June 4, 2020

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Telehealth Is Grabbing the Pandemic Spotlight. Can California Do More to Help It Grow?


Mei Wa Kwong, executive director of the Center for Connected Health Policy. Photo: José Luis Villegas

In a decade at the Sacramento-based Center for Connected Health Policy, Mei Wa Kwong has had to answer a basic question more times than she can count: “What, exactly, is telehealth?” And until recently, she doesn’t recall the word being used so frequently by a president of the United States.

Telehealth, previously known as telemedicine, generally refers to the use of interactive video and audio to diagnose, treat, or facilitate the delivery of health services. It allows doctors, nurses, or therapists in one place to connect with and perhaps visually examine a person in a different place. In the midst of a coronavirus pandemic that has swept the world and overwhelmed the health care systems of many countries, telehealth is having a moment in the spotlight.

In California and the rest of the nation, the pandemic is an urgent wake-up call about the need for policy reforms to expand telehealth accessibility.

Since it was established in 2008 with funding from the California Health Care Foundation, the Center for Connected Health Policy has worked to build telehealth capacity into the US health care system. In 2012, the center was designated by the federal government as a telehealth policy resource center, providing technical assistance to policymakers, health systems, consumers, and providers. Kwong joined the center as an analyst in 2010 and has served as executive director since 2018. 

I joined Kwong for a video interview, not unlike the way many Californians are now connecting with health professionals. This transcript has been edited for length and clarity.

Q: The coronavirus is threatening to overwhelm our health care infrastructure. How can telehealth help?

A: Telehealth is a powerful tool to expand the capacity of our health care system. Because of COVID-19, the US Centers for Disease Control and Prevention (CDC), the California Department of Public Health (CDPH), and other authorities are urging health care providers to use telehealth when possible to prevent spread of the coronavirus and protect the health care workforce. We need all our health professionals to meet the expected surge in demand for care.

Through telehealth, many routine appointments can be handled by phone or live video. For example, an older cardiac patient can check in with her cardiologist from her living room rather than traveling to a medical center where she may encounter people who are infected.

A health care provider can remotely check on a patient who’s been exposed to COVID-19 but may not be infected, or someone who has been infected but has only mild symptoms. With fewer patients needing in-person visits, we can reduce exposure between patients and the exposure of our health care workforce. This is important to ensure that those on the front lines remain available to serve the sickest patients.

California has taken more steps than many other states to make telehealth an option for patients in California’s Medicaid program, Medi-Cal. Yet significant gaps remain. —Mei Wa Kwong

Even before the COVID-19 pandemic, California had a severe shortfall of health care providers, especially in rural and other underserved areas.  Telehealth tools help overcome these gaps. For example, an infectious disease specialist can review a patient’s records remotely and give treatment advice to the patient’s doctor electronically or over the phone without having to travel to the patient’s location. Patients in serious condition are still going to need hands-on care. Expanding telehealth use — as the CDC and CDPH have called for — will help ensure our hospitals have the capacity to serve the highest-need patients.

Q: How widely available are telehealth services in California, especially for Medi-Cal patients?

A: It’s hard to make a general statement about the availability of telehealth in California since access varies between insurers, public systems, and providers. What we can say is that California has made some good progress in recent years to make telehealth options more widely available.

California has taken more steps than many other states to make telehealth an option for patients in California’s Medicaid program, Medi-Cal. Yet significant gaps remain. For example, the first ever analysis of the telehealth landscape among Medi-Cal managed care plans, completed just before COVID-19 hit, showed low use of telehealth among members and widespread challenges to expansion.

Limitations on how community health centers can bill Medi-Cal for some services provided by telehealth represent another hurdle. Since community health centers provide about one-half of outpatient visits to Medi-Cal patients, these limits put telehealth options out of reach for many Californians who could benefit most from them. The exceptional circumstances of COVID-19 have prompted the California Department of Health Care Services to provide more flexibility, but more can be done.

Q: How has COVID-19 changed the telehealth landscape?

A: The pandemic has focused national attention on telehealth’s potential to expand the capacity of our health care system. The federal government and state government have taken important actions that will enable California to expand telehealth use in the pandemic.

At the federal level, President Trump signed legislation that will enable more Medicare patients to use telehealth services. Until now, Medicare significantly restricted providers from being paid for telehealth services. The federal government also is temporarily allowing health care providers to use common technology platforms to provide telehealth care during the crisis without violating privacy laws.

And in California, the Department of Health Care Services has issued new guidance that — for the duration of the “state of emergency” declared by Governor Newsom — will eliminate significant barriers that had precluded Medi-Cal patients from accessing care through telehealth. For example, under the temporary waivers, Medi-Cal will pay for phone visits, which is important for people who don’t have smartphones or internet access at home. Additionally, some of the barriers that Federally Qualified Health Centers, Rural Health Clinics, and other community health centers faced when using telehealth have been temporarily removed. The new guidelines allow community health centers to use telehealth to reach patients in their homes.

In the short-term these measures will help ease stress on the physical resources of our health care system, but they are also an opportunity to showcase for patients, providers, and policymakers how telehealth can expand opportunities for Californians in the safety net to access care.

The Center on Connected Health Policy is tracking new federal and state (including California) telehealth policies as they emerge.

Q: In California, Kaiser was an early adopter of telehealth. How is that working for them as they address COVID-19?

A: For the last few years, Kaiser has been urging the use of technology for mail-order prescriptions and for phone and video appointments with doctors. Kaiser is telling members these options limit their risk of infection. Kaiser’s advanced use of technology has positioned it to be better prepared than other systems for this type of situation. My own parents are Kaiser members in the highest-risk category, so it’s been great that their medication is delivered to them, and that they interact with providers over technology. Their risk of exposure is reduced by these options because they’re not going to the doctor’s office. I just wish more people, especially those in the safety net, had options like this.

Q: What is on your list of policy fixes to enable greater use of telehealth in an emergency?

A: Our federal and state governments need to consider connectivity. Many homes in California lack broadband access. People with lower incomes and seniors may not have computers or smartphones. In this crisis, the phone needs to be allowed to provide as many services as the medical professional feels they can effectively and safely provide. Some states allow reimbursement only for limited “check-ins” by phone and not for longer consultations or follow-ups. California should be thinking more expansively and not limiting phone interactions to short check-ins.

More funding is needed to rapidly stand up telehealth programs. For example, the Federal Communications Commission just made $200 million available to certain kinds of health care providers, including community health centers, through its COVID-19 Telehealth Program. However, that’s $200 million for the entire country, so it will only go so far.

Federal policies should waive limitations on community health centers using technology to care for patients in this emergency. State officials can clarify and better communicate telehealth policies. We need comprehensive outreach to let providers know what is allowable, and we need to educate patients so they understand that they can ask for telehealth services.

The California Telehealth Policy Coalition released a letter in March (PDF) with some other important recommendations for California.

If we can expand telehealth now, especially in the safety net, and keep supportive policies in place after COVID-19 is over, then we’ll be better prepared for the next public health crisis and much better positioned to improve overall access to care across the state, particularly in low-income and rural communities.

Q: Thanks very much.

A: Same to you. And don’t forget — wash your hands!

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