The first COVID-19 public health emergency (PHE) was passed on January 31, 2020.[1] Almost two-and-a-half years later, over one million people have lost their lives to the infectious disease, and the nation is still struggling to emerge from the pandemic. According to the Centers for Disease Control and Prevention, 78 percent of the counties in the United States are currently classified as having a “high” COVID-19 community transmission rate.[2]
To reduce exposure to the disease, the Medicare program provided temporary waivers to increase flexibilities around telehealth use during the PHE. It resulted in a 63-fold increase in telehealth use in 2020, with most beneficiaries (92%) accessing telehealth visits from their homes.[3] The Centers for Medicare & Medicaid Services (CMS) allowed individual states to waive within-state licensure requirements for Medicare beneficiaries to receive telehealth services as part of those temporary flexibilities.[4] Additionally, all 50 states and Washington, D.C. also issued emergency orders allowing out-of-state clinicians to perform telehealth across state lines (i.e., interstate telehealth). As of April 2022, most states (37) and Washington, D.C., have ended their emergency declarations resulting in the expiration of many temporary licensure waivers.
A new study published in Health Affairs examines the trends in interstate telehealth use by Medicare beneficiaries, beginning before the pandemic and stretching into its first year (2017-2020). Researchers found that despite the fact that the number of out-of-state telehealth visits grew in 2020, reflecting the overall growth of telehealth services, the percentage of telehealth use that occurred across state lines did not substantially change. A caveat noted by researchers was that the percent of out-of-state telehealth varied by state and was “strongly correlated with the percentage of in-person out-of-state care received by beneficiaries in the state.” For most states, out-of-state telehealth visits amounted to fewer than 1%. States such as Vermont and New Hampshire, along with Washington, D.C., however, relied considerably on out-of-state telehealth.
Researchers also discovered that out-of-state telehealth was primarily used for continuity of care for established patients and routine diagnoses, rather than for new patients. Finally, researchers found that a higher percentage of rural patients used both out-of-state in-person and telehealth service. They noted this was in line with established literature about “health care provider shortages and extended distances that rural patients have to travel for care.”
This finding led the researchers to conclude that “interstate telehealth legislation and policy changes are best prioritized at the individual state level.” It was recommended that state governments could determine if they should prioritize out-of-state telehealth by examining how much total care (in-person and telehealth) occurred across state lines. Additionally, it was recommended that since about 66% of out-of-state telehealth services are between a clinician and patient in bordering states, “states with rural counties located along their borders may consider policies such as licensure reciprocity to enable continued telehealth access in rural communities.”
The Center for Medicare Advocacy has been closely monitoring the expansion of telehealth services and its potential impact on beneficiaries since the beginning of the pandemic. We recently released a special report entitled Telehealth and the Medicare Population: Building a Foundation for the Virtual Health Care Revolution. Included in the report are policy recommendations for lawmakers and policy makers. The Center holds the perspective that interstate telehealth is beneficial and should be promulgated where needed.
June 6, 2022 – C. St. John
[1] Office of the Assistant Secretary for Preparedness and Response. Public Health Emergency Declarations. ASPR. (n.d.). Available at: https://www.phe.gov/emergency/news/healthactions/phe/Pages/default.aspx
[2] CDC. CDC COVID Data Tracker. Centers for Disease Control and Prevention. (Updated June 7, 2022). Available at: https://covid.cdc.gov/covid-data-tracker/#county-view?list_select_state=all_states&list_select_county=all_counties&data-type=Risk&null=Risk
[3] ASPE. Medicare Beneficiaries’ Use of Telehealth in 2020: Trends by Beneficiary Characteristics and Location. (December 2021). Available at: https://aspe.hhs.gov/sites/default/files/documents/a1d5d810fe3433e18b192be42dbf2351/medicare-telehealth-report.pdf
[4] Andino, J. J., Zhu, Z., Surapaneni, M., Dunn, R., & Ellimoottil, C. Interstate Telehealth Use By Medicare Beneficiaries Before And After COVID-19 Licensure Waivers, 2017-20. Health Affairs. (June 2022). Available at: https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2021.01825?journalCode=hlthaff