health care

It's Time to Permanently Suspend Regulatory Barriers to Telehealth

Patients and providers should be able to meet remotely without bureaucrats getting in the way.

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After years of unfulfilled predictions about high-tech health care, the use of telehealth—like telecommuting—boomed during the pandemic and lockdowns. While the delivery of medical services via phone call, videoconference, and other electronic communications isn't universally appropriate, it's often helpful, and a huge boon for people who have limited mobility or live far from medical providers.

But while the COVID-19 pandemic has driven the use of telehealth technologies, that's largely because of the emergency suspension of regulatory barriers. Once the crisis is over, telehealth could disappear as an option for many people if regulators move to reclaim the ground they temporarily ceded.

I'll say up front that, as a rural dweller who lives far from most specialty providers, I'm a big fan of telehealth. In recent months, I've had the preliminaries of a skin cancer diagnosis done through emailed photos and a videoconference with a dermatologist 100 miles away. My son's acne was similarly treated by a distant doctor. The proliferation of phones with built-in cameras, video tools, and secure online portals for sharing files and lab results makes much of this a breeze.

Not everything can be done remotely, of course. I did have to make an in-person trip for a biopsy, and another to have the offending cells sliced away. But my son has yet to meet his dermatologist in-person. We've avoided multiple long drives and opportunities for catching COVID-19 or other diseases.

My wife is on the other side of this phenomenon in her role as a pediatrician. She meets with patients and their families through videoconference calls as a tactic for reducing the chance of infection.

We haven't been alone in embracing remote medical visits. Department of Health and Human Services (HHS) data shows that "nearly half of Medicare primary care visits were provided via telehealth in April, compared with less than one percent before the [public health emergency] in February."

Even after lockdowns eased, many medical appointments continued through phones and computers. "As in-person visits started to resume from mid-April thru May, the use of telehealth in primary care declined somewhat but appears to have leveled off at a persistent and significant level by the beginning of June," HHS adds.

Telehealth services were so rare before this year partially because of discomfort among providers with providing services to people who aren't physically present. It's new, it's different, and it's not always appropriate to diagnose and treat patients without in-person visits.

But even if physicians and other providers were less resistant, they still would have been stymied by regulatory barriers that hobbled the use of telehealth. Until March of 2020, seeing a patient remotely meant navigating a maze of privacy rules, licensing restrictions, and the very real likelihood that the visit was an act of uncompensated charity.

"Beginning on March 6, 2020, Medicare—administered by the Centers for Medicare & Medicaid Services (CMS)—will temporarily pay clinicians to provide telehealth services for beneficiaries residing across the entire country," CMS announced earlier this year. "Prior to this announcement, Medicare was only allowed to pay clinicians for telehealth services such as routine visits in certain circumstances. For example, the beneficiary receiving the services must live in a rural area and travel to a local medical facility to get telehealth services from a doctor in a remote location. In addition, the beneficiary would generally not be allowed to receive telehealth services in their home."

Medicare isn't the only game in town when it comes to paying for care, but Medicaid follows much the same rules, and, sad to say, private insurers tend to stick closely to the government program's policies.

Payment restrictions, while a huge concern, weren't the only regulatory barrier to the use of telehealth. A list of pandemic-inspired HHS policy changes regarding telehealth assures providers that "the federal government has taken concrete steps to make telehealth services easier to implement and access during this national emergency."

Under the revised rules, providers can now treat patients across state lines—something not permitted in the past. They can also see new patients online and not just continue existing relationships.

Importantly, given the minefield of privacy rules in the Health Insurance Portability and Accountability Act (HIPAA), providers can meet with patients using common "non-public facing" tools including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, and Skype. That means patients don't have to install and master the use of specialized software to see the doctor.

Also important: "A practitioner can prescribe a controlled substance to a patient using telemedicine, even if the patient isn't at a hospital or clinic registered with the DEA."

But, as helpful as all that is, don't get too comfortable. "These changes are temporary measures during the COVID-19 Public Health Emergency and are subject to revision," warns the document.

Also temporary is the relaxation of state rules—medical licensing, in particular—that stand in the way of telemedicine. Traditional licensing makes it illegal to hold a videoconference appointment across a state border, although driving across that border to see the same doctor in person is perfectly acceptable.

"The removal of state licensure restrictions allowed physicians to practice across state lines, which played a major role in allowing telehealth to step in as a national 'load balancer' of medical services," points out Roy Schoenberg, a physician and head of Amwell, a telehealth company. "For the first time in history, the nation could beam in specialists from where they were available to where they were needed most."

If old-fashioned licensing requirements are reinstated, that will leave patients and providers alike stuck in little boxes of medical care defined by their state borders, even though they have the ability to easily speak and share information with anybody on the planet.

Then again, if old payment, HIPAA, and prescription restriction are put back in place, it won't matter what size boxes we're stuck in, since telehealth will go back to being a rarity. That uncertainty hangs like a cloud over the whole practice of remote medicine.

"Multiple physicians mentioned that the lack of certainty regarding the post-pandemic policy environment reduced their willingness to invest in telehealth over the long term," writes Lori Uscher-Pines, a RAND Corporation senior policy researcher. "By signaling their intentions sooner rather than later regarding payment policy, policymakers could reduce uncertainty and encourage investment in sustainable telehealth models. For example, Congress should act to permanently remove geographic and originating site requirements for telehealth in Medicare."

To his credit, President Donald Trump ordered in early August that some telehealth rule revisions be extended. But the effect is largely limited to rural areas. And what can be done by executive order can be undone the same way.

It's great that regulators backed off a bit on telehealth-hobbling red tape that proved to be life-threatening during a pandemic. But if those rules are potentially deadly during a crisis, they'll still be inconvenient and dangerous once life returns to something like normal. If they care at all about health, politicians and bureaucrats need to get out of the way—permanently.

NEXT: Oregon Ballot Initiative Would Decriminalize Low-Level Possession of All Drugs

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  1. I’ve used telehealth for years though in my experience they can only prescribe a month of drugs and then you have to see a real doctor (or call a different telehealth company). And they are somewhat restricted on what kinds of drugs they can provide. Nevertheless it can be useful in various situations. During the pandemic all the offices shut down and telehealth was the only option and they came through until the offices started opening again.

    Also many insurance companies have phone lines to contact a nurse or doctor for routine things. It’s free and you don’t need to go in but they always end with, “See your doctor if it happens again.”

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    4. I’m disabled and no longer drive. I even sold my car. I get by on limited social security benefits. Life is not cheap and even with Uber, which is my only means of transportation now, getting anywhere can be expensive, especially when you have 4 or 5 specialists to see. Telehealth has been a godsend for me. It combined with the right remote monitoring equipment limits the need to see a doctor in person, in most cases. It’s a lot easier on my budget, less stressful, and provides the same or more information to your doctor than an in-person visit. I have a pacemaker in my chest and a device that monitors the pacemaker and transmits the data to my electrophysiologist. I have a bathroom scale that connects via Bluetooth to a small tablet and sends the data, along with my answers to several questions, to a nurse every day so they can monitor me for fluid retention and weight gain due to congestive heart failure. I have a home oxygen concentrator that supplies me with the supplemental oxygen I need due to my COPD. I have my own blood pressure kit, oximeter, and EKG to monitor my cardiac issues and make sure everything is ok. I take 15 separate medications every day, half of them twice a day. Being able to get them delivered the same day as I order them saves me the cost of an Uber round trip. I normally would have to make 2 round trips to the pharmacy each month because I have to submit a new prescription for my pain meds in person. Plus, the pain meds and all the other meds are refilled at different times. The only doctor I have to see every month now is my pain specialist just so I can get those prescriptions for opioids refilled for another month, costing me $45 in copay and $20 for roundtrip Uber rides. That $65 per month is significant when you are on a limited income. Get us medical MJ and I won’t have to do even that every month.

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    6. I’ve used telehealth a few times now and and so far I really like it. I have to take a cab to my appointments (no Uber or Lyft here), and they gets pricey after a few times.

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  2. People always get the wrong impression. The federal government has little to no role in the actual practice of medicine. The individual states control all of that and make their own rules.

    If you are in physically in New Jersey and doing a telemedicine consult with a patient in Texas you are in Texas as far as the state is concerned. You must apply for and receive a Texas license, those are a big deal. You must comply with all rules and regulations for a Texas doctor. The feds don’t make the rules.

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  3. Good article. Telemedicine is hopefully something that everyone can get behind. It can be especially important easing access to specialist that may not be readily available locally. The case of the dermatologist is great example. Another example would be for access to women to get prescriptions for medical abortions. Like other significant events, the coronavirus pandemic will force changes and greater use of telemedicine would be a plus coming from the pandemic. Privacy issues will be important as will access to the internet. But these are technical issue we should be able to solve.

  4. It’s Time to Permanently Suspend Regulatory Barriers to Telehealth

    There, that’s better.

    1. Love the backdoor swipe at Trump. Reason never forgets.

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    2. Anyone know an *actual* libertarian magazine that advocates for the right to buy medicine and medical care from whomever we damn well please?

  5. As someone who works in IT in the medical field I find it is not just the obvious regulations that are holding them back but the ones you don’t see that have held back telemedicine. Every piece of software that can be used for direct patient care must go through massive bureaucratic red tape before they can even be offered for use, and that includes any updates, upgrades and feature improvements. Because of these obstacles only the big vendors for the most part can afford to offer these systems and they are as clunky and outdated as most government written software. I left the oil field services industry 20 years ago and a lot of the imaging software current in the medical field is just starting to surpass what we had then. I met with a friend who still works in the oil patch and while we are just starting to experiment with VI in medical imaging they have implemented it and are using it to discover patches they thought were dry, they just found a billion-barrel reservoir where they thought it had run dry years ago. We, on the other hand might have VI ready for FDA approval in 10 years here.

    1. Are you talking about virtual imaging? It will no doubt emerge as a clinical tool at some point. I do not know much about it from a technical point of view. It seems to me the next step from what we now call 3D such as MIP and volume rendering.

      Perhaps you can show me something to learn more about it.

      One thing is that in a way the radiologist or surgeon does this in their head. With much practice they can imagine from regular imaging and reconstructions from CT or MRI what the lesion looks like in the body. This is very interesting.

  6. Well, two months ago, I was able to go to the pot store a block away from here and talk to a doctor on the telephone, while the store people entered some stuff into the computer. Didn’t even have video for the call. Only took a couple of minutes. That’s all it took to get the pot prescription (along with some cash).

    I’d love to do a lot of medical stuff that way.

  7. Telemedicine if used properly is a good thing.

    That said, as with everything in the corporatization of health care, it will be abused to the max to cut costs and maximize profit, at the expense of the standard of care. This is already happening in other areas where you see a PA instead of an MD (typically 2 years of post-grad training vs. 6 to 10).

    Despite all the lofty corporate mission statement, corporate healthcare (including all aspects: Big Pharma, insurance companies, provider corporations like HCA, PBMs, and chain retail pharmacies, etc) don’t give a flying fuck about our health – it’s all about the Benjamins.

    1. I have seen a PA for things. Even had a skin precancer removed by a PA. I have no problem with PA for basic medical services. I don’t want a PA for surgery, but they can stich me up afterwards.

      1. As a person who has worked in healthcare for most of his career, I am aware of what a PA and an MD each can do. The point is, it is not the care that is the determining factor, but the money and any potential liability.

        You cannot learn in 2 years what an MD learns in 10. Heck, even pharmacists have to go to school for 4 years just to put it in the bottle, but PAs can prescribe after only 2.

        And as the other poster above pointed out – they are under strict time limitations – my PCP talks to me as a colleague in ways he would not most patients. He said he has 11 minutes including the paperwork for each patient. It’s a bullshit way to practice medicine. But corporate America could fuck up a wet dream, so something as delicate as medicine never had a chance.

        1. The PA is not a medical practitioner; he is a data entry clerk for an ‘expert’ computer system. They will prescribe only what shows up on the computer screen, only ask questions that come up on the computer screen, and follow a script for the “consultation” questions.
          I haven’t seen an actual MD in five years, and everything the PA did could have been done directly on the web, as long as I can take my own temperature, blood pressure, O2 reading, and pulse rate. All of those things can be done at home with machines that cost less than the commute costs to go “see the doctor”.

    2. Pretty much spot on. And the corporatized Drs are pushed to their limits and time checked so they often can’t give those who really need them the amount of time they need.

      Because of changing to a specialty pharmacy I finally see how much the “non-profit” hospital is charging. What should be a $5000 medicine on Good-RX plus a $40/hr nurse (I hope they’re the high paid ones there), $38K. Just the $40/hr nurse, $1200. Even the actual negotiated price insurance pays is not that impressive, $15K, so they’re still well over twice a competitive price with insurance negotiating.

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  8. Next week on Reason: Telehealth used to spy on you.
    Maybe not next week if they use home video schooling, it’s already happened where a teacher called the police about a BB-gun.

    I’ve found telehealth to be worthless. Too many people (Dr and his assistant) talking in a echoy speaker phone. I thought it was just me who didn’t understand or retain anything from the call but now, here I am 4 months later down an additional 5lbs to the 20lbs I told him about. Since I messaged and said I need to change my meds because “keep doing what you’re doing” wasn’t working NOW he wants to waste time running tests.
    I’ve also seen telehealth pushed by corporate shills, an obvious easy profit margin increase. It’s not about making better healthcare more available, it’s about corporate bottom line. Same high price for less time to screen out the cases that don’t need a Dr (my insurance finally has cut the co-pay for telehealth but before, “Do I need to be seen for this?” “Yes that’ll be $30.” Go get seen for another $30.).

    I’m not against all e-health. I think messaging is great for follow ups or to keep the space free for more important cases. It could be better if not for the bureaucracy of screening messages through a nurse to a Dr and back to the nurse. If your Dr actually has an interest and does his own messaging with you that’s gold. Telephoning not so much. A choppy echoing video call is no better. You could message a high resolution picture of anything you need to ask about better any video call I’ve seen.

    Don’t forget, capitalism is not only about you making more from consumers. It’s also about consumers getting better or more for less. If you think it’s all about how much you can soak everyone for you’re the real socialists/communists.

    1. Well, we haven’t had true capitalism in this country for a very long time. This is crony capitalism, which is almost a 100% antithesis of capitalism.

      There is ZERO price discovery in the medical market in the USA. That’s why the corporations want in, and why they pay our government so handsomely to keep it that way. And why we pay out the ass.

      Thank God only other countries are corrupt cesspools.

  9. Other than for crisis situations, telemedicine would work well if done correctly. Rather than just a video conference, the experience could start with an email, where the patient describes in detail symptoms and concerns. The doctor could then respond, asking the patient to try various things. That could lead to the doctor sending the patient to a lab for testing, or setting up a video conference to discuss the matter and exchange information. As long as there are sufficient doctors available willing to do this, I could get answers to questions in minutes or hours, rather than having to wait for my appointment next week. I would love that. Too many times in my life have symptoms cleared up before I could get in to see my doctor.

    1. There is NO substitute for placing your hands on the patient in most situations.

      It is just another step towards pure “bell curve” medicine by increasingly inferior providers (in general, of course, there are still many fine clinicians) – God help you if you are outside the middle 2 standard deviations, and outliers are almost certainly doomed. With the time limitations and all the other corners cut, there is zero doubt that the standard of care will continue to diminish, even more than it already has.

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  11. The pandemic changed the way we will interact with HCPs for all time. There is no going back. Telehealth is here to stay.

    I have had an emergency telehealth visits (epileptic family member having seizures), and a couple of other routine telehealth visits during this pandemic. It really depends on your circumstance. But I definitely want the option, as a patient. In case you were wondering, the emergency worked out Ok.

  12. In no way am I against telehealth – properly applied, it can be a valuable resource.

    It is the impetus behind it leading to overuse, inappropriate use, and the reduction in the standard of care that concerns me.

    Think of it this way: I offer to take you out for an expensive dinner, which is a nice thing to do. You think I am a nice guy and genuinely interested in you as a person. Halfway through the dinner, I begin to pitch you on some MLM scheme.

    Is buying someone dinner a bad thing? Heck no. Did I do it for altruistic or self-serving reasons? Clearly the latter. And that makes all the difference in the world.

    In medicine, more than almost anything in the world, the impetus behind any action MUST be the patient’s best interest. When that is contaminated by profit motive it can change the entire dynamic.

    Keep in mind, doctor salaries, adjusted for inflation, are flat or even down. C-suite executive salaries at organizations dispensing medical care have skyrocketed.

    And lastly, the term “health care” as used in the media and politics is bullshit. Health care is something you do for yourself, like eating better, exercising, de-stressing, getting enough sleep, etc. Nobody else can care for your health except you – they can only provide “sick care” or medical care.

  13. I’m confused. The majority of the changes sans the licensing which is a state by state issue have been added to the regs that are being currentky reviewed for adoption for CY21. It’s in the comment period, but it seems pretty certain that most of the expansions will be adopted. Go to CMS.gov and look up the article on the physician fee schedule. Now these will probably be adopted. Whether they are only for 2021 or will continue depend on who wins in November.

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