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by Meghan McIntyre, Virginia Mercury

As the federal public health emergency spurred by the COVID-19 pandemic expires this May, so will waivers that expanded the amount of health care services patients can access through telehealth. 

But Virginia officials say most of the services the waivers allowed, such as being able to have virtual appointments instead of in-person visits at a provider’s office, have been signed into state law and are here to stay for both Medicaid enrollees and those with commercial insurance.

“Virginia really stepped up – the General Assembly codified many of the waivers that were put in place early on in the public health emergency,” said Dr. Karen Rheuban, director and co-founder of the University of Virginia Center for Telemedicine and a decades-long advocate for expanding access to virtual health care. When the public health emergency expires on May 11, she said, Virginia “won’t fall off the telemedicine cliff.” 

Telehealth is an umbrella term for a broad spectrum of health care tools and services. That includes telemedicine — direct clinical care provided at a distance using electronic communications. During the COVID-19 pandemic, with widespread concerns about transmission and restrictions on health care, both telehealth and telemedicine became increasingly mainstream. 

Rheuban said telehealth includes many benefits for patients and providers, such as increasing access to health care regardless of location, improving health care staffing shortages and reducing the need to readmit people to hospitals. 

Sen. George Barker, D-Alexandria, said telehealth access is an important part of state public health planning. 

“When my mother-in-law – she just died last year at 99 – when she moved down here we actually had to work with her on some telehealth things,” said Barker, who has sponsored three laws expanding telehealth access in Virginia since 2020. “It was a lot easier than getting her over to the doctor’s office when she was mobility limited.”

Other services that will continue in Virginia after May 11 include the ability for a person to continue seeing an out-of-state provider not licensed in Virginia for a year after initially establishing an in-person relationship with them in that state.

Del. Amanda Batten, R-James City, said these bills mainly apply to people who move to Virginia, either permanently or for a temporary purpose like school, and give them time to find an in-state provider while seeing their out-of-state provider. 

“That year allows folks to sort of have a transition period where they can continue receiving the care that they need, but also put an expiration date on it so that they do make a connection with someone locally in the community,” said Batten.

Medicaid enrollees and certain Virginians with commercial insurance also will continue to have coverage for remote patient monitoring services, which let doctors and nurses monitor the health of patients with chronic and acute conditions through applications and devices such as blood pressure cuffs and oximeters. Additionally, a provider who has a license to practice in Virginia will not be required to live in the state if they want to enroll as a Medicaid provider.

Not everything available during the pandemic will remain in place, however. Waivers that will end in Virginia include the use of platforms that don’t comply with federal restrictions on medical privacy, such as FaceTime or Zoom, for virtual visits and some commercial insurance coverage for audio-only services. The ability for people to get prescriptions of controlled substances like Adderall and Ritalin without a prior in-person evaluation could also end, depending on what the U.S. Drug Enforcement Agency decides.

Skyrocketing use of telehealth

Telehealth allows patients to interact with their health care provider through live video or a telephone call, or by sending medical information digitally to a doctor or nurse who can then access it at a later time without having to bring the patient into the office. 

Patients can access these services “in their car, they could be in school, they could be in any other location,” Rheuban said. 

The benefits of telehealth are especially evident in rural areas of the state, where patients may have to travel long distances to see a provider, said Rheuban. Patients in these areas, especially those who are low-income, may not have access to broadband or smartphones, however, which is why she said the continuation of audio-only services is essential. 

Virginia has been one of the leading states in providing telemedicine access, even before the pandemic started, Barker said. As a result, he said, the state has seen an outpouring of people and providers wanting to use the services.

A report from the Virginia Telehealth Network found 75% of providers in the state were using telehealth as of March 2022 – a significant increase from before March 2020, when approximately 70% of providers did not use it.  

While no data exists yet on the amount of telehealth users in Virginia, an October 2020 CDC report found use of these services nationwide rose 154% between March 2019 and March 2020.

“Patient satisfaction is incredibly high, political outcomes have been great and the costs have not risen through the use of telemedicine,” Rheuban said.

Many providers have also been positive about the expansion of telehealth, said Barker, pointing out doctors and nurses can see more patients if some of their appointments are through telehealth.

A timeline of telehealth in Virginia

1995 – Virginia launches pilot to provide Medicaid coverage for telehealth services2003 – Some telehealth services become available for certain Medicaid enrollees under then-Gov. Mark Warner’s administration. Those services include types of consultations, some clinical services and coverage for patients at certain rural health care facilities. 2010 – State Sen. William Wampler, R-Washington, expands telemedicine coverage by commercial insurers through legislation that excludes audio-only services. 2019 – Coverage for most remote patient monitoring services become available for those with commercial insurance through identicallegislation from former Sen. Ben Chafin, R-Russell, and Del. Terry Kilgore, R-Scott.2020 – Barker and Del. Dawn Adams, D-Richmond, pass identicallegislation that allows Medicaid coverage for telehealth services regardless of the patient’s location. 2020 – Legislation from Kilgore directs the Board of Health to develop a statewide telehealth plan2021 – Barker and Adams pass identicallegislation expanding Medicaid coverage for audio-only services and remote patient monitoring.2022 –  Legislation from Del. Chris Head, R-Roanoke, and Sen. Richard Stuart, R-Westmoreland, permits out-of-state health care providers who aren’t licensed in Virginia to continue providing services for a year after initially establishing an in-person relationship with a patient. Batten passes a bill doing the same thing for out-of-state non-Virginia licensed behavioral health providers. 2022 – A bill from Sen. Siobhan Dunnavant, R-Henrico, adds individuals with an acute illness to the list of people eligible for remote patient monitoring under Medicaid.2023 – If a provider is unavailable to see a patient with whom they have a previously established relationship, a provider from the same practice can see the patient via telehealth instead, under bills from Head and Stuart.2023 – Legislation by Del. Roxann Robinson, R-Chesterfield, and Sen. Todd Pillion, R-Washington, allows providers and practices to provide telehealth services through Medicaid if they live out-of-state as long as they already hold a license to practice in Virginia.  2023 – Legislation introduced by Batten and Sen. Dave Marsden, D-Fairfax, would have provided audio-only telehealth coverage under commercial insurance but was referred to the state’s insurance commission for study. 

Federal pushes

On the federal level, telehealth waivers for enrollees in the federally run Medicare program won’t expire until the end of 2024. The bipartisan CONNECT for Health Act reintroduced by Warner, now a U.S. senator for Virginia, in April 2021 would make those expanded telehealth services permanent for Medicare beneficiaries.

“I’ve seen firsthand how hard it can be for Virginians to access health care in rural or underserved communities,” said Warner in a press release issued in 2019, when an earlier version of the bill was introduced. “This legislation will allow more individuals across Virginia and our country to take advantage of telehealth services that require less travel time and provide affordable, quality care.”

Warner and U.S. Sen. Tim Kaine, D-Virginia, also called for the permanent expansion of these services in a letter to congressional leadership in 2020, as well as including a provision to expand telehealth services for substance abuse treatment in the Opioid Crisis Response Act of 2018.

Future of telemedicine

The pandemic waivers not only enabled the General Assembly to permanently expand telehealth services, Rheuban said, but allowed the development of new virtual health care models. 

Legislation in 2020 from Kilgore directed the Board of Health to develop a Statewide Telehealth Plan, which aims to promote and integrate the use of telehealth services in Virginia. 

The Virginia Telehealth Network, where Rheuban also serves as president, was contracted to work with the state to develop the plan through legislation by Kilgore and Barker in 2022.

“The type of plan will help us figure out what we are providing and what types of things patients or providers might want to have that we’re not providing support and compensation for,” Barker said.

Workgroups in the network consist of experts who are tasked with identifying high-priority needs and barriers to telehealth and sketching out how the state can increase the use of telehealth.

“These pandemic waivers have enabled us to create new models of health care, for which many will endure thankfully,” said Rheuban.

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