NCHR Letter to Senate Finance Committee on Telehealth Legislation

August 22, 2022

The Honorable Ron Wyden
Chairman
Senate Finance Committee
Washington, DC 20515

The Honorable Mike Crapo
Ranking Member
Senate Finance Committee
Washington, DC 20515

Dear Chairman Wyden and Ranking Member Crapo:

We write today on behalf of the National Center for Health Research (NCHR), a nonprofit think tank that conducts, analyzes, and scrutinizes research on a range of health issues. We focus on evidence-based policymaking to ensure medical products are safe and effective for patients and consumers.

We are writing to express our support for the Advancing Telehealth Beyond COVID-19 Act (H.R. 4040) which would expand access to telehealth services for millions of older Americans. The bill passed in the House of Representatives on July 27, and we urge you and your Senate Finance Committee colleagues to build on the foundation of H.R. 4040 and introduce legislation that ensures these important services remain available, while improving the bill. H.R. 4040 greatly improves access to telehealth, but it does not address the numerous known barriers, such as internet connectivity and digital literacy, which limit use for many older Americans. Additionally, although research has demonstrated that patient and physician satisfaction with telehealth remains high, questions remain around the efficacy for improving long-term health outcomes. Below we have detailed our overall support for H.R. 4040, highlighted specific provisions (i.e., originating site, audio-only, etc.), and provided additional recommendations for consideration in future legislation.

  1. Quickly introduce companion legislation to H.R. 4040.

As you know, Congress authorized flexibilities for Medicare under the Coronavirus Preparedness and Response Supplemental Appropriations Act (H.R. 6074) to cover telehealth services during the COVID-19 public health emergency. It is essential these flexibilities be extended to allow continued access for beneficiaries. There is a large body of research that indicates the benefits of telehealth for various services. Studies comparing telehealth appointments across specialties versus in-person visits have demonstrated that patient experience is comparable.1 Extension of telehealth flexibilities is essential to meet the growing need for a variety of healthcare services. We strongly suggest that companion legislation be introduced quickly to extend the flexibilities addressed in H.R. 4040 that allowed telehealth to prosper during the COVID-19 pandemic.

  1. Extend waivers of geographic telehealth restrictions and expand originating sites.

We support efforts in H.R. 4040 to extend the waiver of geographic telehealth restrictions and expand originating sites. As a result of these flexibilities, most Medicare beneficiaries (92%) received telehealth visits from their home in 2020.2 In a systematic review evaluating thousands of research citations, home telehealth was shown to be feasible and acceptable across different populations of older adults (average age 65) with various physical and mental co-morbidities.3 This study also recommended routine use of home telehealth to reduce travel barriers.3 We support the continued use of this waiver and expansion of site requirements to promote greater access to healthcare.

  1. Expand Medicare coverage of audio-only telehealth services.

We also support the provision in H.R. 4040 to expand Medicare coverage of audio-only telehealth services and strongly recommend inclusion in future legislation. Audio-only telehealth is an essential measure to expand access to healthcare for rural patients without the ability to travel to a healthcare facility and without reliable access to internet connectivity. More than 40% of the Medicare population lacks access to devices with wireless internet, often making audio-only telehealth the only alternative to in-person care.4 In addition, research has shown that older adults are more likely to engage in audio-only rather than video appointments, particularly due to barriers such as digital literacy and the cost of technology.5,6 Expanding coverage for audio-only telehealth allows seniors in rural communities without reliable internet access to receive care.

  1. Provide funding to reduce barriers to telehealth.

As mentioned above, H.R. 4040 aims to improve access with audio-only coverage but fails to address the barriers to telehealth access. We recommend appropriations be included to create long-term solutions such as addressing rural internet connectivity and digital literacy. Beneficiaries should not be limited to audio-only telehealth when video-based appointments better match their preferences and required level of care. Additionally, there is minimal research evaluating the clinical effectiveness of audio-only telehealth compared to video telehealth across different healthcare services. Existing research suggests that audio appointments are shorter, result in fewer diagnoses, and generate lower patient satisfaction and comprehension rates than video visits.7 While audio-only coverage offers a short-term solution for individuals who could not access healthcare otherwise, it may perpetuate health inequities in the long-term if only certain populations have access.8 We recommend funding for broadband expansion be included in companion legislation. Further, digital literacy perpetuates equity issues in telehealth, as seniors make up approximately 33% of the 32 million Americans that are digitally illiterate; Black and Hispanic, low-income individuals, and people without a college education are also populations that are disproportionately affected by digital illiteracy.9 These groups already experience worse overall health compared to others. Funding toward digital literacy must be included to provide technical assistance for Medicare beneficiaries.10

  1. Expand programs to evaluate the impact of telehealth services on health outcomes.

Finally, we recommend any future legislation address the gaps in research surrounding the impact of telehealth services on costs and health outcomes of Medicare beneficiaries. The Medicare Payment Advisory Commission (MedPAC) recommends continued coverage for telehealth expansion under conditions including the potential clinical benefit of selected services.11 However, few research studies have evaluated the impact of telehealth on health outcomes. One program, the Community Health Access and Rural Transformation (CHART) Model, which is currently being tested by the Center for Medicare and Medicaid Innovation (CMMI) in four states (Alabama, South Dakota, Texas and Washington), provides the opportunity to evaluate these services based on value rather than volume of telehealth care.12 The CHART Model is a voluntary payment model designed to meet the unique needs of rural communities by including flexibilities such as Medicare telehealth waivers. We recommend Congress expand this type of program to evaluate payment models such as CHART to gain a better understanding of the impact of telehealth services on access to care, quality of care, and health outcomes for vulnerable populations.

Many seniors have come to rely on telehealth care in response the COVID-19 pandemic. We urge you to act quickly to introduce and advance your telehealth legislation building on the strengths of H.R. 4040. We strongly urge that your legislation increase coverage and access to telehealth for the Medicare population, while continuing to address the underlying barriers faced by rural and underserved communities. In addition, funding for research to evaluate the efficacy and quality of these services will help policymakers gain a full understanding of the impact on the overall Medicare population, as well as specific age groups or beneficiaries with specific demographic backgrounds. By working together, you have the opportunity to protect the telehealth flexibilities that have become essential to meet the rising need for healthcare services among the 64 million Medicare beneficiaries.

Please contact the NCHR Health Policy Director, Thomas Eagen (te@center4research.org) with any questions.

Sincerely,

Diana Zuckerman, Ph.D.
President, National Center for Health Research

 

  1. Bilimoria, K., et al. (2021). Comparison of Patient Experience with Telehealth vs. In-Person Visits Before and During the COVID-19 Pandemic. Joint Commission journal on quality and patient safety, 47(8), 533–536. https://doi.org/10.1016/j.jcjq.2021.01.009
  2. Samson, L., et al. (2021) Medicare beneficiaries’ use of telehealth in 2020: trends by beneficiary characteristics and location. Assistant Secretary for Planning and Evaluation. https://aspe.hhs.gov/sites/default/files/documents/a1d5d810fe3433e18b192be42dbf2351/medicare-telehealth-report.pdf
  3. Batsis, J., et al. (2019). Effectiveness of Ambulatory Telemedicine Care in Older Adults: A Systematic Review. Journal of the American Geriatrics Society, 67(8), 1737–1749. https://doi.org/10.1111/jgs.15959
  4. Robeznieks, A., (2020). Why so many patients still can’t connect to doctors via telehealth. American Medical Association. https://www.ama-assn.org/practice-management/digital/why-so-many-patients-still-can-t-connect-doctors-telehealth#
  5. Li, H., et al.(2021). Transition of Mental Health Service Delivery to Telepsychiatry in Response to COVID-19: A Literature Review. Psychiatric Quarterly. Jun 8:1-7.
  6. Kruse, C., et al. (2020) Utilization barriers and medical outcomes commensurate with the use of telehealth among older adults: systematic review. JMIR Medical Informatics. 8(8):e20359.
  7. Benjenk, I., et al. (2021). Disparities in Audio-only Telemedicine Use Among Medicare Beneficiaries During the Coronavirus Disease 2019 Pandemic. Medical Care: November 2021 – Volume 59 – Issue 11 – p 1014-1022 doi: 10.1097/MLR.0000000000001631
  8. Uscher-Pines, L., & Schulson, L. (2021). Rethinking the Impact of Audio-only Visits on Health Equity. RAND Corporation. https://www.rand.org/blog/2021/12/rethinking-the-impact-of-audio-only-visits-on-health.html
  9. Improving Digital Literacy to Improve Telehealth Equity. (2021). Telehealth Equity Coalition. https://www.telehealthequitycoalition.org/improving-digital-literacy-to-improve-telehealth-equity.html
  10. Zhai, Y. (2021). A Call for Addressing Barriers to Telemedicine: Health Disparities during the COVID-19 Pandemic. Psychotherapy and psychosomatics, 90(1), 64–66. https://doi.org/10.1159/000509000
  11. Winter, A., et al. (2021). Telehealth: Updates on use, beneficiary and clinician experiences, and other topics of interest. Medicare Payment Advisory Commission. https://www.medpac.gov/wp-content/uploads/2021/09/Telehealth-MedPAC-Nov-2021.pdf
  12. Community Health Access and Rural Transformation (CHART) Model Fact Sheet. (2020). Centers for Medicare and Medicaid Services. https://www.cms.gov/newsroom/fact-sheets/community-health-access-and-rural-transformation-chart-model-fact-sheet