Telehealth: Building on Flexibilities from the Public Health Emergency
October 12, 2023

This blog post is part of our Policy Pulse series, which spotlights crucial policy issues in independent and community-based primary care, along with potential solutions from Aledade’s Policy team.

Telehealth is a critical tool for strengthening relationships between the patient and primary care team.

At Aledade, many of our accountable care organizations (ACOs) regularly use telehealth for mental and behavioral health services, Annual Wellness Visits (AWVs), Transitional Care Management (TCM) services and helping patients manage chronic conditions. Congress extended many popular telehealth Public Health Emergency (PHE) flexibilities in Medicare through 2024. These include the ability for Medicare beneficiaries to have a telehealth visit from home, and allowing more health care professionals such as therapists to offer telehealth. Some flexibilities are now permanent, like allowing telehealth for mental health services and audio-only mental health services for established patients with certain caveats. However, there are still gaps to fill in aligning telehealth policies with patient needs.

Telehealth … accelerated

The COVID-19 pandemic led to a 10-fold increase in telehealth use among Medicare beneficiaries – from 5 million services the year prior to the pandemic to 53 million during the first year. While telehealth use has leveled off 3+ years in, most health care stakeholders agree that the telehealth landscape will never go back to pre-pandemic times. As the technology continues to advance and “digital native” generations begin to age into Medicare in the coming years, it’s safe to assume that telehealth is here to stay. 

Aledade is advocating for telehealth policies that strengthen primary care, reduce burden for ACOs and advanced alternative payment models (AAPMs), and increase flexibility at the state level.

We are advocating for Congress and CMS to:

  • Design telehealth policies that protect and strengthen the primary care relationship through telehealth flexibility. Data from Aledade member practices shows that certain primary care services work well for telehealth, including mental health services, AWVs, triaging patients when they are unsure about going to the Emergency Department, TCM visits, and Chronic Care Management services. Primary care practices that provide these population health services and engage patients across the continuum of care have to pay the costs of both brick and mortar and virtual services. Payment should reflect the costs to maintain this infrastructure – practices should not be disincentivized because they offer both office visits and virtual services.
  • Increase telehealth flexibility for ACOs and other AAPMs. CMS recognizes the value of these models and has set a goal of having 100% of Medicare beneficiaries in accountable care arrangements by 2030. Since the beginning of MSSP, ACOs have had telehealth flexibilities. However, those flexibilities are much less generous than the flexibilities made available during the PHE, and burdensome reporting requirements prevent the widespread use of available waivers. Telehealth flexibilities could be a lever to encourage participation in risk-bearing value-based payment arrangements. CMS should allow clinicians in the MSSP to test additional telehealth services to contribute to the evidence base needed for broader adoption. 
  • Encourage licensure flexibility across state lines. Telehealth policies should aim to minimize and simplify administrative burden for clinicians. For example, licensure portability allows clinicians to care for patients across state lines both in person and virtually. Many of our member practices located near state borders see patients from different states. It doesn’t make sense for patients who might live minutes from each other to have different rules for telehealth visits. Medicare beneficiaries who fly south in the winter months (“snow birds”) should be able to receive telehealth services from the primary care practice near their primary residence. There should be easy ways for practices to request exceptions or other flexibilities to practice telehealth for patients they see regularly and for whom they are responsible. 
  • Maintain flexibilities established during the COVID-19 PHE to allow for virtual prescribing of controlled substances without an in-person visit. The Drug Enforcement Agency and other federal agencies are considering how to proceed with balancing learnings from the PHE with protecting patient safety and preventing diversion of controlled substances. In October, the DEA issued a temporary rule extending the full set of telemedicine flexibilities regarding prescription of controlled medications in place during the PHE, through December 31, 2024. This extension authorizes all DEA-registered practitioners to prescribe schedule II–V controlled medications via telemedicine through December 31, 2024, whether or not the patient and practitioner established a telemedicine relationship on or before November 11, 2023. We support telehealth flexibilities remaining permanently in place for certain populations being prescribed schedule II medications for pain and symptom management as part of palliative care. 

    Many palliative care patients experience multiple complex conditions and are often frail, elderly, immunocompromised, homebound and at high risk for hospitalization because of complications or poor symptom management. We are advocating for physicians managing palliative care patients to be able to continue to manage patient care and prescribe schedule II medications through telehealth without an in-person visit, which is very difficult for seriously ill patients. We believe there are learnings and practices from hospice care that could be applicable to palliative care patients, such as a certification from the attending physician that the patient is terminally ill among other criteria. We envision a similar certification process for palliative care physicians to certify that the patient who will be receiving telehealth services has a serious illness and is involved in a care plan with the physician to manage symptoms. 

We also advocate for Congress to continue to make investments in broadband infrastructure so that underserved populations in all communities can benefit from telehealth.