COVID-19 and the Rise of Telehealth
By Scott Boisvert, JD, Sravya Durbha, MBA and Elaine Nguyen
With the coronavirus drastically limiting in-person contact and appointments, healthcare providers have turned to a new tool that may change the healthcare industry in the long-term: telemedicine. Physicians are able to use an internet connection and computers, smartphones, or tablets to conduct virtual visits with their patients. An additional advantage of the telehealth visit is that it allows doctors to assess the patient’s home environment and whether it may be contributing to the patient’s health issue.
Acknowledging the need for telehealth visits during this time, state and federal regulators have made accommodations to increase access to this kind of care. The Centers for Medicare and Medicaid Services issued a waiver in March to expand the use of federally funded health insurance (Medicare, Medicaid, and the Children’s Health Insurance Program) to pay for telehealth visits. Before this waiver, Medicare would only cover telehealth visits on a limited basis, like for patients who lived in designated rural areas and had trouble getting to a medical facility. The Department of Health and Human Services also announced that they would relax HIPAA privacy restrictions so that health providers could use more common platforms like FaceTime and Zoom to communicate with patients. On the state level, North Carolina Medicaid similarly expanded its coverage of telehealth visits, as did Blue Cross Blue Shield of North Carolina, the state’s largest insurance provider.
While the COVID-19 pandemic can be seen as the catalyst for the rise of telehealth tools and utilization, public and private sector systems must ensure that these services evolve in parallel with the U.S.healthcare system, which is increasingly emphasizing value-based principles. One characteristic of telehealth that appeals to many is its ability to generate cost savings, as costs related to traveling to an in-person medical visit would not be incurred. Some argue that the convenience and potential accessibility of telehealth services will lead to their overuse by providers and patients, which will increase the total cost of care. In contrast, 32 states have enacted telehealth “parity laws”, which require insurance companies to pay health care providers for the same telehealth services that would have otherwise been covered during an in-person visit. This regulation is intended to incentivize physicians to take advantage of telehealth services over in-person services. North Carolina is one of 18 states that do not have a telehealth parity law, claiming that full parity, or equal payments, for telehealth services may undermine their cost-effectiveness due to overuse. States like North Carolina argue that, to take full advantage of the value of telehealth services, they must be reimbursed at a lower rate to reflect their value. While the U.S. struggles to resolve questions around payment for and the value of telehealth services, we also continue to face hurdles with respect to variations in telehealth insurance coverage and physician licensure requirements, as well as patient privacy and accessibility to medical data.
Furthermore, a broad and rushed expansion of telehealth may lead to disparate impacts on communities lacking sufficient internet connectivity. According to the Pew Research Center, only 73% of American households have broadband access. Broadband access is the gold-standard of internet connectivity—representing the fastest download speeds and corresponding device operability. Even more troubling is that this fundamental service is especially limited in rural communities (63%), low-income households (56% for incomes <$30,000), and among racial minorities (61% of Hispanic adults, 66% of Black adults). Known as the “digital divide”,the widening gap in internet connectivity between underprivileged communities and wealthy, suburban communities has implications far beyond Netflix buffering times. As more fundamental services have moved online in response to COVID-19—such as education—the detrimental impact of limited broadband access has become increasingly stark.
The digital divide presents an alarming picture of the current state of inequity in the U.S.with respect to access to internet services and telehealth. However, it is also a looming harbinger of the potential exacerbation of health inequities among underserved communities. The New York City Department of Health and Mental Hygiene found a substantially higher number of hospitalized and non-hospitalized COVID-19 cases among Black and Hispanic populations in the city. Furthermore, COVID-19 death rates among Black and Hispanic populations were 92.3 and 74.3 per 100,000 people respectively, compared to 45.2 deaths per 100,000 among white populations. Racial and ethnic minority groups are also more likely to experience inadequate economic and social infrastructure, underlying health conditions, lower access to care. Given these conditions, the populations deprived of broadband access and telehealth services may actually be at the highest risk for COVID-19.
Tying healthcare access to internet connectivity through the rapid adoption of telehealth measures adds a further barrier to already underserved communities. Telehealth necessitates base levels of internet connectivity to support providing services digitally. Less connectivity may result in decreased provider flexibility in diagnosis tools (such as access to high-definition video) and treatment options (such as using internet-connected devices)—let alone the 14,551,297 Americans excluded from telehealth entirely due lack of internet access at any speed.
To overcome the digital divide in healthcare and expand meaningful access to telehealth for all, we propose the following recommendations:
1. Policymakers should prioritize expanding digital infrastructure as part of telehealth rollout. Absent a broader definition of health care development that includes internet infrastructure investments, deploying telehealth broadly risks leaving beyond some of America’s most vulnerable populations.
2. Hospitals and policymakers must work together to incorporate value-based care principles into utilization of and reimbursement for telehealth services. Although telehealth presents the possibility of considerable cost-savings, stakeholders must fully consider the costs and benefits of telehealth over in-person visits when making decisions regarding parity laws and reimbursement rates.
About the Authors
Scott Boisvert, JD, recently graduated from the Duke University School of Law in May 2020 and was a Margolis Scholar in Law.
Sravya Durbha, MBA, recently graduated from the Duke University Fuqua School of Business in May 2020 and was a Margolis Scholar in Business.
Elaine Nguyen is a JD Candidate at the Duke University School of Law and is a Margolis Scholar in Law.