States Consider Cutting Back on Telehealth Freedoms

The pandemic created a surge in virtual care as state and federal lawmakers relaxed the rules to expand telehealth access and coverage, but now some states are looking to tighten the regulations

With COVID-19 slowly moving into the rear-view mirror, some states are dialing back the telehealth freedoms that healthcare providers enjoyed during the pandemic.

In Alabama, Senate Bill 272 and House Bill 423 aim to mandate in-person visits for certain virtual care services, with supporters arguing that a visit to the doctor's office is needed to maintain the physician-patient relationship and to ensure quality care.

Specifically, the Alabama bills would mandate:

• At least one in-person visit every 12 months for physicians who meet with a patient four or more times a year via telehealth (current language allows for in-person care when necessary to meet the standard of care); and
• An in-person visit whenever a physician prescribes a controlled substance (current language allows for prescription of controlled substances via telehealth if that service meets state and federal regulations and telehealth is consistent with the standard of care).

The debate over a telehealth visit meeting the requirements of the doctor-patient relationship is long-standing, but was pushed aside during the pandemic in the rush to adopt telehealth, when the federal government and every state relaxed guidelines on access and coverage to encourage more virtual care.

Now, with the federal public health emergency scheduled to expire later this year, some state governments are debating whether to make those emergency measures permanent. And some are pushing to crack down on what they see as an excessive use of telehealth.

“Today, telehealth is being done, but there are no guidelines, there is no foundation in the state of Alabama,” Alabama Rep. Paul Lee, a Republican who sponsored the House bill, told the House Health Committee he chairs, according to the Alabama Daily News. “It’s basically the wild, wild west.”

“I think there’s no substitute for in-person contact, for face-to-face contact, for actually talking to the patient, actually examining the patient,” Republican State Senator Larry Stutts said during a hearing on the Senate bill, as reported by the Alabama Political Reporter. “I don’t think there’s any replacement for actually seeing the patient, examining the patient.”

Across the country, the debate is especially contentious with abortion rights, with some states moving to make telemedicine abortions illegal while supporters argue the platform is safe and should be available for women who can’t easily access a care provider in person.

Another point of contention is the telephone, also called audio-only telehealth. While the rules were relaxed during the pandemic to allow providers to conduct some services by phone with patients, critics say the phone isn’t adequate enough to meet the requirements for a doctor-patient relationship.

In Alaska, a proposed bill would have required an in-person visit before any telehealth service. The bill was voted down in committee.

Supporters say the legislation would protect Alaska providers by curbing virtual care services from providers based in other states.

“I made a promise years ago working on a telehealth bill to Alaska physicians that I would never undercut them,” Republican State Senator Lora Reinbold told State of Reform. “This amendment keeps the promise that I made years ago. I truly believe that if we have all these doctors moving [services] up here, and they want to treat Alaskans, and we’re doing telemedicine, you miss so much. It is so important.”

Opponents, meanwhile, say the bill would reduce negatively affect healthcare access and quality.

“I actually want to introduce competition,” Republican State Senator Shelley Hughes said. “I don’t want to inhibit that. I love our in-state providers, but I do believe the health care cost situation has become so severe that we should not be trying to stop Alaskans from seeking more affordable care.”

Telehealth supporters argue that the provider should establish when in-person care is necessary, and that these bills would create barriers to access for underserved and rural patients who can’t easily get to the doctor’s office.

Many have petitioned both Congress and the Centers for Medicare & Medicaid Services to make those pandemic telehealth freedoms permanent, saying those services have been proven to boost access to care and, in some cases, improve clinical outcomes and provider workflows. They also argue that an abrupt end to those freedoms, as would happen when the public health emergency ends, would force health systems to shut down programs and patients to lose access to important services.

"One acknowledged bright spot resulting from COVID-19 has been the extraordinary use of telehealth that has allowed patients to access quality care from the convenience of their homes," Kyle Zebley, vice president of public policy for the American Telemedicine Association, said in a press release accompanying a letter signed by more than 430 organizations, including health systems, urging Congress to make those freedoms permanent.

"However, there is now much uncertainty around the future of telehealth, creating chaos and concern for patients and healthcare providers alike, as the 'telehealth cliff' threatens to abruptly cut off access to care, especially for our underserved and rural populations," he said.