In A Nutshell:
- Telehealth services were utilized sparingly prior to COVID but have become increasingly common over the last three years.
- Telehealth offers an effective way to address some of Michigan’s shortcomings in mental health services.
- While some of the temporary policies that expanded telehealth during the height of the early stages of the pandemic have been codified, further policy changes could expand telehealth access in the state.
The availability of telehealth services for different kinds of medical treatment has become a topic of interest for both patients and providers in Michigan, particularly in the last few years. The onset of the COVID-19 pandemic fundamentally altered both patient needs and provider willingness to expand services. For some types of health care, telehealth is not a viable option and may result in inferior quality of care. Certain mental health care services, however, are well-suited for expanded telehealth options.
The deficiencies in Michigan’s mental health services have been well-documented and a variety of different policy options have been presented as levers to mitigate the problem. Telehealth has the potential to reduce costs and increase access to mental health services by alleviating localized provider shortages and making it easier to attend appointments. Despite the potential benefits of telehealth, deployment was relatively limited prior to the pandemic due to a variety of practical and policy barriers. The pandemic necessitated an on-the-fly adoption of large-scale telehealth services that generated positive outcomes for the state. Michigan has an opportunity to learn from that experience and enact policies that make telehealth services permanent and sustainable features of mental health care.
Overview of Telehealth
Telehealth is broadly understood as health care services provided remotely using a variety of telecommunications tools, such as videoconferencing (e.g., Zoom) or patient portals that can be used for uploading and downloading materials. “Telehealth” and “telemedicine” are often used interchangeably. Michigan law refers to these types of services as telemedicine. Specifically, Michigan law defines telemedicine as “…the use of an electronic media to link patients with health care professionals in different locations” that allows the health care professional to be able to examine the patient via a HIPAA compliant “secure interactive audio or video, or both, telecommunications system, or through the use of store and forward online messaging.”
Telehealth presents a number of potential solutions to problems in the health care system. In particular, the ability to see health care providers who are located anywhere reduces the burdens associated with localized provider shortages. Similarly, patients and providers who have mobility issues, lack access to reliable transportation, or have limited free time also benefit from telehealth access. Mental health services are particularly ripe for telehealth expansion as many these services do not require any sort of physical examination or treatment. Additionally, the provider-patient fit is extremely important for individuals in need of mental health services (e.g., those with anxiety and depression) and telehealth facilitates a wider range of options, especially for those in areas with fewer providers. Lastly, telehealth options allow individuals to avoid the potential stigma of seeking out mental health services, which may prevent some individuals from seeking treatment.
Despite the potential benefits of telehealth, a number of barriers impede the broader deployment of telehealth services in Michigan.
- Reimbursement: While state law requires private insurers to cover telemedicine services (i.e., coverage parity), it does not require insurers to reimburse providers equally for in-person and telehealth visits (i.e., payment parity). Similarly, while Medicare and Medicaid covered telehealth services prior to the pandemic, the scope of covered services was restricted and reimbursements to providers were lower than the equivalent in-person service in some cases.
- Licensure: State law requires that telemedicine services be provided by professionals who are authorized to practice in Michigan, restricting out-of-state providers from serving patients in the state. Specifically, the law states that telemedicine “must be provided by a health care professional who is licensed, registered, or otherwise authorized to engage in his or her health care profession in the state where the patient is located.”
- Technology: Most telehealth services require high-speed internet, an internet-accessible device, and access to specialized software. While many homes and businesses in the state have the necessary internet access and devices, coverage is not universal. Additionally, there are costs associated with HIPAA-compliant software for providers.
While telehealth services were an emerging area of health care prior to COVID, they were not widely utilized. The Kaiser Family Foundation reported in a nationwide survey that 2.4 percent of “enrollees in large employer health plans with an outpatient service…had utilized at least one telehealth service in 2018 (up from 0.8 percent in 2016).” Similarly, only about 0.25 percent of Medicare beneficiaries utilized telehealth in 2016.
The pandemic upended every facet of life in Michigan but led to particularly salient changes to health care services, including a significant shift from in-person personal and professional meetings to virtual settings. With public health officials recommending – and in many cases the state requiring – limitations on in-person meetings and gatherings to prevent the spread of COVID, many industries turned to telecommunications technologies to bridge the gap.
Providers began offering telehealth visits at a much higher rate during the spring and summer of 2020. During the first months of the pandemic, 71 percent of Michigan providers offered telehealth visits. Nationally, Medicare telehealth visits increased by 28 times during the first year of the pandemic compared to the previous 12 months. While the highest share of telehealth visits occurred during the earliest months of the pandemic, nearly 24 percent of Michigan households reported a telehealth visit during the last four weeks.
Due to executive orders that limited in-person meetings during the first year of the pandemic, providers were pushed to acquire the equipment and software necessary to offer telehealth to serve their clients. While some patients still lack high-speed internet and devices, providers are better equipped to offer telehealth. In addition, temporary policy changes by the federal government, state, and insurers facilitated expanded access to, and higher reimbursement for, telehealth compared to the pre-pandemic status quo.
- Medicare: The federal government instituted a number of temporary changes to broaden Medicare coverage during the COVID-19 public health emergency. These include changes in location requirements and expansion of provider and service eligibility, among others. Congress passed legislation to ensure those changes continue for several months following the end of the emergency, but the changes have not been made permanent.
- State Executive Actions: During the COVID-19 state of emergency, Governor Whitmer issued several executive orders that impacted telehealth in the state. These orders, among other things, expanded telehealth coverage to allow Medicaid beneficiaries to receive services in their homes; expanded telehealth services to include asynchronous services instead of only real-time services; and allowed professionals licensed in other states to practice in Michigan. These temporary orders ended when the state of emergency ended in October 2020. The state also encouraged insurers to cover the use of telehealth to the fullest extent possible.
- State Laws: While the executive authority to expand telehealth was limited to the lifespan of the state of emergency, which ended in October 2020, the legislature took steps in June 2020 to codify some of the changes that were made during the height of the pandemic. Specifically, state law was changed to permit Medicaid beneficiaries to receive telehealth services at home and the general definition of telemedicine was expanded to include asynchronous services (see Public Acts 97 to 101 of 2020). The statutory changes did not address the question of out-of-state providers and no formal steps were taken on payment parity.
- Insurers: While there was no legal mandate to reimburse telehealth services at the same rate as in-person services for private insurers, many (if not all) insurers did institute some form of de facto payment parity during the pandemic and have kept it in place
Making Telehealth a Permanent Part of Michigan Healthcare
The pandemic offered an opportunity to evaluate the arguments for and against changes in public policy related to telehealth. In general, the pandemic experience showed that telehealth can be utilized effectively in Michigan, particularly for mental health services. More robust telehealth access in Michigan can be achieved by addressing the pre-existing barriers mentioned above.
First, expanding access to high-speed internet would help to ensure that telehealth is available to more Michigan residents. Telehealth is just one of the benefits of improving Michigan’s internet infrastructure, and there is significant ongoing work on this topic.
Second, telehealth has been less attractive to providers because insurers typically have reimbursed for telehealth visits at lower rates than in-person visits. As a practical matter, this has changed due to the pandemic and most insurers are reimbursing for telehealth at similar rates as in-person visits, but these changes have not been formally codified and could potentially be eliminated. While the state cannot control the Medicare policy, it could establish payment parity for Medicaid and private insurers.
Legislation has been introduced on payment parity recently: Senate Bill 707 and House Bill 5651 would mandate payment parity for private insurers. Additionally, appropriations’ boilerplate language has aimed to create payment parity for Medicaid in the last two budgets, but those changes are not permanent. Alternatively, the state could stop short of true payment parity and instead set a percentage rate at which telehealth must be reimbursed (e.g., no less than 85 percent of the equivalent in-person service). However, these types of mandates may face resistance from insurers. In addition, payment parity may not account for the true cost-of-service and mandating parity might prevent the state from observing cost savings associated with lower overhead related to telehealth.
Third, the state currently requires providers to be licensed to practice in the state to offer telehealth services. However, the state does not prevent Michigan residents from crossing state lines to receive in-person care. As a practical matter, it is unclear why the licensure requirements should be fundamentally different for telehealth. For example, a Monroe County resident may cross the border to see a provider in Toledo in person but may not have a telehealth visit with that same provider covered by insurance. Exploring an interstate licensing compact and/or reciprocity could open the door to more providers without totally disrupting the state’s health care licensing regime.
Telehealth services are not suitable for all kinds of health care. Mental health care is one area where telehealth can increase access while providing comparable or even superior quality of care. Patients seeking mental health care should continue to have the option of in-person visits, but there is little risk in increasing telehealth options for patients who prefer or require remote visits. Addressing mental health can be fraught with complications and the road to recovery and healing is far from linear. Those suffering from mental health disorders will inevitably encounter numerous barriers to receiving treatment, but limited access to services does not have to be one of them.