Telemedicine Can Change Care for the Better — With the Right Rules

Mehrotra is among the policymakers, doctors, and researchers working to find the best path forward. They’re doing so by figuring out how to make sure patients can continue to reap the benefits of telemedicine and other forms of remotely delivered health care without increasing spending, lowering quality, or threatening the crucial role that in-person care still plays.

Adapting to change

Telemedicine use skyrocketed during the shutdowns and surges of the early part of the COVID-19 emergency in the United States, as both government and private insurers created more flexible rules about the kinds of health care people could access from their homes or mobile devices. Although less so than at the peak of the outbreak, patients and clinicians want it to remain an option in care.

Technological advances, evolving patient and physician preferences, new laws, and changes to business models and the way people work have also contributed to demand for bringing health care to people where they live.

With that demand has come questions about the best uses and best practices for telemedicine and what the future of care delivery in the U.S. should look like.

A growing body of evidence shows that telemedicine is a good option for many patients and in many situations, said Mehrotra. And some of the Medicare and Medicaid policy changes that facilitated telemedicine during the early days of the pandemic have already been made permanent.

But more answers are needed, and soon. Some of the other Medicare and Medicaid policies allowing telemedicine are set to expire in December 2024. For example, Mehrotra notes that starting in January 2025 patients will be asked to have an in-person visit before a telemental health visit, some payment rates for remote care will be cut, and the “hospital at home” program that allows some patients to receive hospital-level acute care in their homes will no longer be an option.

Mehrotra and others have been gathering data to help policymakers, healthcare administrators, practice managers and other key players answer questions such as:

• Whether Congress should continue telemedicine access for patients within Medicare.
• How in-person practices can compete with remote-only caregivers.
• Who can access remote care and from where.

Along the way, it’s important to make sure policymakers prioritize high-value care — the kinds of care that bring the most benefit at the lowest additional cost — and pay close attention to how it fits into the big picture of health care going forward, Mehrotra said.

Medicare telehealth services

For Medicare and Medicare, the decision about whether to extinguish, extend, or amend telemedicine access is mostly about finding the right balance between costs and benefits, Mehrotra said.

Part of finding this balance is to consider whether telemedicine during the COVID-19 era made it too easy to see the doctor, so patients had more visits, thus raising spending and taxing an already overburdened health care system and whether telemedicine has helped or hurt the quality of patient care.

Mehrotra’s latest in a string of studies on the impact of telemedicine, published April 17 online ahead of print in the May issue of Health Affairs, compared Medicare patients in the health systems that have had the biggest increases in telemedicine use since the early pandemic with those that had the smallest increases.

The research represents the first system-wide analysis of the impact of increased telemedicine use at a national scale, the authors said.

The findings suggest that the temporary rules put in place to facilitate remote access to health care should be made permanent.

Cost-benefit analysis for U.S. health systems

The team found that in 2021 and 2022, patients in the high-use systems had 2.2 percent more visits per year (telemedicine and in person) but 2.7 percent fewer non-COVID-19 emergency department visits. Patients in the high-use systems also spent 1.6 percent more ($248 per patient) but were more likely to take their prescribed medications for chronic diseases such as diabetes and heart disease. There were no clear differences in hospitalizations or preventive care.

The findings reinforce studies by Mehrotra and colleagues at HMS and elsewhere that focused on care for specific conditions, such as telemedicine for mental health, and on specific groups of people, including research on telemedicine in pediatrics during the pandemic and how telemedicine changed the quality of care for people in rural communities.

Across these studies, and many more by other researchers, greater use of telemedicine improved patient access by number of visits and continuity of care with a modest increase in spending.

“Based on what we’ve learned about the ways telemedicine has improved access to care at relatively low cost, it makes sense to make these changes permanent,” Mehrotra said.

Over the past six months, Mehrotra presented some of these findings and policy recommendations to the U.S. Senate and testified on telehealth before the U.S. House of Representatives. Based on available evidence, Mehrotra recommended that Congress permanently expand Medicare access to video visits for all patients, for all conditions.

Protecting in-person practices, preserving access to care

In his testimony, Mehrotra recommended that Medicare pay providers for telehealth visits at a lower rate than for in-person visits. This would help in-person practices remain competitive with telemedicine-only providers who have lower operating costs.

If no additional Congressional action is taken, starting in January 2025, a patient and a care provider must have met in person at least once before they can have a telemedicine visit for mental health, Mehrotra noted. He suggested that the new rules instead permanently remove such in-person visit requirements for mental health telemedicine appointments.

“In-person visits might not work for a lot of patients,” Mehrotra said in an interview. “For one thing, many clinicians don't have a physical practice anymore — something like 12 percent of mental health providers have gone virtual-only since 2020.”

Fixing the rules set to go into effect in 2025 could help patients with Medicare or Medicaid, but for people with private insurance, telemedicine regulations vary state by state. Many state regulations and private insurers follow the patterns set by federal regulation, but in some cases, additional work might be required to ensure patient access to telemedicine and protect in-person clinics.

Telemedicine care across state lines

Things can also get tricky when patients and doctors find themselves in different states.

Most current rules require that a provider be licensed to practice medicine in the state where their telemedicine patient is located. That means most patients who have a medical issue while out of state for business or vacation can’t have a telehealth visit with their regular doctor.

For patients with serious illnesses who seek care from specialists out of state, telemedicine rules can sometimes lead down a Kafkaesque path.

In 2021 Mehrotra wrote about Maki Inada, a biology professor at Ithaca College in New York, who was being treated for lung cancer by a team of specialists in Boston. When the care began, during the height of the COVID outbreak, she was able to have follow-up visits by video conference from home. But the regulations changed, and she learned that she would have to be physically present in Massachusetts to have a telemedicine visit.

The hospital told her she didn’t need to drive to Boston — she could “just” drive three and a half hours to the border and have a telemedicine visit from her car on the side of the road.

“Telemedicine has a lot of potential to make lives easier, to reduce strain on patients and the health system, and to enhance the long-term relationships between patients and providers that are so important for delivering high-value, high-quality care. That’s obviously not happening in cases like this,” Mehrotra said. “We need to make sure that the rules and regulations let patients get the best care possible from these new tools.”

Mehrotra and colleagues also found, in a 2022 paper published in JAMA Health Forum, that restrictions on out-of-state telemedicine may disrupt existing patient-clinician relationships in primary care and mental health treatment.

Mehrotra suggested that Congress consider passing federal laws that make it possible for doctors to see patients via telemedicine across state lines when they have an existing relationship, no matter which U.S. state the patient or provider is in.

New ways of practicing medicine

The even bigger challenge, Mehrotra said, is that the way doctors practice medicine is changing.

Most policies about telemedicine focus on video and audio conferences that are facsimiles of traditional patient visits to the doctor’s office. But there are new ideas — and with them, new questions, he said.

Suppose a student starts college out of state and has a follow-up question for their doctor back home about an issue they had at the end of the summer.

“If they send a message to their physician through the health care portal, can the doctor respond?” Mehrotra asked. “Technically, that medical communication might be considered practicing medicine, and right now that’s not allowed across state lines.”

The rules should be clarified and modernized to allow doctors and patients to make the best possible use of all the ways that care can be delivered long-distance, Mehrotra said, noting that these changes should also include fair ways of charging for services like answering emails.

There are also new technologies that gather medical data and send a report directly to the doctor’s office. If a patient’s pacemaker sends alarming heart rate data or their blood glucose monitor signals that medication needs tweaking while the patient is on a business trip, can their cardiologist or endocrinologist send an alert?

“It’s challenging to navigate all of the technological advances in the last decade or two that have slowly been changing how we define the practice of medicine,” Mehrotra said. “But it’s worth figuring out how to do it right, because there’s so much promise in these innovations to help patients and health care providers.”