GAO Tells Congress to Wait on Expanding Telehealth Coverage Past the Pandemic

The US government’s financial watchdog is advising lawmakers to wait a while and gather more data before deciding on whether to permanently expand telehealth coverage for Medicare and Medicaid programs beyond the pandemic.

In a 27-page report and testimony before the Senate Finance Committee this week, representatives from the Government Accountability Office told lawmakers that connected health services have been crucial to expanding access to care during the COVID-19 public health emergency. But the full effect of those new services on cost, safety and clinical outcomes hasn’t yet been determined.

“The quality of telehealth services provided to Medicare beneficiaries has not yet been fully analyzed, and evidence from the few existing studies is inconclusive,” the report, prepared by Jessica Farb and Carolyn Yocom, reads. “According to (the Medicare Payment Advisory Commission), some researchers have concluded that, in addition to increasing access to care, telehealth can also improve the quality of care. Other researchers caution that the convenience of telehealth could harm the quality of patient care. (Centers for Medicare & Medicaid Services) officials told us in February 2021 that they are still exploring how to measure the quality of care when services are delivered via telehealth.”

CMS has issued more than 230 Medicare waivers since the coronavirus pandemic took hold in early 2020, helping to expand telehealth coverage by allowing more providers to use the platform, adding more sites where telehealth could be used, and allowing those providers to use different modalities, such as audio-only telehealth. A few of those telehealth waivers have been made permanent, but most will end when the PHE ends.

“Medicare telehealth waivers resulted in increased utilization of telehealth services, and provided beneficiaries access to services that would not have otherwise been available during the early days of the COVID-19 pandemic,” the report says. “However, the long-term effect of these waivers on spending and quality of care is not yet known. In addition, we reported that careful monitoring and oversight is warranted to prevent potential fraud, waste, and abuse that can arise from these new waivers. Existing research and preliminary observations from our ongoing work indicate the following effects of telehealth waivers on service utilization and access to care.”

The same holds true for the more than 600 Medicaid waivers, state plan amendments and other flexibilities approved by CMS, the report says.

That said, the GAO wants more information on how telehealth has worked – or not worked – during the past year and a half before making any final recommendations. It has concerns in four categories:

1. Spending: The GAO noted that the increased demand for telehealth remains high, even as in-person visits are ramping back up, and wants to know whether some providers are using telehealth as means of reaping more reimbursement from CMS than they should be getting. They’re also worried that waivers issued to bypass the Physician Self-Referral Law could lead to an increase in unnecessary services.
2. Program integrity: While the pandemic has produced a surge in the use of new modalities like audio-only telehealth to help underserved populations access care, the GAO said some of those platforms aren’t reliable or safe for many services, and could expose providers and patients to fraud and abuse. They’re also worried that the surge in telehealth and relaxed rules could mask an underlying surge in inappropriate Medicare claims.
3. Patient health and safety: While the pandemic has led to a surge in all telehealth uses, behavioral health care has seen the biggest increase, as the nation grapples with a surge in mental health and substance abuse issues. Medicare and Medicaid waivers have helped providers use telehealth to reach more people in need of help, but it’s unknown whether the increase in telehealth use is improving patients’ health and safety.
4. Equity: The surge in telehealth has also exposed problems with who’s using telehealth and who’s able to access it. Rural communities, minorities, those with disabilities and other underserved populations are still having problems accessing care through telehealth, due to economic, technological and cultural barriers. At the moment, there isn’t enough information to determine whether CMS waivers have helped to improve equity.

The GAO report and testimony add to the challenges facing lawmakers in developing a long-term policy for telehealth. Several states have made their emergency measures permanent, and Congress is faced with dozens of bills and lobbying efforts to do the same.

But they’re also being advised by MedPAC and others to take it slow and avoid a rush to judgment.

“Continuing these flexibilities after the public health emergency declarations end could increase certain risks to the Medicare and Medicaid programs,” Farb and Yocom concluded in their report. “Careful consideration of these benefits and risks will be key to determining the path forward.”