key: cord-302513-u9n56pnb
authors: Breitinger, Scott; Gentry, Melanie T.; Hilty, Donald M.
title: Key Opportunities for the COVID-19 Response to Create a Path to Sustainable Telemedicine Services
date: 2020-10-01
journal: Mayo Clin Proc
DOI: 10.1016/j.mayocp.2020.09.034
sha: 
doc_id: 302513
cord_uid: u9n56pnb

nan

"There have been as many plagues as wars in history; yet always plagues and wars take people equally by surprise," wrote Albert Camus in his 1947 novel, The Plague. 1 The current coronavirus pandemic is sweeping through every continent, leaving health care systems scrambling to screen, diagnose, and treat COVID-19 patients -and to deal with the public health repercussions secondary to social distancing. Worsening morbidity and mortality related to behavioral health and substance abuse are ubiquitous sequalae to epidemics and disasters, and COVID-19 has unsurprisingly demonstrated the same pattern. 2 In March 2020, federal and state agencies implemented rapid regulatory changes to expand and enhance the use of telehealth for those affected by COVID-19. This included:

• Temporary easing of telehealth restrictions for Medicare beneficiaries,

• Reimbursing providers at the same rate as in-person consultations for video with acceptable reimbursement mechanisms for telephone and text communications as well,

• Many states providing waivers for out-of-state practitioners, and

• Temporary easing of controlled substance prescribing limitations as defined by the Ryan Haight Online Pharmacy Consumer Protection Act.

There is a deep resonance with Camus' observation regarding the predictability with which pandemics take civilizations by surprise. The COVID-19 pandemic has exposed and amplified systemic deficits in health care systems' ability to manage the secondary J o u r n a l P r e -p r o o f Breitinger 3 health effects of psychosocial isolation, economic strain, and cultural turmoil. Obsolete regulations of telemedicine that have been temporarily modified demonstrate opportunities for policymakers to transform temporary successes into permanent adaptations.

During the COVID-19 era, telemedicine has been an essential method to ensure the continuation of health care services while allowing for social distancing and reducing rates of COVID-19 transmission. Studies show rates of telemedicine increasing upwards of 6-to 7-fold during the COVID-19 era. 3 The expansion of video-based care has been an effective means of seeking care for many patients. 3, 4 However, many other patients have been left behind in this rapid switch to video-based carepotentially worsening health care inequities -particularly for those without access totechnology. Some systems (e.g., Mayo Clinic, Veterans Health Administration) have patients go to a care facility in the system to use equipment, and other countries direct patients to use equipment in malls or libraries, while this is less common in the United States. This disparity in access has made telephone visits an equally important component of the recent telehealth expansion. 4 Telemedicine is an important tool to expand care delivery, though it may not be applicable in every health care setting or clinical scenario. Telemedicine has been shown to be effective with similar clinical outcomes and high levels of patient satisfaction across diverse areas of health care including psychiatry, cardiac rehabilitation, and orthopedics. 5 Some aspects of care may require help from in-person clinicians for parts of the physical examination or a medical intervention to effectively evaluate and manage patients, particularly for urgent or emergent situations. 5 Consumer demand for telehealth services has long outpaced the implementation of such programs within health care organizations. The COVID-19 pandemic has led to rapidly increasing demand for such services. With the increased exposure and comfort with virtual health care amongst patients and providers, the demand for expanded access to telehealth services is not likely to wane once the pandemic has passed. Importantly, while routine and low intensity telemedicine services can keep financial revenue in rural communities, 5 theoretically revenue could be redirected from already struggling rural hospitals to larger health care organizations better equipped to make this rapid transition to digital care. In turn, this could reduce the financial sustainability of rural clinical facilities that also provide acute medical care. For this reason, precaution and foresight are essential in both policy and operational planning to ensure financial sustainability of complex care for underserved and rural populations. If telemedicine is to continue as a critical component of health care delivery, the following regulatory hurdles must be addressed.

The Ryan Haight Online Pharmacy Consumer Protection Act has been a longtime barrier to the widespread implementation of tele-mental health services due to its restriction on prescribing controlled medications without a face-to-face office visit. 6 These restrictions were lifted by a federal emergency declaration in January 2020. The 

Telemedicine was introduced as a covered service under the Medicare program in 1997 but maintained significant limitations based on site of service provision and geography. 7 Reimbursement has generally been limited to patients being present at rural originating J o u r n a l P r e -p r o o f Breitinger 6 facilities. These restrictions significantly hamper the ability of health systems to develop and sustain telemedicine interventions for older adults and those with disabilities. 8 Loosening restrictions on telehealth reimbursement under COVID-19 emergency orders has resulted in a dramatic expansion of virtual care, which has allowed for providing crucial medical services to vulnerable patient populations during the COVID-19 pandemic. However, as these are temporary measures, it is unknown which, if any of these waivers will remain in place after the emergent COVID-19 response period.

Going forward, a few things are working and should be continued through the following measures:

• New legislation governing the Centers for Medicare and Medicaid could extend temporary waivers to support telehealth including expanding the types of covered providers, types of covered services, and importantly, removing restrictions on patient and provider location for telehealth visits. Going forward, in response to COVID-19:

• Federal legislation could be used to redefine the "place of service." Instead of the site of the patient arbitrarily defined as the virtual place of service, the site of the clinician redefined as the site of care delivery would alleviate the need for providers to have multiple state licenses to practice telemedicine.

• Expansion of the Interstate Medical Licensure Compact to include all states/territories and provide for reduced requirements and fees for telemedicine only licensure. Stakeholders across the country must advocate for their individual states to adopt legislation to participate in this Compact to help make interstate telemedicine practice more ubiquitous.

The expansion of telehealth during the COVID-19 pandemic has allowed many providers and patients to experience better access to effective care. This is a unique opportunity to leverage this increased interest and demand for telehealth in creating permanent regulatory changes to improve the access to health care and to build resilience and capability into the health care system before the next unforeseen but inevitable public health crucible arrives. To maintain the progress made possible by this pandemic, some well-intended regulatory parameters of telehealth could be revised to permit greater freedom for patients, providers, health care systems and states to connect patients' needs with effective health care.

J o u r n a l P r e -p r o o f

The Plague. London: Penguin

The Mental Health Consequences of COVID-19 and Physical Distancing: The Need for Prevention and Early Intervention

COVID-19 transforms health care through telemedicine: evidence from the field

Digital Health Equity and COVID-19: The Innovation Curve Cannot Reinforce the Social Gradient of Health

The effectiveness of telemental health: a 2013 review

Telepsychiatry and the Coronavirus Disease 2019 Pandemic-Current and Future Outcomes of the Rapid Virtualization of Psychiatric Care

The transition from reimagining to recreating health care is now. NEJM Catalyst Innovations in Care Delivery

Geriatric Telepsychiatry: systematic review and policy considerations