Health Care

Telemedicine rose rapidly during COVID. It might be here to stay.


Telemedicine National Cancer Institute | Unsplash

A year and a half into the COVID-19 pandemic, Pennsylvania still has no law on the books to authorize, regulate or prohibit the use of telemedicine. It’s an issue that lawmakers have been aching to address over the last several years in order to structure how telemedicine services can and can’t be used in the state. 

Currently, access to telemedicine can vary by health care system and by insurance provider, and coverage is not guaranteed for appointments the same way they are for in-person visits. 

The onset of the health crisis, however, brought a renewed focus to telemedicine, with patients forced to utilize phone calls, video visits and other means to access health care services. The rules around telemedicine – or lack thereof – were also temporarily addressed, thanks to a series of regulatory waivers from Gov. Tom Wolf’s administration that offered flexibility to medical providers. But those waivers are planned to end at the end of September, likely prompting a renewed conversation on how to address telemedicine policy in Pennsylvania.

Under the COVID-19 regulatory suspensions, a lengthy list of medical professionals licensed by the state were able to utilize telehealth technologies to care for patients. That meant traditional doctors, nurses, chiropractors, optometrists, pharmacists, psychologists, therapists, speech pathologists and even veterinarians were able to take advantage of new rules surrounding telemedicine. 

The waivers even allowed practitioners who were licensed in another state to treat patients in Pennsylvania. 

Many view the expanded use of telemedicine as one of the few silver linings in a devastating pandemic that has resulted in the deaths of more than 27,000 Pennsylvanians. The regulatory suspensions for it have been so well received that lawmakers even voted to continue the waivers despite terminating Wolf’s COVID-19 emergency declaration. 

And it hasn’t just been embraced by patients – medical providers have also found that telehealth tools can supplement traditional forms of coverage.

“With the advent of COVID, it was becoming a real necessity, and it was a real impetus for telemedicine,” said Dr. Michael DellaVecchia, an ophthalmologist who serves as the president of the Pennsylvania Medical Society. “It was slowly evolving, no doubt about it, but the pandemic was the booster shot for telemedicine.”

Interest in telemedicine services has also appeared to increase despite a dropoff in COVID-19 cases. David Fletcher, Geisinger Health System’s associate vice president for telehealth, said that before the pandemic, Geisinger offered telemedicine services for about 20 different medical specialties, largely confined to hospitals and clinics due to certain regulations and payment rules that precluded Geisinger from offering at-home telehealth services. 

The relaxed telemedicine regulations that came with COVID allowed Geisinger to increase the specialities for which access to e-doctors were made available.

“We expanded enormously,” Fletcher said. “We have over 60 specialties now that use telemedicine regularly, both in the home and in hospitals and clinics. We've had very high satisfaction rates from our patients who have used it. It’s been very popular. We use it for everything from regular kinds of primary care-type services, specialties like pulmonology, behavioral health – a very high percentage of our visits are done via telemedicine in space.”

The state-based waivers implemented by Wolf were made under his COVID-19 emergency declaration, which was terminated by the Republican-led General Assembly in June. But lawmakers decided to extend the regulatory waivers and suspensions until Sept. 30 – a date that will likely force them to reckon with the state’s lack of a telemedicine law. 

A spokesperson for the Pennsylvania Department of State, which issued the waivers, told City & State that because Pennsylvania does not have a law authorizing or prohibiting telemedicine, that health care providers would still be able to treat people this way even after the waivers expire. 

However, telemedicine services from out-of-state providers, currently allowed under the state’s regulatory suspensions, would have to stop. “There is nothing in the law that allows for telemedicine for out of state providers at this time,” Laura Humphrey, a spokesperson for the department, said in an email. 

Fletcher added that health care providers are also keeping an eye on the status of regulatory waivers made at the federal level that deal with Medicare.

“Once that public health emergency ends at the federal level, then all those rules go back into place unless some sort of legislation happens. Now, the good news is there [are] very strong signals,” he said. “We're optimistic that something is going to be put in place.”

For years, state lawmakers have attempted to approve legislation that would set parameters for telemedicine. State Sen. Elder Vogel, a Republican from western Pennsylvania, has repeatedly introduced bills to regulate telemedicine. His proposal would require state licensure boards to establish regulations for the use of telemedicine within their respective fields and set guidelines for health care providers to follow.

The legislation – Senate Bill 705 – would also require insurers cover “medically necessary” services received from an in-network provider and prohibit health insurance policies from excluding a service just because it’s conducted through a telemedicine appointment. And insurers would not be required to cover services from out-of-network providers. 

Vogel has routinely introduced the same proposal in multiple legislative sessions and come close to getting his bill signed into law, but a controversial abortion-related amendment caused Wolf to veto the bill last year.

The amendment would have blocked health care providers from prescribing drugs that show up on the U.S. Food & Drug Administration’s Approved Risk Evaluation and Mitigation Strategies (REMS) list, including one that induces non-surgical abortions.

Throughout his two terms in office, Wolf has established himself as a defender of abortion access and vetoed the bill believing it would restrict the right to choose. 

“I supported a prior printer’s number of the bill, but as amended in the House of Representatives, this legislation arbitrarily restricts the use of telemedicine for certain doctor-patient interactions. As amended, this bill interferes with women’s health care and the crucial decision-making between patients and their physicians.”

Vogel, speaking to City & State, said he does not believe any abortion-related language should be added to his bill. “That legislation needs to stand alone on it's own,” Vogel said. “It has no business being in my telemedicine bill.”

Vogel said he waded into the issue of telemedicine policy years ago after hosting a senior expo in his district. He said he was approached by one woman who experienced difficulties getting from Lawrence County to Pittsburgh for her doctor visits.

In addition to convenience, Vogel said increased access to telemedicine also has the potential to drive down costs for patients who might be able to forego transportation worries or mounting health care costs due to better, earlier access to care. 

“Hopefully, they'll be able to feel more comfortable to contact a doctor via telemedicine,” he said. 

As lawmakers continue to assess how telemedicine should be regulated in the Commonwealth, health care professionals say they must stay abreast of improvements in technology, which may warrant updates to laws and regulations surrounding the service.

DellaVecchia told City & State that the continued development of telemedicine offerings will not only help patients with limited access to health care receive needed services, but also allow health care practitioners to better assess patient needs.

“They give us the opportunity to expand our scope of practice,” he said of telehealth technologies. “Telemedicine, we hope, will allow us to care for those patients, but also act as a form of triage.”

DellaVecchia added that lawmakers need to take a forward-looking approach as they craft legislation to regulate telehealth. “With legislation, it tends to lag behind the reality, whether it's technology, medicine or even banking or stock transfers,” he said. “They have to look into the future and say, ‘How are we going to use this technology to take better care of people? How are we going to write the rules to see that this is done properly and not profiteered?’” 

Fletcher said that advancements in medical technologies have the opportunity to expand what telemedicine can be used for in the years to come. He said health care providers will have an extensive amount of data coming out of the pandemic to determine how to improve telemedicine treatment and telemedicine tools. At-home stethoscopes and cameras, he predicted, would become increasingly more common.

“I think that's probably years out that you'll start to see that more commonly, but I think it's definitely on the horizon,” he said.

But while technology is improving and conversations at the state level continue to take place, barriers still exist that prevent access to telehealth technologies – namely, access to broadband internet. 

Natalie C. Benda, in an editorial published in the American Journal of Public Health, writes that broadband internet access, or BIA, must be treated as a social determinant of health. 

“Reduced BIA, particularly during this pandemic, has the potential to exacerbate this country’s existing health disparities because it dis-proportionately affects those who are already vulnerable,” Benda writes. “Indeed, those who are older, are racial/ethnic minorities, have lower incomes, are less educated, or live in rural areas may experience worse health outcomes under normal circumstances and are even less able to access health-enhancing resources during social-distancing orders.”

A 2021 report from AARP Pennsylvania and Drexel University’s College of Nursing and Health Professions found that hispanic and Black Pennsylvanians were much more likely to express concerns over paying for high-speed internet and cell phone coverage during the pandemic, with 54% of hispanic respondents and 36% of Black respondents worried about broadband costs, compared to 21% of white broadband users.

The same held true for cell phone expenses, with 56% of hispanic respondents and 39% of Black respondents concerned about the cost, as opposed to 22% of white respondents.

More than half of respondents that were deemed low-income (those making below $30,000 a year) also worried about the costs of broadband and cell phone use. 

The report outlines a series of recommendations to improve access to telehealth services, including improving access for those who are medically underserved, creating regulatory flexibility within the telehealth space and using telehealth in primary care settings to reduce redundancies in care. 

As members of the General Assembly continue efforts to regulate telemedicine, they do so with a slate of recommendations and resources at their disposal. The questions that remain surround what components will be in the legislation that eventually gets sent to the governor’s desk, and when that legislation will be approved.

“We don't expect any bills, especially at this embryo stage, to be all inclusive and all exclusive, but we appreciate the legislators trying to take a step in the right direction,” DellaVecchia said. “And we hope that they consult with us to the ability we're able to help them.”