The Connected Health Initiative (CHI) and our members worked tirelessly with the Department of Health and Human Services (HHS), Congress, and state officials to expand access to connected health solutions during COVID-19 pandemic. In just a few short months, we made more progress in opening up Medicare and Medicaid to telehealth visits, remote patient monitoring (RPM) tools, and other connected health solutions than in the previous decade.
In this blog post, we will explore the three key challenges that previously limited the impact of connected health technologies, the myriad of temporary policy changes recently made to address the COVID-19 public health emergency, and the opportunities and challenges that still remain. Over the coming months, we’ll provide regular “dispatches from the frontlines” exploring the effectiveness of current policies and connected health technologies around the country.
Key Challenges for Telehealth, RPM, and Other Digital Health Technology
Before the COVID-19 pandemic, connected health solutions like telehealth and remote patient monitoring (RPM) showed enormous promise but had a modest impact on the practice of healthcare in the United States.
For example, venture capital investment in digital health grew more than 40x over the past decade from a mere $200 million in 2010 to a high of nearly $9.5 billion in 2018. Yet, the latest data from the Centers for Medicare and Medicaid Services (CMS) indicates that Medicare pays just under $30 million per year supporting telehealth claims out of a $600+ billion annual budget.
The impact of connected health technology had limitations due to three key challenges that every new device or healthcare technology face.
Showing it Works
In the healthcare industry, any new technology generally must demonstrate substantial evidence supporting its effectiveness, quality, and reliability before its use in a professional setting by a doctor or other healthcare provider. The data is already clear that established digital health technologies, including telehealth and many remote patient monitoring tools, improve patient outcomes while reducing system costs, particularly for the chronically and acutely ill, but each new app or device must clear this hurdle. Very often, those on the front lines are too busy utilizing new technology to improve patient outcomes to focus their time and resources on generating prolonged studies.
Clarifying Liability Concerns
Before the adoption of the latest digital health tools within the practice of medicine, both the developer of the technology and the medical providers who intend to use it must have clarity about the liability involved. If the liability involved with a new technology is substantially higher than relying on older methods, providers will be reluctant to adopt them despite any benefits they may confer in terms of effectiveness and efficiency.
Paying for it
The most critical and complex barrier to widespread adoption of connected health technologies is the question of payment—how they are paid for and by whom. Medicare, the largest healthcare payer in America, along with state Medicaid and Children’s Health Insurance Program (CHIP) programs, have long-standing measures in place to address overutilization and fraud, a situation made even more complex by a gamut of components to deliver digital health that also need funding, including:
Patient connectivity (broadband and smart devices)
Provider connectivity and capacity (commercial broadband and technology infrastructure)
Connected health devices and services
Doctor, nurse, and physician assistant time (to setup, maintain, and analyze data from connected health devices)
Connected Health Policy Changes During COVID-19
As the nation attempts to limit the risk of exposure for vulnerable populations, bend the curve of infections, and conserve our limited supplies of personal protective equipment (PPE) and other key supplies, healthcare providers and policymakers turned to connected health technologies as part of the solution. HHS, the U.S. Food & Drug Administration (FDA), the Federal Communications Commission (FCC), and various state agencies all took steps to remove barriers to the use of connected health technologies.
CHI tracked the many policy changes affecting connected health technology since the start of the pandemic. The changes made thus far are primarily temporary (limited to the length of the public health emergency) and focused on removing barriers to paying for the deployment and use of connected health technologies.
We maintain an exhaustive list of relevant policy changes here, but from a practical level these changes largely fall within three major categories.
Remove Legacy Restrictions on Telehealth Payment/Reimbursement
The most important challenge to increasing the use of established telehealth and remote patient monitoring technologies are long-standing limitations to what Medicare and other insurers will pay for and reimburse. These restrictions have a profound effect on the growth of telehealth because they only reimburse doctors for telehealth visits involving patients who are in Healthcare Professional Shortage Areas (HPSAs), which are primarily rural areas. In response to COVID-19, CMS made a series of important but temporary changes to the way they pay for and reimburse connected health:
Geographical restrictions removed. CMS removed long-standing geographical restrictions that restricted the vast majority of healthcare providers from reimbursement for Medicare telehealth services.
Matched telehealth fees to in-person service fees. CMS agreed to pay the same fees to providers as if the medical service was an in office visit.
Allowed reimbursement for audio-only telehealth visits. Previously, Medicare would only pay for real time telehealth visits conducted using both live voice and video. This requirement made it impossible for those patients without broadband or some form of camera-enabled smart device to take advantage of telehealth.
Removed previous patient relationship and in-person visit requirements for telehealth. CMS also temporarily removed requirements for healthcare providers to have an in-person appointment with a patient to establish the relationship or continue a relationship before they receive reimbursement for any telehealth visits.
Expanded list of providers and services eligible for telehealth reimbursement. CMS expanded the list of healthcare professionals who are able to provide distant site telehealth services to include all those who are eligible to bill Medicare for their professional services. This includes physical therapists, occupational therapists, speech language pathologists, and others. CMS also expanded the types of services provided via telehealth to include radiation treatment management, certain clinical examinations for dialysis patients, neonatal and pediatric critical care, etc.
Remove Legacy Restrictions and Expand Use Cases for Remote RPM Technologies
Remote patient monitoring (RPM) technologies and telemedicine can play a particularly important role in protecting vulnerable populations, minimizing the use of our limited supply of PPE, and as a force multiplier for our healthcare community.
CMS, the FDA, and state governments all took steps to set aside legacy restrictions that affect remote patient monitoring technologies and telemedicine:
CMS temporarily allows providers to offer RPM services to new patients. Previously, CMS would only allow reimbursement for RPM services and technology if the patient had an established relationship (including a physical visit) with that healthcare provider. During the crisis, providers can provide RPM services without requiring a new patient to come to the office or hospital first.
CMS clarifies use of RPM for chronic and acute conditions. Typically, use of RPM is associated with monitoring patients with chronic conditions like high blood pressure or diabetes. CMS advised practitioners that it can reimburse uses of RPM services provided to patients with an acute respiratory virus, like COVID-19, to monitor pulse and oxygen saturation levels using pulse oximetry.
FDA expands availability and capability of medical equipment and RPM solutions. The FDA issued guidance that expands the use cases for x-ray, ultrasound, magnetic resonance imaging systems, non-invasive fetal and maternal monitoring devices, and other non-invasive remote monitoring devices. It also invoked an Emergency Use Authorization for Philips IntelliVue Patient Monitors for use by healthcare professionals in the hospital environment. This allows the use of RPM tools within hospitals to limit risk of exposure.
Expanding Access to Telehealth and RPM Solutions in Underserved Communities
One of the oft-forgotten challenges to implementing telehealth and RPM solutions for rural and other underserved communities is that providers and patients often lack access to adequate broadband internet, technical equipment, and smart devices necessary to support those services. CMS and the FCC took important steps to increase access to these technologies during the pandemic.
FCC grant program for underserved communities. Congress provided $200 million for an FCC “COVID Telehealth Program” to fund telecommunications services, information services, and devices necessary to enable telehealth and telemedicine services for rural and other qualifying healthcare providers.
FCC temporarily opens up spectrum for rural communications services. The FCC waived various spectrum use requirements on communications service providers that serve rural communities to meet the spike in internet use from telehealth and working from home directives.
CMS allows healthcare providers from FQHC and RHCs to provide telehealth from any location. CMS also shifted the rules for Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) to allow their practitioners to receive reimbursement from Medicare for telemedicine services from any location, even their homes, during the crisis.
An Early Look at Policy Outcomes
The temporary policy changes combined with similar efforts by private health insurers and state Medicaid regulators jumpstarted the use of telehealth and RPM services around the country.
The Partners Healthcare system, which includes Massachusetts General and Brigham and Women’s hospitals, went from 1,600 telehealth appointments for outpatient care in February to 242,000 in April. Jefferson Health, a healthcare system in Pennsylvania and New Jersey, saw an 11-fold jump from February to the end of April. George Washington Hospital and Medical Faculty Associates report providing “40 percent to 50 percent of its care” over telehealth platforms.
According to recent polling sponsored by CHI, nearly 40 percent of Americans have had virtual healthcare appointments of some sort since the beginning of the COVID-19 pandemic, and the experience has been overwhelmingly positive. Ninety percent of those who did have a voice or video appointment with a healthcare provider reported that the visit helped them address their symptoms, concerns, or questions. In fact, 70 percent of all respondents want the law to be permanently amended to allow telehealth visits for all patients who want them.
Efforts to expand access to rural and other underserved communities have also been well received. According to the Wireless Internet Service Providers Association (WISPA), the pandemic and its shelter-in-place orders have prompted an average 35 percent bump in traffic for wireless networks serving rural America and many are taking advantage of new spectrum the FCC made available to meet the challenge.
The FCC’s COVID Telehealth Program has also been very popular. With in a few weeks, the FCC had approved funding for 132 healthcare providers in 33 states plus Washington, DC, for a total of just over $50 million in funding.
In essence, the United States effectively launched a massive field test of telehealth, telemedicine, and RPM technologies in response to COVID-19. The initial indicators are very positive, but over the course of the coming months we will learn a great deal about the effectiveness of various technologies, best practices for adopting these technologies and services within the healthcare system, and the appropriate policy frameworks to support effective, safe, and fair adoption of these services over the long run.
CHI will be collecting data and stories from patients and providers who are using connected health technologies during the COVID-19 pandemic and sharing them via our “Dispatches from the Frontlines: Connected Health and COVID” series.