Note: the Center for Medicare Advocacy issued a version of these principles in last week’s CMA Alert. They have been updated, and are now issued jointly with the Medicare Rights Center.
During the COVID-19 public health emergency, legislative mandates and administrative authorities have allowed the Centers for Medicare & Medicaid Services (CMS) to issue temporary Medicare waivers and rules. Combined, these policies have let beneficiaries receive a wider range of health services from home, from a broader array of providers, and using more types of technology.
Although the country is still in the midst of the COVID-19 crisis, some stakeholders are already pushing to permanently extend many of these new flexibilities. Concurrently, CMS has signaled a willingness to do so through rulemaking, and there is bipartisan support in Congress for legislative action.
We recognize the recent expansion of Medicare-covered telehealth services has helped beneficiaries and their families safely and responsibly obtain needed care during this unprecedented time—likely leading to improved outcomes and reduced transmission of the COVID-19 virus. We applaud these successes and understand the impulse to keep many of the underlying policies in place. However, doing so would risk reflexively locking in an unexamined expansion of services that was developed for and during a crisis. Instead, we urge Congress and the Administration to move forward deliberately. Any policy changes should be directly informed by the current experience with telehealth and made through existing legislative and regulatory processes that allow for public comment and stakeholder input.
We are concerned that without careful study and evaluation concerning the expansions—including the types of services being provided; consumer participation and utilization barriers; changes in program and beneficiary spending; quality measures, including patient satisfaction; as well as impacts on beneficiary health and any disparities—calls for and steps toward permanence are premature. Further, policy decisions made without this critical information could fundamentally change the care delivery landscape for people with Medicare in unanticipated, and potentially unwelcome, ways.
While telehealth’s potential may not yet be fully realized, neither are its pitfalls. An intentional and aware approach to post-pandemic expansion is needed to safeguard and advance beneficiary health and well-being.
The following principles are intended to aid such a process. When making decisions about whether and how to expand Medicare coverage for telehealth, we urge policymakers to:
- Ensure any covered telehealth services are clinically appropriate;
- Ensure that telehealth options supplement, rather than replace, in-person care—and ensure that payment incentives align with this goal;
- Promote behavioral health parity to help address the unmet needs of current and future beneficiaries in both urban and rural settings;
- Ensure that any expansion of telehealth does not exacerbate health, racial, or income disparities, and that actions and expenditures are authorized to meaningfully address the digital divide many Medicare beneficiaries face—including lack of or limited access to digital literacy training, reliable broadband, and remote technologies;
- Ensure equitable access to telehealth for underserved communities, including Black Americans and people of color, individuals with disabilities, and people with limited English proficiency; purposefully collect data on such access; and ensure compliance with all existing civil rights laws, including rules requiring the use of interpreters and the provision of materials in alternative formats and non-English languages;
- Require providers to accurately disclose beneficiary cost-sharing obligations prior to service, and to fully document such disclosures; connect beneficiaries and providers with the resources they need to understand their financial responsibilities; and carefully monitor to ensure that any waivers of cost-sharing are not happening in a discriminatory or otherwise problematic way;
- Ensure that any expansion of telehealth protects patient privacy and data security for personal health information. HIPAA privacy protections must apply to telehealth interactions between the patient and provider and personal health data must also be kept secure;
- Ensure any expansion of telehealth is identical in traditional Medicare and private Medicare Advantage, and that the services and necessary equipment to access telehealth are equally available to all beneficiaries, regardless of the coverage pathway they choose;
- Ensure that telehealth does not weaken Medicare Advantage network adequacy standards, including by prohibiting telehealth providers from satisfying network adequacy requirements;
- Require public release of data concerning Medicare-covered telehealth, including the type of services provided, beneficiary experience and preferences, programmatic and beneficiary spending, health outcomes, and quality measurements; ensure monitoring, oversight, data collection, and evaluation continues ongoingly so as to best inform future telehealth policymaking; and
- Provide an extended phase-out period for the temporary COVID telehealth waivers and rules in order to minimize interruptions in care and prevent rushed policy development.