With the end of the COVID-19 public health emergency on the horizon, some healthcare organizations are struggling to come to grips with the impending loss of telehealth freedoms.
For healthcare providers treating some of the most underserved populations and communities, the end of the COVID-19 public health emergency is pretty bleak. Federal waivers expanding access to and coverage of telehealth will end with the PHE, forcing them to curtail or even end programs that had seen quite a bit of success over the past few years.
"It's going to be a challenge," said Chris Grasso, MPH, chief information officer for Fenway Health, a Boston-based federally qualified health center (FQHC) serving more than 35,000 patients annually, many of them part of the LGBTQ+ community. "It's a lot to untangle and figure out."
That's top of mind for the more than 4,700 rural health centers (RHCs), more than 1,400 FQHCs and another 16,000+ so-called look-alike FQHCs in the country, many of which serve populations who face geographical, cultural, or societal barriers to accessing healthcare. The Centers for Medicare and Medicaid Services (CMS) sharply limits how those facilities use telehealth, though those limits had been eased during the pandemic.
Grasso, who keynoted a recent telehealth summit in Massachusetts hosted by the Northeast Regional Telehealth Resource Center (NETRC), said these all-in-one healthcare centers serve patients who fall through the cracks because of those barriers.
"Now that the COVID restrictions are coming back, it's going to be harder to do our work," she says. "But we need to keep the lights on and the doors open."
NETRC is one of 12 regional and two national resource centers in the federally funded National Consortium of Telehealth Resource Centers. Based in Augusta, Maine, it serves as the clearinghouse for telehealth policy and information for all of New England and New York.
Healthcare organizations of all sizes across the country often rely on the consortium and individual TRCs for the latest news in telehealth policy and regulations, and these regional summits serve as focal points for catching up on the latest.
At the NETRC event in Southbridge, Massachusetts, Christina Quinlan, an executive consultant and advisor to the NETRC who'd previously worked as the chief operations officer for an FQHC on an island off the Maine coast, noted FQHCs and RHCs have long balanced the need to use new technology to reach patients with ROI.
"Telehealth and innovative technology wasn't anything new to us," she pointed out. "We just never got paid for it."
That changed with the pandemic, which thrust these types of healthcare providers into the spotlight as an important resource for both primary and specialty healthcare services at a time when hospitals were overcrowded and people were avoiding them and the doctor's office for fear of infection. Among the federal and state waivers to expand telehealth adoption were measures specifically focused on FQHCs and RHCs.
Quinlan noted that despite the positive results seen from the increased use of telehealth, CMS has only made permanent six CPT codes for telehealth services related to behavioral healthcare.
"It's primarily for psychotherapy," she said. "What they've expanded isn't nearly enough."
Grasso said Fenway Health, which sees more than 2,000 patients seeking HIV care, embraced virtual visits early on during the pandemic to provide a safe means of accessing care for those at heightened risk. As time has passed, they've seen patients from more than 40 states and 1,000 zip codes, as well as transgender patients from states who've taken action to restrict healthcare services.
"There have been lots of opportunities for us to be innovative," she said.
And they have to. According to Grasso, a 2015 study indicated one-third of all LGBTQ+ patients have reported a negative healthcare experience, and 23% have avoided seeking healthcare because of fears of mistreatment. This puts the pressure on providers to find new methods for providing discreet care, such as through digital health messages and virtual visits.
"Our patients are some of the biggest disruptors in healthcare right now," she pointed out.
FQHCs and RHCs are also facing stiff competition, she noted—not only from hospitals and health systems ramping up their efforts to address social determinants of health and connect with underserved patients, but from free-standing and retail health clinics offered by the likes of CVS and Walgreens, telehealth providers and health plans with their own provider resources, and direct care platforms launched by Amazon, Google and others.
"We have to continue to be creative to compete in this market," she says, mentioning a plan to explore the use of kiosks in locations around Boston and surrounding cities.
Part of the problem may be that FQHCs and RHCs haven't been vocal enough about the lack of permanent telehealth coverage.
"For them [CMS], it's like, if we're not complaining about it enough, it's not an issue," said Quinlan, who's urging advocates to give federal officials an earful so that CMS might address the issue in its proposed 2024 Physician Fee Schedule, which is slated to come out next July.
They're also hoping that Congress may step in and enact new legislation making those telehealth waivers permanent. Danielle Louder, the NETRC's program director for technology-based initiatives, noted there are more than 100 telehealth-related bills now before Congress, alongside lobbying efforts from a broad range of stakeholders to take action.
For now, FQHCs like Fenway Health are continuing to look for new ways to reach and deliver care to underserved communities—Grasso said they've "had to do a lot of MacGyvering" along the way—and keeping an eye on the end of the PHE, which is still a moving target. The latest news puts that date in 2023, and Congress has ensured that the CMS waivers will remain in effect six months after that.
"It's their job to continue doing what they're doing," Quinlan says. "But it will be much harder."
“Now that the pre-COVID restrictions are coming back, it's going to be harder to do our work. But we need to keep the lights on and the doors open.”
Chris Grasso, MPH, Fenway Health.
Eric Wicklund is the Innovation and Technology Editor for HealthLeaders.
There are roughly 4,700 rural health clinics (RHCs), 1,400 federally qualified health centers (FQHCs), and 1,600 so-called FQHC look-alikes in the US, all providing healthcare services for underserved communities and populations.
These providers have seen a lot of success in using digital health and telehealth during the pandemic, thanks to federal and state waivers expending access to and coverage of telehealth.
Those waivers will end with the end of the federal public health emergency, and no action has been taken yet to allow FQHCs and RHCs to use telehealth permanently.