At the onset of the COVID-19 pandemic, federal and state regulators issued orders enabling the rapid expansion of all virtual health visits, from mental health to physical therapy. The changes included paying the same for virtual visits as for in-person visits and allowing the use of familiar video platforms such as FaceTime or Zoom alongside a host of platforms developed specifically for virtual health care. Rules around the physical location of the provider or patient were relaxed. These changes were necessary to keep people safe at the heights of the pandemic.
The changes ushered in an explosion of virtual care. It is hard to imagine going back to a system where virtual health isn’t an option that patients can choose for many types of care. In 2019, the National Quality Task Force anticipated this exact landscape when it developed its recommendation, published in the report “The Care We Need,” to expand the use of high-value care settings, notably virtual health, throughout the delivery system as a key means of improving patient engagement, closing access gaps, and improving health outcomes.1
To further scale and improve virtual health care usage, we must know that it will continue to be reimbursed in a manner that is appropriate for health care providers and systems. We must also ensure that virtual care is used to narrow, not widen, health disparities based on age, language, disability, geography, income, race, or ethnicity. We must set up a method to measure the safety and effectiveness of virtual care from the perspectives of both the patient and the health care provider. Finally, we must consider how virtual care can be used as a lever to improve the value of care delivered.
These challenges and their optimal solutions are part of a national debate. Once the public health emergency declarations end, physicians, therapists, patients, and families need clarity on the future of virtual health care and the flexibility that many of us have enjoyed over the past few years. The New Jersey Health Care Quality Institute has been considering these issues in New Jersey and nationally. In April 2021, with multistakeholder input, the Quality Institute issued “Emerging From COVID-19: An Action Plan for a Healthier State,”2 which includes several recommendations on advancing virtual health care. The action plan calls for New Jersey to measure virtual health’s value to patients, caregivers, and providers, and to apply those findings to future policy decisions, such as whether payment for virtual visits should be the same as for in-person visits. It also shares examples of entities that are providing equipment, training, and investments to increase access to virtual health care and to address the digital divide.
The Quality Institute was 1 of 30 organizations that participated in the National Quality Forum (NQF) Action Team on Virtual Healthcare Quality, with the goal of identifying actionable opportunities to assess and ensure the quality of virtual health care. The NQF Action Team recently released an issue brief that outlines challenges and recommends next steps for measuring virtual health care’s quality and effectiveness to support its continued reimbursement and to normalize this setting for safe, high-quality care.3
The NQF issue brief is timely and written to guide stakeholders, including public and private payers who must decide whether to continue paying for virtual health care and under what terms. The question of what will happen to virtual health care payments after the public health emergency ends is being debated in state capitols throughout the country. We urge federal and state lawmakers to look at the NQF issue brief for inspiration.
In addition, lawmakers should carefully consider New Jersey’s recent telehealth legislation, enacted in early 2022, addressing telehealth payments and other regulatory changes.4 The law leaves most telehealth payments in place for 2 years, thereby creating a glide path for virtual care to continue, encouraging further training and investment in it, and providing time for the state to collect data and study its effectiveness for patients and providers. At the end of this study period, the New Jersey Department of Health must make recommendations about telehealth, including whether—and under what circumstances—the payments for virtual health care should continue. We support this type of evidence-based decision-making, which aligns with the 4 recommendations of the NQF Action Team:
- Measure the quality of virtual care.
- Develop a national strategy on virtual health care use and reimbursement.
- Seamlessly and securely share virtual health care information across care teams and organizations.
- Use virtual health care to expand access to care and promote health equity.
Each NQF Action Team objective includes actionable recommendations designed for different health care stakeholders, including advocating for, and implementing, evidence-based expansion of public and private payment for virtual health care beyond the public health emergency.
Nationally, the future of virtual health care is a top priority for health systems and providers. Health care providers argue that they cannot invest in needed technology and training to support virtual care if they are not assured of adequate payment. Payers and purchasers are concerned that virtual health care may not always be effective or appropriate for the care needed and could lead to higher utilization and visits that are not helpful to patients.
There is much that we need to determine through data. Are virtual health care visits of the same quality and as safe as in-person visits? How do the audio-only visits that many older and rural patients use compare with video visits and in-person visits? How does the success of mental health visits compare with physical health visits on virtual platforms? The debate also includes issues over state boundaries and whether providers may see patients across state lines. We also must assess the health equity issues surrounding virtual care and determine whether some patients are being left behind and how to address inequities.
Finally, we should not tie innovations in virtual health care to the fee-for-service model of reimbursement that has led to fragmented care and inefficient spending. As we learned during the transition to electronic health records in the past decade, we cannot replicate ineffective processes in new technologies and expect different outcomes. Consistent with the National Quality Task Force recommendations and those of the Health Care Payment Learning & Action Network, the objective of paying for virtual health care must be to improve equitable health outcomes while reducing the total cost of care.
Speculation and lobbying will not give us answers. We need good information and an intelligent conversation informed by evidence. The Quality Institute’s action plan and NQF’s issue brief align in their commitment and approach to advancing virtual health care. Both sets of recommendations emerged from separate multistakeholder expert panels with minimal individual or organizational overlap yet reached similar recommendations. Both the Quality Institute Work Group and the NQF Action Team identify the importance of advancing virtual health care through structured, evidence-based approaches.
Additionally, we recommend evaluating that evidence against the domains for health care quality identified in the 2001 Institute of Medicine report, Crossing the Quality Chasm5: safe, effective, patient-centered, timely, efficient, and equitable. The Quality Institute Work Group calls for a statewide Telemedicine and Telehealth Review Commission to be convened to assess how virtual care can flourish equitably and efficiently. Meanwhile, the Action Team recommends the creation of a national virtual health care strategy that includes the thoughtful expansion of public and private reimbursement for virtual care and the broadening of regulations to increase access to and payment for telehealth within and across state lines.
The recommendations transcend payment. Both the Work Group and the Action Team recommend the development of a clear strategy on the definition and measurement of virtual health care quality. This work should identify a priority set of measures that are applicable to virtual and in-person care and are aligned with existing and new telehealth measurement frameworks from NQF, the World Health Organization, the Agency for Healthcare Research and Quality, the American Academy of Pediatrics, and other organizations.
Our respective expert panels also recognize the importance of identifying which forms of virtual care reduce health disparities and which exacerbate them. Both groups recommend stratifying and comparing data across different populations to identify benefits and inequities based on race, ethnicity, age, geography, functional status, income, and other factors that can affect whether and how a person can access and use virtual health care. One additional area where our expert panels align is the shared recommendation to explore creative ways to make virtual health care available to underserved populations through the provision of technology and tools. The Work Group identifies opportunities related to remote monitoring devices, which could have a positive impact on both health outcomes and total cost of care for some chronically ill patients, whereas the Action Team recognizes the benefit of virtual health care hubs in public locations such as libraries, veterans’ halls, and retail stores. Both expert panels recognize the opportunities that could be created by providing high-risk underserved populations with hardware devices to help with access to virtual health care.
By immediately acting upon these recommendations, local, state, and national health care programs can develop strategies and gather data to inform long-term decisions on the use and payment of high-quality virtual health care.
Both NQF and the New Jersey Health Care Quality Institute support virtual health care and its role in the continuum of care. We believe in the technology’s promise. But we also believe that we must collect needed data on virtual health care’s use, accessibility, patient satisfaction, quality outcomes, equity, and impact on overall health care spending before we make payment parity permanent. Then we should use these data to shape an informed and thoughtful approach to telehealth payment that equitably serves patients, providers, payers, and every other health care stakeholder.