Background

The Patient Protection and Affordable Care Act (ACA) passed in 2010 dramatically expanded coverage to people who were previously uninsured or underinsured. Health insurers scrambled to meet the needs of these newly covered individuals, including access to specialty care in what are often medically underserved regions.

Now a decade later, the current unprecedented time of the COVID-19 global pandemic presents its own set of challenges for U.S. healthcare—namely the distribution of medical attention to those who need it and limiting unnecessary exposure to the virus, all the while adapting to the dramatic shift in the way patients can access care.

The application of technological advancements to health care delivery, which encompasses “telemedicine,” “telehealth,” and “mobile health” may be leveraged to remedy each obstacle mentioned above—meeting the growing demand for care while also avoiding exposure to Coronavirus.

In California, there are no legal prohibitions on using technology in the practice of medicine if the practice is done by a California licensed physician. Traditional industry terms like “telemedicine” and “telehealth” do not allow for the flexibility to include newer care programs, technology, and infrastructure advancements. Instead, the term “virtual care” could encompass wellness programs, specialist consult (eConsult), virtual inpatient observation or care team collaboration across the continuum of care. Broadly defined, virtual care is any interaction between patients and caregivers, occurring remotely and using information technologies to maximize the quality and effectiveness of patient care.

Learn more about the terminology of virtual care from our blog post here.

The development of virtual care as a burgeoning sector of the overall health care industry is a result of several factors.

1. First, the broad adoption of telecommunication technologies contributed to patient and provider “readiness” for virtual care.
2. Second, health care consumers demand a health care system where convenience and access play a critical part in the treatment process.
3. Finally, the need to balance provider access and cost containment has driven the adoption of virtual care.

The traditional barriers to telehealth – lack of reimbursement and health insurance coverage, restrictive state licensure laws, and the absence of protocols for telemedicine visits – are disappearing quickly.

Recent health care reforms have created a fundamental paradigm shift in focusing efforts on driving wellness and preventive care rather than on episodic care. The long-term relationship between the patients and providers has put patient engagement and care coordination at the center of care delivery. This need has created more viability for adopting virtual care programs, providing convenient, clinically valuable and cost-effective ways for patients and providers to interact, and expanding to provider-to-provider with eConsult.

To improve patient access and cost management across the care continuum, many hospitals and health systems are using virtual care (telehealth) technologies to deliver high quality care in a timely fashion. Using an ecosystem of virtual and remote services and technology, health plans will be able to support high quality, cost-effective care at a distance.

Such solutions for remote, quality healthcare delivery transformation take on many different shapes and forms. Our blog post about virtual care modalities breaks virtual care into four major categories and delineates what is made possible by each. Additionally, another blog post defines virtual care initiatives, offering a framework for strategic approach to virtual care implementation across various healthcare settings.

State and Federal Telehealth Policy Updates

COVID-19 has limited the ability of healthcare providers to offer in-person care to their patients. With medical facilities at risk of being overwhelmed and citizens encouraged to stay home, timely access to medical care may be harder than ever to achieve.

In light of this, governmental and healthcare authorities and systems are increasingly backing virtual care (telehealth) as one of the safest, most efficient ways to provide care during such times, as it allows patients and providers to connect without face-to-face visits. Virtual care is not a distinct service, but a way that providers deliver health care to their patients that approximates in-person care. The standard of care is the same whether the patient is seen in-person or virtually.

Actions resulting from these acknowledgments above, however, were already underway in 2019, a landmark year for telehealth legislation in California, including the passage of AB 744, which requires payment parity for telehealth and AB 1264, which allows a prior examination to be conducted over telehealth.

In California, the Department of Health Care Services (DHCS) considers telehealth a cost-effective alternative to health care provided in-person, particularly to underserved areas. Effective on July 1, 2019, DHCS’s revision of the Medi-Cal telehealth policy increased flexibility for providers to use telehealth as a medical platform to deliver necessary medical services to patients. DHCS’s updated policies include allowing Medi-Cal providers the flexibility to decide clinically appropriate medical services or benefits for telehealth and no limitations on beginning or distant sites. DHCS’s coverage and reimbursement policies for telehealth align with the California Telehealth Advancement Act of 2011 and federal regulations.

State law defines telehealth as “the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care while the patient is at the originating site and the health care provider is at a distant site.” Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.” This definition applies to all health care providers in California, not just Medi-Cal providers.

With the first emergency Covid-19 authorization, Congress lifted provisions that limited telemedicine services to rural areas, allowing the use of telemedicine services for all beneficiaries of fee-for-service Medicare. The Center for Medicare and Medicaid Services expand the use of telehealth by using the Center for Medicare and Medicaid Innovation (CMMI). The CMMI have experimented with and tested new payment options and care delivery models for patients and their influence on the quality and cost of healthcare. To enhance the technology infrastructure available to clinicians to support these visits, the Office of Civil Rights (OCR) at the Department of Health and Human Services (HHS) has announced that it is using its enforcement discretion and will not impose penalties for using HIPAA-noncompliant private communications technologies to provide telehealth services during this public health emergency (Covid-19 and Health Care’s Digital Revolution, NEJM).

Medi-Cal also complies with federal regulations for telehealth, which are the same for Medicaid as they are for Medicare. According to the COVID-19 Medi-Cal Services and Telehealth Notice, Medi-Cal providers may utilize existing telehealth policies as an alternative modality for delivering Medi-Cal covered health care services when medically appropriate, as a means to limit patients’ exposure to others who may be infected with COVID-19, and to increase physician capacity.

Because virtual  has a vast scope, policy makers have taken various approaches when governing the industry including regulating:

• Patient and physician settings: the patient’s location, or the “originating site,” and/or the location of the provider offering care or consultation, or the “distant site;”
• Allowable provider types (e.g., psychiatrists);
• Eligible technology and services (e.g., videoconferencing or remote monitoring);
• Distance or geography standards (e.g., requiring a patient to live in a rural setting to receive services via telemedicine);
• Requirements that another certified individual, or telepresenter, be present with a patient during a telemedicine visit; and
• State licensure requirements that require providers to be licensed in the state which they are delivering telemedicine services.

Each year, new federal and state legislation is introduced to address some of the barriers to telehealth use. On the state level, California continues to make adjustments to existing and new policies in order to mitigate the COVID-19 crisis (California Telehealth Policy Coalition).

Summary

The healthcare industry can slow the spread of COVID-19 while maintaining quality healthcare and even increasing access by using virtual care.

We must continue to leverage the latest technology and workflow engineering to innovate and meet both the current and future needs of patients and providers that serve them. Virtual care empowers individuals to manage their health and care in new ways. We are now at the tipping point where remote monitoring and real-time meaningful interventions will fundamentally change the way populations engage in their health.

We must deploy virtual care strategies to meet the needs of a growing healthcare consumer base. These strategies cover a wide range of services and approaches, including increasing access to psychiatry, connecting members in rural areas to specialists, using electronic consults (eConsult) to enhance communication between providers, and integrating physical and mental health.

We must also investigate and implement services that enables patients to speak with their own doctor, lets them interact with a doctor they do not know for simple questions — great for the uninsured or limited insurance and those without a primary physician.

Virtual care leverages technology to coordinate care and extends the settings in which care can be delivered. Virtual care can take place through a video conference, over the phone, or through electronic messaging, including images, test results and other data. Consultations can take place between a doctor and a patient, or between two or more doctors. Virtual care can help patients who live in areas with few specialists get the care they need more quickly or more conveniently, sparing them a long trip. It can also help specialists with heavy caseloads dispense care more efficiently, providing consults to primary care physicians (PCPs) and providing direct access for patients with more complex needs. This increased coordination not only addresses access problems; it also can help bend the cost curve.

Virtual care, provided remotely from a clinic or hospital directly to a patient at home, using existing and inexpensive technologies, continues to grow become part of the value-based care approach. Tracking our patients remotely, whether to manage chronic conditions through a prescribed device or kit, or through an ecosystem of apps enabling patients to manage their day-to-day health, is the future.