Health

States and insurers resurrect barriers to telehealth, straining patients


Telemedicine is here to stay. But its free-for-all era may be coming to an end.

State-issued emergency declarations and insurer policies that were issued at the start of the Covid-19 pandemic and that were meant to encourage the use of telemedicine are being phased out across U.S. states, one by one. And as they fade away, rules that make telemedicine more complicated — and costly — are setting back in.

Experts say the moves, which come as vaccinations have ramped up and case counts have dwindled, are causing headaches among patients and providers alike. Doctors are scrambling to stay on top of rapidly-changing rules. Patients are contorting themselves to keep their virtual appointments — even driving into different states and taking calls from the side of the road so they can legally receive care.

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“The party is winding down in subtle ways that are really going to impact patients,” said Ateev Mehrotra, a hospitalist and health care policy researcher at Harvard Medical School who focuses on telemedicine. “And I shouldn’t use the future tense, I should say are currently impacting patients in really, really important ways.”

That was the case for Victoria DeLano and her husband Jim, who were back on the road last week, hauling their two kids and three dogs in a 30-foot RV to visit a doctor with their son James, who has three rare diseases. During the pandemic, they were parked at home. James, 16, was able to receive the specialist care he needed via telemedicine: the cardiologist in Ohio, the geneticist in Atlanta, the gastroenterologist in South Carolina, the neurologist and NIH clinical center in Maryland.

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They had saved thousands of dollars, and had to take less time off of work and away from family activities. But most importantly, James didn’t have to handle the exhaustion of constantly traveling with a wheelchair, his service dog, and a cooler of IV medications, fluids, and supplies for his feeding tube.

In May, James had a televisit scheduled with his cardiologist in Ohio. But a week before the appointment, his mom received notice: Telemedicine was off, and they needed to reschedule for in-person. “Now, having that taken away like this,” she said, en route from their Alabama home, “it’s really devastating.”

One of the most visible impacts is playing out on state borders, where the lifting of pandemic restrictions is creating a new phenomenon: the rest stop televisit.

Such visits are becoming more common, especially for patients who see doctors in city centers near state lines, or those who live in New England’s tightly-clustered states. It’s something Stephanie Titus, a primary care physician in Massachusetts, is watching unfold firsthand.

In the last year, Titus has treated patients located in Rhode Island, Vermont, New Hampshire, and even Maine virtually. That would normally require her to obtain a license in each of those states — a process that can take months and cost hundreds of dollars. But thanks to emergency orders from state governors and licensing boards, some of which expedited the application process or extended telehealth licenses to providers in neighboring states, that was no longer necessary.

Many of Titus’ far-flung patients now want to continue televisits whenever they’re practical. “For something as simple as blood pressure checks when they have a reliable blood pressure monitor at home,” said Titus, “it doesn’t make sense to have them travel.” But on July 1, Titus’ network, Mass General Brigham, decided to end telemedicine appointments for patients in states where their providers are not licensed, in anticipation of the lifting of temporary license allowances.

Titus started asking her out-of-state patients to make a choice: come back into the office, or take their telehealth appointments within Massachusetts’ borders. One of her patients from Rhode Island drove just across the border, parked in the lot outside of a BJ’s superstore, and called in from her car.

Cobbling together cross-state care can be especially challenging for patients using virtual mental health visits. While weekly, conversation-based mental health services have been a natural fit for telemedicine, their frequency also makes them uniquely susceptible to the impacts of expiring rules.

After Minnesota’s governor rescinded a number of executive orders on May 28, Doug Anderson, clinical services director at Sioux Falls Psychological Services in neighboring South Dakota, had to start asking patients to drive across the border to continue telecare. Even if patients agree, providers are stuck in an ethical bind: Without a reliable way to verify location, do you trust your patient, or do you try to protect yourself from accidentally practicing illegally? Some of his colleagues, Anderson said, have been asking patients to take a screenshot of their location on Google Maps and share it at the beginning of the appointment.

“Frankly, it leaves an awful lot of people in the lurch,” said Anderson. “It makes life difficult for clients, as well as therapists.”

For some, driving across a state border just isn’t an option. In Massachusetts, independent clinical social worker Cooper McCullough has been seeing a client who lives in New York via telehealth. He made clear that they might not be able to continue working together after New York lifted its temporary license waivers, and kept a close eye on regulatory websites so he could be sure to give the client notice. July 5, he read on the site, would be the last day of the waiver.

But on June 24, the governor ended the disaster emergency, immediately taking with it the executive order that allowed McCullough to see his client. They had to cancel their exit session.

“This person is not somebody who would’ve entered therapy lightly,” said McCullough. “I don’t know if he’s going to be comfortable continuing that with somebody he doesn’t know.”

With behavioral health accounting for more than half of all telehealth visits during the pandemic, the end of license waivers could have a dramatic impact on patients. “The restriction across states is bad for clients: bad for access to care and very much bad for continuity of care,” said Roy Huggins, a counselor and founder of Person Centered Tech, a consulting company that helps mental health providers navigate telehealth. “Needing to switch a therapist is unhelpful at best, or harmful at worst,” he added.

To many providers, the reversion to pre-pandemic regulations on telehealth is nonsensical.

“One of the big benefits of what happened during the pandemic was an expansion, but it was also a sense of clarity. You knew what the rules were, because everything was fine,” said Mehrotra in a recent symposium on telehealth. “We’re about to enter a time where it’s very, very confusing because everyone’s going to potentially have a different set of rules. And for a telehealth provider, that makes things 10 times worse because you have 10 sets of rules for every state you’re in.”

Based on current executive orders, Titus could still legally see some of her out-of-state patients via telehealth, but her health network decided to implement a single cutoff date because it was just too complicated to keep track. “Elaborating that to the thousands and thousands of patients that we have this is just too burdensome, and the risk is not worth it,” said Titus.

There are good reasons for states to issue their own licensure requirements. States want to protect their patients, and so do providers. With individualized licenses, states decide what level of experience, certification, and continuing education is required to practice. They also provide a clear path to discipline doctors who harm patients. And with more state-specific knowledge, providers might have a better chance of being able to direct in-person services to a patient who has a medical crisis during a video appointment.

Those arguments have led to one set of solutions: interstate compacts, which would streamline the process of applying for cross-state or state-specific licenses. For physicians, there’s the Interstate Physician Licensure Compact, which 30 states have signed onto since 2017; physicians still have to pay for each state’s license, but the process moves faster. Psychologists have PSYPACT; providers licensed in its 26 states can apply for a dedicated, cross-member telepsychology authorization. Social workers will start developing their own compact soon, with funding from the Department of Defense, whose frequent transfers have made it a proponent of interchangeable licenses for military spouses who practice medicine.

Some states are also passing legislation to extend temporary telehealth provisions without burdening physicians with new license applications. Connecticut will continue to acknowledge out-of-state licenses for two years for telemedicine, and Arizona will do so in perpetuity; others are allowing physicians to hold onto their emergency licenses for as long as it takes for their new, long-term licenses to be approved.

All those solutions keep states in charge of license issuance, theoretically providing better protection for patients. But Mehrotra sees a different motivation at work in states’ possessiveness. “I think the much bigger issue and concern is that state medical boards are focused on protecting their members from the outside competition,” he said.

While federal licensure is viewed by most as an unlikely solution, telehealth’s impact on interstate commerce could open up a path to a comprehensive federal solution, perhaps legislation requiring license reciprocity between states, Mehrotra wrote in a recent perspective in the New England Journal of Medicine. “I would love a telemedicine-only license that would allow me to take care of any established patient anywhere in the U.S.,” said Titus, a sentiment echoed by many of the providers who spoke with STAT.

For patients like James DeLano, who have benefited the most from telehealth provisions during the pandemic, reform can’t come soon enough. His mom is grateful for the care he receives — the visit in Ohio went well — but she hopes that new regulations will make it easier to use telehealth when it’s practical. “I kind of feel like we didn’t know what we didn’t have until we had it,” said Victoria DeLano, in the middle of a 12-hour stretch in the RV. “We didn’t recognize the value of telehealth until the shutdown.”


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