Telehealth Continues Rapid Growth but Regulatory Barriers Persist

Lack of uniformity in state and national regulations poses challenges

Stephen Miller, CEBS By Stephen Miller, CEBS December 6, 2017
Telehealth Continues Rapid Growth but Regulatory Barriers Persist

Left to right: Israel Robledo, Chatrane Birbal and Joel White

updated Feb. 10, 2018

Telehealth is transforming health care, allowing providers to deliver services when and where patients need them, thereby improving outcomes and lowering costs. Legal and regulatory roadblocks, however, still hinder telehealth providers' effectiveness, according to speakers at a Nov. 28, 2017, policy forum in Washington, D.C.

More employers are offering—and more employees are using—services that provide diagnosis, treatment or prescriptions following a consultation with a health care professional by phone or computer video.

Several bills introduced in Congress would help to make telehealth more accessible, said health care experts at the forum, sponsored by Health IT Now, a Washington, D.C.-based coalition that supports expanding health information technology to improve patient care.

"Employers collectively spend $668 billion on health benefits each year. That's one of the reasons why employers are pursuing a wider array of approaches to reduce health care costs and risk," said Chatrane Birbal, a senior advisor for government relations at the Society for Human Resource Management (SHRM).

The annual premium for family health care coverage for those covered by their employers rose on average 3 percent from 2016 to 2017, she noted. This year, family coverage costs on average $18,764, and "while employers pay most of these costs, families pay on average $5,714."

Looking ahead, "employers expect health care costs to increase by 5.5 percent in 2018, up from a 4.6 percent increase in 2017," Birbal said.

Telehealth Growth

"Health plans are using electronic visits, video technology, and remote monitoring to provide maintenance and preventive care for their enrollees, as well as diagnosis and treatment when it is clinically appropriate," Birbal said.

A 2017 study of large U.S. employers by the nonprofit National Business Group on Health in Washington, D.C., found that "virtually all—96 percent—will make telehealth services available in states where it is allowed next year," Birbal noted. The survey of 148 U.S. employers, two-thirds of which belong to the Fortune 500 or the Fortune Global 500, also found that:

  • More than half—56 percent—plan to offer telehealth for behavioral health services next year, which is more than double the percentage this year.
  • Nearly 20 percent of employers providing telehealth services experienced use by 8 percent of employees or more.

SHRM's 2017 Employee Benefits survey, which polled HR professionals at companies of all sizes earlier this year, showed an 11 percentage point increase over the past year in the prevalence of telemedicine as an employee benefit, rising to 34 percent from 23 percent in 2016.

Among other data Birbal cited, the nonprofit Kaiser Family Foundation's 2017 Employer Health Benefits Survey showed that:

  • 63 percent of large firms that offer health benefits cover the provision of some health care services through telecommunication in their largest health plan, up from 39 percent in 2016.
  • Among these firms, 33 percent reported that workers were given a financial incentive to receive services through telemedicine instead of visiting a physician's office.

Employers are encouraging the use of telemedicine to improve employee productivity and reduce absenteeism, Birbal said. "The rationale is that a telemedicine visit is far less time-consuming than taking time off from work for routine doctor appointments involving nonthreatening health issues. This is especially true for employees who are caregivers and need to coordinate care for themselves as well as children and elderly relatives."

[SHRM members-only toolkit: Managing Health Care Costs]

Behavioral Health Care

According to a survey by HR consultancy Towers Watson earlier this year, more employers will provide coverage for treatment of behavioral health issues through telemedicine for convenience and to improve access to mental health specialists that might not be available locally for in-person consultations, Birbal said. Today, 25 percent of employers provide coverage for treating behavioral health issues via telemedicine. Another 46 percent are planning to or considering it over the next three years.

"Health plans are increasingly using telehealth to provide clinical care and strengthen coordination of services across settings, giving employees greater control over their schedules—and their lives," Birbal said. For instance, behavioral treatment via telehealth services can help to provide care for employees struggling with opioid addiction, she noted.

Satisfied Users

Employers are "finding high enrollee satisfaction with this approach and no degradation in the quality of care. In fact, remote technologies provide the opportunity for improvements in the quality of care because they increase the amount of interaction between the patient and health care team and the information available on the patient's health status," Birbal said.

That viewpoint was shared by Israel Robledo, an advocate for people living with Parkinson's disease and a member of the Michael J. Fox Foundation for Parkinson's Research patient council. Robledo, who was diagnosed with Parkinson's at age 42 in 2007, said that cutting-edge Parkinson's care cannot be found in every community, but that "traveling 1,000 miles to see a Parkinson's specialist is prohibitively expensive for many patients." Telehealth consultations can resolve the access issue, he noted.

Effective Communications

Younger employees may be more comfortable with telehealth, said Joel White, executive director of Health IT Now. But some workers may dismiss a telemedicine option as just another cost-cutting move by their employer, feeling "now they don't even want me to see my doctor face to face."

He advised tailoring communications to different populations. For those who are likely to be more hesitant, he advised, the messaging could be "Give it a try, see if you like it. It's not care 'on the cheap'; it's modern health care."

Emergency Response Time

"The average time it takes for a patient to see an emergency physician after calling 911 is over 60 minutes," said Tim Peck, MD, co-founder and CEO of Call9, a service that connects patients with an emergency physician. "Decreasing the time it takes for individuals to see an emergency physician to within moments of an actual event saves lives," he noted.

This service is especially appropriate for skilled-nursing facilities, he said, where the nursing staff often send patients to an emergency room for health issues that a doctor could diagnose and treat online. However, constraints on Medicare reimbursement have hindered use of this service in elder care settings, Peck said.

Medicare Barriers

White called for removing government barriers that stand in the way of telehealth services. For instance, the bipartisan VETS Act now before Congress would allow Veterans Affairs telehealth providers to more easily see patients in their homes and to treat patients across state lines.

White also urged passage of the Increasing Telehealth Access in Medicare Act, which would allow Medicare Advantage plans to fully use telehealth services, as well as the Furthering Access to Stroke Telemedicine Act, which would improve access to home dialysis therapy with telehealth oversight. [Update: These provisions were enacted within the Bipartisan Budget Act of 2018, see box below.]

"Medicare lags the majority of other health payers—including Medicaid, the private sector, the Department of Veterans Affairs and the Federal Employees Health Benefits Program—in covering and reimbursing for telehealth-enabled services," White said. Medicare legislation now being considered "will allow health care providers to more effectively deliver the same or better quality services, when and where patients need it."

Update: A Medicare Game-Changer

The Bipartisan Budget Act of 2018 was signed into law on Feb. 9, 2018. The omnibus measure includes a provision that expands Medicare coverage for telemedicine and its use in certain situations. Given the size of the Medicare program, this development is likely to yield more data on utilization, outcomes and other key program metrics. It also is expected to produce the critical mass necessary for providers to identify ways to streamline and improve telemedicine services and approaches.

The law, among other changes, allows Medicare Advantage plans to include telehealth services as a basic benefit and allows Medicare to reimburse for telehealth dialysis services at the patient's home and at independent facilities.

Increased use of telehealth services by Medicare enrollees is likely to bring this service further into the mainstream, as more people see friends and relatives having good outcomes using telemedicine.

State-Based Regulation Varies

While many states have parity laws that require insurers to cover a telehealth visit the same as an in-person visit, state-based regulations can still be an impediment to use of telehealth, White said.

Although not participating in the forum, the ERISA Industry Committee (ERIC) in Washington, D.C., has addressed the lack of uniformity in telehealth legislation and regulations at the state and national levels. ERIC represents large employers.

"It is extremely important that laws do not create unnecessary barriers to access telehealth," such as by requiring an initial face-to-face visit with a doctor before allowing insurers to reimburse phone or online consultations, said Allison Wils, former director of health policy at ERIC and a health policy advisor at Cozen O’Connor Public Strategies.

Individual states should "consider the benefits of telehealth and adopt flexible rules that permit the practice of telemedicine without burdensome restrictions, while maintaining a high standard of care," she urged.

Progress is being made on this front. In December, the Texas Medical Board substantially revised its telemedicine regulations, repealing two prior requirements that restricted the use of telemedicine in the state: (1) its requirement that the provider conduct an in-person evaluation prior to issuing a prescription, and (2) its requirement that telemedicine services be provided only at "established medical sites." The board also relaxed restrictions on the provision of mental health services via telemedicine.

Related SHRM Articles:

Telemedicine Improves Health and Saves Money, If Employees Use It, SHRM Online Benefits, May 2018

Telemedicine Missteps: Beware HSA Eligibility and Other Compliance Traps, SHRM Online Benefits, June 2017

Telemedicine: An Emerging Health Care Trend, SHRM Online Employment Law, October 2016

Mental Health Access Back on the Agenda, SHRM Online Benefits, September 2016

Employers Eye Potential Savings Through Telemedicine, SHRM Online Benefits, November 2014

Related SHRM Resource:

SHRM Vendor Directory: List of Telemedicine Companies


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