Addressing Tension Over the Future of Telehealth in Palliative Care

If you currently use telehealth to provide palliative care for some of your patients, how would you react if that privilege were revoked? Many of us who have come to rely on its convenience and accessibility hope that one day, we won’t be living with the uncertainty about whether we can continue telehealth operations indefinitely. In the meantime, we have to live with the tension as we contemplate the future.

Since March 6, 2020, clinicians across the country have modified their operations thanks to the Medicare waiver of telehealth payment limitations. Specifically, clinicians have been able to bill for telehealth visits with their patients regardless of where that patient is located—including their own homes. For Medicare, the use of telehealth—and its cost—increased tenfold in the first year of the waiver alone. The Medicare telehealth waivers enabled us at my facility, UT Southwestern Medical Center, to begin seeing our palliative care patients virtually, using telehealth platforms to provide care and support for patients in the comfort of their homes. We were even able to manage chronic opioid therapy for patients experiencing cancer-related pain, who make up a significant portion of our patient panel.

The catch? These telehealth payment flexibilities were only temporary, tied to a continuation of the COVID-19 public health emergency (PHE). As the pandemic lagged on, the Secretary of Health and Human Services continued to extend the anticipated end date of the PHE, which is now slated for May 11, 2023.

Throughout this time, patients and providers alike voiced their concerns that the prior limitations on beneficiary location for telehealth billing would return. Those of us who manage opioid therapy for our patients were especially concerned, because the prescribing of controlled substances over telehealth would also come to an end if Congress didn’t take action.

I held out hope for a piece of federal legislation, the Advancing Telehealth Beyond COVID-19 Act, which the House of Representatives passed in late July 2022 to extend telehealth through the end of 2024. This legislation stalled in the Senate, but was quickly replaced with what we now have: the Omnibus spending package that extended the Medicare telehealth flexibilities through the end of 2024. The current legislation implies that the flexibilities will remain in place, contingent on information collected during this time.

Unfortunately, the full flexibilities around prescribing opioids and other controlled substances through telehealth are still tied to 180 days after the end of the PHE on May 11, 2023—November 2023. The federal Drug Enforcement Agency (DEA) has recently issued a proposed rule that would allow telehealth prescribing to continue if the clinician has previously conducted an in-person examination with that patient. It is only with patients whom have not yet had an in-person medical evaluation that telehealth prescribing is limited. In this case, the clinician may prescribe only a 30-day supply without an in-person visit.

My practice relies on telehealth to help us manage the care of our patients, many of whom are from a large comprehensive cancer center in Dallas. Without the option of telehealth visits, we simply could not keep up with the demand. For one thing, we don’t have the physical space for our patient volumes. We currently have many patients and only four exam rooms. We would need to double or even triple that number to accommodate our patients if they all had to return to the office for all of their visits. Even patients who just need opioid prescription renewals would still have to visit us in person every three months, which would be a burden for many of them. If payment for telehealth visits went away, we could potentially lose many of our patients to follow up when in-person visits become required. They might forego palliative care altogether and just let their oncologist manage care for them, or seek some other type of more convenient care that may or may not meet their needs.

Additionally, payment for telehealth visits has enabled some of our team members to work remotely, which would become impossible if in-person visits were the only means of income. The ability to work remotely has greatly enhanced job satisfaction by allowing flexibility throughout the time of the PHE.

But perhaps most importantly, telehealth has been a gift to our patients. Imagine how you might feel if you were undergoing treatment and had to contend with bumper-to-bumper traffic, parking, and time in the waiting room to see your palliative care team or get a prescription renewed. The challenge would be compounded if you had to load up any medical equipment, including motorized wheelchairs or oxygen tanks for the trip, too. But with telehealth options, our patients can log into a secure telehealth platform, consult with their doctor, and, with the exception of a single in-person visit, can even get their opioid prescriptions renewed at a local pharmacy—all without the burdens of leaving home.

To put it bluntly, we are not prepared for payment for telehealth to go away. It would force our prior in-person visit policies, and cause unnecessary suffering for some of our patients. They might not access care as often as they really need to—or worse, they might choose to forego care altogether.

The U.S. needs to eliminate the telehealth limitations permanently. It enhances access to care for our seriously ill patients. Removing this particular option of health care delivery would be detrimental to people living with high-risk medical conditions and would decrease our ability to provide care for those living with significant disability and lack of access to medical services. Ultimately, it would hurt the seriously ill patient population, imposing further disparities and risks to their health, which would lead to worse outcomes.

However, my support for the permanent role of telehealth in the field of palliative care does not mean that I believe we need to provide all care via telehealth. The best medicine is delivered through a combination of in-person visits and telehealth—a hybrid model of care delivery. Telehealth cannot replace certain types of care, such as in-person physical examinations and diagnostic testing needed to create a plan of care. In my practice, we often alternate telehealth and in-person visits, which means we may see a patient in person every six months instead of every 1-3. If we detect a problem that requires an in-person evaluation, we ask that patient to come in to the office to see us. Assuming that the new DEA proposed rule goes into effect as is, we would also require an in-person visit to initiate opioid therapy.

We also need research to support and ensure the safety and quality of palliative care delivered through telehealth. I believe that we can uphold the same standards of care that we follow in person, and I believe that chronic opioid therapy can be safely managed via telehealth, too. But I hope that our specialty will embark upon research to prove it. Further, sufficient research would enable the creation of guidelines or best practices for effectively using telehealth in tandem with in-person visits.

If you use telehealth in your practice, as we do, I encourage you to become familiar with the current situation. Reach out to your elected lawmakers and let them know that telehealth has become an integral part of your practice and a valuable opportunity for your patients to receive the care they need.

For additional perspectives on both the benefits and the challenges in delivering palliative care via telehealth, read CAPC’s article, Views on Palliative Care via Telehealth: A Virtual Panel Discussion.

Edited by Allison Silvers, MBA. Clinical review by Andrew Esch, MD, MBA.