease their telehealth offerings. Adequate reimbursement for virtual services also is key to ensuring providers have the means to invest in HIPAA-compliant technologies and to deliver these services with high quality of care. We urge Congress to work in conjunction with CMS to ensure the ability of providers to deliver high-quality care and improved patient outcomes.
Expanding the Types of Providers Eligible to Deliver Telehealth
The COVID-19 pandemic has had an unprecedented impact on the front line workers who have tirelessly provided care during this crisis. Policies that increase the types of health care facilities and providers that can offer telehealth care will benefit both patients and providers. Medicare provides reimbursement to both an originating and distant site for telehealth services. The originating site is the location of the patient receiving the telehealth service, while the distant site is the location of the health care provider providing the telehealth service. Specifically, the AHA supports allowing rural health clinics (RHCs) and federally qualified health centers (FQHCs) to serve as distant sites, so that these facilities may use the providers at their own sites to offer care to patients, ensuring patients remain connected to their primary providers. AHA supports allowing critical access hospitals the same ability to offer and bill for telehealth services. The AHA also supports expanding the types of providers that can deliver and bill for telehealth services to include, among others, physical therapists, occupational therapists and speech-language pathologists.
Expanding Health Care Digital and Data Infrastructure
As Congress considers infrastructure proposals, there is an opportunity to support a robust, secure digital health infrastructure. We urge Congress to consider expanding access to adequate, affordable broadband connectivity, which is essential to enabling telehealth and increasing access to care, as well as support for telehealth infrastructure to ensure all Americans, and particularly those in underserved communities, can realize the promise of digital health. Additionally, we must prioritize strong cyber defenses to protect the privacy and safety of patients and their health information. Finally, we must continually modernize the key data systems that support the ability of government and health care organizations to identify, track and respond to issues that affect health equity, racial and ethnic disparities, the quality of health care delivery, and public health responses.
Specifically, we ask Congress to consider policies to support:
- Completing the nation’s broadband infrastructure. Significant new funding should be provided to the Federal Communications Commission’s (FCC) Rural Health Care Program to support broadband access and make other program improvements as needed.
- Expanding telehealth capacity. Congress should establish new funding programs to offset the high upfront and ongoing maintenance costs of telehealth infrastructure and ensure fair and sustainable reimbursement for health care professionals and hospitals providing telehealth services.
- Strengthening cybersecurity defenses. We should strengthen our cybersecurity defenses by advancing efforts, including development of coordinated national defensive measures; expansion of the cybersecurity workforce; disruption of bad actors that target U.S. critical infrastructure; and utilization of a “whole of government” approach to increasing consequences for those who commit attacks.
- Modernizing the nation’s data infrastructure. We should do this through dedicated funding for upgrades and maintenance of the systems hospitals and other health care providers use to report vital quality data, as well as investing in public health data system modernization and workforce development to support expanded surveillance and response capabilities.
The ongoing COVID-19 pandemic has brought unprecedented demands on the nation’s health care system, and it also has changed the way people receive care. For patients, the need to continue to receive care remotely from their trusted health care provider is important for healthy outcomes. We thank you for your attention to telehealth and consideration of our comments on behalf of hospitals and health systems. We look forward to working with Congress to ensure continued telehealth access to care for patients.