AHA Comments on Ensuring Medicare Beneficiary Access to Telehealth Services and Ensuring Stability for Providers

Re: Subcommittee on Health Care Hearing on Ensuring Medicare Beneficiary Access: A Path to Telehealth Permanency

Dear Chairman Cardin, Ranking Member Daines, Chairman Wyden and Ranking Member Crapo:

On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, and our clinician partners, including more than 270,000 affiliated physicians, 2 million nurses and other caregivers, the American Hospital Association (AHA) appreciates the opportunity to comment on ensuring Medicare beneficiary access to telehealth services and ensuring stability for providers.

At the outset of the COVID-19 pandemic, the federal government moved quickly to ensure hospitals and health systems were able to respond efficiently and effectively to a wave of unprecedented need. The Centers for Medicare & Medicaid Services waived certain regulatory requirements and Congress provided significant legislative support to ensure hospitals and health systems could manage the numerous challenges facing them, including by increased virtual care options. These swift actions provided hospitals and health systems with critical flexibilities to care for patients during what has been a prolonged and unpredictable pandemic.

We greatly appreciate the committee’s focus on this critical issue and the extension of the key telehealth flexibilities through Dec. 31, 2024:

• Expanding originating site to include any site at which the patient is located, including the patient’s home;
• Expanding eligible practitioners to furnish telehealth services to include occupational therapist, physical therapist, speech-language pathologist and audiologist;
• Extending the ability for federally qualified health centers (FQHCs) and rural health clinics (RHCs) to furnish telehealth services;
• Delaying the six-month in-person requirement for mental health services furnished through telehealth, including the in-person requirements for FQHCs and RHCs;
• Extending coverage and payment for audio-only telehealth services; and
• Extending the ability to use telehealth services to meet the face-to-face recertification requirement for hospice care.

We urge Congress to make these waivers permanent to ensure continued access to telehealth services for Medicare beneficiaries.

CONNECT for Health Act

The AHA supports the CONNECT for Health Act of 2023 (S. 2016/H.R. 4189), comprehensive legislation addressing many of these waivers. Patients across geographies and settings, including both rural and urban areas, have benefited from increased access and improved convenience provided by telehealth services. Specifically, we strongly support the provision in the legislation which would permanently remove the geographic restrictions that currently limit where patients can access telehealth services and would add homes and other clinically appropriate sites as eligible originating site locations. We would encourage consideration of simply eliminating originating site restrictions altogether. Doing so would ensure that all Medicare beneficiaries can access services regardless of where they and their providers are physically located.

Behavioral health is one specialty area that has seen sustained growth in telehealth utilization. In fact, prior to the pandemic, telehealth visits accounted for less than 1% of behavioral health visits. During the pandemic, they peaked at about 40% of all behavioral health visits and have been sustained at around 36%.¹ Geographically dispersed patients have benefited from increased access to behavioral health services provided through telehealth, especially in areas that may have provider shortages and in-person visits are not possible. As a result, we appreciate the proposed removal of the requirements that a patient must receive an in-person evaluation six months before they can initiate behavioral telehealth treatment and also must have an in-person visit annually thereafter.

Additionally, the AHA supports allowing rural health clinics and federally qualified health centers to serve as distant sites, so that these facilities may use the providers at their own sites to offer care to patients, ensuring patients remain connected to their primary providers. The AHA also supports allowing critical access hospitals (CAHs) the same ability to offer and bill for telehealth services and would encourage consideration of adding language to include CAHs as eligible distant sites.

We also appreciate the ability to waive restrictions on the use of telehealth during national and public health emergencies (PHE) and support improving Medicare’s process for coverage of telehealth services given the positive impact of improving patient’s access to care.

Continuing Payment and Coverage for Audio-only Telehealth Services

We also urge the committee to consider support for audio-only telehealth services. Virtual care represents a spectrum of ways that telecommunications technologies can be used in care delivery, from synchronous real-time video visits to audio-only phone visits to remote monitoring of patient vitals. Prior to the pandemic, most payers, including Medicare, required that telehealth be performed using real-time audio-visual technologies. However, COVID-19 PHE waivers allowing coverage of audio-only services provided a needed access point for patients who had bandwidth constraints, lacked data plans or devices to support video-based visits, or who otherwise were not able to participate in audio-visual encounters. Indeed, a recent report from the Office of the Assistant Secretary for Planning and Evaluation reviewing Census Bureau data from 2021 found that there were differences in utilization of audio-visual versus audio-only visits across different demographic subgroups like age, income level, race, insurance coverage and education level. For example, the majority of surveyed respondents 65 and older used audio-only visits (56.5%) compared to video visits, partly driven by the fact that over 26% of Medicare beneficiaries reported not having computer or smartphone access at home.² Continued coverage and reimbursement for audio-only services will ensure that patients without access to technology are still able to access care where clinically appropriate. Therefore, we would encourage the explicit addition of Medicare coverage and payment for audio-only services in statute.

Removing Unnecessary Barriers to Licensure

Prior to the pandemic, many states required that out-of-state providers delivering telehealth have a license in the state where the patient was located. However, COVID-19 PHE waivers allowing licensure flexibilities including abbreviated applications and reciprocity arrangements enabled provision of care across state lines more easily. In addition, licensure compacts, although established prior to the pandemic, have grown, in part to streamlined licensure, facilitate provision of care across state lines (especially for telehealth) and reduce financial burden to the extent possible. Indeed, reducing barriers to licensure can help maximize limited provider capacity, particularly in areas where there are shortages. The AHA supports efforts to ensure that licensure processes are streamlined for providers employed by hospitals and health systems operating across state lines and encourages additional research be done on the feasibility, infrastructure, cost and secondary effects of licensure reform options.³

Hospitals, health systems, providers and patients have seen the benefits and potential for telehealth to increase access and transform care delivery. We appreciate your leadership on this important issue and look forward to working together to ensure telehealth permanency.

Sincerely,

/s/

Stacey Hughes
Executive Vice President

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¹ Telehealth Has Played an Outsized Role Meeting Mental Health Needs During the COVID-19 Pandemic | KFF
² telehealth-hps-ib.pdf (hhs.gov)
³ Telemedicine and Medical Licensure — Potential Paths for Reform | NEJM