Expanding Telehealth Access for Older Adults: The Role of the Aging Network

The COVID-19 pandemic has at times made it unsafe for vulnerable older adults and people with disabilities to see their health providers. As a result of a federal Declaration of a Public Health Emergency, many of the rules restricting Medicare reimbursement of remote telehealth services were waived.^1,2,3 But while many older adults and people with disabilities have in recent years used telehealth services, others could not because of such barriers as a lack of technical skills and/or access to broadband or technology.

Many within the aging network already have some experience with helping older adults and people with disabilities in the community access health care and social services via telehealth. Yet there may be some confusion around which services are covered or around how to help the people Aging Network advocates serve to use telehealth.

Area agencies on aging, community-based organizations, and others in the Aging Network are well-poised to expand access to and use of telehealth. NCOA and USAging have put together a helpful policy spotlight that details how various community leaders and aging network staff can help older adults and people with disabilities overcome digital inequities. The resource shares many best practices from organizations, which have incorporated various strategies, including: 

• Helping those who wish to improve their digital literacy
• Providing low-cost equipment that helps individuals connect to telehealth services
• Providing translation services

Developed in partnership with USAging’s Aging and Disability Business Institute, the policy spotlight also presents policy and programmatic recommendations to improve uptake and effectiveness of telehealth:

NCOA is providing the aging network with this telehealth policy spotlight given the recent extension of the Declaration of a Public Health Emergency and given the possibility that telehealth continues to be a safe option for vulnerable patients regardless of whether COVID cases and hospitalizations rise.

We also wish to continue talking about telehealth as an alternative to in-person health care visits, in some cases, because more individuals today can use it for the first time. As a result of recently passed bills such as the Infrastructure Investment and Jobs Act and the American Rescue Plan, both of 2021, the federal government continues to make investments in tech infrastructure such as rural broadband. As these investments connect more individuals in the community, area agencies on aging and community-based organization staff, among others, have more opportunities to help interested older adults and people with disabilities access health and social services that might otherwise be challenging to access or inaccessible altogether.

How can the Aging Network improve the use of telehealth?

Unfortunately, the benefits telehealth could bring are sometimes inaccessible to those who could benefit most. In cases when the internet is available, it may be too expensive. The aging community can, however, help facilitate access. The Aging Network has an excellent opportunity to help their communities in new ways to meet the ever-changing needs of patients.  

One tool in the available toolkit: the Internet for All Initiative, which launched in May 2022. The program will provide $45 billion toward providing internet infrastructure and home equipment for individuals as well as teaching digital skills. Finalized in the summer of 2022, the infrastructure law’s Affordable Connectivity Outreach Grant Program, according to the Federal Communications Commission, “plays an integral role in addressing affordability barriers to broadband access and adoption by providing qualifying low-income households with a monthly discount of up to $30 per month (and up to $75 per month for households on qualifying Tribal lands) as well as a one-time $100 discount toward a laptop, desktop computer, or tablet.”

As NCOA continues to advocate for equity-promoting and equity-conscious Medicare telehealth policies, the Aging Network may wish to play a vital role in making audio-visual telemedicine more accessible to groups of older adults who are currently experiencing disparities in access to care.

Physicians at Johns Hopkins Medicine examined their employer’s all-payer utilization data from March 2020 to August 2022 and found that audio-only telehealth services, when compared to audio-visual ones, accounted for 60% of visits for patients over 65 years of age and comprised a larger share of visits among Black (as compared to those who identify as white), Spanish-speaking, and rural patients. In a New England Journal of Medicine  article, the physicians emphasize that policymakers need “to ensure that the current digital health transition helps bring about a more equitable—rather than an even more inequitable—care delivery system. We believe audio-only (telephone-based) visits currently represent an important stepping stone to digitally inclusive health care.”⁴

What are Medicare’s telehealth coverage rules and challenges in and beyond 2023?

Coverage rules: The Biden Administration has expressed interest in ending the public health emergency declaration in the spring of 2023. Once the emergency’s flexibilities end, extenders will kick in and carry the same flexibilities through to the end of 2024.⁵

Need for Better Data: In September 2022, the independent congressional agency called the Medicare Payment Advisory Commission (MedPAC) recommended the telehealth waivers should be extended temporarily in order to provide time for data to be collected on telehealth quality, cost, access, waste, and fraud and then analyzed.⁶ According to MedPAC in November 2021, the federal Department of Health and Human Services' Centers for Medicare and Medicaid Services (CMS) was not at the time receiving utilization data on audio-only services as well as virtual Medicare home health and hospice visits and recommended a few remedies: better data collection, and the introduction of new billing codes.⁷ It may be some time before conclusions can be reached about these types of services.

Outcomes and Cost Study:  In order to better understand costs and utilization trends, lawmakers in 2022 mandated a study on telehealth’s outcomes and costs.

In-Person Visit Requirement: The Consolidated Appropriations Act says that HHS must delay in-person visit requirements associated with a telemental health service until “on or after the day that is the 152nd day after the end of the emergency period.”

CMS has since finalized several rules that could in 2023 require any patient using telemental health services to also have an in-person visit within six months prior to the virtual service and then again 12 months after the same telemental health visit.

CMS will implement this change in somewhat different ways, which depend on the site of service. For Medicare Part B-covered outpatient services provided by a hospital, the physician will in 2023 be able to waive the in-person visit requirements associated with a telemental health visit if the clinician has a relationship with the patient and if the clinician feels the in-person visit would come with risks and burdens that outweigh the benefits arising from an in-person visit. For Part B services performed outside the hospital setting, CMS does not give the provider the same flexibility. The in-person visit requirements will kick in following the 151-day extension.

Audio Only Limitations: On or after the 152nd day following the end of the Public Health Emergency, the Consolidated Appropriations Act also says that various other telehealth waivers will go away, and restrictions to telehealth present before the pandemic will return. CMS will not, for instance, reimburse an audio-only telehealth visit for physical health services, virtual audio-visual occupational and physical therapy services, as well as virtual audio-visual audiology services. As evidence of the limited scope of future telehealth service reimbursement, patients will only be able to use audio-visual telehealth services if the patient lives in a rural area and uses the telehealth service at a hospital or outpatient clinician’s office (also known as the originating site requirement).

Congress may also pass legislation that extends the Declaration of a Public Health Emergency telehealth waivers beyond the end of the emergency longer than the 151 days mandated by the Consolidated Appropriations Act. NCOA will continue to update this article with the latest developments to ensure the Aging Network has accurate, up-to-date information.

Sources

1. U.S. Department of Health and Human Services, Health Resources and Services Administration. Policy changes during COVID-19. TELEHEALTH.HHS.GOV. Found on the internet at https://telehealth.hhs.gov/providers/policy-changes-during-the-covid-19-public-health-emergency/

2. U.S. Department of Health and Human Services, Administration for Strategic Preparedness and Response. Renewal of a Determination that a Public Health Emergency Exists. Found on the internet at https://aspr.hhs.gov/legal/PHE/Pages/covid19-13Oct2022.aspx

3. U.S. Department of Health and Human Services, Administration for Strategic Preparedness and Response. Declarations of a Public Health Emergency. Found on teh internet at https://aspr.hhs.gov/legal/PHE/Pages/default.aspx

4. Helen K. Hughes, et al. Health Care Access on the Line—Audio-Only Visits and Digitally Inclusive Care. New England Journal of Medicine. Nov. 17, 2022. Found on the internet at https://www.nejm.org/doi/pdf/10.1056/NEJMp2118292

5. The National Law Review. Omnibus Bill Extends Medicare Telehealth Flexibilities and HDHP Telehealth Safe Harbor. Dec. 28, 2022. Found on the internet at https://www.natlawreview.com/article/omnibus-bill-extends-medicare-telehealth-flexibilities-and-hdhp-telehealth-safe

6. Ledia Tabor and Ariel Winter. Mandated Report: Study on the expansion of telehealth. MedPAC. Sept. 29, 2022. Found on the internet at https://www.medpac.gov/wp-content/uploads/2021/10/Telehealth-MedPAC-29-Sept-2022.pdf

7. Ariel Winter, Ledia Tabor, and Bhavya Sukhavasi. Telehealth: Updates on use, beneficiary and clinician experiences, and other topics of interest. MedPAC. Nov. 8, 2021. Found on the internet at https://www.medpac.gov/wp-content/uploads/2021/09/Telehealth-MedPAC-Nov-2021.pdf