Congress only has a few more months to ensure expansive telehealth access continues

The clock is ticking on efforts to maintain the telehealth flexibilities that have been in place since the start of the COVID-19 pandemic, with advocates hoping Congress will act before year’s end.

Key waivers will conclude at the close of 2024 unless legislation is passed to extend them. Congress faced a similar scenario in 2022 and passed a two-year extension in an omnibus bill during the post-election lame-duck session.

Among the flexibilities scheduled to expire is nationwide Medicare payment eligibility for services furnished to beneficiaries in their homes. Established law allows for reimbursement only for telehealth provided to patients living in specifically designated rural areas, and only while those patients are visiting a medical facility.

A few services will remain universally reimbursable, including behavioral health services, along with monthly clinical assessments for end-stage renal disease. But the usual restrictions will apply starting in 2025 for other services if Congress does not move on the issue.

Legislators are aware of the situation, as indicated by the dozen or so bipartisan bills that have been drafted to extend telehealth waivers. Although some bills would codify the policies permanently, those that have advanced out of committee limit the extension to two years.

In testimony for a congressional hearing that took place in April, a health system leader said an extension is vital and ideally would be permanent.

“The urgency for Congress to act on Medicare telehealth flexibilities cannot be overstated,” Eve Cunningham, MD, MBA, chief of virtual care and digital health at Providence, said in testimony to the House Energy and Commerce Committee’s Health Subcommittee. “Our healthcare systems and providers need clarity and stability to implement and maintain the administrative and medical practices that ensure seamless, quality care for millions of Medicare beneficiaries nationwide.”

The state of affairs

After surging to 48% in 2020, the share of Medicare Part B beneficiaries who received care via telehealth dropped to roughly 25% in 2023, according to the latest trends report from CMS. Quarterly, the peak of 47% in Q2 2020 was short-lived, with the share falling below 30% during the second half of the year and hovering in the 12% to 13% range during the final three quarters of 2023.

But even those lower numbers are substantial.

“Patients and clinicians want telehealth to remain an option, and policymakers will find it difficult to take away telehealth,” Ateev Mehrotra, MD, professor and chair at Brown University’s School of Public Health, said in testimony for the Health Subcommittee hearing.

The House has queued up two bills that would authorize expanded telehealth availability through 2026. A bill unanimously passed in May by the Ways and Means Committee would allow all Medicare patients to continue receiving telehealth services in their homes. Another provision would continue reimbursement for audio-only services if that’s how the patient prefers to connect, as long as the clinician has the capability to connect by video. The legislation also includes clauses to improve telehealth services for individuals with limited English proficiency.

A separate bill unanimously passed by the Health Subcommittee contains many of the same provisions as the Ways and Means Committee’s bill. The subcommittee bill is a scaled-down version focused on telehealth, whereas the other bill extends the Medicare hospital-at-home waiver for five years and payments to low-volume and Medicare-dependent hospitals through FY25.

On the regulatory front, CMS has drafted policies to promote the continued widespread use of telehealth in 2025 if Congress takes the needed legislative action. The latest proposed rule for Medicare physician payments includes provisions that would maintain key waivers.

Promise and peril

Hesitation to permanently expand telehealth within Medicare stems from concerns about driving up costs and creating greater potential for fraud, waste and abuse.

The HHS Office of Inspector General examined program integrity risks among providers that furnished telehealth services during the first year of the pandemic. Among more than 742,000 that billed Medicare for a telehealth service, 0.2% (1,714) engaged in questionable billing practices, most frequently by charging a facility fee along with the telehealth service.

“It appears that telehealth can be used to deliver care without actually raising those serious [program integrity] concerns,” Rep. Brett Guthrie (R-Ky.), chair of the Health Subcommittee, said during the April hearing.

One example of approaches to limit fraud and waste would be to require an in-person visit before a physician can order specific high-cost tests, Mehrotra said.

In an August viewpoint article (login required) that he co-authored in JAMA, Mehrotra called for reframing the telehealth debate around the question of whether it increases value, i.e., by improving healthcare at a reasonable cost. It’s not realistic to expect telehealth to lower costs, given the increase in access and utilization that surely would result from a permanent expansion, the article states.

“To reduce spending, Medicare could reimburse only for clinical circumstances in which telehealth visits are likely to substitute for in-person visits and simultaneously reimburse telehealth visits at a substantially lower rate than comparable in-person visits,” wrote Mehrotra and Lori Uscher-Pines, PhD, of the RAND Corporation.

“We do not advocate this approach because telehealth’s greatest strength is its ability to increase access and convenience, and poor access to care is a critical problem in many communities,” they added.

Settling on a payment rate

After questions over whether telehealth payment parity would continue to apply once the PHE ended, CMS incorporated the non-facility Medicare physician payment rate for 2024 (using modifier 93 or 95 for hospital-based clinicians).

Any move to make Medicare coverage of telehealth services permanent is likely to include a rigorous assessment of payment rates, namely how telehealth reimbursement should compare with in-person payment levels.

In his congressional testimony, Mehrotra said telehealth visits should be paid at a lower rate. He noted such an approach would come over the objections of clinicians and administrators who say their practice expenses do not decrease when they add telehealth services to a menu that continues to include in-person visits.

During the hearing, for example, Lee Schwamm, MD, professor and associate dean at the Yale School of Medicine, said providers “can’t simply take a 50% pay cut when they could be seeing an in-person patient at full rates. … Right now, the cost is actually higher because we have to [maintain] full in-person capability and telehealth capability. If we have a permanent roadmap, we can start to actually readjust the expense base and figure out ways to deliver telehealth at lower cost.”

Mehrotra, though, cautioned against using telehealth to cross-subsidize in-person visits because doing so “will create distortions in the market. Paying the same amount for telehealth visits will also give virtual-only companies a competitive advantage and incentivize brick-and-mortar clinicians to give up their practice.”

He said a 25% reduction in payment for services provided via telehealth is generally “a reasonable starting place” but should be adjustable based on data that comes in regarding practice expenses.