Overcoming Barriers to Telehealth

Telehealth always tops the list of broadband’s potential social benefits, yet it remains maddeningly out of reach. The broadband technology exists. The software exists. The user experience is far better than the “TV on a dessert cart” of a decade ago. Case studies that demonstrate cost savings and improved patient outcomes abound. So why do most people still take days off work to drive long distances and wait for hours in doctors’ offices and hospitals?

The Federal Communications Commission (FCC), which allocates close to $600 million per year from the Universal Service Fund (USF) for telehealth infrastructure, has been impatient with the progress of telehealth. In 2018, it raised the annual USF allocation from $400 million to $571 million, indexed it to inflation, and permitted unused funds to be rolled over to the following year. The commission then asked its intergovernmental advisory committee – a group of 30 state, local and tribal officials who offer guidance to the commission on telecommunications issues – to study and report on the obstacles to telehealth and recommend measures to encourage the growth and use of telehealth technology.

In November 2019, the committee submitted its report to the FCC. Not surprisingly, it identified a long list of barriers, both technical and regulatory, to telehealth. It concluded that “‘people-based’ issues, not those technology-based, are some of the most significant challenges related to the adoption of telehealth.” In addition, it offered recommendations to address these barriers.

Barriers to Telehealth

The committee listed the following barriers impacting telehealth:

Broadband issues include lack of access to broadband in many rural and tribal areas, where telehealth is most needed, and lack of redundancy in broadband infrastructure, which affects reliability. Adequacy of broadband access is defined not only in terms of download speed but also of upload speed, latency, dropped packets and other measures. Because telehealth requires high-quality audio and video, as well as simultaneous access to medical records and real-time data from monitoring devices, broadband infrastructure needs to be robust and well managed; fiber is the most desirable type of infrastructure for this application.

The committee noted the requirement for better broadband mapping and planning: “Lack of accurate geographic broadband availability data and USF coordination between state and federal universal service programs, aimed at expanding broadband, creates inefficiencies and fragmentation.”

Regulatory issues include reimbursement, licensing, health information exchanges, insurance parity and malpractice coverage, privacy and doctor-patient relationships.

• Reimbursement: Although every payer reimburses some telehealth visits, there is no common standard. Medicare reimbursement policies are extremely restrictive because of outmoded laws; only about 100 of 80,000 codes are reimbursable, and only under certain special conditions. Medicaid policies are different in each state, and private insurance companies set their own policies. The result is “a complex and confusing landscape for practitioners to navigate, especially if they have patients from multiple payers and multiple jurisdictions.” According to the report, not categorizing certain broadband-enabled services, such as remote patient monitoring, as telehealth increases their chance of being reimbursable.
• Licensing: Because health care professionals must be licensed in the state where a patient is located, treating out-of-state patients requires an investment of time and money. States and professional associations are working to streamline the process, but each professional group is taking a different approach.
• Health information exchanges: These exchanges, which are mostly still in the formative stages, will facilitate the sharing of patients’ electronic medical records.
• Insurance parity and malpractice coverage: Not all malpractice carriers will cover telehealth services, or they may charge additional or high premiums for such coverage. Additionally, not all carriers’ plans operate in all states.
• Privacy: Telehealth providers may need to take different or additional steps to ensure patient privacy that might not have been necessary were the service delivered in person.
• Doctor-patient relationships: States have different laws regarding whether a telehealth interaction constitutes a doctor-patient relationship. This affects whether a doctor can prescribe medications to a telehealth patient, especially controlled substances (relevant to addressing the opioid epidemic).

Other issues include digital literacy and the lack of integration of telehealth into disaster recovery plans. In terms of digital literacy, the committee was less concerned about patients, who are increasingly comfortable with digital devices. Rather, the report noted, “It is the overall telehealth infrastructure of federal, state, territorial, tribal, and local governmental policymakers and regulators that needs to improve to provide the necessary legal and regulatory framework for success.”

One of the most important potential uses of telehealth is in disasters, when local health care facilities may be destroyed or otherwise unavailable. “Telehealth may be the only way for vital health care services to be provided to the public,” the report noted, adding, “An effective telehealth system should not be closed to those people or organizations that might be prepared and uniquely able to assist during an emergency, just because they are not part of the coordinated system that existed before the disaster occurred.” However, most state, local and tribal governments have not yet integrated telehealth into their disaster recovery plans.

Recommendations

The committee’s broadband recommendations included these:

• Broadband needs to be funded through FCC initiatives such as the the proposed Connected Care pilot program and the Rural Digital Opportunity Fund.
• State and federal universal service programs should coordinate better to avoid duplication of efforts and ensure coverage of all unserved areas.
• Telehealth policy should address the deployment of infrastructure wherever it is needed, including in homes of older adults and provider offices in rural and frontier communities that are far from a hospital.

The committee’s regulatory recommendations included these:

• The FCC Rural Health Care Program should expand eligible equipment and services to cover institutional mobile technologies not currently covered. Mobile telephones and service should be eligible cost items.
• The FCC should work with relevant federal agencies to address reimbursement disparities for services categorized as “telemedicine” in Medicare and other medical services.
• Because telehealth is a geographically dispersed, often interstate, service, interstate licensing, credentialing and privileging should be revised and simplified.
• Malpractice insurance coverage should cover services delivered via telehealth and should extend into other states in which telehealth services are offered.
• Health benefit plans should not exclude from coverage a covered health care service or procedure delivered by a preferred or contracted health professional to a covered patient solely because the covered health care service or procedure is not provided through an in-person consultation.
• The FCC should work with other governmental agencies to ensure that the same standard of care and other measurements should apply to both in-person and virtual visits.
• HIPAA and other privacy rules should be revised to allow patients to share telehealth information with telehealth providers and to allow telehealth providers to share that information with one another.
• The FCC should encourage legislation or regulations that detail how telehealth can be used to establish a patient-provider relationship and when it can be used for prescribing medicine, particularly controlled substances.

The full report is available at https://docs.fcc.gov/public/attachments/DOC-360696A5.pdf.