Public Health's Role in Telehealth

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: the evolution of telehealth, how it's performed during the pandemic, and the future as providers welcome patients back to their waiting rooms.

DR. SCOTT HARRIS:
Telehealth is a very powerful tool for reducing health disparity, and that sums it up right there.

MEI KWONG:
It's not going to go back to the way it was before the pandemic. There have already been changes if you look at on the state level—some on the federal level, too—that have been made permanent.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Telehealth or telemedicine was around long before the COVID-19 virus, but it was the pandemic that made it a household name. When face-to-face doctor's visits weren't possible in the early days of the outbreak, patients suddenly became very familiar with the idea of visiting their provider online, talking to them over a computer instead of seeing them in the exam room.

Our guests today know a lot about telehealth. Mei Kwong has spent the last two years tracking changes in federal policies that made it possible for more providers to use the technology more often. Kwong is the executive director of the Center for Connected Health Policy. She's along shortly with her assessment of the performance and the future of telemedicine.

But first, we hear from Alabama state health officer Dr. Scott Harris about the impact of telehealth in his state and who gets hurt if it becomes less available after the pandemic.

HARRIS:
There are a lot of ways in which telehealth has really increased its coverage throughout the country—although, interestingly, maybe not so much in Alabama just because of the way that we're set up here.

There's an expression you've heard applied to a lot of situations, but with telehealth it's also true—if you've seen one telehealth program, you've seen one telehealth program.

And so, the way Alabama developed its program, we built our capacity internally using, you know, our audio-visual capabilities to serve as a facilitator for outside providers. And really with a public health emergency that existed, as people began using these audio-only calls to reach out directly to patients and providers, there really wasn't as much a need for us to be involved in that role in some way.

So, in some ways, there are many more people who are accessing telemedicine services because they have cell phones. But what we're doing in public health and our individual state agency really has declined somewhat.

JOHNSON:
How do you feel about that? Has that held you back from doing the kind of response work you'd like to do? Or is it going fine anyway?

HARRIS:
Yeah. You know, we're happy that if people are able to get connected to their provider, that's a good thing in every case. Although I think we would argue that you do lose—potentially lose—some of the benefits of a face-to-face, you know, real-time video interaction when you're simply talking over the cell phone, we certainly understand the reasons for that and support the fact that that change was made. But as a pandemic is at least temporarily waning, as we see decreased numbers of infections going on around us, the idea that, you know, we need to allow that just as a way of moderating the risk infection is not as good an idea.

So, I think we would like to get back to the kind of work that we've always been doing all along. You know, ultimately the most obvious reason for people to have telehealth is because it increased access to care. I mean, that's the obvious reason for it. There's so many aspects of that though. You know, it's access to care for an individual patient who just can't travel because they live in a rural area, or they can't afford to pay someone to drive them to another city. But access to care actually also applies to providers and communities who are in these more remote areas as well.

You know, we see younger physicians who are coming out of training; they're used to having lots of medical specialists around them. And to have them in a rural area where they don't have that specialty support, it makes it really difficult for us to get them to stay in those areas. And so, having telehealth services available for their patients is really important to maintaining those providers in those communities.

And it's exactly the same explanation for rural hospitals themselves. Our rural hospitals in Alabama are really struggling in a lot of different ways. And so, telehealth is a way for them to continue to provide a broad range of services that they might not otherwise have available.

JOHNSON:
So, would you say they'd like to see that continue even as the pandemic hopefully starts to wane?

HARRIS:
Yeah, I think that that's absolutely true. There's no question.

And right now, just because of the economic situation we're facing, travel has become, you know, more challenging and expensive than ever. Alabama is a big rural state, you know, with a low population density. Most of our medical specialists are concentrated in just a couple of cities in the state. And, you know, most people live in fairly small communities around the state. And these rural areas, you know, face a lot of challenges, of course not just in the area of healthcare.

But, you know, as a rural hospital, because care has become so increasingly specialized, if you can provide, you know, fairly sophisticated and specialty care, it's hard to remain open just as a general hospital in a rural area that's addressing, you know, the types of things that really patients no longer get admitted to the hospital for anymore.

So, I think rural providers and rural hospitals in particular really are hoping to get back to the type of telehealth services that we've always wanted to provide for them.

JOHNSON:
Some consider telehealth to be on the bubble, meaning it may or may not continue to benefit from those flexibilities that have made it so popular the last two years. How do you feel about the possibility that access to telehealth could start to be restricted again from a federal perspective?

HARRIS:
Certainly there are going to be some challenges there. You know, we all of a sudden gotten used to, in every aspect of life, to the convenience of just being able to access things electronically. And, you know, when we first began developing our telehealth technology at our agency about eight or nine years ago, there really wasn't such a thing as Zoom meetings or FaceTime to speak of and those kinds of technologies just weren't widely available. Now, everyone knows those and they're just sort of a normal daily part of life. And I do think there's an expectation on the part of the public to have access to that when it's appropriate to do so.

We certainly do think that some of this flexibility is going to be lost, you know, as the public health emergency subsides. We are seeing actually in our state the first real serious legislative effort by our state legislature to formally regulate telehealth practices, to enable our medical board to write rules for how that practice is conducted, to allow our medical licensure commission to begin to address that.

So, there's certainly going to be a formalization and there's going to be a regulation aspect that we haven't had before. There's always trade-offs with that. I think on balance that's a good thing; but you know, we live in a state here that looks suspiciously at regulation by the state. You know, it's always a real battle, and people are always quick to see the negatives in our state compared to the positive.

So, I do think there are going to be some big changes. We just hope that we can maintain all the major benefits that we've enjoyed from telehealth.

JOHNSON:
Who is impacted the most if telehealth were to become less available in Alabama or across the country?

HARRIS:
Without a doubt—in our state, anyway—it's going to be rural areas. You know, we're at the bottom of many different rankings of health outcomes. We have tremendous health disparities between our urban and rural centers like a lot of places do. We have tremendous racial disparity, you know, the health outcomes for African Americans in our state far trail health outcomes for white Alabamians. And that's really one of the most important missions that our department is trying to address.

Telehealth has really been helpful in helping people to access care in these areas that are more rural. You know, as we mentioned, just, you know, driving a couple of hours away to another city where medical care is available in-person, you know, probably cost three times what it cost a few months ago, just because of the issues with inflation. Again, rural hospitals have to be able to access care for people or else the folks in their own community are no longer going to use those institutions, or they're just going to ignore them and go elsewhere. So, it's really rural areas that are going to suffer the most.

We have telehealth services provided through public health in every county in our state except for one, and the one county where we don't actually provide telehealth services is the one county where most of the medical care is already available. That would be Jefferson County with the city of Birmingham where our major academic medical centers, our only dedicated children's hospital's located, transplant center, burn center, and so on. So, we are going to see some issues in rural areas if we can't maintain them.

JOHNSON:
Thinking about how the policy might change, does public health have a lever to pull in support of keeping broad access to telehealth going forward?

HARRIS:
You know, we have levers to pull in the sense that we have allies who can help us. It really comes down to the issue over sources for the most part, and that's the story that all public health agencies know. In just about every program, there's never enough resources to do all the things that you think you would like to be able to do. But we do have a broad support by some groups that can help us. Our largest medical centers, particularly our academic medical centers, have been great partners with us and strong advocates.

I mentioned earlier that we don't have a telehealth program exactly in Jefferson County, but the largest medical center there, the UAB Medical Center, has about 1400 providers who are all credentialed to be telehealth providers. They all participate in the program, even if we're not actually facilitating encounters in that particular county. So, they have a large interest in doing that. As a major referral center, they see people from all over the state and, in fact, all over the Southeast. And so, we rely on them pretty heavily to help carry our message out and communicate with other public officials and people who can help us get resources.

We have good connections with our major payer in our state—in Alabama over 85% of the commercial insurance market belongs to one single company, which is not found in every particular state. So anything that we want to do that's going to potentially add costs to treatment, means that we have to work really closely with our largest payer to try to make sure they're on board with that, and they pretty much have been.

We've considered telehealth parity laws in our state. You know, some of our surrounding states have enacted those. Actually in our state, we've not enacted that, but that's really because that effort was forestalled by our largest private insurer that went ahead and agreed to go ahead and start reimbursing, you know, virtually every medical specialty, effectively enacting a parity law on their own.

So, having those supporters will make a big difference, even if public health itself is not the most powerful or vocal or capable agency for convincing people to give us more resources.

JOHNSON:
Is that why partners are so important, because they can make that megaphone bigger?

HARRIS:
Yeah, that's exactly right. We have, you know, for example, you know, state laws—as most states do—that actually limit us as state employees for lobbying for policy. You know, we can educate on policy; there's always that fine line about when you're educating and when you're trying to talk someone into a position. But our partners don't have those restrictions; and in fact, you know, just by the very nature of their business, they lobby public officials all the time, which is something that we can fortunately attach ourselves to as well in some cases.

JOHNSON:
We're all hoping that COVID goes away sooner rather than later, but people are watching what's happening in Europe again and elsewhere around the world. And so, we're not really sure, I guess, what will come later this year, if not sooner.

What happens if telehealth starts to become a little harder to deliver? What does the system look like at that point, with or without a pandemic?

HARRIS:
Yeah, it is going to, again, be a challenge. You know, we have used our telehealth services just internally in an agency in a lot of ways, and fortunately I think we'll be able to continue to do that. You know, we use that for some really basic public health functions, like disease intervention specialists, you know, interacting with STD patients, or we have an HIV re-engagement program that attempts to locate patients who've fallen out of care. And so, there are a lot of ways that telehealth has been used by us, not for the public at-large, that we'll continue to do.

But in order to continue facilitating visits for specialists and other cities with patients and rural areas, it really very much matters what else is going on in society. The pandemic has disrupted so many different things. It's just made us make a lot of choices at the time because they were the best choices that we have available to us at a given moment. And I think ultimately we are just going to have to be able to sit down and reflect and think more long-term than we've been able to do over the last two years.

JOHNSON:
Given that, and wrapping up here, what's the best argument for a continued robust telehealth approach?

HARRIS:
Telehealth is a very powerful tool for reducing health disparity, and that sums it up right there. Our mission, again, is to improve health outcomes by addressing disparity. Telehealth is not the only tool or maybe not even the most important tool, but it is a very important tool for doing that. The more we're able to build that capacity ourselves to encourage other providers to attach themselves to that, the more we're going to be able to reach people who otherwise are just not going to have access to care in most cases.

JOHNSON:
Mei Kwong spends her days answering questions about telehealth. It's her job as executive director of the Center for Connected Health Policy to know everything about telemedicine technology. She says while the impact of telehealth during the pandemic is well documented, the future is less certain.

KWONG:
It's been extremely important, especially in those early days of COVID when things were shut down and people were trying to minimize contact to prevent the spread of COVID-19.

So, for those who aren't familiar with it, telehealth is the use of technology to provide health services from a distance. So, during a time where there's a highly infectious disease going around, you can see the benefits of that in that you can engage with your healthcare provider to receive services still, but not have that physical contact with them. But that also means it's not going to be used for every situation, but it can definitely be used for a lot of situations, and that minimizes people's exposure to COVID-19.

So, it was very useful in those very early days when we weren't sure what was going on and we were just trying to, like, corral the pandemic as much as possible. It's also very useful for folks who might have issues with transportation in trying to get health services as well, let alone, you know, worrying about being exposed to some type of infectious disease.

JOHNSON:
How important has telehealth been to the nation's COVID-19 response?

KWONG:
It definitely did—I've been doing this for over 10 years, and before the pandemic I had family and friends who still didn't quite understand what I did for a living. And then, after COVID-19 hit and a few weeks afterwards, telehealth became I think sort of more incorporated into the lexicon of our everyday vocabulary. People understood what it was, what it could do, and that, you know, it was something that was around that they can access.

And really telehealth, before COVID-19 happened, had been around for really decades as a way of providing services. But it was very limited because of the fact that it wasn't widespread, and that's partially due to policy barriers or reimbursement barriers that limited its use.

JOHNSON:
Did the pandemic give telehealth the boost it needed to become more of a mainstream tool? Did it help advance the cause of telehealth?

KWONG:
It's definitely dropped. It hasn't gone back to pre-pandemic levels, the lower levels of utilization, but it hasn't been at those high levels in those early months of the pandemic. If you look at data, for example, from Medicare, you can see that there's been a drop in use, but there's still been high use for it. It's been used more frequently in certain specialties than others. So, people going back to the office for certain things, yes, they are going back to like the brick-and-mortar type of visits that they are using.

But then, there are other things that people are utilizing telehealth more and more for. And one area that, you know, especially where you see a lot of high use for and continued high use for is for treatment of mental behavioral health issues.

JOHNSON:
Do you think providers will continue to use telehealth, or will it go back to the way it was before the pandemic?

KWONG:
It's not going to go back to the way it was before the pandemic. There have already been changes if you look at on the state level—and some on the federal level, too—that have been made permanent. So it will, you know, at least stick around for a couple of years. Who knows, like, down a couple of years down the road, there may be like, you know, changes to it again.

But we're definitely not going to go back to those pre-pandemic levels right now because there are already permanent changes being made both in like, you know, some service states and on the federal level as well for Medicare.

JOHNSON:
What about efforts to regulate or further deregulate telehealth? Can you tell us what's happening on the legislative front?

KWONG:
Well, there have been over 200 federal bills that have been introduced to impact how health in some way. A lot of them are keeping the temporary waivers in Medicare around. I think there's also been I think something like over 300 different groups or organizations have written to Congress and said, "We need to keep some of these telehealth waivers around, these telehealth relaxations around." And a lot of it really does center on, like, there's a concern that people are going to lose services if these waivers go away.

So, we talked about earlier that not only was telehealth a great tool to provide services during a pandemic when there's a highly infectious disease, but it was a great access for folks who may have issues accessing services just on the regular. Because maybe they live in a rural area, maybe they don't have a certain specialist within their community, maybe they have mobility or transportation issues. They will definitely be impacted if suddenly telehealth is taken away from them because some of these temporary relaxations go away.

There are also, I would say, a lot of interest from policymakers, both on federal and state levels, in keeping telehealth around. I think a lot of policymakers do get it, and telehealth has proven itself to be a very bipartisan issue. You get both sides of the aisle in support of it. But I also understand the policy makers want to still balance the concern of, you know, efficacy and like whether, you know, this is appropriate for everything and how far to expand things. So, there's a lot of things that they are weighing in, like, you know, what to keep around too.

And that's understandable, but it also has to be balanced with, I think, the fact that you can really put some people, some populations, in a very dire situation if we suddenly take this away from them, too.

JOHNSON:
How has telehealth impacted health equity across the country?

KWONG:
You know, there's been rightly some discussion about that in that, you know, does telehealth inadvertently create inequities? Because telehealth is the use of technology and not everybody's going to have access to that technology, whether it's because they don't have the connectivity, because maybe they live in a certain community where there's just not great connection, or it's really expensive and they can't afford it. Plus you need like the thing, like the equipment at the other end—whether it's a laptop or smartphone—and not everybody has access to that.

So, there are questions regarding that of like, you know, if we like keep these waivers around or keep these temporary policies around, are we creating disparities among different population groups? And I say part of that I think is a larger discussion. Definitely the connectivity issue is definitely a larger discussion that goes beyond telehealth because telehealth wasn't the only one relying on that connectivity. You had education rely on it too when kids were being schooled at home, and you have people rely on it for their livelihoods because they were working from home.

So, I think that's a bigger infrastructure question that goes beyond telehealth—which, you know, to policymakers' credit, a lot of them from the federal and state level started trying to address that. We definitely had, like, some funding from the federal government put into expanding broadband. There's been, like, programs to try to give subsidies to people to access conductivity a little bit better. But that's, I think, a larger issue than just telehealth itself.

JOHNSON:
We've been talking a lot about how providers use telehealth, but what about public health? How does public health engage the process?

KWONG:
So, really a lot of the established telehealth policy has been—and when I say established telehealth policy, I'm talking about policy that specifically is about telehealth, it says telehealth within there in some way. A lot of that has really been centered around Medicare and Medicaid, to be quite honest. So, that has been where a lot of discussion has been, and that's why it's under so much on providers and patient use.

So, really it's been kind of, where public health has concerned, they've been a little bit newer to the conversation, but so is, you know, different other sectors of government, such as like education. They've been a little bit, you know, not as involved in helping to shape the policies over the years. So with the pandemic, they definitely have been, you know, more active players in it.

But really just because of the way the policies existed going into pandemic has been sort of more centered in like that reimbursement side—what's paid, what's covered—there. But definitely I encourage—and I mean, CCHP is a program under the Public Health Institute—definitely do encourage greater involvement of public health departments in that discussion. I think it is more useful that sort of more government agencies understand what another agency is doing around telehealth because it has such impact over multiple agencies. Housing is another one that's, like, been new to the discussion when COVID-19 hit.

JOHNSON:
Using Medicaid as the example, how might public health leaders build partnerships to address reimbursement and coverage for telehealth services?

KWONG:
Yeah, they definitely need to reach out to their counterparts in those agencies. And it may be difficult because, quite frankly before the pandemic—and it's hopefully gotten a little better now—before the pandemic, you really didn't have like a telehealth person on a lot of Medicaid programs where that was their title. It may be, you know, an aspect of somebody's workload. It was like, "Oh, they cover 15 different things and telehealth," and telehealth may have been a small part of their workload. So, it's sometimes is difficult finding, like, who is that point person that I really need to engage with.

So, that's sort of like the first hardest step to do is like find that point person. But once they do—and it may be easier now because there's so much discussion on COVID and like what policies to keep around where telehealth that they might have an easier time finding that person—but to engage that person say like, you know, "What are the policies that you are thinking of and how are they going to impact my work?"

JOHNSON:
Jurisdictions are investing a lot of money in their infrastructure thanks to funding that was provided as a result of the pandemic. Are they spending any of it on telehealth?

KWONG:
I can't say for every jurisdiction. I think they are maybe examining at least on that conductivity issue, on like what regions may need sort of more hard wiring of those expenses if they're not willing to like, you know, spend it on people but maybe like on an actual infrastructure there. So, I think they are examining it as where is connectivity a little iffy or not as great. And that was definitely like impact the telehealth side of things.

I don't know how much they are considering telehealth making those decisions, or if it is just sort of a straight, "We know this is sort of a dead zone here and we need to like, you know, help this particular community." So, I don't know how much telehealth is, like, weighing in on their decision there because, as I said, definitely when you're talking about like connectivity, it's not just about telehealth—it stretches across different issues there.

JOHNSON:
So do you think it's a good idea, then, to invest some of those dollars into telehealth before the next wave of COVID or the next pandemic hits?

KWONG:
I definitely think it is. I mean, I definitely think, you know, part of why there was such a hard pivot to telehealth and there are so many people were just in like those first couple of days very confused of like, "I don't know what this is, and I don't know how to do this," was that there wasn't that investment in telehealth.

And it was really incredible, like the speed of like the ramp-up. But it did take time to like do that, and it did take a lot of resources to do it where, if we had it established, it could have been a much easier transition.

So, you know, my thought is we've got telehealth now. We've learned some lessons. Now, let's build on this so next time something happens—and it doesn't have to be another pandemic, what if there's like a natural disaster, too, that also happens—then you need, like a lot of times you need healthcare personnel to try to deal with it. And sometimes they can't get into a specific region, maybe, for whatever reason. So, telehealth can be a way of still trying to provide that expertise and that service in that area.

JOHNSON:
Last question here: what do you think telehealth will look like a year from now?

KWONG:
You know, that's a good question because a year from now is actually not that long, so I'm not quite sure. I think we'll definitely have like a better idea of, like, what's going to be sticking around permanently a year from now; like either the decision will be made or they'll be about to make that decision, et cetera. So, I think we'll have a clearer idea on, like, what's going to be allowed.

Going into the pandemic when you looked at the policy landscape for telehealth, I equated it to a patchwork quilt. It was just like all different, like in every state, just different things; and you have the federal government, they were doing different things too. It's still going to be like that. There were always things where, you know, it was like, okay, you see this over multiple jurisdictions, but you don't see it like everybody's doing X type of thing like nationwide. So, there's always variations and nuances to the policy, and I think that's going to continue just looking at like what has been made permanent on the state level.

But definitely there'll be an expansion. Certain things that I think will stick around will be—they'll allow the use of tele-health even more for treatment of mental and behavioral health condition. And especially there's a lot of interest in using it for substance use disorders, people who have those conditions. So I think that will be around.

Also what I think will stick around is allowing telehealth to be used when the patient isn't in a clinic setting. So they don't have to be in a doctor's office, they don't have to be in a clinic or a hospital when they're accessing telehealth—they can be in the home. I think that will be the big thing that will stick around as well, too, in a lot of places.

And I think probably an expansion of the type of providers who could use telehealth to provide the services. A lot of times before the pandemic, it was limited to, oh, just doctors and nurses can do this. I think we'll see like, you know, a lot more health professionals be able to have access to it and that their services will be covered as well.

JOHNSON:
Thanks for listening to Public Health Review.

If you like the show, please share it with your colleagues. And if you have comments or questions, we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org. Also we'd love it, if you could leave us a rating and a review—those are two great ways to give us feedback.

Finally, make sure you never miss another episode by following the show—it guarantees that every new conversation will be delivered to your mobile device the moment it's posted. Look for the follow button on Apple, Spotify, or anywhere you stream audio.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.