Telehealth Policy in 2021: What We Make It

#TelemedNow Twitter Chat Wednesday, February 3 – 8 PM ET Introduction & Welcome: Nathaniel Lacktman (@Lacktman) – Moderator “Telehealth Policy in 2021: What We Make It”

Q1: Should there be a “single” medical license or nationwide reciprocity? Why or why not?

A1 Notable Responses: Jamey Edwards (@JameyEdwards) We should absolutely do a single license. Streamlines licensing process & closes door on issues that might remain from each state managing disparate process which could cause future issues. $$$ can still be divided amongst states based on primary residence. Stacy Hurt (@stacy_hurt) “A national crisis requires a national response.” How else can #patients obtain digital 2nd opinions across state lines? #TelemedNow Matt Sakumoto (@MattSakumoto) No reason why there shouldn't be reciprocity. Unlike state-to-state Laws and the Bar, medicine is medicine across state lines. Also state licenses very $$$ #TelemedNow bloomrhealth (@bloomrhealth) Nationwide because that will help provide access to communities that are not in metro areas #TelemedNow Andrew Watson (@arwmd) I know this is a difficult topic, and @TheFSMB compact has been a real step forward. With that being said, does Covid make this more of an imperative? A national license or some type of telemedicine sharing? #TelemedNow Matt Sakumoto (@MattSakumoto) Great outline rationale and implementation guide from @sacjai #telemednow Ceci Connolly (@CeciConnolly) It’s clear we need to do something to make reciprocity between states easier. Jury still out on single license (folks at @HIA_DC know it’s been discussed for a LONG time), but we need to find a way to make practicing #telemed easier #TelemedNow Judd Hollander (@JuddHollander) Is there any data regarding the number of people who get licensed in one state but turned down in another? Has to be near zero. If they all basically let you in, if you are in good standing somewhere else, it is just about the revenue. #telemednow Aditi Joshi (@draditijoshi) reciprocity. the difference in practice is nil, the amount of money, time in paperwork wastes time and limits how much we can practice. if we really want healthcare without geographical limits then should be single license. #TelemedNow Andrew Watson (@arwmd) And, does this fall under some clause of interstate commerce we have to consider? #TelemedNow I know the states control the standard of care and also can be very creative. Nathaniel Lacktman (@Lacktman) See this discussion from 6 years ago.…ichael Michael Bagel (@MichaelBagel) Virtual care is all about access and convenience. Flexibility on licensure across state lines allows patients more access to physicians working at reasonable hours and more opportunities for virtual care.

@achp members are good examples of how this can work! #TelemedNow Ritu Thamman (@iamritu) iMLC “The compact is the first line of defense against changing the site of practice from where the patient is located to where the physician is located for #TelemedNow ” could usurp state authority to regulate the practice of medicine” This is bloomrhealth (@bloomrhealth) Technology and solutions are extremely scaleable so we can look at a nationwide/global expansion and break the existing century silos #TelemedNow Andrew Watson (@arwmd) Or communities like us in Pittsburgh which are right beside multiple states. I routinely see people from multiple states But I do not have licenses in those states. it always seems a little backwards, and I know there’s a logic behind this. Helen Burstin (@HelenBurstin) #COVID19 burning platform for license reform. Two @JAMAInternalMed articles Jan 13 offered options: 1) National license - difficult, but done by @VeteransHealth 2) Expand (?mandate all states) interstate compact 3) Regulate #TelemedNow as interstate commerce Ami Bhatt (@AmiBhattMD) So here's the thing. We need local practitioners in inner cities and rural areas. Our natioanwide reciprocity needs to account for and be responsible for that human access factor as well. It's an ethical issue… Ritu Thamman (@iamritu) This is (KEY EMOJI). Medicaid expansion saw #TelemedNow expansion & has potential to decrease disparities Ceci Connolly (@CeciConnolly) Yes so this is another way that #telehealth improves access and equity, delivering care to underserved populations Judd Hollander (@JuddHollander) Is there any data regarding the number of people who get licensed in one state but turned down in another? Has to be near zero. If they all basically let you in, if you are in good standing somewhere else, it is just about the revenue. #telemednow Andrew Watson (@arwmd) As you know Judd, the real limitation is the process of getting the license. Pennsylvania isn’t that bad, I hear New Jersey is quite hard. I didn’t find New York to be difficult. It’s also expensive to get the license, and also time consuming to maintain them. Ami Bhatt (@AmiBhattMD) Yes, and attorney generals will want to make sure that large local hospital conglomerates can be held accountable for quality across all areas they serve, for inpatient and outpatient care. #TelemedNow Erin Gillespie (@ErinGillespieMD) Agree! Reciprocity needed for medical licensure to facilitate #TelemedNow. Full article Judd Hollander (@JuddHollander) Its not just the application. I had 11 different sets of fingerprints for my 19 states. Then each state has different CME requirements. It takes work to keep it straight. #TelemedNow Q2 What happens to telehealth when the Public Health Emergency waivers end? A2 Notable Responses: Jamey Edwards (@jameyedwards) PHE Waivers end = longer wait times, decreased access & increased cost for #telemedicine services. Will make it tougher to build #digitalhealth first #healthcare system that meets #patients where they are & improves practice environment for clinician. #telemednow #Telehealth Stacy Hurt (@stacy_hurt) #Telehealth becomes a permanent part of the continuum of the “next normal” of #healthcare for #patients because its use cases have proven instrumental in improving outcomes #TelemedNow Dr. Salim (@dr_salim_MD) we keep flying higher n” higher #telemednow Matt Sakumoto (@MattSakumoto) Access shrinks for patients. With PHE I can see pts in LA, NJ, PA, FL, NY, MO. That goes away as soon as PHE ends. #TelemedNow Ritu Thamman (@iamritu) #TelemedNow is here to stay with or without government support because of consumer demand #TelemedNow is progress; policy shows modest administrative savings could offset the costs of such increases Nathaniel Lacktman (@Lacktman) Here’s what happens to Medicare telehealth when waivers end… Ami Bhatt (@AmiBhattMD) We have to pass legislation to ensure coverage. Otherwise: 1. Patients will be unhappy 2. Access will decline 3. Physicians will be more frustrated 4. We will have lost all the advances in how we think about care provision and return to low quality care #TelemedNow @ACCMass Matt Sakumoto (@MattSakumoto) I'm counting on #PatientAdvocacy to drive and sustain the telemed gains. Right, @stacy_hurt? (and reimbursement, but mostly patient voice) #TelemedNow Aditi Joshi (@draditijoshi) although the demand will continue for certain things. also if we close rural hospital, will become even more issues and need for access. #TelemedNow Ceci Connolly (@CeciConnolly) #Telehealth is here to stay. Washington can definitely foster adoption, but consumers (ie voters) know the value of this tool and it’s only going to grow. #TelemedNow Ritu Thamman (@iamritu) I recently learned that over 800 rural hospitals have closed (40%) and #TelemedNow is needed more than ever. @CMSGov @SeemaCMS did make rural sites eligible originating sites HR133 Andrew Watson (@arwmd) I feel a major challenge will be physicians rebalancing on a limited set of platforms. And, what can we learn operationally from the platforms that were used under the PHE? #TelemedNow are we going to be able to develop a lessons learned from those temporarily used platforms ? Matt Sakumoto (@MattSakumoto) Sounds like there should be levels of rating and functionality for Telehealth Platforms? Based on level of interop, patient/provider ratings, quality, uptime, etc. Judd Hollander (@JuddHollander) What makes you so sure the PHE will end? Only about 30% sarcastic....we dont have a society that is super dedicated to doing the simple things Dave McSwain (@DMcSwainMD) Over/under on July 2022 as the end date? Judd Hollander (@JuddHollander) Thats probably the right place for the Vegas odds. I will take before. Ritu Thamman (@iamritu) I think we will go over into 2022 #TelemedNow Q3 In an increasingly digital world, how much does privacy *actually* matter to patients when choosing health services? A3 Notable Responses: Jamey Edwards (@JameyEdwards) Consumers have traded #privacy for convenience in many industries. In #Healthcare, its is mor aboute keeping medical conditions from becoming public & identity theft. Bigger issue is #healthcare fraud which ironically doesn't directly impact the patient as much. Stacy Hurt (@stacy_hurt) It matters, but it matters a whole lot less in life or death situations. Concerns for privacy take a back seat to quick answers and actions for better outcomes (ie 2nd opinions) As #patients, our job is to survive. It’s the HC system’s job to guard our privacy #TelemedNow Nathaniel Lacktman (@Lacktman) here’s another example of convenience over privacy @jameyedwards… Helen Burstin (@HelenBurstin) We need to ask patients! After pandemic, need to reassess #TelemedNow privacy protection. Recent @JAMA paper suggested "user-friendly approaches” like periodic audits.… Andrew Watson (@arwmd) vs another Q. #TelemedNow - do we know how much privacy was a challenge under the relax #telemedicine platforms that were used? We don’t hear much about data breaches in the last 6 to 9 months regarding healthcare. I could be out of touch here. Nathaniel Lacktman (@Lacktman) I think you’re right, with the exception of using PHI for direct marketing. Nobody likes that. #telemednow Jamey Edwards (@JameyEdwards) agreed. we get enough SPAM as it is. Interesting that even with CANSPAM Act, there is little to no enforcement. Aditi Joshi (@draditijoshi) part of it is already past, we use data and given up some of our security for it in other parts of our life. we probably need to reassess as if we are able to improve outcomes, it might be worth it. #TelemedNow Jamey Edwards (@JameyEdwards) lets be honest, privacy is one of things holding interoperability up too. Doctor's offices still point to #HIPAA as one of the biggest challenges to data portability...May not be true, but its certainly an excuse. Patient should be in control of their data. Andrew Watson (@arwmd) Yes Jamey. And also the consent around their data. #TelemedNow @commons_prjct Has been looking at both the data and the consent. Jamey Edwards (@JameyEdwards) absolutely. If we were to design the system today, patient record would be associated with national identifier. Patient could then grant access to provider giving care. They document and then get out of the record. patient can share data with whomever they choose! Matt Sakumoto (@MattSakumoto) TBH patients are surprised when I *can't* pull up their chart from an outside org. There's an expectation of interop that's not being fulfilled. #TelemedNow #InteropNow Jamey Edwards (@JameyEdwards) #frustration over what is a totally solvable problem. that has nothing to do with Tech, but rather people being willing to share...#telemednow Angela Nguyen (@anguyener1) On a scale of 1-10 with 10 being the most important, I think it should be 11. Health systems are already vulnerable wrt cybersecurity. It shouldn’t be another vector for privacy breaches in our call for digitally connected world. #TelemedNow Erin Gillespie (@ErinGillespieMD) Ain’t that the truth. Let’s fax those records instead... #telemedNow #Interoperability

Q4 Do digital health reimbursement policies influence clinician decision making? How would you make it better? A4 Notable Responses: Andrew Watson (@arwmd) Absolutely !!!!!! #TelemedNow especially in smaller practices, but any business has to make sure the Telemedicine gets reimbursed. A real challenge is #RPM and how to get paid for data interpretation. @nickisnpdx? Can we bill easily for a call center ? Stacy Hurt (@stacy_hurt) I’m saying this as a patient: please reimburse my clinicians what their time is worth both virtually AND in-personally to provide the care and info I need for the appropriate visit I need #TelemedNow Ceci Connolly (@CeciConnolly) Not to put too fine a point on it but, money talks. That’s why it’s critical we continue the push toward value-based care, ESPECIALLY for #telehealth. We can’t let consumers and doctors stay trapped in a system that prioritizes volume over value. #TelemedNow Ritu Thamman (@iamritu) 100 reimbursement is tied to uptake of #TelemedNow Need pay parity If coverage for phone visits goes away, so will telehealth access for many vulnerable pts forcing them to receive in person care during #covid19 data shows how age impacts phone use h/t @chadellimoottil Matt Sakumoto (@MattSakumoto) Commitment (from govt/payors) to reimbursement signals commitment to providers and health systems. Fear of overuse/misuse is misguided, and we should treat pts/providers as adults. (Also fraud happens in in-person clinic, too). #TelemedNow Jamey Edwards (@JameyEdwards) Reimbursement definitely affects choice of venue (in-person vs. telemed), but I hope it doesn't truly drive clinical decision making. I guess we would be naive to think financial incentives don't influence clinical behaviors directly or indirectly. Ami Bhatt (@AmiBhattMD) Important Issue. 1. If we could define value, then we could avoid reimbursement for every tiny step that creates longitudinal care. I'm a bit negative on value propositions these days. 2. Clinical decision making will use the best tools available to care for patients. If a device or platform or method of communication is not supported, clinicians will use what they have available. 3. Therefore, it is up to organizations and #payors to survey and offer what their clinicians need to provide high quality care and include #digitalhealth and #telemedicine as needed (and it is needed!) Helen Burstin (@HelenBurstin) #TelemedNow reimbursement influences systemic issues like willingness to redesign care, but not clinician decisionmaking for patients. Need permanent payment fix to forever embed virtual into care! Ritu Thamman (@iamritu) So tough to define valué universally. It all depends on your point of view #TelemedNow @CircOutcomes Judd Hollander (@JuddHollander) The commitment to reimbursement cannot be for 3 months at a time. Kicking the decision down the road does not allow us to plan for the future, either short or long term #TelemedNow Andrew Watson (@arwmd) I agree that these three month increments are quite painful. It’s hard to build a long-term strategy around them. #TelemedNow Ceci Connolly (@CeciConnolly) This cannot be overstated; must educate policymakers on how many vulnerable Americans do not have Internet or sophisticated video technology #TelemedNow Stacy Hurt (@stacy_hurt) YES PLEASE that part about “embed virtual into care”! I’ve waited for this for 15 years for my #IDD son! Make it so! #TelemedNow Jamey Edwards (@JameyEdwards) So frustrating when hear we are worried people may overconsume #healthcare or #telemedicine. While there are always #hypochondriacs out there, you can't overconsume low acuity preventive care. Early & often will save $$$ vs. resulting chronic & acute episodes later

Q5 What’s your top prediction for telehealth policy in 2021? A5 Notable Responses: Nathaniel Lacktman (@Lacktman) more tech-neutral telehealth laws #asynch @nickisnpdx… Ritu Thamman (@iamritu) pass legislation to keep #TelemedNow @kjercich The Protecting Access to Post-COVID-19 Telehealth Act of 2021 legislation was just introduced by @RepThompson D-Calif Ceci Connolly (@CeciConnolly) Think we can count on new Admin to renew PHE for duration of pandemic. But that may take pressure off Congress to to lock in #telehealth gains of past year (I fear!). Would be a shame since this is terrific bipartisan win #TelemedNow Stacy Hurt (@stacy_hurt) That CMS will continue to fully reimburse #teleheath (including audio-only) visits beyond when the public health emergency ends #SDoH #mentalhealth #patientoptimist #TelemedNow Andrew Watson (@arwmd) I think we will have better clarity on cross state licensing, perhaps a better understanding of permanent payment parity, and fingers crossed about monitoring. In that order. #TelemedNow Ami Bhatt (@AmiBhattMD) √ Favorable changes to HIPAA to encourage data sharing for treatment trying to achieve balance with √ Local consumer laws to protect data privacy Ami Bhatt (@AmiBhattMD) realistically? More temporary waivers Maram Museitif (@MaramMPH) √ Telehealth will continue to expand √ It will address the health disparities and inequities that marginalized communities experience √ It will be highly utilized in FQHC's & √ The best tool to bridge public health with healthcare Sam Lippolis (@Samiamlip) No geographic restrictions and ANYWHERE a patient is standing is an acceptable place of service Helen Burstin (@HelenBurstin) Permanent pay fix and expanded #telehealth reimbursement (your #5 prediction!). It's always harder to take something back. Genie out of the bottle on #TelemedNow! Jamey Edwards (@JameyEdwards) My top prediction is more of waivers put in place for #COVID19 that increased access to care via #telemedicine become permanent. Let's not backslide, but rather seize this opportunity to make some real progress and break down some barriers!

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