Together with the American College of Physicians, the American College
of Chest Physicians (CHEST) issued a request to congressional members
to extend coverage of telehealth appointments beyond the COVID-19
public health emergency (PHE).
When the PHE was announced, federal COVID-19 waivers and regulatory
changes made it easier for providers to deploy telehealth solutions to
serve their patients. Patients from lower income areas found typical
barriers to care, such as distance or lack of reliable transportation,
eased.
The letter to Congress urges expanded telehealth services as a method
of health care delivery that may enhance the patient–physician
relationship, improve health outcomes, increase access to care, and
reduce medical costs when used as a component of a patient's
longitudinal care.
To address the needs of those who do not have access to high-speed
internet services, the letter also requests that Congress enact
legislation to ensure that payment for audio-only telehealth evaluation
and management services will continue for 2 years after the end of the
PHE, along with an option for CMS or Congress to extend it even
further, or consider making it permanent.
“While the COVID-19 pandemic posed a myriad of challenges, the ability
of providers to offer remote care via telehealth services to patients
who didn’t require in-person visits was a huge benefit,” says President
of the American College of Chest Physicians, David Schulman, MD, MPH,
FCCP. “With equitable care being a top priority for CHEST, we support
the extension of coverage of these services, as they will continue to
offer the greatest benefit to those in traditionally underserved
communities lacking access to care.”
March 8, 2022
The Honorable Charles Schumer
Majority Leader
United States Senate
Washington, DC 20510
The Honorable Mitch McConnell
Minority Leader
United States Senate
Washington, DC 20510
The Honorable Nancy Pelosi
Speaker
House of Representatives
Washington, DC 20515
The Honorable Kevin McCarthy
Minority Leader
House of Representatives
Washington, DC 20515
Dear Majority Leader Schumer, Minority Leader McConnell, Speaker
Pelosi, Minority Leader McCarthy:
On behalf of the undersigned organizations, who represent hundreds of
thousands of physicians and medical students across the country, we are
writing to share our recommendations for legislation expanding
telehealth flexibilities beyond the declared public health emergency
(PHE) for the COVID-19 pandemic. We are grateful that the Centers for
Medicare and Medicaid Services (CMS) and Congress have enacted reforms
to expand the use of telehealth during the public health emergency, but
we remain concerned that many of these flexibilities are set to expire
at the expiration of the PHE, or soon thereafter. We urge you to extend
these flexibilities, some on a permanent basis, and pass reforms, as
outlined below, to ensure that our physicians have the tools and
resources they need to continue providing increased access to care for
their patients through telehealth.
Our organizations support the expanded role of telehealth as a method
of health care delivery that may enhance the patient–physician
relationship, improve health outcomes, increase access to care from
physicians and members of a patient's health care team, and reduce
medical costs when used as a component of a patient's longitudinal
care. Telehealth can be most efficient and beneficial when
appropriately utilized in the context of an existing and ongoing
patient-physician relationship and can serve as a reasonable
alternative for patients who lack in-person access due to
circumstantial factors such as transportation limitations or lack of
relevant medical expertise in their geographic area.
Studies have shown the benefits of the use of telehealth, which has
risen sharply since the start of the pandemic. According to the
Department of Health and Human Services’ (HHS) December 2021
report
on telehealth use, the number of Medicare fee-for-service beneficiary
telehealth visits increased 63-fold in 2020, from approximately 840,000
in 2019 to nearly 52.7 million in 2020. A recent
study
by the Centers for Disease Control and Prevention (CDC) concerning the
use of telehealth in health centers suggested that “telehealth can
facilitate access to care, reduce risk for transmission of SARS-CoV-2,
conserve scarce medical supplies, and reduce strain on health care
capacity and facilities while supporting continuity of care.” An
article published by the
Commonwealth Fund, notes that “tele- mental health has a robust evidence base and
numerous studies have demonstrated its effectiveness across a range of
modalities (e.g. telephone, videoconference) and mental health concerns
(depression, substance use disorders).”
Extend the Expansion of Telehealth Services Under the 1135 Waiver
Authority
Our organizations are concerned that some of the telehealth services
expanded by CMS under the 1135 waiver authority are set to expire at
the end of the PHE. These telehealth services, which are discussed
later in this letter, allowed Medicare to pay for office, hospital, and
other visits furnished via telehealth at a patient’s homes and have
expanded access to health care for beneficiaries across the country.
They are used by our members to provide evaluation and management (E/M)
services to treat chronic conditions and have been a valuable resource
to expand access and coordinate patient care. For these reasons, we
believe telehealth services should remain in place for at least two
years after the end of the PHE to ensure that our physicians are able
to continue to use this modality to enhance patient care.
We are pleased that Senators Cortez Masto and Young have introduced
bipartisan legislation, S. 3593, the Telehealth Extension and
Evaluation Act, that would extend the telehealth expansions under the
1135 waiver for an additional two years after the end of the PHE. We
also appreciate that Representatives Doggett and Nunes have introduced
H.R. 6202, the Telehealth Extension Act of 2021, that includes a
provision to expand 1135 waivers for telehealth services, including
Medicare coverage of audio-only telehealth services between physicians
and patients, for an additional two years after the PHE declaration
expires.
Expansion of Telehealth Services Under the Medicare Physician Fee
Schedule
Our organizations are also pleased that the 2022 Medicare Physician Fee
Schedule Final Rule provided coverage through the end of 2023 for all
services on the temporary Category 3 list of Medicare-covered services.
While our organizations support these extensions, we strongly recommend
that Congress enact legislation to ensure the Category 3 list itself is
made permanent to provide for a more consistent and efficient on-ramp
for new telehealth services to be added. Our organizations strongly
encourage CMS to add coverage for audio-only E/M telehealth services to
the Category 3 list and retain these services until at least the end of
CY23.
Comparable Pay for Audio-Only Telehealth Services
During the PHE, Medicare has covered some audio-only services for
tele-mental health as well as E/M services and will reimburse for both
types of telehealth services, including when the services are delivered
via audio-only technology, as if they were provided in-person. Primary
care services delivered via telephone have become essential to a
sizable portion of Medicare beneficiaries who lack access to the
technology necessary to conduct video visits. These services are
instrumental to patients who do not have the requisite broadband and
cellular phone networks, or do not feel comfortable using video visit
technology. In addition, these changes have greatly aided physicians
who have had to make up for lost revenue while still providing
appropriate care to patients.
We are discouraged to learn that CMS will not continue coverage of
audio-only telehealth E/M services beyond the PHE, despite
mounting evidence
about the effectiveness of expanding coverage for these services. The
abrupt ending of coverage could potentially have negative consequences
to access and equitable care, which would particularly impact
beneficiaries living in rural areas in addition to those who have
transportation and technology limitations.
We urge Congress to enact legislation to ensure that payment for
audio-only telehealth evaluation and management services will continue
for two years after the end of the PHE, along with an option for CMS or
Congress to extend it even further, or consider making it permanent,
based on the experience and learnings of patients and physicians who
utilize these visits.
Geographic Site Restriction Waivers
Our organizations are strongly supportive of CMS’ decision to lift
geographic site restrictions to allow for reimbursement of telehealth
services to those that originate outside of metropolitan statistical
areas or for patients who live in or receive service in health
professional shortage areas. While limited access to care is prevalent
in rural communities, it is not an issue specific to rural communities
alone. Underserved patients in urban areas have the same risks as rural
patients if they lack access to in-person primary or specialty care due
to various social drivers of health such as lack of transportation or
paid sick leave and insufficient work schedule flexibility to seek
in-person care during the day, among many others.
We are pleased that in the 2022 Medicare Physician Fee Schedule Final
Rule CMS broadened the scope of services for which the geographic
restrictions do not apply and for which the patient’s home is a
permissible geographic originating site to include telehealth services
furnished for the purpose of diagnosis, evaluation, or treatment of a
mental health disorder, effective for services furnished on or after
the end of the PHE. We support any efforts to expand access to mental
and behavioral health services, including allowing beneficiaries to
access services from home, or if the technology is not available at
home, from a rural health clinic or hospital.
We appreciate that the Telehealth Extension Act, H.R. 6202, would
permanently lift geographic and site-based restrictions for additional
telehealth services covered under Medicare regardless of a
beneficiary’s zip code. Due to these flexibilities, beneficiaries would
continue to have access to these services in the comfort and
convenience of their own home or at designated health facilities
offering telehealth. We urge adoption of this provision that will
increase access to telehealth services beyond mental and behavioral
health services in any legislation that Congress chooses to advance on
telehealth.
Telehealth Cost-Sharing Waivers
At the conclusion of the COVID-19 PHE, we recommend that Congress urge,
or if necessary, require, CMS to continue to provide flexibility in the
Medicare and Medicaid programs for physician practices to reduce or
waive cost-sharing requirements for telehealth services, while also
making up the difference between these waived copays and the Medicare
allowed amount of the service. This action in concert with others has
the potential to be transformative for practices while allowing them to
innovate and continue to meet the needs of patients where they reside.
Improve Health Equity in Telehealth
We remain concerned about the increasing inequities associated with
telehealth, as there are disparities in access to this technology. A
February 2022 HHS
publication
reported that telehealth utilization during the period of April to
October 2021 varied by race, region, education, income, and insurance.
For those in rural and underserved communities, the nearest clinic may
be hours away. Unfortunately, rural communities also suffer from more
limited access to broadband internet, which restricted the ability of
many in rural communities to access telemedicine pre-pandemic.
Additionally,
research
shows that Black and Hispanic Americans own laptops at lower rates than
white Americans, further dividing pre-pandemic access to telemedicine.
Equitable access to broadband internet is critical to the promotion of
health equity and quality of care outcomes through telehealth. We are
pleased with the additional 65 million in broadband funding that was
established through H.R. 3684, The Infrastructure Investment and Jobs
Act. We encourage Congress to continue to expand support for further
broadband deployment to reduce geographic and sociodemographic
disparities and access to care.
Conclusion
We urge Congress to act on these bipartisan recommendations to advance
access to telehealth and reduce inequities in its adoption. We look
forward to working with you to advance these objectives as Congress
considers legislation to improve the use of telehealth in the weeks and
months ahead. Should you have any questions regarding this letter,
please do not hesitate to contact Brian Buckley, Senior Associate for
Legislative Affairs at
bbuckley@acponline.org.
Sincerely,
American Academy of Neurology
American Association of Clinical Endocrinology
American College of Allergy, Asthma, and Immunology
American College of Cardiology
American College of Chest Physicians
American College of Gastroenterology
American College of Physicians
American College of Rheumatology
American Gastroenterological Association
American Geriatrics Society
American Medical Society for Sports Medicine
American Society for Gastrointestinal Endoscopy
American Society for Transplantation and Cellular Therapy
American Society of Hematology
American Society of Nephrology
American Thoracic Society
Association for Clinical Oncology
Infectious Diseases Society of America
Renal Physicians Association
Society for Post-Acute and Long-Term Care Medicine
Society of Critical Care Medicine
Society of General Internal Medicine
Society of Hospital Medicine
The Endocrine Society
The Gerontological Society of America