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Making the pandemic's emergency suspension of Medicare's telehealth rules permanent got overwhelming support at a virtual hearing of the House Committee on Energy and Commerce's health subcommittee on Tuesday.

Members touted their bipartisan appreciation for what the technology has done and can yet do for healthcare.

"It's time to make Medicare reimbursement for telehealth permanent," said subcommittee chairwoman Anna G. Eshoo (D-Calif.) in opening the hearing. "Telehealth isn't the silver bullet for the deeper problems that exist in our healthcare system, but it's demonstrated great promise for high quality, innovative care if we intentionally create legislation that fits our nation's needs."

Subcommittee member Markwayne Mullin (R-Okla.) told how he had just been on a telemedicine call for his son with traumatic brain injury at the beginning of the hearing.

"I wasn't sure if I liked it at first," he said. Now, his family in rural Oklahoma has embraced it and has a care team at UCLA, with the overseeing specialist in California and another in Illinois. "I'm living this and it's beneficial. It's beneficial for us in rural America because we have the same access to care as those in major metropolitan areas."

CMS temporarily waived geographic and site-related restrictions allowing broad use of video and audio-only telemedicine and has continued to renew those waivers each time the public health emergency has been extended.

However, with COVID-19 vaccination reaching ever broader swaths of the country, many are looking to the post-pandemic future.

"The genie is out of the bottle concerning telehealth flexibilities and expansion," said Brett Guthrie (R-Ky.), the ranking member of the subcommittee. However, he argued for "guardrails" against fraud and abuse of the technology and noted that broadband is a key limiting factor.

Jack Resneck Jr., MD, of the American Medical Association Board of Trustees, agreed with many of the representatives who weighed in that broadband isn't just a problem in rural areas, but also for those in urban areas who cannot afford it.

But in terms of fraud, Resneck noted that national take-down cases that he has been involved with have actually been telefraud, not telehealth fraud. The fraudsters didn't use the new CPT codes or otherwise bill for telemedicine. The HHS Office of the Inspector General and Department of Justice already have the tools they need to address this and are doing so, Resneck argued.

Budget Buster?

Cost was another concern raised by the ranking member of the full House committee, said Cathy McMorris Rodgers (R-Wash.), who is also a leader in the rural health caucus. While Rodgers acknowledged that "telehealth can and should be part of modernizing healthcare in America," she pointed out that Medicare's Hospital Insurance Trust Fund is projected to go bankrupt even at the current pace by 2024.

The perception of overuse leading to increased healthcare costs hasn't been borne out in California's Stanford Health Care system, said its chief of staff, Megan R. Mahoney, MD, who was one of the witnesses called to testify at the hearing.

"Telehealth is a tool in our tool kit that is largely substitutive, not additive to in-person care. Practically speaking, we find that the physician's time is still the rate limiting factor for visits per day," she said.

Now after the initial peak in use during the lockdown and early pandemic, "across all Stanford clinics, we have stabilized at around 30 to 40% of visits being conducted virtually, and we believe this is our new normal," Mahoney said.

Before the pandemic, it had been additive, so more research may be needed after the pandemic, testified Ateev Mehrotra, MD, MPH, a healthcare policy researcher at Harvard Medical School in Boston. He argued that full telehealth access should not be maintained because it "can be too convenient in some circumstances." He argued for a focus on high-value applications.

Mahoney argued that virtual visits take the same effort and medical decision making, so they should be reimbursed the same as in-person visits.

The key to getting the balance right is adopting payment models with value-based accountability, agreed Elizabeth Mitchell, president and CEO of Purchaser Business Group on Health, which represents more than 40 "jumbo" employers that provide insurance to a total of over 15 million Americans.

Frederic Riccardi, president of the nonprofit Medicare Rights Center, advocated a "glide path" to wind down telehealth expansion after the pandemic has been over for perhaps a year or two. With so much unstudied, it's premature to make permanent, he argued.

A Role for the Humble Telephone

Audio-only telehealth was rarely reimbursed by government or commercial insurers before the pandemic, but temporary waivers to put it on equal footing have been well used.

One-third of Medicare beneficiaries have had audio-only visits, according to the early data available thus far from CMS.

Phone calls have been a lifeline, Riccardi noted. Older, poorer, rural, and minority groups have disproportionally less access to video technology, he pointed out. It's also proven particularly useful for behavioral health visits, he added.

On the other hand, it is more prone to fraud and abuse and sets up a two-tier system, Riccardi argued, again calling for extending the waivers for 1 or 2 years after the pandemic and instead focusing on ensuring all Americans have access to video visits.

Mehrotra noted that private insurers and Medicare Advantage plans are concerned about the same issues and most are not planning on covering audio-only telehealth in the future.

Eshoo noted that the latest stimulus package -- the -- includes $7 billion earmarked for broadband access, which should help address these concerns.

A number of plans for how to extend the waivers have been introduced, including the and , which would both be effective until 6 months after the public health emergency ends.

The introduced by a bipartisan group in the House would eliminate most geographic and originating site restrictions on the use of telehealth in Medicare and continue reimbursement for it for 90 days after the end of the pandemic, and would permanently allow HHS to expand telehealth in any disaster situation.

The would permanently remove Medicare's geographic and originating site restrictions and pull in more types of providers to deliver telehealth, including physical therapists and other allied health professionals.

"If we can get this done and done well, we will have made an extraordinary contribution for the American people," Eshoo concluded.

Among the 50 some groups that weighed into the congressional record on the hearing was the , which supported an end to the geographic and originating site restrictions, permanent coverage of audio-only services, and equal reimbursement for telehealth and in-person visits.

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