The COVID-19 pandemic expedited the use and growth of telehealth and telemedicine[1] throughout the United States by over 4,000 percent.[2] This explosion was due, in part, to the various emergency measures taken in response to the pandemic by the federal and state governments, which effectively loosened or waived various regulatory requirements.[3] As the pandemic began to wane, questions over whether the expansive telehealth regulations would remain or expire sparked debate. Some states introduced bills to make the changes made during the pandemic permanent.[4] Though it now appears a certainty that telehealth will remain a major part of health care in the United States in the post-pandemic world, the question of payment and reimbursement lingers.[5]
Some states have enacted emergency Payment Parity laws that require reimbursement of telehealth visits in the same amount as in-person visits.[6] These laws can vary based on type of health service, patient population, and method of delivery.[7] An interesting point of differentiation is on payment policies for live video and store-and-forward modalities of health services. While every state offers some type of reimbursement for live video health services, less than half of states offer any reimbursement for store-and-forward services[8] and federal law limits store-and-forward to certain projects in Alaska and Hawaii.[9]
Live video is, as its name suggests, a form of telehealth involving real-time online-based audiovisual consults.[10] In contrast, store-and-forward, or asynchronous, telemedicine involves gathering data from the patient through a cloud-based platform to be later analyzed by a provider who then sends the patient a diagnosis and treatment plan.[11]
The benefits of such a modality are strikingly obvious and practical – patients can seek care at more convenient times, providers can better schedule their workload, less time is wasted in transition, and the process can break down language and cultural barriers.[12] However, this mode is not without its limitations: it would not be useful in emergency situations and may diminish the patient-provider relationship to some degree.[13] In terms of efficacy, more research needs to be done on patient outcomes from asynchronous telehealth solutions, but preliminary studies have been promising.[14] Additionally, most health systems and providers that utilize asynchronous telemedicine tend to use it as a supplement to synchronous visits with increasing success.[15] Integrated use of the two technologies is likely the future of telemedicine.
With all these considerations, why don’t some states and the federal government reimburse asynchronous telemedicine? Though preliminary findings are promising, more data on the efficacy of store-and-forward technology is needed. Not only so, but there are real concerns, such as delays in healthcare and treatment, the possibility of miscommunication, the risk of over-reliance on patient reported metrics and data for diagnosis and treatment.[16] There is also the growing concern of increasing fraud and abuse in telehealth, which is only made more readily available to would-be fraudsters in an asynchronous environment.[17]
But in all likelihood, we are probably in the midst of a transition period. More voices are calling for change towards the adoption of asynchronous telehealth. A report by R Street Institute, a public policy research organization, directly calls for increased adoption of asynchronous telehealth reimbursement.[18] There is, also, movement in legislatures towards amending current federal and state telehealth laws to account for this discrepancy in payment and reimburse asynchronous telehealth through Medicaid and Medicare.[19] It seems almost a certainty that asynchronous telehealth will exist in some form, the only matter to be resolved is whether it will be reimbursed at the same rates as in-person or live video visits.
Telemedicine during the pandemic proved to the world that healthcare professionals can provide effective care to patients even when separated in space. It may now also be proving that healthcare is just as effective even when separated in time.
[1] Though telehealth and telemedicine have separate and nuanced definitions, this post will use the two terms interchangeably. The American Medical Association defines telemedicine as “remote clinical services” and telehealth as a broad array of services using various forms of technologies. https://www.ama-assn.org/practice-management/digital/ama-telehealth-quick-guide
[2] https://www.jdsupra.com/legalnews/increases-in-telemedicine-and-use-of-4068147/
[3] Manatt releases updates on the various Federal and State legislative actions taken in response to the COVID-19 pandemic. The full timeline and tracker are available through Manatt on Health. https://www.manatt.com/insights/newsletters/covid-19-update/executive-summary-tracking-telehealth-changes-stat
[4] https://www.nature.com/articles/s41591-021-01447-x
[5] https://www.ama-assn.org/practice-management/digital/telehealth-here-stay-payment-key-future-use
[6] https://www.manatt.com/insights/newsletters/covid-19-update/executive-summary-tracking-telehealth-changes-stat
[7] Id.
[8] https://www.cchpca.org/resources/state-telehealth-laws-and-reimbursement-policies-report-fall-2021/
[9] https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf
[10] https://mhealthintelligence.com/features/store-and-forward-telemedicine-services-expand-connected-health#:~:text=Whereas%20real%2Dtime%20telemedicine%20consists,to%20a%20cloud%2Dbased%20platform.
[11] Id.
[12] Id.
[13] Id.
[14] A study of asynchronous telepsychiatry consultations found no statistically or clinically significant differences in patient outcomes as compared to synchronous telepsychiatry. Both forms of telehealth were shown to have statistically and clinically significant improvement in outcomes. https://www.jmir.org/2021/7/e24047; See also, A meta-analysis of the use of asynchronous telehealth in dermatology found evidence suggesting a potential for shorter wait times, fewer unnecessary referrals, higher patient satisfaction, and equal (or better) accuracy. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2765770/
[15] https://mhealthintelligence.com/features/store-and-forward-telemedicine-services-expand-connected-health
[16] https://www.aaha.org/aaha-guidelines/telehealth-guidelines/considerations-for-choosing-technology/asynchronous-vs.-synchronous/
[17] https://news.bloomberglaw.com/health-law-and-business/bills-to-avoid-telehealth-cliff-delayed-by-higher-priorities
[18] https://www.rstreet.org/wp-content/uploads/2021/11/RSTREET245.pdf
[19] The Rural Telehealth Expansion Act, introduced earlier this year, would expand Medicare coverage for asynchronous telehealth programs throughout the country. https://mhealthintelligence.com/news/new-bill-seeks-nationwide-medicare-coverage-for-asynchronous-telehealth-services ; See also, https://www.discoursemagazine.com/economics/2021/05/20/telehealth-and-the-asynchronous-revolution/