June 01, 2021
FBIQ’s Post-Pandemic Telehealth Forecast
How do we envision telehealth for the next decade—is it central to healthcare, or optional?
This question is being debated as temporary waivers, adopted along with the COVID-19 Public Health Emergency (PHE) declaration, are set to expire at the end of 2021. As House Ways & Means Health Subcommittee Chair Doggett (D-TX) stated during an April 28 hearing, “we need to fully explore how [telehealth] stays and at what cost in both dollars and quality of health care to preserve patient choice, protect beneficiaries from fraud and exploitation, and avoid exacerbating long-standing health disparities.”
Telehealth use over the past pandemic year increased dramatically and, even after a mid-year peak, remains elevated well above pre-COVID levels. The pattern is consistent in private sector health plans, Medicare, Medicaid, the Department of Veterans Affairs, and the Military Health System. Part of the intensified use was due to unprecedented flexibility and waivers of existing law, particularly in Medicare, and now the question is how much of that flexibility will be carried forward. During 2020, a flurry of telehealth legislation was enacted in states, and in the 117th Congress dozens of telehealth bills have been introduced to expand telehealth use or make waivers permanent.
Looking to the future, public health experts, medical professionals, legislators, and economists are analyzing many factors, including:
- Outcomes What was successful about telehealth over the past year and which practices should be continued post-pandemic?
- Access Who did telehealth reach and who was left unconnected?
- Technical What are the technical barriers and opportunities?
- Cost Does telehealth supplement or replace other healthcare?
- Policy What are the legal and policy issues?
Across all of these, equal access to telehealth opportunities must be addressed. President Biden has emphasized equity issues in healthcare; on his first full day in office, he established a COVID-19 Health Equity Task Force. The Task Force is charged with looking at all aspects of health equity, including the use of and access to telehealth, and with making recommendations. For example, there have been significant challenges to telehealth access in some urban and rural areas—location matters.
We recognize, in our country, ZIP Code is still a stronger predictor of health than genetic code.
COVID-19 Health Equity Task Force Chair Nunez-Smith, May 11
Evaluation of Claims and Technical Barriers
The COVID-19 Healthcare Coalition, a Mitre-led private sector organization with over 900 members, evaluated almost 9 million private insurance claims for 2019 and 2020 in their COVID-19 Telehealth Impact Study, finding the percentage of overall claims for telehealth visits was steady at 1.5% until the pandemic hit, rose to 49% of claims in April 2020, and settled to 23.8% in December of 2020. The majority of telehealth claims were for behavioral and mental health.
The Coalition also conducted a Physician Survey, managed by the Mayo Clinic. The survey asked 1,594 practitioners about barriers to their patients in accessing telehealth. The results were reported for urban, suburban and rural practices. Overall, physicians reported the greatest barriers to be: “lack of patient access to technology,” “lack of digital literacy in patient,” and “lack of patient access to broadband/internet.”
In Medicare, the independent Medicare Payment Advisory Commission (MedPAC) reported that telehealth accounted for 16% of total allowed physician charges in April 2020, compared with 0.1% in April 2019. As in-person visits resumed, the percentages of telehealth to all visits declined to 7% in June 2020 (the latest available data).
From a patient perspective, MedPAC found that 15% of Medicare beneficiaries had a video telehealth visit and 37% had an audio-only phone visit. Overall, more Medicare beneficiaries had audio visits than did privately insured patients (37% versus 30%) and were slightly less likely to have a video visit (15% versus 18%). The technical barriers for Medicare beneficiaries echoed those noted above by the Coalition physician survey—lack of equipment, lack of knowledge, and lack of internet access.
To round out the analysis, CMS reported on Medicaid and Children’s Health Insurance Program use through October 2020 with similar results to the private sector and the Medicare program. Services delivered through telehealth were the highest in April 2020 and, for all age groups, use of telehealth fell from May through October. A year-to-year comparison of 2020 versus 2019 shows 67,811,157 more services delivered through telehealth in 2020, an increase of 2,745%. CMS also had useful demographic data showing wide variability in use of telehealth across states and across ages within states. However, overall, the rate of telehealth was highest for those between 19 and 64, while children under age 19 and adults aged 65 and older had lower rates.
Industry Forecast for Digital Health
As part of a broad evaluation of investor interest in the digital health market, McKinsey looked at the impact of COVID-19 in December, including telehealth growth. They focused on five categories: research and development, wellness and disease prevention, screening and diagnosis, care delivery, and finance and operations. Care delivery is the largest category at $157 billion (in 2019) representing 45% of the total market. While digital health overall is expected to grow at 8%, each of the care delivery sub-categories (termed “value pools”)—remote patient care (telehealth), more effective therapies, and direct supply of therapies to patients—are expected to outpace that and grow by 10%. This includes telemedicine companies, specialized technology and wearable devices, and online pharmacy services. Concurrently, McKinsey forecasts that care delivery technologies have “the greatest measurable cost-savings potential, approximately $270 billion.”
Reflecting on the popularity of telehealth, 73 telehealth-related bills have been introduced in the 117th Congress. Bipartisan legislation (the “CONNECT for Health Act”) to make telehealth waivers permanent has been introduced in the Senate (S. 1512 with 53 cosponsors) and in the House (H.R. 2903), organized by the bipartisan and bicameral Congressional Telehealth Caucus. Other legislation includes “The Telehealth Modernization Act of 2021” (S. 368/H.R. 1332), with similar purpose. Senator Wicker (R-MS), a cosponsor of S. 1512, stated “Telehealth is enabling more people to receive the care they need, leading to improved outcomes and lower costs. This bipartisan legislation would build on the success of telehealth in states like Mississippi to eliminate existing barriers and expand access to lifesaving care for more Americans.”
Solutions are being proposed to improve telehealth access by addressing the lack of broadband in many communities. President Biden’s American Jobs Plan originally included $100 billion “to begin affordable, reliable, high-speed broadband to every American.” On May 21, Biden revised his broadband request to $65 billion as part of a reduced $1.7 trillion infrastructure offer to Senate Republicans in an attempt to advance negotiations. The $65 billion matches Senate Republicans’ original infrastructure plan, and it is included as “one-time” funding in their May 27 $928 billion infrastructure counter-proposal to Biden. There is no doubt that broadband and internet access for unserved and underserved populations is necessary to support health and economic equity goals.
Removing barriers to telehealth accessibility—particularly in rural and urban low-income areas—requires investments in broadband infrastructure. With razor-thin margins in the House and Senate, we expect the size of President Biden’s $2.25 trillion infrastructure proposal to shrink significantly on Capitol Hill. Telehealth and broadband will make the cut.
We are… expanding broadband so that every American has access to high-speed and affordable high-speed Internet. In the 21st century, broadband is critical infrastructure…. Over the past year… a lot of people—the only way they could work, if they had the ability, was to work online. Our children had to go to school online. Seniors and others—the way they could see their doctor: telemedicine—online.
Vice President Harris, April 30
99% With Administration support, Congress extends expiring telehealth waivers/eligibility before the end of 2021
75% Congress permanently extends telehealth waivers this calendar year
95% To address accessibility for rural and urban low-income areas, infrastructure legislation enacted in 2021 includes at least $65 billion for broadband.