NUR 740 Assignment 13.1: Contemporary Health Policy Project: Presentation

Learning Materials

Reading these materials will provide you with information regarding health policy implications for advanced practice nurses who address the needs of the populations outlined in these chapters.

Read the following in your Health Policy and Advanced Practice Nursing textbook:

• Chapter 15, “The Impact of the Doctor of Nursing Practice on Primary Care”
• Chapter 16, “Telehealth, Distance-Driven Modalities of Care and Interstate Policy Implications”
• Chapter 17, “Interface of Practice and Policy in Mental Healthcare: Implications for Psychiatric Mental Health Nurses”

Additional Required Resources

Review the following website to access information on telehealth policies along with coverage and reimbursement in your state:

National Conference of State Legislatures. (n.d.). State telehealth policies (Links to an external site.).

Telehealth: A Flash in the Pan(demic) or Here for the Long Haul? Webinar

Review this webinar where national experts and state legislative respondents discuss implications of telehealth policy during the pandemic and beyond.

NCSLong. (2021, August 26). Telehealth: A flash in the pan(demic) or here for the long haul? Webinar (1:00:41 minutes) (Links to an external site.) [Video]. YouTube.

Telehealth Transcript

Telehealth A Flash in the Pan(demic) or Here for the Long Haul Webinar

Jack Pitzer: Hello everyone, and thank you for joining us. We are going to just wait 10-ish or 15-ish seconds here while people trickle into the Zoom room. I hope wherever you’re tuning in from the weather is nice. It is very sunny and hot here in Denver, which is part of the reason I am here at our Denver office because we have nice air-conditioning in our office here and I do not have air conditioning at my house and I didn’t want to sweat for you all on video during this webinar. But yes, appreciate you all joining and looking forward to the next hour that we’ll be sharing with each other.

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And I am looking through who’s joining us and see some familiar faces and some new ones. So, thank you for those who are joining us for some NCSL events again, and welcome to anyone who this may be their first NCSL event.

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All right, I am getting the notification that I could stop filling the space and talking and we can go ahead and actually officially start this thing. So, thank you everyone for joining us and good afternoon or good morning. You are here watching NCSL’s webinar, Telehealth: A Flash in the Pan(demic) or Here for the Long Haul. My name is Jack Pitzer and I am a policy associate with NCSL’s health program and I will be your or moderator for today.

And just a few things before we go ahead and get started. The first is that we encourage and look forward to your participation throughout the next hour and there’s two ways to do that. There is the chat function where you can go ahead and throw in any questions or comments and insights that you may have, and then throw questions in the Q&A box. See, I’m already messing things up, but you can put questions in the Q&A throughout the entire next hour. We will be taking a few burning questions after a few presentations, and then we’ll save more time at the end of the hour for a larger Q&A session. So go ahead and pose those questions to all our speakers throughout our time together.

And let’s go ahead and do a little bit of a warm up in the chat. So I’d love for you all to enter in your name, the state where you’re tuning in from, and what is one change to your day to day life brought on by COVID that you would like to continue practicing post pandemic? So that can be spending more time outdoors hiking. It could be connecting with family and friends that live far away via Zoom. It could be working every single day from the comfort of your home in the comfort of your sweatpants. Whatever has been a positive change to your life that you hope to continue practicing post COVID.

And while you all are entering those responses into the chat, I just have a few quick reminders for you all. The first is that today’s webinar is being recorded and will be posted within the week on our NCSL website. Also, if you are having any technical issues, please reach out to registration@ncsl.org. And also we are going to have a brief survey at the end of the webinar. So I’m flagging that for you now, so you all can look forward to that. And then lastly, I want to show some gratitude to the Health Resources and Services Administration for their support for today’s webinar.

Okay. And before we do jump into our agenda and presentation, I wanted to very quickly plug NCSL’s very timely Telehealth Toolkit that we released at the end of last month and that my NCSL colleague, Kelly Hughes is throwing into the chat now. So, this toolkit looks at different opportunities, challenges, and key topics related to state telehealth policy. And so it touches on things like Medicaid and private insurance coverage for telehealth, provider licensing requirements, states that are permanently incorporating those COVID flexibilities into state law permanently, and much, much more. So go ahead and check out that toolkit for the latest legislative trends and examples related to telehealth.

And with those logistics and shameless plugging out of the way, we can actually go ahead and get started now. So going back to the prompt question, there’s a reason that I had asked you all which sort of COVID-related changes you hope to continue practicing. I’m seeing weekly Zoom meetings with family. That was something that my family did too and we really, really loved it. Working remotely. I mean that’s a given and we love the work from home life and the flexibility. And so the reason why I ask this is because just as we are determining how COVID-19 has changed our lives for good, state policy makers are really taking stock of the many telehealth flexibilities they pursued during the COVID-19 pandemic and looking at which of these changes they’d like to continue on for the long haul. So, part of that telehealth explainer series contains our COVID-19 brief where we have tracked at least 51 enacted bills across 37 states, where those states have permanently incorporated those telehealth flexibilities into state law.

So for today’s webinar, we’re really going to be looking into these trends and much more with the help of some wonderful speakers. So, first we’re going to hear from Mei Wa Kwong, the Executive Director for the Center for Connected Health Policy, and she’s going to provide an update on federal and state policy changes made during the pandemic and actions to make some of these changes permanent. And then we’re going to hear from Heather Dimeris, who is the Deputy Associate Administrator for the Federal Office of Rural Health Policy at HRSA and she’s going to discuss how HRSA, as a federal agency within the Department of Health and Human Services, has been leveraging telehealth during the pandemic and also touch on some funding opportunities and resources for the states. And then lastly, we are going to hear from two legislative respondents, Representative Cobb of Arizona and Senator Lyons of Vermont who are both heavily involved in legislative efforts in their states to permanently extend telehealth flexibilities beyond the pandemic. Then of course, we are going to wrap up with a little Q&A.

With that, I’m going to pass it over to Mei to go ahead and kick us off.

Mei Wa Kwong: Thank you Jack and thank you NCSL for inviting me here today. As Jack mentioned, my name is Mei Kwong, the Executive Director to Center for Connected Health Policy. Next slide please. And I am an attorney by training and education. So whenever I speak, I always have to start off with couple of quick disclaimers. So, any information provided in today’s talk is not to be regarded as legal advice. It is strictly for informational purposes. CCHP always recommends that you consult with legal counsel if you’re interested in formal legal opinion. And also if I happen to mention a company or show a picture of a product, know that neither I nor CCHP has any type of relevant financial interest arrangement or a relationship with such a company.

Next slide. A bit of background about CCHP. We were established in 2009 as a program underneath the Public Health Institute as a California telehealth policy organization. However, an opportunity to become the federally-designated national telehealth policy research center became available in 2012 through a grant from HRSA. We applied for that and we have been serving in that capacity ever since. What that means is that CCHP provides technical assistance to people who have question regarding telehealth policy. We are primarily there to help the other 12 regional telehealth resource centers underneath the same grant program. They help specific states and with the program operational level questions around telehealth. So whenever they encounter a telehealth policy question that they can’t answer, they send it on to CCHP. But really we do have a more broad landscape or scope of work of what we do. So we have helped everybody from the administration at the White House to congressional members to state policy makers like yourselves to nonprofit organizations that are nationwide, such as ARP and the Association of State Maternal and Child Health Programs to health systems, health payers, providers, and more increasingly during COVID-19, directly helping consumers and patients who were new to telehealth or just found out about it and had questions around it.

We also work with a variety of other funders and partners on the state and federal level on more specific telehealth projects. And we act as an administrator for the National Consortium of Telehealth Resource Center. So the National Consortium is made up of the 14 telehealth resource center who receive a grant from HRSA like CCHP does. We decided a couple years ago to really be more efficient with our federal funds to work very collaboratively together on joint projects. So we pool a bit of our grants into a common pot to work on these joint projects and we work underneath the umbrella of the National Consortium Telehealth Resource Centers. So CCHP acts as that main point of contact and also the administer of those funds and helps do with the administrative work that keeps that organization running.

We also convene a group in California called the California Telehealth Policy Coalition. That’s been around for about nine years. It started off with six organizations who are interested around telehealth policy because there was a significant bill going through the California legislature. But after that bill passed and was signed into law, the organization decided they still wanted to meet and discuss telehealth policy in the state, and it’s grown from those six organizations to over 100 statewide and now national groups who are members of the coalition.

Next slide. So it was very interesting, the title, oops, the title of the webinar for today, which was, is telehealth a flash in the pan? And it is not necessarily. If we can go back a couple of slides? Yes, to this slide here. This is your 100,000 foot level view of all the changes that happen around telehealth policy on the federal and the state level. And as you can see, there’s a lot of commonalities at least to issue area that they touched upon, such as location, the type of providers able to provide services, what types of services we cover, what modalities were used. And then a couple of other areas that were a little bit more prevalent on the federal side than they were on the state, such as the DEA and allowing telehealth to be used to prescribe controlled substances, and on the state side discussion around what private payers needed to do around covering telehealth. But overall there were a lot of similarities, at least as far as what area policy changes, temporary policy changes had to touch upon.

Now, that’s mainly because these are the areas that typically telehealth policy existed around. And a lot of those areas concern reimbursement. So we’re talking like Medicare, Medicaid, what do they cover when telehealth is used? Although there were a couple other issue areas that policy touches upon and where telehealth does have some sort of element that is impacted, such as prescribing. But for the most part, a lot of the policy changes that we saw, the temporary waivers did relate to what’s covered, what’s paid for, and who can provided and where it can be provided.

Now, the question is, is this going to stick around though? Or was this just a one-off of being used to address the pandemic? And as Jack mentioned earlier, there’s actually been significant changes made in a lot of states already to make permanent some of these telehealth policies. I’m going to cover what’s going on on the federal level, as far as trying to make some of these things permanent and also what’s going on on the state level. And you may ask yourself, why am I bothering covering what’s going on the federal level, because mainly there are states here? It’s because those federal policies will impact the state level in a couple of ways. There may be things that are happening in Medicare that may influence what’s done in Medicaid, but also the people that are impacted. And I’m thinking particularly of community health centers like federally-qualified health centers, their policies are being changed on the federal level, so that can impact these community healthcare clinics in your states and how they may be utilizing telehealth and servicing your populations.

Next slide please. All right. So, what’s going on on the federal level? A lot of the telehealth policy changes on the federal level would really require a federal statutory change because a lot of the existing telehealth-specific policy on the federal level is in Medicare, and the Medicare telehealth policies are embedded in federal statutes. So you literally need an act of Congress to change a lot of those barriers to telehealth that were temporary away during the pandemic. There is a way to change a couple of things though, administratively. So these are be things that CMS can do, and the way CMS would go about that is they will issue a proposal to change the regulations, and they typically do it through the Physician Fee Schedule.

For those who are not familiar with this, the Physician Fee Schedule is basically CMS issuing their proposals on how they will be operating and the changes that they’re going to make to the Medicare program for the following year. So the proposed Physician Fee Schedule for 2022, they issued their draft proposals in July of 2021. There’s a comment period for the public, and then they finalize them around towards the end of the year, some time in November, sometimes it stretches to early December if they’re running a little bit behind, but around that time of year, they’ll finalize it. And then all those proposals kick in unless they’re dated out for a further date, usually by January 1st. So what CMS has done this year is that they’ve actually made some significant changes in their telehealth policy. A couple of things that were pretty surprising and that significantly impacted community health centers like FQHCs.

So next slide. So one of the first things that they are able to do that they don’t have to require a statutory change is that Medicare can add what services are eligible to be provided via telehealth and be reimbursed by the Medicare program. And they didn’t really do that this year. They didn’t necessarily add any new services to be covered, but what they had done the previous year was they had created a holding pen of services that were allowed temporarily because of the pandemic where they said, “We’re going to create a holding pen for these services and we’re going to give them a bit of time, if the pandemic ends a bit of time beyond the pandemic to see if there’s evidence to show that they would be good to continue to be provided via telehealth and we will reimburse you for them.” So what they did with that temporary holding bucket, they extended it to the end of 2023 in order to gather that evidence to decide if they’re going to put them on the permanent eligible list for services to be delivered via telehealth and covered by the Medicare program.

So they didn’t necessarily add new services to be allowed to be provided via telehealth and covered by Medicare, but they extended the time for the temporary list, which they called Category Three to stick around at least through 2023.

Next slide. The other thing that they had to do was because they were required to do it due to the Consolidated Appropriations Act passed by Congress in December of 2020. Now in that act, there weren’t a lot of permanent telehealth changes. None of the waivers, the temporary waivers on the federal level were actually in that bill, but what Congress did was they added this clause or this section in there where they said that for mental health services, some of the restrictions that we typically have for telehealth and the Medicare program, which means the patient needs to be in a certain geographical area and they need to be in a certain type of health facility usually. They said that, “In this bill for mental health services, we are going to allow the services to take place in the home,” so remember it’s the site restriction, “and we’re going to not have a geographical restriction apply. However, the patient must have a visit six months prior to the telehealth services taking place in person with the telehealth provider.”

So this was in the bill, then the Physician Fee Schedule CMS has to implement that language now. And so they put out the language of how they were going to implement this. And this is significant because, yes, it does allow you to do more mental health services via telehealth, but you have this caveat of having this in-person visit six months prior to the telehealth visit taking place, which actually narrows your window of availability on what’s allowed because now you need this in-person visit so it’s going to be very difficult if you were using a mental health provider who was maybe not necessarily located near you and you would have to either drive there or you would need to try to come in under the usual exceptions, which means going into a clinic for that telehealth interaction.

The sort of… Oops, if you can go back. The one element that they put in here was that they said, and this was not in the statutory language, but this is the process or how CMS is going to propose implementing it, is saying that that six month in-person visit, we’re going to require that that exists before each telehealth visit. So what that means is, if I do my six month visit, I have my telehealth visit, and then I do not see my telehealth provider for like another eight months, I’m going to need to have another in-person visit in order to have that eight month telehealth visit. So every six months before a telehealth visit, I need to have had some type of in-person visit with that provider. So it’s also a bit of an additional burden there on the patient. And this is significant because it was never required. This in-person visit was never required before for telehealth underneath the Medicare program. So this was significant that this was put into statute, and now it’s being implemented now in the Medicare program.

Next slide. Now here are the more significant changes. So CMS was required to do that because that is in federal law. So they had to implement that. But the next couple slides that I’m going to go over are things that they are proposing. And one of the big things that happened during the pandemic was, not only with telehealth more broadly used, but audio only was allowed to be a modality. Now before COVID-19, I think most of your states probably excluded audio only from being underneath the umbrella of telehealth. There was either an explicit exclusion, such as a, “Telehealth means X, Y, and Z. It does not mean audio only or audio only is not covered.” Or it was in your Medicaid policies, but there were a lot of states that explicitly excluded it and said, “This does not count as telehealth.” However during the pandemic, policy makers recognizing that everybody having access to live video or the technology, because for whatever reason, audio only may be their only way of accessing health services.

So the question a lot of policy makers have been struggling with, both on the federal and state level is like, “What are we going to do with audio only beyond the pandemic?” CMS made the first step on at least making something permanent. So for audio only, they have said, “We’re going to allow audio only for provision of mental health services if certain conditions are met.” So these conditions that are bulleted here, such as it’s for an established patient, so the provider who’s doing audio only already has a patient-provider relationship with the patient. The patient’s at home and the reasoning for that they said is that that’s most likely what you’re going to use audio only for, because you’ve run into connectivity issues so you can’t use live video. But the provider does have the capacity to use live video and the patient doesn’t want to do live video, and again, they’re adding that six month in-person requirement before.

So this is very interesting that they did this because as I said, CMS does not have a lot of leeway as far as what they can do with telehealth policy, because a lot of it’s embedded in federal law, but in federal law when they talk about telehealth being delivered, how it’s being delivered, they say it’s being delivered through a telecommunication system and it’s not defined as statute as to what that means. So CMS is taking advantage about that and saying that audio only can fall underneath that definition of a telecommunication system, so we’re going to allow this narrow exception to be used for audio only. And the reasoning was because they felt comfortable that this was a way that services could be provided effectively to the patient and also the great need for mental health services.

Next slide. Now, the other big thing that they did revolved around community health centers like FQHCs and RHCs. Now in Medicare underneath federal law, FQHCs and RHCs are not allowed to provide services via telehealth. They can be basically [inaudible 00:22:13], they can be the site where the patient goes to and then they can connect them to telehealth, but they are not that telehealth provider. And that is in federal statute. So the way CMS approached this is that they are saying, “We’re going to redefine what a mental health visit means for an FQHC and RHC and we are going to put in that new definition that it also includes encounters furnished through interactive real-time telecommunications technology.” So they are not saying FQHCs and RHCs are allowed to use telehealth, they are just saying that for the definition of a mental health visit, it can be furnished through this interactive real-time technology.

What that means is it includes live video and audio only. So it’s not telehealth, so they’re not going to be held to the same restrictions that you would of a telehealth visit, such as it needs to be in a rural area, it needs to be in these types of facilities and everything, because what they’re redefining is what a visit means for these particular community health centers. And that’s significant. So that is significant in that, as I said, and this is why I said that some of this federal stuff is going to impact the states as well, because now this opens up your FQHCs and RHCs who are treating Medicare patients to use, at least for mental health visit, telehealth or use the technology to provide the services. And these community health centers will continue to receive their usual rate, their typical rate. They’re not going to be paid a lesser amount like they were during the pandemic when they were using telehealth. They’re going to get their PPS and air rates.

Next slide. So this slide is on the audio-only side of things. So as I said, FQHCs and RHCs will be allowed to use both live video and audio only to provide these mental health visits. Now just want to stress that, these are for mental health visits. So it’s not all services that FQHCs and RHCs supply, but just mental health visits, but we’re seeking comments, CMS is seeking comments on like, “Oh, should we include the six months prior visit requirement like we had underneath the Consolidated Appropriations Act? Should that also be included here too?” So they are asking for comments on whether that should be applied to FQHCs and RHCs.

Next slide. Some other things that are going on. We can go down a big rabbit hole here, but the way CMS approaches services delivered via telehealth technologies are two things. You have your telehealth bucket, which is controlled a lot by federal statute, and then you have your other bucket of technology-enabled services that they use telehealth technologies but CMS does not regard them as telehealth services, but they use those telehealth technologies to provide their services. And underneath that bucket are remote therapeutic monitoring services. So they are proposing new codes to end services to be reimbursed and that’s what that is.

Next slide. And then they had a bunch of other proposals in there as well. So, some of these were COVID-19 temporary proposals, such as some of their other codes like permanent adoption of G2252, it’s a virtual check-in code. So this is, and some of their supervisory allowances. They were asking, “Should we keep some of these things around?” But these were a couple of other more miscellaneous types of proposals that they made in the Physician Fee Schedule.

Next slide. Federal legislation. Now I said a lot of the federal stuff is embedded in its federal statute. So what is going on with changing that? There’s over 100 pieces of federal legislation that CCHP has been tracking. A lot of them deal with making permanent some of those COVID temporary changes, but also around licensure, mental health, and doing pilots around telehealth.

Next slide. The major bill around that is the Connect Act for Health. It’s being authored by Senator Brian Schatz. I think he has over 50 co-sponsors in the Senate. It would remove a lot of the barriers that we see on the federal level in regards to telehealth. So this is a list of it. I’m not going to go over every single one, but that’s one of the more significant bills out there.

Next slide. And then we can just go to the next slide and the next slide. So I’m happy if folks want a copy of this PowerPoint, Jack has it so he can send it out if he wants, but we also did do a fact sheet on that particular bill too. So you can download that if you want.

Now, next slide, we’re going to get into the state law. So prior to COVID-19 and COVID-19 we took a look at what were permanent policies here in Medicaid regarding what’s going on in the states. All states were doing some sort of live video reimbursement, store and forward and remote outpatient monitoring not as popular, but it did exist for almost half the states in a little bit over that in the remote patient monitoring case.

Next slide. States also have private payer laws. So these are laws, unlike what commercial health plans are supposed to do around telehealth, and they range from everything from health plans, you shall cover telehealth if it’s… Or health plans, you may cover telehealth delivered services all the way to a state law MSA. Health plan, you shall cover telehealth delivered services. And by the way, you will pay the same amount for that if you would’ve in person, and everybody else kind of falls in between.

Next slide. So audio only, this is research that was based between February and June of 2021. This is what we have for audio only that we found at CCHP. Now CCHP, we look at states where there is actual policy that has been implemented there. So there may have been legislation saying that they were allowing audio only in the Medicaid program, but until we see the actual Medicaid policy in writing, we did not count that. So that may be a lower number than what you might see with other people and what they’re saying is allowed for audio only. So that’s what we had from February to June of this year.

Next slide. Changes that we have seen. Jack had gone over a little bit of this, but I just want to give you a little bit of a perspective here, is that in 2020, there were states who were already making changes. So there were 104 legislative billed passed in 36 states that had some sort of telehealth component to it. We’re not sure how many of those are actually related to COVID, so some of them were obvious in that they would say COVID or pandemic, but then others were not as obvious. So we weren’t sure if they were already in the works before the pandemic and they just went along the process, but that was basically around a lot of Medicaid reimbursement, around a lot of private payer laws adjustments. Not as many licensure bills or demonstration projects, which are typically what we see a lot with state legislation at least before the pandemic.

Next slide. These were some changes, examples of some of the changes that were made in specific states and what they did around remote patient monitoring and private payer laws and audio only as you saw.

Next slide. State telehealth in 2021. What we’re seeing now, as far as legislation is the trends are around licensure. We’re seeing that returning again, which was a significant issue because we actually had quite a few calls of patients who were stuck in states because travel restrictions or they were caring for family members and saying like, “But I can’t access my regular doctor because they’re not licensed here.” Board guidelines of directing boards, licensing boards to do guidelines or do something around telehealth, be a little bit more explicit in what you want your licensees to do. And then the recurrence now of pilots and demonstration projects, having that in legislation, that took a little break in 2020, but we’re seeing a lot more of them in 2021. Policy makers are really struggling, I think, with deciding on what to keep around, particularly around that audio-only question. I did see something pop up saying there was a concern that audio only may increase fraud. So yes, that’s one of the factors I think policy makers are thinking of in deciding whether to keep audio only around or to what extent to keep it around.

Next slide. So here are some of the things that have happened in 2021 so far. So there’s been temporary extension of the COVID-19 waivers. California and Connecticut did that. California, they even said that at least the temporary extensions would extend to 2022. Licensure changes that we see, being a little bit more broad and relaxed with their licensure requirements. Private payer laws allowing changes to that and what they are expecting them to cover in telehealth. And audio-only payment. And then the big question that we get a lot from people is, what’s going to happen when the PHE ends? What’s going to happen to all these telehealth extensions? And the answers we always give is like, “Well, it depends. It depends if the extension was tied to the federal PHE or a state one and then how they’ve written that as well.”

So these are some of the things that are still looming on around there, and I think that’s the end of my slides here. I just want to say, and talk about putting in a shameless plug, CCHP has been doing a series of Medicaid webinars. So we did one in the winter and we did one in the spring where we invite Medicaid programs to talk about their telehealth policies and their experiences. So we have a fall one scheduled for September through October. If anyone is interested in that, that information is on our CCHP website. I can also send that on to Jack if he is interested in having that information on hand. And I think that is it and my time is up and I turn it back to you. Thank you.

Jack Pitzer: Thank you so much Mei. Great federal and state examples in there and we love a shameless plug and I rolled in those Medicaid webinars, so looking forward to those. And there are a lot of good questions and comments in the chat, we’ll maybe take just one real quick one. There was comments about that audio only and then the question that I have in relation to that is, are states following CMS’s lead in putting any restrictions on audio-only telephone consultations, making it only available for mental health, when they’re looking at making those changes permanent?

Mei Wa Kwong: You know what? I want to say CMS may have followed some of the state leads because some of the states back in 2020 actually did make audio only permanent. I think Tennessee did, but Tennessee was clear and said like, “This is only for mental, behavioral health services.” So there were a couple of states back in 2020 in their Medicaid program where they made audio only permanent, but for a very narrow set of services, such as for substance use disorder was a big one for treatment, SUD.

Jack Pitzer: Wonderful. Thank you. And we are going to move on to our next presentation, but we will loop back to a lot of the great questions that we have in the chat and continue putting those into the chat. But we are next going to hear from Heather Dimeris, who is the Associate Deputy Director for the Federal Office of Rural Health Policy at HRSA and she’s going to talk a little bit about how HRSA has been prioritizing telehealth during the pandemic and touch on some resources and funding opportunities that HRSA has put out there for the state. So Heather, the virtual floor is yours.

Heather Dimeris: Thanks so much Jack and thanks to NCSL for having us on. It is an honor and I’m humbled to speak after Mei. She is such an expert on telehealth policies across federal and state, so it’s wonderful to share the space with her.

I would like to go ahead to the next slide and just provide a little bit of an overview about what HHS and HRSA and the Office for Advancement of Telehealth is doing around telehealth. Certainly everything that Mei covered really gave a glimpse at how things have changed over the last year and a half, but really as we call it, Office for the Advancement of Telehealth or OAT, really serves across HHS to coordinate with other federal partners around telehealth. And now because broadband, as you know, is such the foundation of telehealth services and really anything that we’re doing virtually from home during social distancing, we really do incorporate broadband services within the work that we do around telehealth too, and really promoting technology in order to help deliver access to healthcare. And that was what we did before the pandemic, certainly with the public health emergency, things have escalated and really just expanded so much for the work that we do.

So I’ll go ahead on to the next slide and just describe a little bit about what Mei has reviewed in a lot of detail, but in one quick slide, these are the changes that used to be, or these are the current changes under the telehealth flexibilities that Mei reviewed and prior to the pandemic and the public health emergency, these were often the barriers where, as she mentioned, federally-qualified health centers or rural health clinics couldn’t bill as distant site providers. Now under the public health emergency, that flexibility has allowed them to go ahead and bill for those services. And so this is just a really nice glimpse at some of the policy changes that Mei has already gone over in detail. So I’ll go ahead and go onto the next slide.

Some of the investments that we had over the pandemic came through CARES Act funding. So our Office for the Advancement of Telehealth receives quite a bit of funding, and as you know, the Health Center Program, the National Service Corps, Ryan White Programs, a lot of the maternal and child health programs like the Home Visiting Program, all include pieces of telehealth. So certainly within HRSA, we have a big footprint beyond just the Office for the Advancement of Telehealth and our regular appropriation. I want to say in 2020, we had over 3,800 awards that were made across HRSA that included a telehealth component. So even though we have programs within the Office for the Advancement of Telehealth that just focus on telehealth, there’s a lot that’s touched across HRSA and there’s a lot that’s touched across telehealth in any department or agency that you look at in government, especially right now.

But specifically with CARES Act funding, we received funding for provider telehealth training in our Bureau of Health Workforce. We also received funding, as you see, for the Maternal and Child Health Bureau to assist with services for the pediatric and maternal populations. And then as Mei mentioned, the telehealth resource centers are such an incredible resource to help providers understand how to incorporate telehealth into their practice. So, that level of interest in the telehealth resource center’s technical assistance increased over 285% from the years prior to the pandemic. So the funding that they received through CARES Act was much needed and really utilized to help provide any technical assistance needed to those providers during such an urgent time last year, and continuing in some degree this year as we see the COVID rates rise and fall.

I also just want to mention, we received $5 million to assist clinicians on licensure and credentialing. And certainly, this is specific to telehealth in our eyes through the Licensure and Portability Program, but it can also help for providers who practice across state lines and who don’t use telehealth services. And the neat thing that I’ll show you in a few slides are some of the resources that were built through this funding to really help clinicians facilitate that process, decrease the burden on them, because they do have so much time that they need to spend on clinical care, the paperwork to get credentialed in multiple states can be difficult. So I’ll share those resources with you in a minute.

And then last but not least, the $8 million on the slide that you see to support telehealth broadband came about later in the public health emergency, and really that understanding that broadband was such an integral part and foundation for telehealth services, especially for rural areas through a newer, at the time, memorandum of understanding, it’s about a year old now, that served the Rural Health Initiative, the Department of Health and Human Services, along with the US Department of Agriculture and the Federal Communications Commission, all gathered to really think through how to help support rural communities with telehealth broadband services and those conversations continue, as you can see, through the work in state and federal government, in addition to the work on the hill with the infrastructure bill language. And through this smaller amount compared to those other dollar amounts, the $8 million is really a pilot program to assess in four states, select rural counties and testing out their broadband access, not just within the county itself, but within specific sites.

So if you’re in a clinic or a hospital or your home, how much access do you have? Rather than the broader mapping capabilities we have right now at the FCC where if one person in the county has access to broadband, it counts as the whole county has access. And we all know from teleworking and probably also having some telehealth visits ourselves over the past year and a half, that if you have access in one part of your house or one part of the county, it doesn’t mean you have it everywhere. So I think this is going to inform us a lot about rural communities and getting access to broadband services.

Next slide. The other piece of funding that we received was to really develop one resource for both patients and providers to turn to for telehealth assistance. And through the last year it was launched April 2020, the Department of Health and Human Services created Telehealth.HHS.gov. It really has grown since we launched it and had the minimum viable product that was released. We got the information out that was needed, but now, oh my gosh, we’ve built resources for providers that tap into the resources that the telehealth resource centers, as well as other US Department of Health and Human Services agencies have for providers and for patients around accessing telehealth.

One example is a best practice guide for telehealth services on direct to consumer care. Another one is on emergency services and another one is on telebehavioral health. And we keep adding them as we find topics that are relevant to the field of telehealth and what providers need, so they can really have a nice tutorial of what to do and how to walk through it in one place. And so, just really encourage folks to go to this website for resources and it will patch them into a lot of other great information, whether it’s reimbursement, licensure or technical assistance.

So next slide. As I mentioned, there are a lot of different resources I wanted to share with you. The top one is the website I just mentioned. Clearly the telehealth resource centers is second. And the licensure resources I mentioned in which we received an additional $5 million through the CARES Act funding predominantly went towards the Provider Bridge that you see in the third bullet, as well as the Multi-Discipline Licensure Resource Project, the fourth bullet. The first one, the Provider Bridge really focuses on MDs, DOs, and physician assistants to help facilitate that licensure portability application process. And then the second one focuses on psychologists, social workers, occupational therapists, and physical therapists. So, really encourage folks to disseminate that information as it does help providers facilitate that care. And then the telehealth research center that we have some published research that we’ve done through the Office for the Advancement of Telehealth, as well as the Rural Health Information Hub.

So with that, I believe that was my last slide. I wanted to make sure I went through things quickly, but certainly am available for questions.

Jack Pitzer: Wonderful. Thank you so much, Heather. It’s really great hearing all the ways that HRSA has been turning to telehealth both a little bit before, and especially during the pandemic and hopefully soon after the pandemic. But now we are going to move on to our next segment of the webinar, and so I am going to invite to the virtual stage, Senator Lyons of Vermont and Representative Cobb of Arizona because we’ve taken a broad look at state and federal actions and we want to hear a little bit about state experiences from the legislative perspective. So thank you both so much for being here today. Greatly appreciate it. And I would love to just start off with a little bit of level setting of what telehealth looked like in your states, both pre-pandemic, and then right at the beginning of the pandemic. So what was the telehealth policy landscape in Arizona and Vermont before the pandemic and what were some immediate changes the state pursued either legislatively or through executive action at the very beginning of the COVID-19 pandemic? And Representative Cobb, I’ll throw those questions to you first.

Representative Cobb: Thank you. Thank you so much, Jack. I’m just going to do a quick introduction as far as what my background is. I have been in the legislative for seven years, been a Vice Chair of Health for four years, Chair of Health Appropriations for two years, and for the last four years I’ve been Appropriations Chair and Vice Chair of Health. So I have a little bit of background with telehealth in the past. I have ran several bills myself, mostly in specific areas, physical therapy. Also I did a telehealth for dentistry, which allowed someone, a non-dentist from a rural district and has a very rural background that they could telemedicine back into a dentist.

So we were already working on several telemedicine bills before we ever even came into the pandemic, but when the pandemic happened, it seemed like a likely time to implement as much as we possibly could. So it actually, we did a very comprehensive telemedicine during the pandemic and that’s what we decided we needed to advance that a little bit more and make sure that that extended on because that pilot project essentially is what that was, that thrown in pilot project really turned out to be very successful so we wanted to make sure that we continued that on. So when the executive order ended and we had an emergency closet went right into effect. So there was no separation between the pre pandemic and pandemic and post pandemic.

Jack Pitzer: Thank you Representative. Senator Lyons, same question for you. Telehealth policy landscape in Vermont pre pandemic and some immediate changes right at the beginning.

Senator Virginia Lyons: Oh, thank you. And thank you NCSL for having us. This is really terrific. I’m learning a lot, but I will say Vermont does have a history of supporting and utilizing telemedicine, audio/visual connections between providers and patients, but COVID did emphasize a need for expansion of broadband, telephone coverage within our state. You can’t always call there from here when you don’t have a telephone connection. We did use federal dollars, pandemic dollars, and we continue to do that to expand our broadband connections and also to help providers get IT equipment and connections. So that has been a real boom to us.

Telephonic delivery of healthcare was emphasized as a need. For example, for those folks stranded at home and the only thing they have is a telephone or college students who are returning and need to stay in touch with a counselor out of state. So we did put in place some licensure changes. Those are in effect only until March 2022, we may have to revisit, but at the same time, we passed an interstate Nurse Compact Bill and we have moved in the direction of looking at our medical reserve course. So there are a lot of little things going on that contribute to having telemedicine in place.

One of the principles that we put in place during the pandemic that reinforced who we are is that we put in place an insurance that we want to increase telehealth without increasing social isolation and without supplanting local community based medical services throughout our rural state. We want to ensure that we have quality and we want to be able to measure that quality and access for folks. In 2012, Vermont enacted a requirement that health insurance plans cover delivered telemedicine to patients from facilities. And then after, in 2017 we changed facilities to include homes or work. So pretty expansive use of telemedicine overall. And then in 2020, we expanded by allowing for access to all medical services, not simply voluntary services. We had voluntary dental and voluntary teledermatology and teleophthalmology for storing forward that’s been expanded, as has dental for telemedicine.

So we have that long history behind us. And now with our next steps, we’re in the middle, or we’re in the beginning of the middle and looking at how to define the use of audio only. So we did get one report last year, and then this year we’re beginning the process of determining codes, the fee for service codes for folks for clinically appropriate, medically necessary audio-only treatment. And that sort of data collection is going to be going on from 2022 through 2023, and then we’ll evaluate what works and what’s appropriate, and then how moving forward we can go to value-based payment. So there’s a lot going on right now with audio only and we’re very excited about it. So, that’s a little flavor for what’s happening in Vermont.

Jack Pitzer: Wonderful. Thank you, Senator Lyons. And you’re anticipating my next question, which is sort of, what is it that you all have looked at in this latest legislative session and things that you may be continuing to look at? So, my question is, what were some permanent changes that you all in Vermont and you all in Arizona enacted this latest legislative session? And are there any actions that your state took in response to COVID that you all are not continuing or that you want to look in a little bit more before making anything permanent? And Senator Lyons, you started to touch on that, but I’ll throw that at you first in case you have any additional insights.

Senator Virginia Lyons: Yes. Thank you. I think one of the things that we debated about is the use of audio only for psychiatric determinations for hospitalization and we said that would not be appropriate. I think we’ll have to be looking at that again. And then the emergency psychiatric determination certification process, that second opinion should not be audio only. What we did, there was so much discussion earlier by HRSA on mental health, we did determine that it would be appropriate for an initial meeting, audio only, for mental health counseling and psychiatry. The reason for that is we are seeing an escalation of adolescent psychiatric issues related to COVID. We thought this was a place where we might be able to help.

Having said that, one of the things that changed during COVID was moving away from HIPAA compliance on the use of telemedicine and audio only. Our goal is to get back to that certainly, that requirement will come through CMS. We do believe patient consent needs to be in place, both in written and oral. And that was attenuated during COVID and we want to bring that back.

And then the reimbursement piece is going to be important to us and how best to reimburse. And I did touch on that a little bit. There are some other things, but I think that you get the gist and I think then the other piece of it is looking at licensure, taking a new look at licensure and who can treat from out of state and who needs that access? So we’re all thinking about the fall surge right now and it makes us want to continue some of these elements.

Jack Pitzer: Most definitely, we all are thinking about the fall surge indeed and how we all can best react to that. So, Representative Cobb, similar question, same question for you. What were some of those permanent changes Arizona enacted this latest legislative session and are there any changes or any temporary actions the state took that you all are not continuing or looking into just a tad bit more?

Representative Cobb: Well first, let’s start off with changes that we’ve made. And I think one of the reasons you asked me to be here is because the bill that we ran, HB2454, was the most comprehensive bill that’s been enacted in the United States right now. Our bill, I mean Mei touched on just about every piece of my bill that was in there. We looked at what happened over the last year and a half, it’s similar to a war. So telehealth became a shining star, but the problem we did have was broadband. So, that’s probably something that we probably need to expand more on. I did some broadband bills, the state invested 100 million with grants. It also did 35 million on a smart highway and another 48 million on another highway to allow for more internet access.

But what telehealth really shined was with the special needs and elderly and physically disabled. And what this bill did was put in regulations, protections, went through locations. It talked about audio only, especially for controlled substances and with behavioral health, and really there are some guidelines in that, if you want to look at that, we do have guidelines in there as far as what we could do with audio only. It has to be both, it can’t replace the capabilities of visual only. It has to be at the consent of both the doctor and the patient and in behavioral health, they have to have an in-person visit before they can actually prescribe narcotics, so our controlled substances.

It also went over reimbursement and the biggest piece about ours was the interstate commerce piece. So we allowed for interstate commerce and licensure and what we’re going to do at board guidelines for anybody to be able to do telehealth within Arizona, but they have to follow the guidelines and go through the board recommendations. So that is all outlined in that bill also. So there are some things that, when we were talking earlier about the Compact bills, those are bills that we had passed in prior sessions so we don’t foresee that we’re going to be doing any Compact bills, because we think that this is pretty much as comprehensive as we can get. So I think the only thing that I think we can probably add this year is to look into the coding and as telehealth is implemented, we’re probably going to find some kinks in that and we’ll probably be modifying just because of the kinks that we are going to have in our full comprehensive bill.

Jack Pitzer: Wonderful. Thank you, Representative Cobb.

Representative Cobb: Thank you.

Jack Pitzer: I think it’s really great to hear these legislative perspectives and what you all are working on on the ground. So I appreciate both you and Senator Lyons for providing that perspective for us. But we are going to just quickly take a few questions before we wrap up time here. And Mei, I think this first question may be for you, but anyone can chime in if they have any thoughts. So, what insights do we have, are there when it comes to quality of care? Do physicians, mental health providers feel like it works well? Does it need improvement and what do patients think?

Mei Wa Kwong: So there have been a lot of studies that actually predate COVID-19 on the effectiveness of telehealth. Now the thing is, is that studies technically probably would be difficult to do if you say like, “How effective is telehealth?” So you’ve got to really focus more in on the particular service that they’re providing. So it’s like asking, how effective is healthcare? So there’s been a lot of evidence before COVID-19 on telehealth being effective in certain areas. And even as a telehealth proponent, I don’t say it is appropriate for every single case because it’s not. There are going to be some situations where you do need to be seen in person, but there is a lot of evidence that it can be very effective in providing certain services. Mental health is a big one.

So it’s been shown that it is very useful in providing a variety of mental and behavioral health services, but again, there are also going to be exceptions where it’s not going to be appropriate. So I do know a lot of mental health providers, they may be a bit more hesitant to use telehealth when somebody’s more of an at-risk case, where they may want the assurance that there is somebody physically there with the patient during the interaction.

So there is a lot of evidence there, but the way CCHP has always approached telehealth is that we really think it should be left to the provider and the patient to discuss whether telehealth should be used for that particular case, because they have the most information for that case at that time, because you could have two patients who have the same condition, but for whatever reason, one patient might be appropriate to use telehealth for than the other one. And that really should be the provider’s judgment call based upon their training and education and experience, and also the information that they have at that moment, right there with that particular patient.

Jack Pitzer: Wonderful. And I have one more question for you before we wrap up here. So, we know that private insurers expanded telehealth coverage during the pandemic, both voluntarily and due to new state coverage requirements, are private insurers and states planning to maintain these coverage expansions?

Mei Wa Kwong: I believe some of the private payers already have, and I think some of the states have already directed them to do that. I see Representative Cobb nodding her head, which Arizona by the way, again one of the forefront leaders. And making things permanent, they were doing it way in advance of the feds. So, yeah. So some, like the blues, I think one of the blues in Tennessee, literally it was three or four months into the pandemic, they said, “We’re making some of this stuff permanent.” So, yeah, some of the commercial payers are, and then they’re deciding it on their own. They’re not necessarily waiting for a mandate from the state in statute to require to do them.

Now, not all of them are. So some of them actually have even rolled back their COVID expansions by the end of 2020. We actually did a report on that where we looked at some of the larger plans and who had rolled back some of the… But some of the commercial plans have also implemented things permanently too, or were asked to by certain states.

Jack Pitzer: Wonderful. Thank you, Mei. And I want to be conscientious of people’s time here, and I know we’re at the top of the hour, or at the end of our time together, but if we did not get to your questions, we will follow up with you after this webinar.

So first I want to plug that we have that survey for you. We would love for you to take, we really take that feedback to heart when looking at what sort of activities and resources are most useful for you all. I want to, once again, plug some resources like the Telehealth Toolkit and Mei also mentioned a whole bunch of really great resources to checkout for CCHP, and of course all the great resources from HRSA as well. And I wanted to extend a final thank you to all of our presenters and panelists, really thank you so much for your time and your expertise in talking all things telehealth with us. Greatly, greatly appreciate it. And of course, thank you HRSA for your support of this webinar.

And finally, we couldn’t do this without the audience. So thank you for tuning in. There will be a recording of this webinar and a PDF of the slides and all the links that were in those slides on our website within the week. And with that, have a great rest of your day, a great rest of your week, and thank you again so much.