Controversies are raging about the continuation of telehealth services and particularly telehealth reimbursement. Areas of contention about the future of telehealth as the nation starts to emerge from COVID include Medicare telehealth, Medicaid telehealth, telehealth licensure, and related telehealth regulations. Given the amount of information gathered about the pros and cons of telehealth, a variety of companies are publishing reports and white papers related to the data collected since the start of COVID.
For example, a recent Kaiser Family Foundation study of 15 million Medicare beneficiaries used telehealth services during the pandemic. It reported that more than 50% of persons polled who accessed telehealth services are under age 65, have a long-term disability, have six or more chronic conditions, and/ or are Black or Hispanic. The study also reported details of the sessions delivered, including telephone telehealth. Interestingly, 56% of all Medicare beneficiaries using telehealth accessed their provider by telephone:
- 65% were aged 75+
- 61% were Hispanic
- 65% live in rural areas
- 67% were dual-eligible beneficiaries
However, continuing audio-only telehealth visits is currently being evaluated and has stirred a notable controversy in Congress about continuing coverage by Medicare when the public health emergency (PHE) ends. See Controversy about Eliminating Telephone Telehealth Coverage for details. Many groups are lobbying to continue Medicare reimbursement, considering the above statistics, showing that elderly beneficiaries, people of color, and those living in rural areas have been the majority of telehealth users. Further, fewer than half of Black and Hispanic beneficiaries own a computer, thereby limiting their access to telehealth if audio-only visits are no longer permitted. US legislators are keenly focused on such studies as they propose a number of changes to telehealth legislation, telehealth regulations, and telehealth reimbursement. A quick overview of the status of the current progress is below.
Government Accounting Office Wary of Expanding Telehealth
Contrary to the 43 bills that have been tallied by the Alliance for Connected Care as introduced in Congress to make current telehealth changes permanent, the Government Accounting Office (GAO) advised Congress to suspend the expansion of telehealth coverage beyond the PHE. Rather, the GAO has suggested that more evidence be collected to prove that telehealth services are cost-effective, equitable, and produce positive health results. See Risks & Benefits of Telehealth: Controversy about Post-Pandemic Telehealth for more information.
Massive Congressional Support for Expansion of Telehealth Services
In addition, Rep. Liz Cheney and Rep. Debbie Dingle introduced a new bill supporting the codification of the temporary changes made during the pandemic: Advancing Telehealth Beyond COVID-19 Act of 2021. The bill endeavors to continue to allow the sick, rural, and senior citizen populations to use technology to access their healthcare providers, thereby reducing exposure to other sick patients, avoiding long travel, and reducing wait times. The bill has the support of The American Medical Association, The Wyoming Hospital Association, and The Wyoming Primary Care Association.
A remarkable number of bills are being argued across the land. The Alliance for Connected Care, a non-profit dedicated to improving legislative action is currently tracking 43 bills that include significant telehealth or remote monitoring provisions introduced during the PHE related to COVID-19.
Further, the Mental Health Access Improvement Act was introduced by Senator Mike Thompson and Representative Mike Kato to allow counselors to serve Medicare beneficiaries, thereby creating greater access to treatment for beneficiaries. This bill is not the first of its kind over the last several decades, but counselors and marriage and family therapists have a great chance of being accepted as Medicare providers due to the dramatic incidence of mental health problem sparked by the stresses cuased by the COVID pandemic.
Health and Human Services Support for Telehealth Expansion
Health and Human Services (HHS) Secretary Xavier Becerra has repeatedly commented that he is supportive of telehealth, including a focus on disparities. For more on telehealth disparities see Telehealth and Health Disparities. For more information on Secretary Becerra’s views on the expansion of telehealth see Secretary of HHS Becerra & Telehealth.
Telehealth Services & Professional Licensure Rules
To increase access to care during the pandemic, professional licensure rules were relaxed to allow professionals to provide care across state lines. Concerns are being raised by the American Medical Association (AMA) and HHS regarding difficulties that could arise when trying to hold an out-of-state provider accountable for services that were not appropriately provided. AMA President-Elect Jack Resneck, Jr., MD does not want to see these rules made permanent, feeling that the purpose of state licensure is to give states the power to hold professionals accountable for services they provide. For more information regarding professional licensure requirements post PHE see COVID-19 Telehealth Licensure Across State Lines – Bill Reintroduced.
Psychologists on the other hand, are benefiting from the foresight exercised by their regulatory association, the Association of State and Provincial Psychology Boards (ASPPB), which obtained over a million dollars in grants from the Office for the Advancement of Telehealth to study and develop their licensure portability model. Known as the ASPPB PSYPACT, the model has grown considerably since the beginning of the PHE. The PSYPACT is an interstate compact designed to allow licensed psychologists to practice telepsychology and conduct the temporary in-person face-to-face practice of psychology across state boundaries legally and ethically without necessitating that an individual becomes licensed in every state to practice. See https://telehealth.org/oklahoma-psypact/ for a recent update
The roster of enacted and effective PSYPACT states is impressive:
- Arizona – AZ HB 2503 (Enacted on 5/17/2016)
- Colorado – CO HB 1017 (Enacted 4/12/2018)
- Delaware – DE HB 172 (Enacted 6/27/2019)
- District of Columbia – DC B 145 (Enacted 3/16/2021)
- Georgia – GA HB 26 (Enacted 4/23/2019)
- Illinois – IL HB 1853 (Enacted 8/22/2018)
- Maryland – MD HB 970 (Enacted 5/18/2021)
- Missouri – MO HB 1719/MO SB 660 (Enacted 6/1/2018)
- Nebraska – NE L 1034 (Enacted 4/23/2018)
- Nevada – NV AB 429 (Enacted on 5/26/2017)
- New Hampshire- NH SB 232 (Enacted 7/10/2019)
- North Carolina – NC 361 (Enacted 7/1/2020)
- Oklahoma – OK HB 1057 (Enacted 4/29/2019)
- Pennsylvania – PA SB 67 (Enacted 5/8/2020)
- Tennessee – TN S 161 (Enacted 5/11/2021)
- Texas – TX HB 1501 (Enacted 6/10/2019)
- Utah – UT SB 106 (Enacted on 3/17/2017)
- Virginia – VA SB 760 (Enacted 4/11/2020)
For the states below, PSYPACT has been enacted by the state’s legislators but the PSYPACThas not been formally adopted by the PSYPACT Commission, which is slated to meet in August 2021. PSYPACT authorizations are not yet valid in a state until formally accepted.
- Alabama – AL SB 102 (Enacted 3/18/2021/Becomes Effective June 1, 2021)
- Arkansas – AR HB 1760 (Enacted 4/25/2021/Becomes Effective end of July 2021)
- Kansas – KS SB 170 (Enacted 5/17/2021/Becomes Effective January 1, 2022)
- Kentucky – KY HB 38 (Enacted 3/18/2021/Becomes Effective June 29, 2021)
- Maine – ME HB 631 (Enacted 6/22/2021/Becomes Effective September 21, 2021)
- Minnesota – MN SB 193 (Enacted 5/25/2021/Becomes Effective May 26, 2021)
- Ohio – OH S 2 (Enacted 4/27/2021/Becomes Effective July 26, 2021)
- West Virginia – WV SB 668 (Enacted 4/21/2021/Becomes Effective July 6, 2021)
7 Legal & Ethical Tips
Get the facts. For two decades, practitioners have been left to their own devices to read and extrapolate their state rules and regulations with respect to telemental health, online therapy, e-therapy, distance counseling, telepsychology, telepsychiatry, tele-nursing and now, telebehavioral health. Based on multiple reports issued by the Institute of Medicine in the United States, telebehavioral health competencies are needed to clarify best practices for the clinician who simply wants to know what to do to manage risk and be assured of full legal and ethical compliance.
PLEASE NOTE: the Telebehavioral Health Institute (TBHI) has recently been rebranded and is now known as Telehealth.org
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