Testimony of Dr. Joseph C. Kvedar to Senate Committee on Health, Education, Labor and Pensions

Telehealth: Lessons from the COVID-19 Pandemic

Testimony of Joseph C. Kvedar, MD
President, the American Telemedicine Association (ATA)
Professor, Harvard Medical School
Senior Advisor, Virtual Care, Mass General Brigham (Partners HealthCare)

Senate Committee on Health, Education, Labor and Pensions
Telehealth: Lessons from the COVID-19 Pandemic
Wednesday, June 17, 2020, at 10:00 a.m.

Chairman Alexander, Ranking Member Murray, and distinguished members of the Senate Health, Education, Labor, and Pensions Committee. Thank you for inviting me to testify at today’s hearing on behalf of the American Telemedicine Association. I am proud to serve a second term as ATA president and to have the opportunity to share with each of you—virtually—how telehealth has enabled healthcare providers to continue to deliver safe, effective, and needed care, both within and outside the hospital, providing a lifeline for patients across the country during the COVID-19 pandemic.

As a practicing physician at Massachusetts General Hospital in Boston, I have seen first-hand the multitude of ways telehealth has bridged the gap between a critical provider shortage and a growing patient population – a problem that existed before the pandemic, and one that will only worsen due to an aging population and the increasing burden of chronic disease. In my own telehealth clinic, I can deliver specialty care to patients in rural and underserved areas, without the need for them to travel hours to see me, take time off from work, or find someone to care for their child. This is not just happening at my institution but is occurring at hospitals and doctors’ offices every day across the country.

Nearly 30 years ago, when I founded the Center for Connected Health at Partners HealthCare – a healthcare system including two Harvard Medical School-affiliated academic medical centers, community and specialty hospitals, community health centers, a physician network, home health, and long-term care services, now known as Mass General Brigham – I envisioned care delivery that was time and place independent. As technology has advanced, so too has healthcare innovation, creating new and better ways to connect patients and providers, empower individuals to manage their health better, and create more efficient and effective care and improved clinical outcomes. Even just a few short months ago, we could not have anticipated a public health emergency of this magnitude, nor the role telehealth would play in helping to ‘flatten the curve’ while delivering care to millions of Americans.

Founded in 1993, the ATA is the leading non-profit professional association representing the telehealth industry. Our member organizations include hospital networks, technology solution providers, academic institutions, and payers, as well as partner organizations and alliances from around the world. I have been affiliated with the ATA since its inception and remain fully committed to its mission – to create a healthcare system where more people have access to safe, effective, and appropriate care when and where they need it.

Over these past few months, Members of Congress, regulators, patients, and providers across the country have witnessed a reality that the ATA, its members, and I have known for decades: telehealth works. This pandemic has forced America’s healthcare system into the 21st century. Telehealth has not been merely a novelty; telehealth has kept the entire healthcare system afloat and has enabled patients to continue to receive care.

For those previously unfamiliar with telehealth, I realize there may be questions about how virtual care and digital health technologies have been used during the pandemic and whether we should continue to allow providers to care for patients remotely in a post-pandemic world. I hope today I can shed light on the critical role telehealth has played during the pandemic and why we need to ensure Congress continues to allow individuals access to safe, effective, quality care as our world adjusts and our healthcare system evolves to meet our new reality.

Telehealth has saved lives, helped reduce the spread of the virus, and enabled providers to scale the response of an overwhelmed and under-prepared health system during the pandemic. Telehealth options also helped keep older adults connected to their healthcare providers and extended care to at-risk and underserved patient populations, especially in areas where healthcare resources may be limited.

Many of us who have been using telehealth know that virtual visits, remote monitoring, and asynchronous interactions with patients are as safe and effective as in-person care. During the public health emergency, even more providers across the country have turned to telehealth to deliver primary care, specialty consultations and disease management, while making significant investments in technologies to better care for more individuals. Likewise, patients have grown accustomed to the convenience, safety, and quality of remote visits. Right now, three-quarters of U.S. hospitals are using digital technology to reach their patients via video, audio, chat, or email. Patient use of telehealth is up from 11% in 2019 to 46% this year, with 76% of consumers saying they are interested in using telehealth in the future.

I can share with you some extraordinary numbers from my organization that includes Massachusetts General Hospital and Brigham and Women’s Hospital. In just the last three months, our healthcare providers completed over 605,000 virtual visits, including nearly 247,000 in just the month of May. What’s equally impressive is our projections for telehealth usage post-pandemic. Mass General Brigham providers will go from approximately 1,500 virtual visits per month to 250,000. Pre-pandemic, only .2% of all ambulatory outpatient visits were conducted via telehealth. Now, we anticipate 60% of ambulatory care will be delivered remotely.

In my case, as a practicing dermatologist, I cared for many patients using these tools during the pandemic. My patients were universally happy and grateful for the experience. Perhaps more importantly, I was able to diagnose several skin cancers (those patients were directed to come into our emergency dermatology clinic for further care) and reassure several others that the lesions they were concerned about were benign and could wait until their next scheduled visit.

And, again, it’s not just my organization that has implemented a significant shift in care delivery by leveraging the benefits of technology-enabled care. Many of our ATA members have also seen staggering increases in virtual care services.

For example, Providence St. Joseph Health (PSJH) cared for the first confirmed COVID-19 case in the U.S. and subsequently cared for 1,400 infected patients across its seven-state footprint. An established virtual care leader, PSJH’s telehealth network was able to scale services from 70,000 telehealth visits in a year to 70,000 in one week to support the COVID-19 surge. Their clinicians leveraged telehealth technologies in many ways, including helping diagnose appendicitis in a young patient, working with a first-trimester pregnant patient to guide her using a fetal heart rate monitor, providing a more calming experience for behavioral health patients, and staying engaged with frail and elderly patients. Underscoring the power of telehealth, Providence’s reported patient satisfaction was higher for virtual visits than standard in-person care.

Health systems, including Tennessee-based HCA Healthcare and LifePoint Health, are effectively using telehealth for specialty care, including but not limited to orthopedics, ENT, and urology. Under the current Medicare telehealth flexibilities, LifePoint Health, representing over 85 community-based hospitals on the front lines responding to the COVID-19 emergency, can now provide specialty consults to their patients via telehealth without the restraints or limitations of an in-person visit. LifePoint also has leveraged providers in other locations to help care for patients in hard-to-serve communities and its telehealth utilization has grown from a few hundred to more than 28,000 telephone-based visits and 26,000 video-based visits a month.

Telehealth companies like Amwell, Teladoc Health, and Zipnosis have also played a critical role during this crisis with their on-demand platforms and asynchronous solutions, enabling overburdened healthcare systems to effectively respond to the extraordinary patient demand throughout the nation. These companies managed, as you know, record increases in volume and services in the first several weeks of the public health crisis. For example, in the first 45 days of the pandemic, Teladoc Health recorded a 67% year-over-year increase in patient volume nationally and an 84% increase in Tennessee.

Healthcare providers and policymakers often talk about the urgent need for healthcare transformation to address the challenges we are facing, including rising provider shortages, burgeoning patient populations, and growing financial pressure. COVID-19 has fueled a rapid transformation, with telehealth and virtual care driving the new paradigm in care delivery.

While many envision telehealth as real-time audio or video interactions between a patient and provider, many platforms are combined with remote monitoring capabilities, allowing for a virtual care model that offers patients around-the-clock clinical support and convenience. This expanded care model is especially critical for individuals who engage with the healthcare system frequently, including patients with chronic conditions such as diabetes, hypertension, and congestive heart failure, as well as behavioral health conditions.

Today, 147 million Americans live with chronic conditions, accounting for 90% of our total annual healthcare costs. With telehealth, we can improve access to care while reducing many of the acute and long-term health complications that stem from chronic conditions. For example, remote monitoring also allows individuals to self-monitor their health and securely share data with their healthcare providers. This technology has proven to reduce hospital readmissions and trips to see the doctor. Also, by effectively applying data science, many leading remote monitoring companies, such as Livongo Health, can contextualize health trends, determine which individuals might benefit most from a telehealth visit, and offer patients real-time, personalized and actionable recommendations on how to stay healthy – critical for individuals with chronic conditions.

In response to the pandemic, federal and state governments finally removed many of the antiquated barriers to telehealth that were keeping providers from reaching their patients remotely. The ATA wholeheartedly supports these policy changes.

At the federal level, temporary changes to the unnecessarily restrictive requirements in section 1834(m) of the Social Security Act now allow all Medicare beneficiaries – including those living in both rural and urban areas – to benefit from telehealth. ‘Originating site’ restrictions were also waived, enabling providers to interact with new and existing Medicare patients over a range of telehealth modalities – including the telephone – no matter where the patient is. For underserved and rural communities, Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) can finally serve as distant sites, enabling these essential safety net providers to reach patients they serve in ways they have never been able to before. These examples of proactive, common-sense policies paired with significant new funding opportunities and loosened restrictions on licensure, cost-sharing, and the use of certain technologies, have changed the way our nation delivers and receives health care.

In states across the country, Medicaid policies have largely kept pace with the needs of patients and providers. A recent analysis from the Medicaid and CHIP Payment and Access Commission (MACPAC) found that 44 states and territories expanded telehealth services by changing Medicaid policies in response to the pandemic. Additional state-based policies now allow a patient’s home to qualify as an originating site, provide payment parity for telehealth visits, enable other providers to deliver services through telehealth, and allow providers to consult with their patients over the telephone.

These policy changes have enabled unprecedented telehealth utilization during this public health emergency. However, I advise you not to be distracted by these numbers. The overwhelming acceptance and implementation of telehealth during the pandemic – and the significant levels of patient and provider satisfaction – clearly speak to the value of these technologies. In fact, a recent poll of Medicare Advantage beneficiaries found that more than 90% of respondents view their recent use of telehealth as favorable, and nearly 80% reported they would use telehealth for a medical appointment in the future.

Telehealth will not and should not entirely replace in-person care post-pandemic. It should, however, be an option. As patients again feel safe to enter healthcare facilities for nonemergent care, we may see a natural decline in the use of telehealth. Some patients and providers will prefer in-office interactions, while others will want to use telehealth for some aspects of care, and still, others may opt to forgo virtual care altogether. Given the patient and provider satisfaction we have seen, I believe many, if not most, providers and patients will want to continue to use telehealth in some way indefinitely.

Now that Medicare beneficiaries have improved access to telehealth, federal policymakers need to take specific actions to make these services permanent. Failure to do so will result in unnecessarily restricting access to high-quality care. However, if the federal government—and specifically Congress—does not act before the end of the declared national public health emergency, Medicare patients and providers will not have the option to continue to use remote care.

Chairman Alexander, your recent white paper, Preparing for the Next Pandemic, takes a thoughtful approach to public health policy, and we specifically appreciate your recommendation to “ensure that the United States does not lose the gains made in telehealth.” To accomplish this, Congress must move quickly to enact targeted telehealth reform legislation before the national emergency, and public health emergency declarations are rescinded. The ATA and I welcome the opportunity to work with lawmakers to inform these policies.

Moving forward, Congress should first address the current statutory restrictions on patient geography and originating site limitations. These restrictions are out-of-date and must be modernized to enable Medicare beneficiaries to continue to benefit from telehealth no matter where they are, including in their homes. We have seen the value of waiving these specific limitations during the current crisis and learned that they serve no other purpose than to restrict access to care.

Congress should also ensure the Secretary of the Department of Health and Human Services (HHS) has the flexibility to expand the list of eligible practitioners and therapy services and, similarly, maintain the authority to add or remove specific telehealth services, as supported by data, to make certain all eligible services are safe, effective, and clinically appropriate. Allowing the Centers for Medicare and Medicaid (CMS) to determine and manage the range and scope of telehealth services through a predictable and transparent regulatory process will ensure patients and providers have certainty and clarity on the future of telehealth.

Congress showed great leadership in strengthening the capacity of providers treating our nation’s most vulnerable populations by allowing FQHCs and RHCs to be distant sites under the CARES Act. As our nation grapples with how to address disparities in health care access and health outcomes, Congress should work with stakeholders so that our nation’s FQHCs and RHCs are empowered to deliver virtual care to underserved communities with fair and appropriate reimbursement.

These reimbursement challenges represent the most critical barrier at the federal level to the provision of telehealth in a post-pandemic world. Understanding how these specific waivers have improved access to quality care during the pandemic, and how keeping these changes once the public health emergency declaration is rescinded, should be at the forefront of all our minds.

These are not the only policy changes that will be required to ensure telehealth can continue post-pandemic, but they are the most immediate federal policies that must be addressed. Additionally, technology and telehealth infrastructure remain a critical need. Congress can support recent COVID-19 investments by continuing to fund targeted grant, and technical assistance programs at the Federal Communications Commission and Health Services and Resources Administration or consider launching new infrastructure initiatives under HHS.

Federal agencies must also seriously consider other policies that have been loosened during the pandemic to determine if they are appropriate to continue. Such policies include flexibilities to use telehealth for remote prescribing of controlled substances and flexibilities around HIPAA requirements. In addition, states will need to continue to work together to offer more streamlined licensing across state lines. Congress should pay attention to all of these policies, but first and foremost, Congress should ensure federal law does not unnecessarily impede access to telehealth.

Ultimately, we need your support in ensuring patients and providers do not go over the telehealth “cliff” as our nation emerges from the pandemic. Essential telehealth services will abruptly end with the national emergency, and beneficiaries who have come to rely on critical virtual services will be forced back into a world with restricted access to convenient, digitally enabled care. Ensuring HHS and CMS have the needed flexibility to support high quality, safe, and effective virtual care is more important than ever as we look to enhance preparedness for future public health crises and reorient our healthcare system to deliver 21st century care.

Thank you again for inviting me to be here with you today, and I welcome your questions on how we have seen telehealth reach and serve patients during the pandemic and how we should work together to ensure all individuals receive the care they need – where and when they need it – in the future.

About the American Telemedicine Association (ATA)

The mission of the ATA is to support the ability of telehealth to transform healthcare and the patient and provider experience through enhanced, efficient, and more convenient delivery of healthcare services. The ATA is dedicated to promoting a health care system where more people have access to safe, effective, and appropriate care when and where they need it.

The ATA also plays a central role in introducing and supporting reforms in public health policy that can expand access to virtual care. In just one example, in response to the COVID-19 pandemic, the ATA joined with member companies to partner with Congress and rapidly identify and address a range of regulatory barriers that could prevent our nation’s ability to expand the use of telehealth services in a period of unprecedented demand for remote patient care.

The ATA continues to work to make sure that regulations and guidelines related to the use of telehealth reflect the needs of patients and providers as well as advances in technology. Some issues where the ATA and its members are working to introduce changes that will benefit patients and providers include limiting restrictions on access to telehealth services for Medicare beneficiaries, expanding the use of advanced technologies that can improve patient care, and supporting appropriate licensing requirements for providers.

The ATA believes policies that allow providers and patients to access care when and where they need it – using safe and effective technologies – can help improve patient outcomes at reduced costs. As such, we believe Congress must enact policies that will empower patients and allow for provider discretion when choosing how to best treat patients.

We believe federal telehealth legislation should reflect the following principles:

  1. Ensure patient choice, access, and satisfaction
  2. Enhance provider autonomy
  3. Incentivize 21st century care
  4. Enable healthcare delivery across state lines
  5. Empower advanced practice providers
  6. Expand access for underserved and at-risk populations
  7. Support seniors and expand “aging in place.”
  8. Protect patient privacy and ensure cybersecurity