Healthcare Leaders Are Hamstrung by On-Again Off-Again Telehealth Waivers

In ending the federal shutdown, Congress has extended telehealth and Hospital at Home waivers until the end of January 2026. For some providers, it’s difficult to celebrate.

You can forgive healthcare executives if they’re not actually jumping for joy over the return of telehealth and CMS Acute Hospital Care at Home waivers.

The waivers, launched in 2020 at the height of the COVID pandemic, expired at the end of September, but were revived in this week’s Congressional action to reopen the federal government.

But they only extend until the end of January 2026 – less than three months. That gives CIOs, CTOs and other digital health and telehealth leaders little room to plan out any long-term strategies.

Planning for an Uncertain Future

Health systems like Johns Hopkins Medicine have gone through numerous dry runs for shutting down or scaling back telehealth programs over the past five years as each successive deadline for ending the waivers approached. Then they actually scaled things back or continued without Medicare reimbursements in October. And now they’re shifting back again, at least for a little while.

“While we're appreciative that we're going to have 75 days, plus or minus, of extension, it's hard to build healthcare delivery on a 75-day rolling basis, and so that lack of long-term clarity and certainty remains a major issue,” says Brian Hasselfeld, MD, Executive Medical Director of Digital Health and Innovation at Johns Hopkins Medicine.

Brian Hasselfeld, MD, Executive Medical Director of Digital Health and Innovation at Johns Hopkins Medicine. Photo courtesy Johns Hopkins Medicine.

“Lost in the broader political discourse is the real on-the-ground fact that millions of individuals and patients insured with Medicare may no longer have the breadth of options … to connect with their clinical teams,” he adds.

[Also read: Waivers’ End Pushes Healthcare Leaders to Make Tough Decisions on Telehealth, Hospital at Home.]

An extension of the waivers, even for a short period of time, is basically good news. To advocates, it signals broad support across both parties for these flexibilities. Groups like the American Telemedicine Association and the Alliance for Connected Care praised the extension and are lobbying to make those waivers permanent.

“While we are encouraged by this extension, lawmakers must deliver a long-term, stable telehealth policy that gives patients, providers, and health systems the certainty they deserve,” Chris Adamec, the Alliance for Connected Care’s Executive Director, said in an e-mail. “Short term, and even year-to-year, extensions are no longer sustainable for a care model that is now central to how America delivers healthcare. Telehealth is an integrated part of care delivery, and the current system needs to reflect that."

“We were glad to see the telehealth waivers extended since telehealth is broadly supported as a bipartisan issue,” Ethan Booker, MD, Chief Medical Officer of Telehealth at MedStar Health, said in an e-mail. “We would like to see Medicare telehealth support in permanent legislation and will continue to advocate for patient access and affordability.” 

But it’s the disruptions around these waivers – and continually shifting federal policy – that makes long-term planning difficult. And healthcare leaders have said that both telehealth and acute care at home are integral to healthcare transformation.

“Through care model redesign that we refer to as connected care, telehealth and RPM are absolutely a part of our long-term strategy,” Booker said. “Collectively, these are important access advancements that patients are requesting, and we’ve designed our work to also support our team’s wellbeing.”  

“The delivery of care lives with our clinicians and care sites, aligned with a principle that these digital care activities are built into the way we take care of our patients,” added William Sheahan, MedStar Health’s SVP and Chief Innovation Officer and Executive Director of the MedStar Institute for Innovation.

For now, several health systems are taking advantage of the waivers’ return and restarting their programs, including Hospital at Home.

In a LinkedIn post, Constantinos (Taki) Michaelidis, Medical Director of the Hospital at Home program at UMass Memorial Health, said the health system is reopening its program next week.

“During these 48 days, patients were unnecessarily transferred back to brick/mortar hospitals and there was increased emergency department boarding across the country leading to adverse quality, safety, patient experience and cost impacts,” he wrote. “More importantly, confidence was shaken in AHCAH and telehealth in red state and blue state health systems for no substantive reason despite incredible bipartisan support.”

“Today, to protect against the above happening again, we call on Congress to extend the AHCAH and telehealth waivers for at least five years to separate these mission critical health system capacity tools from the ongoing budget process and let us all do what we do best - care for complex and acutely ill patients in the home with second to none quality and safety,” he added.

In the meantime, however, executives are left to hope for the best and prepare for the worst.

An Integral Part of Care

Hasselfeld and Helen Hughes, MD, MPH, Medical Director of the Office of Telemedicine at Johns Hopkins Medicine, say telehealth has become an integral part of providing access to patients since COVID, particularly for those patients who can’t easily see specialists or get to the hospital, clinic or doctor’s office. Hughes says the six-hospital health system had as little as 70 telehealth visits per month prior to COVID, mostly through grant-funded programs, but that number soared to about 90,000 a month during the pandemic and has since stabilized at around 30,000 a month.

Helen Hughes, MD, MPH, Medical Director of the Office of Telemedicine at Johns Hopkins Medicine. Photo courtesy Johns Hopkins Medicine.

Patients need to have “multiple ways to connect to clinical care where it’s appropriate, safe and indicated for a patient’s need at any given point in time,” Hasselbeck says. “For us it’s not new anymore, but an evolving pathway with multiple options to ensure we’re meeting the patients where they are with clinical input.”

Hughes says the constant turmoil created by the long-term uncertainty of the waivers and changes to Medicare billing for telehealth coverage outside the hospital in the CMS 2026 Physician Fee Schedule “feel like death from 1,000 paper cuts.”

“The more you add up all these pieces where OK, telehealth is the same as in-person care except you have to do this and you have to do this and you have to do this,” she says of the decision by CMS to discontinue the policy of allowing providers to report and bill for telehealth services using their currently enrolled practice location, even when they’re connecting with patients from their homes during nights and weekends. “It burdens our already overwhelmed providers and operations teams. They have to keep track of all these changes.”

“We see most of our telemedicine visits [as a] substitute for in-person visits," she adds. "We don't have a ton of extra providers sitting around doing nothing. Our specialists are quite busy, and I think patients generally want to seek care that's necessary. So we have not been seeing on the ground that these visits are kind of additional or superfluous. They tend to substitute for in-person care.”

Hasselfeld says the changes in policy and continuing uncertainty also hinder how they coordinate care with patients.

“Investing [in] and scaling things on a ‘What kind of insurance plan do you have?’ basis is really difficult,” he says. “As a clinician, I don't walk into the room and immediately start thinking about, well, I know I'll have this suite of options for this insurance company and then this suite of options for insurance Company B and Medicare. What we’re left with is a really fragmented future.”

For example, he says, the continuing uncertainty over telehealth coverage could affect patients being treated for cancer.

“I have an immunosuppressed at-risk-for-infection [patient who is] being cared for active cancer, and the safest, best way for me to give updates to my team is through telemedicine," he says. "And for the next 75 days I can do that. But if my indicated follow-up is at 76 days, I don't really know if I have to pay for that out of pocket.”