AMA Adopts Policy to Expand Access to Telehealth

Most physicians at the American Medical Association's virtual special meeting of its House of Delegates agreed that expanding access to telemedicine during the pandemic benefited patients and practices alike -- saving at least one from bankruptcy.

In a recent AMA poll, 60% said that telehealth has improved the health of their patients.

Yet delegates struggled to craft policy recommendations that could preserve newfound telehealth flexibilities while side-stepping unintended consequences, such as payers diverting patients to other non-physicians for care and the perennial issue of caring for patients across state lines.

What started as a set of far-reaching policy proposals -- touching on everything from copayments to in-state licensing -- was whittled down to a set of core principles, first by a designated council following a committee discussion on Saturday, and then by the full House of Delegates in votes on the virtual House floor Monday evening and Tuesday morning.

The agreed-upon policy resolution, included in the AMA's preliminary report released Wednesday, charged the AMA with continuing to advocate "for the widespread adoption of telehealth services in the practice of medicine for physicians and physician-led teams post SARS-COV-2."

The resolution also tasks the AMA with the following steps:

• Urging the federal government, the Centers for Medicare and Medicaid Services (CMS), states, and insurers to "adopt clear and uniform laws, rules, regulations, and policies relating to telehealth services that provide equitable coverage that allows patients to access telehealth services wherever they are located"
• Providing "the use of accessible devices and technologies, with appropriate privacy and security protections, for connecting physicians and patients"
• Advocating for "equitable access to telehealth services" for vulnerable and low-income patients
• Pushing for greater funding and planning related to telehealth infrastructure, for both practices and patients, including for broadband
• Supporting telehealth as a means "to reduce health disparities and promote access to health care"

Use of telehealth has surged during the pandemic, aided by Trump administration orders that increased the number of services available and reimbursements for them.

Some of these flexibilities are slated to expire when the pandemic ends, however, and others may end sooner.

In AMA committee discussions, delegates raised concerns over "scope creep" in telehealth by non-physicians such as nurse practitioners and physician assistants, as well as the limitations in accessing the full array of services for older patients.

The full House then discussed an alternate policy resolution put forward by AMA's Council on Legislation, after listening to and reviewing comments from delegates.

The proposed alternate policy included many of the provisions that were ultimately adopted in the AMA's preliminary report, however the council's proposal -- which combined resolutions on the subject of telehealth from multiple delegations -- called on the AMA to encourage CMS, other agencies, and industry to adopt "clear and uniform" laws, regulations, and policies that would permanently achieve certain goals. Two of those recommendations were adopted in the preliminary report, though the word "permanently" was stricken, and the following provisions were not adopted and instead referred to the Board for further study:

• "Promote continuity of care by preventing payors from using cost- sharing or other policies to prevent or disincentivize patients from receiving care via telehealth from their physician"
• "Provide equitable payment for telehealth services that are comparable to in-person services"
• "Ensure qualifications of physicians duly licensed in the state where the patient is located to provide such services in a secure environment"

During the full House's discussion on Monday, members debated whether the timing was right for these reforms.

Joshua Rosenow, MD, a delegate from the American Association of Neurological Surgeons, said many aspects of reimbursement and care provision in telehealth "are up in the air" currently.

"We don't know what the Biden administration is going to do," he said, with respect to leadership at CMS and other agencies.

"We don't know what the Supreme Court is going to rule on in the [Affordable Care Act] ruling. There's also the new implementation of the [Evaluation & Management] codes in January," Rosenow said.

The resolution encompasses so many important issues and "[w]e have one chance to get this right."

For those reasons, Rosenow recommended the proposed policy be referred to the Board for study and report back to the House.

Others opposed referral, calling for at least some of the policy provisions to be adopted.

"As a family doctor, without telehealth, we would have gone bankrupt and closed the office," said Chris Bush, MD, an alternate delegate from Michigan, speaking on his own behalf. "Now with another surge upon us, this item is of utmost urgency, and I speak against referral."

Michael Miller, MD, a delegate from Wisconsin, speaking for himself, agreed with Bush.

"If there's going to be a change of presidential administration or a Supreme Court ruling, why wouldn't we want to have really good policy in place?" Miller asked. Any necessary modifications to policy could be made later, he added.

The motion to refer was rejected in a vote of 323-158.

The virtual House then attempted to amend and vote on individual provisions, requesting very specific amendments such as stating that "equitable coverage" be granted for patients' from the "originating site" to a physician's "distant site."

Russell Libby, MD, author of that amendment, explained that some patients may travel -- for leisure, for college, or because of a move -- to states where a physician doesn't hold a license and may still want care from their original physician.

"The current situation ... requires that we be licensed in the state where the patient is located when they receive your care, but as we see telemedicine grow, it's going to need to be addressed," Libby said.

That change was voted down by the House.

A handful of other amendments looked to either limit where a physician or patient could receive telehealth or to blow up those restrictions entirely.

Sandra Swantek, MD, a delegate for the American Association of Geriatric Psychiatrists, opposed requiring that physicians be licensed in states where telehealth patients reside -- acknowledging a personal interest, in that she treats "snowbirds" from Chicago who spend winters in Florida.

"Physicians may treat patients temporarily out of state due to school vacation or temporary migration during the winter," Swantek said.

While a local physician would be best for any long-term treatment, Swantek suggested that the relationship between a patient and his or her physician "back home" should be encouraged as it preserves continuity of care.

The proposed policy could potentially "disqualify" physicians from responding to patients who are temporarily out of state, she said, calling for the policy to be referred and clarified.

It was not adopted.

A provision declaring the opposite, that the AMA should advocate for allowing physicians to provide telehealth "regardless of current location," was also not adopted.

Douglas Murphy, MD, a member representing the Florida delegation, put forward an amendment urging the AMA to advocate that payers allow patients to see "the physician of the patient's choice" via telehealth.

The House initially voted to approve that amendment but a handful of delegates panned the idea.

"We're way down a rabbit hole that we shouldn't be down," said Jim Milam, MD, a delegate from Illinois.

The proposed policy aims to prevent payers from cost-sharing with the physician of a patient's choice, but, said Milam, "if you're in the network you already had that."

Lindsay Ackerman, MD, a delegate for the Dermatology Section Council, argued that allowing patients to choose their healthcare provider could lead them to someone with a lower co-pay, for example, "a cadre of NPs providing care all over the place without any historical reference on the patients," which Ackerman said would be "dangerous."

Neither the policy idea around preventing payers from cost-sharing, nor the proposed amendment calling for patients to have their choice of physicians, were included in the preliminary report released Wednesday.

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