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Gov. Ned Lamont’s decision in March to mandate social distancing to slow the spread of COVID-19 forced medical providers to quickly expand telehealth coverage for appointments by video or phone.
This expanded coverage is regulated by a temporary patchwork of major policy changes, including state and federal emergency mandates and voluntary measures by private insurers.
On March 19, Lamont issued an executive order allowing providers for the first time to offer medical visits by telephone. And Medicaid and private insurers have moved to reimburse providers for virtual visits at the same rate as in-person visits.
At an Insurance and Real Estate Committee meeting of state legislators on June 4, the Connecticut Association of Health Plans and representatives of Anthem and Connecticare warned legislators that making these policy changes permanent, without careful consideration, would have unintended consequences.
Last week, in a joint letter, a group of five associations representing behavioral health providers took the opposite view and asked leaders of the Connecticut legislature to make those temporary changes permanent.
A patchwork of measures
Among the most significant changes was the decision to reimburse medical providers for virtual visits at the same rate as for in-person visits.
HUSKY Health, the state’s Medicaid program, had never reimbursed for virtual visits prior to March, said Mark Masselli, president and CEO of Community Health Center, Inc. The center serves about 150,000 patients in Connecticut and about 65 percent are enrolled in HUSKY Health. About 90 percent of visits have been by phone or video since HUSKY Health began allowing reimbursements in March, said Masselli.
According to FAIR Health, a non-profit that collects insurance data, compared to March 2019, there were 15,000 percent more telehealth claims in March 2020 in a nine-state northeastern region.
In 2015, the Connecticut legislature passed a law requiring insurance providers to cover telehealth visits, but the law did not require insurers to reimburse at the same rate as in-person visits. However, telehealth was not widely used in Connecticut prior to the COVID pandemic.
An established practice for behavioral health
Behavioral health providers, more than other fields of medicine, used telehealth to visit with patients before the pandemic. According to FAIR Health, mental health conditions accounted for about 36 percent of telehealth diagnoses in both March 2019 and 2020, far more than any other type of diagnosis.
Middletown psychologist Carrissa Phipps has been providing visits by video since 2017, when she started her practice, Small Victories Wellness. She said that distance medicine is an option for patients without easily-available transportation, for patients who want to work with Phipps, but are a long drive from her office, and for college students who are out of town.
“I really see it as an access issue, because these are folks who might not reach out, if telehealth wasn’t an option, because they don’t see how they can fit visits into their schedule,” said Phipps.
The expansion of telehealth coincides with what mental health providers warn will be a significant increase in the number of people who need their care, due to social isolation, unstable work conditions and health concerns caused by the pandemic.
According to the state Department of Social Services, HUSKY Health will continue to reimburse some virtual visits with behavioral health providers after the pandemic and the department is in a process of reevaluating whether to reimburse other visits.
A group of five associations representing behavioral health providers asked leaders of the Connecticut legislature last week to pass a law requiring that insurers reimburse telehealth and in-person visits on an equal basis.
If providers are reimbursed at lower rates for virtual visits, they could limit those visits, argued Steve Wanczyk-Karp, executive director of the Connecticut branch of the National Association of Social Workers, one of the groups that signed the letter.
“You’re going to have fewer clinicians who are willing to take telehealth clients because they just financially can’t make it work,” he said.
Anthem is voluntarily providing equal reimbursement for in-person and telehealth visits at least until September 30, but hasn’t committed beyond that date.
The legislature gets involved
At the June 4 insurance committee hearing, representatives for private insurers said that the shift toward telemedicine would continue after the pandemic. Still, the shape of telemedicine after the pandemic remains unclear and they urged caution for any permanent changes to telehealth rules.
Anthem Director of Government Relations Christine Cappiello told the committee that the company has been pushing providers to get on a telemedicine platform for years, with little success.
Susan Halpin, executive director of the Connecticut Association of Health Plans said that emergency rules and voluntary measures taken by Anthem were appropriate during the pandemic, but that issues including choice of platform and reimbursement parity demonstrate the complexities of the issue.
“Without further understanding, and some study and analysis, I don’t think it should be any kind of knee-jerk reaction,” Halpin told legislators.
According to Halpin, additional rules on Anthem and Connecticare could jeopardize their compliance with the Affordable Care Act, because plans are bound by benefit structures and calculations in order to be sold on the exchange.
Platforms and state lines
Telemedicine only works if patients have access to the technology, and not everyone in Connecticut has access to the reliable internet connection needed for a video visit.
On March 19, Gov. Ned Lamont issued an executive order that allowed providers to conduct medical visits with patients over the phone, rather than through video.
At Community Health Center, some patients, like homeless people, don’t have ready access to phones, though most do, said Masselli. He says that there needs to be a serious effort to make broadband internet available to everyone, but continuing to allow visits over the phone is essential for patients who don’t have that access.
“Oftentimes, our patients are essential workers, the people on the checkout line helping you put your groceries in your bag or working in some capacity in fast food,” Masselli said. “It doesn’t make sense to take that person off their job, make them drive to where we are, make them wait in the waiting room, drive back and lose pay for it. It undermines the economy and in many cases, it’s not essential to see them in person.”
Masselli and Phipps both said that the barriers of state lines are an issue.
Phipps is working with a partner to open an all-telehealth psychology practice across multiple states. Fourteen states have agreed to allow mental health practitioners licensed in other states to serve patients across state lines. But in most states, including Connecticut, the practitioner needs a license in the state of the patient they’re serving.
“You can get licensed in multiple states, but it costs money and states have different requirements, so it gets messy,” Phipps said.
Some physicians who work in Connecticut live in surrounding states, so they can’t consult patients remotely from their homes. It can also create barriers to connecting with specialists in other states, Masselli said.
“Why is there something different between my Harvard-graduated doc who lives in Enfield, and my Harvard-graduated doc who lives in Springfield?” he asked.
This report was edited in response to an email from an Aetna spokesperson clarifying that the insurer does not require the use of Teladoc for telemedicine services.
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