Telehealth Access, Value & Equity: COVID-19 and Beyond

Wednesday, July 8, 2020
Telehealth Access, Value & Equity

The COVID-19 pandemic presents complex challenges for the US health care system and social safety net programs. In our latest blog post series, IMPAQ experts bring you timely updates and informed insights on the intersection of COVID-19 and pressing policy issues.

The COVID-19 pandemic has changed countless aspects of our lives, including how we live, work, and receive health care services. Telehealth, once viewed by many as a convenient service, is now an essential component of health care delivery worldwide. As we reach the summer months, it’s important to reflect on where we are now, how we got here, and where we’re likely headed in the months and years to come. With an eye to the future, we must ensure that the move to telehealth facilitates greater access and value in our health care system while also improving health equity.

Before the pandemic, states with policies that incentivized the use of telehealth were well- positioned to recruit and retain providers in rural and underserved areas, reduce emergency department overuse, and increase the overall quality of healthcare delivery. While telehealth is not a novel method of delivering care, its use has skyrocketed during the pandemic.

At the 2020 American Telemedicine Association conference, Kelly Kernan of telehealth company Amwell stated that about 20 percent of in-office visits have been transitioned to telehealth, with a potential increase to 25–30 percent of visits after the pandemic ends. Federal agencies including the Center for Medicare & Medicaid Services (CMS), the Substance Abuse and Mental Health Services Administration (SAMSHA), the Drug Enforcement Agency (DEA), and the Food & Drug Administration (FDA) have accelerated this transition by expanding their telehealth policies for the duration of the public health emergency.

Examples of recent federal telehealth expansion:

  • Payment parity, where providers are compensated for telehealth at the same rate as in-person services, has gained momentum and incentivized adoption among providers.
  • Medicare and many state Medicaid programs have allowed for audio-only, or telephonic, care that meets the needs of patients in areas of poor connectivity or those with limited access to smartphones.
  • Medicare added 85 services to the list of services that can be provided via telehealth.
  • Patients can now receive treatment from an out-of-state provider who is not licensed in their state.

Senate Health, Education, Labor, and Pensions (HELP) committee Chairman Lamar Alexander (R-TN) recently called for the permanent expansion of telehealth services eligible for Medicare and Medicaid reimbursement and for payment to providers for telehealth visits regardless of patient location, noting that “steps should be taken to ensure that the United States does not lose the gains made in telehealth.”

As we acknowledge the tremendous progress over the past few months, how are policies shifting during the pandemic and what must be considered in the creation of effective and equitable telehealth policies going forward? Examining these questions in greater detail will provide a view into how telehealth may continue to evolve.

How common was telehealth before COVID-19?

Lack of clarity in state and federal laws rendered early pre-COVID telehealth policies limited and often ineffective. Medicare laws created payment and coverage barriers that contributed to less than 1 percent of beneficiaries receiving telehealth care. In a survey of private insurance telehealth claims from 2010-2015, the odds of receiving a telehealth visit were 29.8 percent greater in states requiring payment parity between telehealth and in-person appointments than in non-parity states.

Surveys show that nearly half of all physicians in the United States are now using telehealth to treat patients. In 2018, only 18% of physicians used telehealth. This represents a 178% increase.

Commercial fee-for-service payers including Blue Cross Blue Shield of Kansas have previously countered that “[parity] takes away the ability of the insurance companies to be able price accordingly for services provided, while also keeping an eye on how to keep premiums as low as possible for our employer groups and our members who purchase insurance.”

How have payer policies shifted in response to COVID-19?

As CMS has now expanded its Medicare policies to include payment parity, three of the five largest commercial payers in the United States have also shifted their policies for the duration of the pandemic.

However, a lack of uniform action has left some states scrambling to adapt. The President of the Florida Medical Association, Dr. Ronald Giffler, called on the Florida Insurance Commissioner in March to issue a uniform order that would prevent insurers from denying coverage and payment parity for care during the pandemic. Similar parity orders have already been issued in states nationwide. While these actions can incentivize provider adoption and prevent the closure of practices, it is critical for telehealth payment policies to emphasize value-based health care.

What opportunities does telehealth offer for expanding value-based care?

A significant concern with telehealth is the low utilization rates among minority and socioeconomically disadvantaged patient populations. One important measure for consideration is how to address the unique needs of patients with limited-English proficiency. While policymakers should examine policies to increase the supply of language professionals, expanding telehealth can further the opportunities for patients to be connected with providers who speak their language. Telehealth services also provide a unique opportunity to eliminate barriers to in-person care such as finding childcare, potential for lost wages due to work absences, and lack of available transportation.

Surveys show that nearly half of all physicians in the United States are now using telehealth to treat patients. In 2018, only 18% of physicians used telehealth. This represents a 178% increase.

Access to preventive care is another area of importance when considering the expansion of telehealth services. A 2016 study in Houston, TX found that patients triaged via telehealth to determine if an emergency department visit was necessary resulted in a $928,000 annual cost savings. Other modalities including remote patient monitoring (RPM) can equip patients with tools to evaluate their health and manage chronic conditions without requiring an in-person appointment. These advancements can enhance patient agency and autonomy while containing costs for health care systems.

Can expanding audio-only coverage promote access to care?

COVID-19 sheds further light on the existing inequities for patients who are older and who live in more rural or poorly connected parts of the country. A recently introduced bill by Rep. Robin Kelly (D-IL-2) aims to analyze the utilization of telehealth services while evaluating disparities and outcomes during the pandemic.

Mandating a video connection for telehealth services can amplify barriers with respect to patients’ age, digital and health literacy, and financial situations. A 2017 telehealth bill proposed by the Montana legislature failed to pass as senators argued that the ban on audio-only consultations would hinder care for more than half of Montanans who lacked sufficient broadband capabilities.

Reliable and affordable broadband internet services are essential for telehealth services, yet an estimated 42 million Americans lack access to wired or fixed internet. A 2019 Pew Research Center report found than more than 90 percent of US adults aged 65+ have cellphones, but less than 40 percent of this population have smartphones with video capabilities. 

Telehealth can help eliminate barriers to in-person care, such as:

Given the slow progression of viable broadband expansion, audio-only coverage is necessary to provide care for low-income and underserved patients. Fortunately, many state insurance commissioners have allowed temporary reimbursement and coverage parity for audio-only telehealth services. Innovations in the private sector also have the potential to improve access for patients.

Forging ahead, policymakers should take deliberate steps to ensure telehealth policies address the unique challenges faced by vulnerable populations. Experts at IMPAQ and AIR can provide extensive experience to assist state and federal policymakers in addressing the intersecting issues of telehealth, equity, access, and value based care.

Continue the Conversation on Telehealth Access & Equity at our Upcoming Webinar

Join IMPAQ President Dr. Adaeze Enekwechi as she leads a conversation with nationally recognized experts on how payers, providers, and policymakers can use telehealth to advance health equity. The free webinar will take place on July 16, 1-2pm. Register now.


Stevland Sonnier, Research Intern, IMPAQ Health
Dr. Brandy Farrar, Principal Research Associate, IMPAQ Health
Kevin Van Dyke, Managing Director, IMPAQ Health
Dr. Yael Harris, Vice President, Research and Evaluation, American Institutes for Research