Among the many changes spurred by the COVID-19 pandemic, Americans made significant changes in how they use and access healthcare. Notably, new flexibilities to allow for telehealth visits accelerated an already growing trend of telehealth utilization across the country. As we all grapple with the evolving pandemic, which includes new variants and infection surges, telehealth continues to play an important role in providing access to health services. State officials also recognize that many individuals appreciate the convenience telehealth offers by bringing services directly to their homes.
Recently, with support from the Patient-Centered Outcomes Research Institute (PCORI), the National Academy for State Health Policy (NASHP) convened a group of state officials representing insurance departments (responsible for regulating individual, private health insurance coverage) and the state-based health insurance marketplaces for a conversation about telehealth issues and challenges in developing policies responsive to evolving patients needs in this changing environment. As framed by one official, there exist both opportunities and vulnerabilities in expanding access to telehealth through private insurance coverage. As officials monitor shifting trends, they are considering several important questions:
Where is telehealth working to serve unmet need? To increase access to services during the pandemic, temporary policies were put in place that lifted restrictions on telehealth services. These changes enabled telehealth access to a broad range of provider types (e.g., behavioral health providers, specialists, out-of-state providers) and the use of technology available on smartphones and personal laptops (e.g., video conferencing apps like Skype and Zoom, audio-only platforms). Although these changes were implemented to maintain access to care while mitigating potential spread of the virus through in-person encounters, the benefits of connecting with health providers virtually have had some advantages. Eased telehealth restrictions opened access to providers in areas with known physician shortages and reached patients that, due to physical or social barriers such as disability and lack of transit options, had been limited in accessing care in the past.
Many state policymakers are considering whether to sustain less restricted access to telehealth. However, some policymakers shared concerns that these policies, while designed to sustain increased access, do not inadvertently exacerbate existing disparities. For example, one study of telehealth use during spring of 2020 found that race/ethnicity, socioeconomic factors, age and English proficiency all factored in to accessibility of telehealth services to treat ambulatory care services. Additional surveys and studies examining telehealth use during the COVID-19 pandemic have similarly found disparate use of telehealth by patients across age,language, and racial/ethnic groups. State officials expressed additional concerns that enabling telehealth access in some communities could inadvertently encourage isolation among populations that would benefit from in-person services, including those with certain behavioral health conditions. Similarly, would it limit access to services that can only be performed in-person, like vaccination services for children?
What effect will increased telehealth access have on provider networks? Health insurance carriers and regulators are considering what the permanent adoption of telehealth policies could mean for their networks. Some carriers are seeking feedback from state insurance departments about whether access to providers via telehealth meets network adequacy standards. State officials also report that the increased use of telehealth is causing some providers to reconsider how they choose to deliver services, with some providers seeking to permanently close their offices and shift to remote work. Some states are weighing network flexibility that enables patients to have access to a greater number of remote providers but worry this could also result in a decrease in the availability of in-person services. Future policies must balance strategies to maintain in-person access, especially in regions already prone to challenges with retaining health care providers.
What will evolving patient behaviors and capabilities mean for utilization going forward? As the public grows more comfortable with online tools, there is likely to be continued demand for telehealth services. After hitting peak usage in April 2020, use of telehealth has since stabilized with usage level 38 times greater than what they were pre-pandemic. Some state officials noted the return by patients to in-person services was quicker than expected, acknowledging pent-up need and desire for in-person visits, even if telehealth services were available. Others noted that telehealth utilization trends are not consistent across services. One official noted that while telehealth visits had grown by 25 percent for specialty care, they had seen a 65 percent increase in remote behavioral health services. Similarly, a McKinsey study released in July 2021 found that psychiatric and substance use disorder treatments services accounted for the largest share of telehealth claims, while specialty services including ophthalmology, orthopedic, and gynecology ranked toward the bottom. Where possible, flexible telehealth policies may be needed given different needs across patient and provider groups.
What impact does telehealth utilization have on cost and quality of care? Ultimately, the use of telehealth could have a significant impact on utilization and access to the cost and quality of care. As a result, insurance department and marketplace officials are monitoring how these changes may be affecting premiums and coverage of services. For some, telehealth has great potential to improve efficiencies and lower costs, but concerns remain over how effectively telehealth can substitute for in-person services and where it could effectively lead to lower system costs. State officials specifically expressed interest in further evaluation of scenarios in which telehealth was successful in improving costs and outcomes in the case of crisis needs or services. In January 2022, PCORI released one such report which examined 20 studies of the use of videoconferencing for disease prevention, diagnosis, and treatment of various chronic conditions and post-operative care, finding that use of videoconferencing appeared to be as effective as usual care (For more information see: PCORIs First Rapid Review: Video-Teleconferencing for Disease Prevention, Diagnosis, and Treatment).
While the response to COVID-19 opened new access to and experimentation with telehealth, it is premature to fully assess what changes mean for the long-term, especially as patient and provider behaviors continue to shift. Experts and researchers alike are working diligently to provide resources to help inform future efforts, like the growing library of research available through PCORI on telehealth services (for more see, Using Evidence to Inform Evolving Telehealth Policies). NASHP will monitor as more findings emerge and states advance additional efforts aimed at addressing telehealth needs.
