The COVID-19 pandemic has done more than force most people to avoid leaving the house for anything but essentials; it has also prompted lawmakers and regulators to dramatically loosen the rules around the use of telemedicine, which allows doctors to treat patients remotely via phone, email or video.

“Telehealth has emerged as one of the vital tools used in addressing our current reality in a COVID-19 world and policymakers are making swift changes to ensure the flexibility to use the technology is there,” Center for Connected Health Policy Executive Director Mei Kwong wrote in an April 23rd blog post.

A recent analysis of state bills, executive orders and other emergency regulatory changes from the LexisNexis State Net database shows 41 states and the District of Columbia have made at least one significant change to their telemedicine oversight rules.

Among the most common are changes that allow Medicaid to cover services provided in a patient’s home or by telephone. Measures in California, Massachusetts, Maine, Delaware, Montana and Washington, among other states, also now require health insurers to cover telemedicine services at the same rate as in-person visits. New Jersey, Rhode Island, Missouri and Florida are among states that have agreed to waive licensing requirements for health professionals licensed in other states, or eased those requirements within their own state.

These states are not acting alone. In March, the U.S. Office of Civil Rights (OCR) of the Department of Health and Human Services (HHS) announced it was issuing a blanket waiver on a number of health policy privacy laws, including one that waived all HIPAA privacy, security, and breach notification rules as long as the telehealth provider could show it had acted in good faith compliance with the agency’s guidance.

Telemedicine advocates have been pushing for many of these changes for years, and there is data to show that the use of remote health care services was growing even before COVID-19 forced the issue.

For example, a 2019 study by Fair Health – a New York-based nonprofit that tracks health care costs by analyzing billions of health insurance claims from around the nation each year – showed a 53 percent increase in telemedicine claims from 2016 to 2017. Cloud communications provider Vonage recently reported a 2,000 percent increase in telemedicine video usage.

Another study released in April of this year by the research company Global Market Insights predicted the telemedicine industry would grow from its 2019 valuation of $45 billion to $175 billion by 2026, an annual compound growth rate of 19.3 percent.

“As economies are implementing partial or total lockdown, availing healthcare treatment has become a challenge,” the report says. “Amid such conditions, telemedicine is proving to be a key technology to get medical consultations. Increasing number of people are turning towards virtual visits for health check-ups, thus fostering market demand.”  

While at first blush those numbers are eye popping, the Fair Health report notes that the telemedicine claims studied in their survey still comprise just 0.11 percent of the total number of claims in general. Those numbers would reasonably be expected to go up significantly for current billings.

Telemedicine advocates point to a number of benefits to remote care, including greater access to that care – particularly for rural patients or those with specialized needs, such as mental health treatment – and increased cost effectiveness for both patients and doctors. And in the age of COVID-19, the ability to see patients without exposing them to a potentially catastrophic infectious illness has been critical.

Even so, turning in-person doctor visits digital has never been without complications.

Barb Johnston, the co-founder and CEO of HealthLinkNow, a Sacramento-based company that coordinates telepsychiatry services to patients around the country, says telemedicine has long been regulated via a maze of confusing and occasionally contradictory state and federal laws that govern what services may be offered remotely and how those services are paid for.

“We live in a country with a very disconnected set of rules and regulations for Medicare and Medicaid,” she says. “And then you add in the insurance companies, and they have a completely different set of rules.”

Even with state and federal officials trying to ease the pathway, that mix of rules continues to make the telemedicine transition choppy at best, leaving many patients angry and confused.

She says those complications - and the fear of making expensive mistakes – has long led lawyers for many health providers to convince those systems to avoid or minimize their use of telemedicine.

“The real losers there are the patients who lose out on access to health care,” she says.

But insurance is just one hurdle of many. Many conditions simply cannot be treated remotely. Adherence to state and federal privacy laws has also long been a challenge, and patient advocates and even some health providers question the efficacy and continuity of care remote patients may receive.

Telemedicine is also not immune from the same partisan social policy disagreements as standard medical care. This was in evidence last week as Pennsylvania Gov. Tom Wolf (D) vetoed SB 857, a bill that would have established standards for the use of telemedicine in reaching patients in rural areas, over the inclusion of a provision that would have banned abortion-inducing medication.

Wolf also issued cross-agency guidance on the use of telemedicine, noting its importance during the ongoing pandemic.

But no challenge looms larger than how to overcome America’s great digital divide – the gap between those citizens with access to the Internet in their homes and those without.

According to the Federal Communications Commission, as of 2019 at least 21 million Americans did not have access to the Internet at home. Data from the World Economic Forum shows the problem is much worse globally, where only about 55 percent of homes have an Internet connection.

Former California Assemblyman Lloyd Levine, who chaired the Assembly Committee on Utilities and Commerce during his time in the Legislature and who is now a consultant on energy and technology policies, says that chasm must be closed if we are going to continue telemedicine’s rapid expansion after the COVID-19 pandemic has passed.

“The digital divide is another inequity that is going to create even greater disparities in our society,” he says, noting that the problem disproportionately impacts people living in rural areas without access to technology and low-income communities where people simply can’t afford to pay for it.

“Those two groups already have challenges connecting with and engaging with the health care system,” he says. “For most people, telemedicine is just another tool we can use to access health care. But for them, it could be a lifeline.”

Closing the gap will not be easy.

Most health systems around the world have still not built digital platforms to conduct televisits,” wrote Eric Topol, the director of the Scripps Research Translational Institute in California, in a March op-ed for The Economist. “Meeting government standards for privacy is trickier since data shared over a network require special security that would be easier to ensure in a clinical setting. And patients are concerned that their medical data may be hacked or sold.”

It is far too soon to know if the temporary reforms state and federal lawmakers and regulators have put in place will continue after the COVID-19 crisis abates, though there appears to be a growing sentiment among health advocates and providers that at least some of those measures should become permanent.

“This is as much by necessity as it is by want for both doctors and patients,” says Anthony Wright, executive director for Health Access, a California health care advocacy group.

“We need to address the major issues – the digital divide, consumer privacy and balancing telemedicine practices with the needs that can’t be addressed that way – but telemedicine is going to be an important part of keeping the health care system going,” he says.

“Use whatever analogy you want - the genie is out of the bottle or the toothpaste is out of the tube – but it all means the same thing: this is definitely not going to be a temporary thing.”


About 1/3 of States Have Passed COVID-Related Telehealth Legislation

Sixteen states have introduced bills or resolutions this year referring specifically to “telehealth” or “telemedicine” and “coronavirus” or “COVID-19,” according to LexisNexis State Net’s legislative tracking system. Fourteen of those states have enacted or adopted such measures.


To our readers,

Given our historic national crisis, most of this edition of the State Net Capitol Journal is focused on the wide array of efforts being undertaken by state and local officials to deal with the fallout from the COVID-19 pandemic. That said, we will also do our best to keep you informed of other important actions from our statehouses while we faithfully stick to shelter-in-place requirements and other best practices aimed at flattening the curve of the spread of this deadly virus. So please be safe, be smart and let’s all work together to get through this with as little harm as possible.

-- State Net Capitol Journal Managing Editor Rich Ehisen