63-Fold Increase in Utilization Adds Momentum to Drive to Make Telehealth Access Changes Permanent

When it comes to the future of telehealth, there are three undisputable facts: Fact 1: Unprecedented numbers of Americans tried it during the pandemic. Fact 2: Most of the people that utilized telehealth, including those who firmly opposed the concept before the public health emergency (PHE), liked the experience and want to keep engaging in it. Fact 3: Members of Congress are extremely aware of Facts 1 and 2. When you add it all up, it becomes a question of not if but when and how the temporary changes made to allow telehealth access become permanent.

Telehealth & Medicare: Before the PHE

Like most payors, Medicare has historically been skeptical of telehealth and covered it in only very restricted circumstances. But all of that changed when, starting on January 31, 2020, the US declared a PHE in response to COVID-19. Shortly afterwards, states across the country started implementing statewide shutdown orders and local stay-at-home policies to prevent transmission and provide some relief to hospitals overwhelmed with COVID-19 cases. With patients and providers stuck at home, telehealth represented the only way for patients to receive and providers to furnish health care services. Consequently, the Centers for Medicare and Medicaid Services (CMS) issued emergency waivers temporarily setting aside coverage restrictions and allowing access to telehealth service.

The Spike in Utilization of Medicare Telehealth Services

Predictably, telehealth utilization by Medicare beneficiaries increased. A new government study from the US Department of Health and Human Services (HHS) shows just how exponential that increase was. Comparing Medicare fee-for-service (FFS) data from 2020 to data from 2019, researchers from HHS's Office of the Assistant Secretary for Planning and Evaluation (ASPE) found that the share of Medicare visits conducted through telehealth increased 63-fold, from approximately 840,000 to 52.7 million. The increase in telehealth was greatest in the New England states, including (in approximate order of magnitude):

• Massachusetts and Vermont;
• Rhode Island;
• New Hampshire; and
• Connecticut

On the other end of the spectrum, states with the lowest spikes in 2020 telehealth utilization included:

• Tennessee;
• Nebraska;
• Kansas;
• North Dakota; and
• Wyoming.

Other key findings of the ASPE report:

• Despite the increase in telehealth visits during the pandemic, total utilization of all Medicare FFS Part B clinician visits declined about 11 percent in 2020, as compared to levels in 2019;
• Most beneficiaries (92 percent) received telehealth visits from their homes, which was not permissible in Medicare prior to the pandemic; and
• Prior to the pandemic, telehealth made up less than one percent of visits across all visit specialties but increased in 2020 to eight percent of primary care visits and three percent of specialist visits;
• Behavioral health specialists increased the most with telehealth comprising one-third of total visits (While data limitations preclude clear identification of audio-only telehealth services, up to 70 percent of these telehealth visits during 2020 were potentially reimbursable for audio-only services)

Table 2. Change in Medicare FFS Part B Visits (In-Person and Telehealth) from 2019 to 2020, by Visit Specialty

Part B Visit – By Provider Specialty	Total Change in Part B Visits (In-Person & Telehealth)	Change in In-Person Visits	Change in Telehealth Visits	2020 Telehealth Visits as Proportion of Total Part B Visits
Primary Care	-9.8%	-17.2%	24x	8.3%
Specialty Care	-12.2%	-14.5%	38x	2.6%
Behavioral Health	-10.2%	-43.8%	32x	38.1%

Source: Medicare Beneficiaries’ Use of Telehealth in 2020: Trends by Beneficiary Characteristics and Location, ASPE In terms of demographic patterns, the ASPE report also found that rates of increases in telehealth utilization among Black and rural beneficiaries were lower as compared to White and urban beneficiaries, respectively. Telehealth services were accessed more in urban areas than rural communities.

The Drive to Make Telehealth Changes Permanent

The CMS waivers and relaxation of telehealth coverage rules were supposed to be a temporary expedient that would disappear when the expedient created by the PHE ended. But reverting to the status quo ante pandemic is becoming increasingly problematic. Having gotten a taste of telehealth, the overwhelming majority of patients enjoyed its ease and convenience and do not want to give it up. According to a new public relations campaign launched by 16 health organizations, including the American Hospital Association (AHA) and AARP, two-thirds (66 percent) of US voters have a positive opinion of telehealth, compared with only 14 percent who have a negative view. Nearly three in five voters (61 percent) say they have utilized telehealth services in the past 12 months, according to the survey. “Access to telehealth is vital to Americans’ well-being and quality of life,” noted AHA president and CEO Rick Pollack in a press release. “Without action from Congress, millions of Americans who have come to rely on telehealth services will lose access to the care they value.”

Regulatory & Legislative Response

Making telehealth changes permanent will require action along two pathways: regulatory action and legislation. The temporary lift on Medicare telehealth restrictions is set to end in January. But CMS recently announced that Medicare will continue to pay for mental health visits furnished by Rural Health Clinics and Federally Qualified Health Centers via interactive video-based telehealth, including audio-only telephone calls. Additionally, CMS is eliminating geographic barriers and allowing patients in their homes to access telehealth services for diagnosis, evaluation, and treatment of mental health disorders. Other Medicare services added to the telehealth services list temporarily during the pandemic will remain in place through December 31, 2023, while CMS evaluates whether to permanently add them to the Medicare telehealth services list. On the legislative front, several different bills have been tabled to make the PHE changes permanent and increase access to telehealth, including the massive Creating Opportunities Now for Necessary and Effective Care Technologies for Health Act of 2021, (CONNECT), a long-running bill which was exhumed once more in May.