The COVID-19 pandemic disrupted the status quo in healthcare. As we recover, lawmakers now have an opportunity to learn from our mistakes and triumphs to chart a new course. Among the most notable changes in care delivery brought about by the pandemic is the rise of telehealth. Yet as we update this report to reflect actions taken in 2022, it is hard not to notice that states have shown a surprising lack of urgency in making comprehensive updates to their telehealth laws.

While telehealth services were available long before the pandemic, millions of Americans used telehealth for the first time over the past three years. The rapid adoption of telehealth technology was enabled by emergency regulatory reforms undertaken at the federal and state levels. For example, federal officials made select changes to the Medicare program, and governors in nearly all 50 states advanced access with flexible provider licensure for new telehealth uses by executive order.

However, most of the emergency actions taken early on in the pandemic were only temporary. When state public health emergency declarations ended, and executive orders were withdrawn, many of the new flexibilities were lost. While some states recognized the benefits of regulatory flexibility and have adopted permanent reforms, a surprising number have only made minor tweaks to their laws, and most only benefit one kind of service or provider.

States must continue to refocus their efforts to ensure clear laws and guidelines are in place for innovation to emerge so that patients and providers can benefit from this helpful tool in any care delivery toolbox. Immediate action will be needed to avoid disrupting patient access to providers they gained during COVID, as other options may not exist in their community. For many patients, cutting off remote access to care is the difference between them receiving care in this manner versus no care at all.

There are four key areas where states have an opportunity to unleash innovation and embrace the potential of telehealth for expanding patient access to high-quality care:

1. Patients Can Access all Forms of Telehealth: State laws and regulations should define telehealth in broad terms that do not favor one mode of telehealth over others or preclude future innovation in care delivery. This is called modality neutrality.
2. Patients Can Start a Telehealth Relationship by Any Mode: State laws and regulations should not prohibit patients from initiating a relationship with a telehealth provider via their preferred modality.
3. Patients Face No Barriers to Across-State Line Telehealth: State laws and regulations should not prevent patients from accessing virtual care from providers licensed in other states.
4. Patients Can See Many Kinds of Providers Over Telehealth: State laws and regulations should allow providers to practice at the top of their license to take the next step toward a more quality-oriented, affordable, and innovative health system.

This report examines all 50 states in these four key areas.

This report does not cover all telehealth-related policy changes in 2022. For example, it ignores actions taken in states to expand or adopt compacts. Many of these smaller changes are not highlighted because they have severe limits, or only tweak around the edges.

By contrast, adopting this state policy agenda for telehealth innovation would remove deleterious barriers that have historically discriminated against those in certain geographies, such as rural communities or underserved urban areas.

The post State policy agenda for telehealth innovation appeared first on Reason Foundation.

Millions of Americans tried telehealth for the first time during the COVID-19 pandemic. Federal officials made select changes to the Medicare program and governors advanced health access with flexible provider licensure for new uses of telehealth by waiving certain barriers by executive order. All of these changes garnered numerous headlines, and many state legislatures followed suit by updating their laws.

But once the public health emergency declarations started to end or executive orders were withdrawn, overnight or shortly after, many of the new flexibilities were lost. Furthermore, even though many states passed new laws related to telehealth, many of them made incremental changes because policymakers lacked a best practices roadmap for success.

While they cannot and should not replace all in-person medical appointments, virtual visits can save patients time and help them avoid germ-filled waiting rooms. Providers can also cut down on their risk of exposure and take some pressure off overburdened systems as they can see patients from an office or home. To experience the full potential of telehealth, states should follow these best practices.

This toolkit aims to help policymakers take the next step toward a more quality-oriented, affordable, and innovative health system by ensuring that their state laws on telehealth remove deleterious barriers that have historically discriminated against those in certain geographies, such as those living in rural communities or in underserved urban areas. This report explains policy best practices for ensuring that providers and patients can fully realize the benefits of using telehealth services when appropriate and provides a simple-to-read stoplight rating for each state on how closely their policies align with those best practices. The state profiles point state lawmakers to specific sections of law and regulation that need to change to improve their ranking.

States need to act now to ensure the physical and economic needs of their state are met with a more quality and future-oriented health system.

Full Report: Rating States on Telehealth Best Practices

State Policy Agenda for Telehealth Innovation

Previous Jan. 5, 2022 Version of this Report: Rating the States on Telehealth Best Practices

The post Rating states on telehealth best practices appeared first on Reason Foundation.

In an executive order helping make telehealth services more accessible for Californians by relaxing security and privacy requirements for health care providers, Gov. Gavin Newsom highlighted the problems, “I find strict compliance with various statutes, regulations, and certain local ordinances specified or referenced herein would prevent, hinder, or delay appropriate actions to prevent and mitigate the effects of the COVID-19 pandemic.”

Gov. Newsom is right, but his executive actions reducing some of the barriers preventing patients from using telehealth services are temporary and need to be made permanent. A new Reason Foundation report that rates each state’s telehealth policies according to a set of best practices for promoting patient access and flexibility for providers finds California has plenty of room for improvement.

For example, California currently requires out-of-state health care professionals to hold a California license to provide telehealth services in the state. In other words, Californians don’t have access to specialists in other states unless they are willing to travel to that specialist’s location or that specialist is able to—and wants to—undergo the burdensome process to obtain an additional license from California. This bureaucratic hurdle undermines one of the principal benefits of telehealth: the ability for patients to access care regardless of their physical location.

These types of archaic state-by-state licensing schemes don’t make sense in the context of telehealth. Some states, like Texas, Colorado, and Utah, have tried to promote the use of telehealth across state lines by agreeing to multi-state licensure compacts, which make it easier for professionals in member states to receive licensure in other member states that are part of the compact. However, California hasn’t joined any multi-state licensure compacts.

Florida and Arizona have identified an even better approach for enabling cross-state telehealth services. Both states have created a simple telehealth registration process for out-of-state health care providers. To register, a provider must only submit proof that they are licensed to practice in another state. This system is superior to multi-state compacts because it does not require action on the part of other states.

The telehealth study also notes California mandates that insurers cover and reimburse telehealth services in the same manner as in-person care. These mandates are intended to promote the adoption of telehealth, but ignore some of its key differences and benefits. Telehealth has the potential to provide on-demand health care services without the administrative and overhead costs associated with in-person care in California. These differences in costs mean that many telehealth services have the chance to save patients money and thus shouldn’t always be reimbursed at the same rate as in-person services. Moreover, telehealth is still an evolving field and technology, and the state should avoid forcing telehealth into the same rules of the complex, outdated health care system that everyone agrees isn’t working. The best way to promote telehealth improvements is to maximize flexibility and choice for patients and providers.

On the positive side, in the early months of the COVID-19 pandemic, California passed a law that allows nurse practitioners to practice via telehealth to the full extent of their education and training after three years of practice. According to a report from California Health Care Foundation, the share of California health care providers using telehealth increased from 30 percent before the pandemic to 79 percent by September 2020. A Blue Shield of California/Harris Poll of Californians conducted in February 2021 found that 49 percent of respondents had already had telehealth visits during the pandemic and 89 percent were satisfied with the services. Polling also consistently shows that patients remain likely to use telehealth services in the future.

Telehealth cannot, and should not, replace all in-person health care services. But there are plenty of times where telehealth is the best option and California should ensure its telehealth laws do not prevent new technologies and services from advancing and serving patients. Getting rid of arbitrary barriers and enabling cross-state telehealth licensing would help Californians now and in the long run.

A version of this column previously appeared in the Los Angeles Daily News.

The post California should remove outdated barriers to telehealth appeared first on Reason Foundation.

In March, President Joe Biden proposed an additional $400 billion in Medicaid spending on home-based long-term care services as part of his $2.3 trillion infrastructure plan, the American Jobs Plan. Congressional Republicans have criticized the plan, citing its costs and very broad definition of infrastructure. Senate Republicans recently proposed their own nearly $1 trillion infrastructure plan as a counteroffer. 

Setting aside the semantics around infrastructure and the political feasibility of either plan, the idea of shifting resources toward in-home care has some merit.

Home and community-based services (HCBS) enable the elderly and people with disabilities to receive care in their homes rather than in institutionalized settings such as nursing homes. HCBS can be more cost-effective than nursing home care, and older Americans overwhelmingly prefer to receive care in their own home. 

Yet, federal Medicaid policy is biased toward nursing homes. State Medicaid systems are required to cover long-term care services in nursing homes, but most home and community-based services are optional to cover. Many states also cap the number of HCBS enrollees, resulting in waitlists. In 2018, 41 states had waitlists for HCBS waivers—totaling nearly 820,000 people with an average wait time of over three years.

The home health care industry is already facing significant workforce challenges. Low wages and poor benefits contribute to high turnover rates and make it difficult to fill some vacant positions. The majority of home-based care is provided by unpaid family caregivers. However, the caregiver support ratio (the number of potential family caregivers aged 45-64 available for each person aged 80 and older) is expected to decline over the next several decades, driving greater demand for paid home health care workers.

According to the Bureau of Labor Statistics, demand for these types of home health care workers will increase by 34 percent over the next 10 years, translating to more than one million job openings. Labor economist Paul Osterman estimates there could be a shortage of over 355,000 home health care workers by 2040. 

Source: Author’s calculations based on Census Bureau data. 

As the country prepares to serve its aging population, the Biden administration has identified legitimate problems in long-term care. The question, however, is whether an additional $400 billion in Medicaid spending is the best solution. It is not.

President Joe Biden’s $400 billion plan is a one-time cash infusion spread out over eight years that would do little to address structural problems in the long-term care industry. Instead, it would simply double down on a broken system by throwing more federal money at the problem.

Hopefully, the administration’s emphasis on long-term care will at least generate a much-needed conversation about the need to fundamentally rethink our current approach to long-term care.  

Reforming Long-Term Care Financing

Americans are largely unprepared to finance their long-term care needs. As a result, public spending—particularly through Medicaid—tends to dominate in the market for long-term care. In 2018, Medicaid accounted for 52 percent of all long-term care spending. Meanwhile, private insurance and out-of-pocket spending accounted for just 11 percent and 16 percent respectively. The remaining share came from other public and private sources, including the Veterans Health Administration, Children’s Health Insurance Program, and charities.  

The outsized role of Medicaid in long-term care financing is both straining government budgets and contributing to the lack of access to home-based care and the workforce shortages the Biden administration is aiming to address. Expanding the role of private payment sources would help rein in state and federal spending, expand access to home-based care, and increase wages for long-term care workers. 

Part of the problem is that Medicaid “crowds out” private long-term care insurance. As the Commission on Long Term Care noted in a 2013 report to Congress:

The structure of federal health care programs, particularly Medicaid, discourages individuals from taking responsibility for their future long-term care needs. Medicaid resources need to be more carefully targeted to those individuals the program was intended to serve—the needy and the poor.

The report pointed to several reforms that would restructure incentives and provide greater flexibility for insurers to design policies that are more affordable and sustainable. Tightening eligibility rules and strengthening asset recovery efforts, for example, could go a long way. 

A whole cottage industry of elder law attorneys exists to help wealthier Americans restructure their assets in order to qualify for Medicaid benefits. As a consequence, state Medicaid systems are stretched thin and provide insufficient coverage for those who truly need it. 

Medicaid payment rates for long-term care services are also often too low to cover costs, undermining the quality of care. Low payment rates effectively place a ceiling on wages for long-term care workers. For example, efforts to raise the federal minimum wage to $15 an hour received considerable pushback from home health care providers concerned that reimbursement rates would not be raised accordingly. 

Rethinking our approach to long-term care financing and placing a greater emphasis on private payment is a necessary step to addressing the workforce challenges in the long-term care industry.

Without more careful targeting of Medicaid eligibility, increasing reimbursement rates would lead to even higher costs for state and federal governments. Rising Medicaid expenditures would compete with other spending priorities such as education and transportation. Those budget concerns have already motivated states to cap the number of Medicaid home and community-based services (HCBS) waivers they offer, leading to long waiting lists for home-based care. Again, expanding the role of private payment sources would help solve the problems identified by the Biden administration. Achieving meaningful reform in this area would be a significant undertaking, but would be far more beneficial than merely prolonging the status quo.

Regulatory Reforms to Expand Access to Home-Based Care 

Aside from issues with financing long-term care, there are a number of regulatory reforms that could expand access to home-based care while reducing costs for consumers. These reforms would have a substantial impact on long-term care services, and many could be pursued by states regardless of action at the federal level. 

Federal Medicaid rules aren’t the only source of bias toward institutionalized care over home-based services. State-level certificate of need (CON) laws limit the growth of home health services, pushing more seniors into nursing homes. Certificate of need laws require prospective care providers to demonstrate that there is an unmet need in the community before establishing or expanding health facilities or services. Currently, 14 states impose CON requirements on home health agencies. 

Research suggests that certificate of need laws serve to limit competition and prevent the expansion of home health industry capacity. The authors of a 2016 paper on the effect of CON laws on Medicare and Medicaid spending on nursing home care and HCBS concluded that CON laws “act as a direct impediment of expansion of home- and community-based care” and “provide nursing homes with some degree of market power that does not allow the market to respond freely to price changes or federal policies.” Other research suggests certificate of need requirements are associated with lower quality ratings among home health agencies.

Increasing the use of telehealth in home settings would also be beneficial for those seeking to receive long-term care in their homes. Telehealth allows patients to connect with health care providers remotely via telecommunications or digital communications technologies. For example, various wearable devices and monitoring systems enable care providers to track patients’ health status and mobility. The technology can also be used by aides and family caretakers to consult specialists without requiring an in-person visit. Innovative care models that rely on telehealth have the potential to alleviate workforce demands, reduce costs, and improve patient outcomes. 

Unfortunately, state and federal regulations can present an obstacle to the use of telehealth. At the federal level, outdated laws that are intended to protect patient privacy haven’t kept pace with technological innovation. These rules may hinder the use of some communications and remote monitoring technologies. At the state level, licensing laws may limit the ability of providers to practice telehealth across state lines. State laws may also create unnecessary hurdles to establish a patient-provider relationship. These requirements can make it difficult for providers to prescribe medications via telehealth without an initial in-person visit––a potential challenge for many home-bound seniors. Lawmakers should consider reforms that would maximize flexibility in the use of telehealth technologies and avoid policies that could inhibit future innovation. 

Expanding the role of direct care providers could also reduce costs while providing a channel to raise wages. Currently, home health workers are very limited in terms of what they can do on the job due to what is referred to as their scope of practice (SOP). State-level scope of practice restrictions prevent home health aides from performing many routine tasks, such as administering eye drops or oral medications. According to the MIT Sloan School of Management’s Paul Osterman, expanding the SOP of home health workers could go a long way toward improving the quality of their jobs and increasing the efficiency of care delivery. Osterman argues that allowing these workers to take on more responsibilities would help boost their wages. Even with higher wages, these reforms could reduce overall costs by shifting some tasks away from higher-paying occupations such as registered nurses. 

Expanding the Home Health Workforce 

While raising wages and leveraging innovative technologies could alleviate some pressure on the long-term care workforce, the existing labor pool may still be insufficient to meet future demands. Expanding immigration opportunities for long-term care workers offers a solution.

Immigrant workers already play a critical role in the long-term care workforce. In fact, nearly 1 in 4 long-term care workers are foreign-born. Among those, about half are naturalized citizens, and 34 percent are legal non-citizen immigrants. The remaining 16 percent of foreign long-term care workers are undocumented, although that number could be higher than is reported in the official data. 

Despite the importance of immigrant workers in the long-term care workforce, they typically don’t qualify for employment-based visa programs. Instead, most immigrant long-term care workers come to the United States on family-sponsored, refugee, or diversity visas. Some visas are targeted toward “skilled” workers that include many professional health care occupations such as physicians and advanced practice registered nurses. However, long-term care aides are not considered skilled workers under these programs. 

In general, foreign-born workers––particularly women––are more likely to enter the long-term care workforce than native-born workers. Therefore, any reforms that increase the number of low-skill immigrants would likely be beneficial. Efforts to recruit recent immigrants into the long-term care workforce could amplify this effect.

Creating a state-based visa system would decentralize decisions about which types of workers should be prioritized by immigration policy. Under such a system, states could allocate visas according to their own workforce needs rather than rely on federal bureaucrats’ definitions of “skilled” or “unskilled.” The current one-size-fits-all approach pits the interests of states against each other, resulting in unnecessary conflict and, in some cases, a mismatch between supply and demand for different types of immigrant workers. Canada and Australia have implemented similar regional immigration programs that could serve as models. 

Alternatively, lawmakers could pursue reforms specifically targeted toward bolstering the long-term care workforce. One solution proposed by long-term care advocates is to create a new guest-worker program that would extend temporary visas to qualified, English-speaking, foreign-born workers hired to positions that cannot be filled by native-born workers. The workers would be admitted for a fixed, three-year period that could be renewed one time for a total of six years. Another solution would be to simply include long-term care workers under existing skilled worker programs. 

Such reforms may experience newfound support in light of the COVID-19 pandemic, which has highlighted workforce shortages across the health care industry. For example, a recent bipartisan effort in Congress would recapture 40,000 unused visas and allocate them to foreign-trained physicians and nurses to help combat the pandemic. As those shortages continue to grow in the coming years, more permanent efforts may gain similar traction among lawmakers. It is essential that lower-skilled long-term care occupations not be excluded from potential reform efforts.

Whenever lawmakers decide to act, it is clear that the long-term care workforce would benefit from immigration reform. Moving forward, policy debates surrounding both immigration and long-term care reform should consider the relationship between the two.

Conclusion

President Joe Biden’s recent proposal identifies some of the right problems facing the long-term health care services but, unfortunately, does not offer meaningful solutions to the challenges posed by a rapidly aging population. Rather than simply throwing more money at the problem, tackling the looming long-term care crisis will require thoughtful, meaningful policy reforms. 

The most significant challenge to the industry is to rethink the current approach to financing long-term care services. Reducing the role of Medicaid in favor of private payment would help expand access to health care and alleviate workforce pressures by increasing wages. 

Regulatory reforms could expand the supply of home-health providers, unlock the potential of technological innovation, and better leverage the role of home-health workers.

Immigration reform would also expand the home-health workforce to prevent future shortages. 

Combined, these policy reforms would help address the structural problems affecting the home-health care industry while improving access, reducing costs, and giving home-health workers a much-needed pay raise. The scale of the challenge presented by America’s aging population demands such comprehensive solutions, not just a massive influx of federal dollars. 

The post Addressing America’s Aging Population and Long-Term Health Care Crisis appeared first on Reason Foundation.

Municipalities across the country are addressing this problem by experimenting with alternative approaches to dealing with mental health crises and 911 calls. Many reform efforts are promising, but some of their efficacy may be hampered by poor implementation, lack of resources, or budgetary constraints. Telehealth can alleviate some of these challenges and should be considered a tool to help bridge the divide between law enforcement and mental health services.

Telehealth enables law enforcement to connect with health care professionals remotely via telecommunications and digital communication technologies.  Police officers generally lack the training and resources to respond appropriately to emergency calls involving individuals with mental illness. Consequently, individuals with untreated mental illness are 16 times more likely to be killed during a police encounter than those without mental illness according to data from the Treatment Advocacy Center. Even when interactions are not fatal, they can result in unnecessary physical trauma, arrest, and incarceration.

Many situations involving mental illness would be better addressed through health care rather than criminal punishment. Non-violent incidents related to public decency or disorderly conduct, for example, may not warrant a response from law enforcement. However, police officers are often the first to respond to these types of calls. Under those circumstances, officers have generally faced a decision between three options:

1. Do nothing, leaving the individual in crisis and the public unserved;
2. Make an arrest, perpetuating the alarming rate of incarceration among those with mental illness; or
3. Initiate an involuntary psychiatric hold, subjecting the individual to a period of involuntary confinement in a treatment facility

Overreliance on law enforcement in these situations places undue demands on police officers and diverts limited resources away from more serious criminal concerns. Substituting or augmenting law enforcement in response to individuals experiencing mental health crises can alleviate some of this burden.

Several municipalities have deployed specialized teams to handle mental-health-related emergency calls. Specific approaches vary, but in general, these teams may consist of specially trained police officers, health care professionals, or both. Evidence on the impact of these reforms is somewhat mixed but suggests they can be successful when implemented well.

However, it is not always feasible for local governments to implement these sorts of programs. It may be difficult to determine the appropriate response before an officer is on the scene. Moreover, uncertainty about the nature of certain situations could raise legitimate safety concerns for unarmed personnel. Rural and financially stressed communities may also lack the financial or workforce resources necessary to employ or contract with health care and social work professionals.

An innovative approach using telehealth to connect police officers with mental health services could alleviate some of these barriers to reform. Pilot programs have been initiated in multiple states including Texas, Florida, and South Dakota. Typically, the programs equip officers with tablets that can be used to contact mental health professionals via audio and video. The technology enables mental health professionals to interact directly with individuals experiencing mental distress. Mental health professionals may also aid officers by providing guidance and identifying available resources.

In 2017, the Harris County Sheriff’s Office launched the Clinician and Officer Remote Evaluation (CORE) Pilot Program. An analysis of the CORE program in 2019 conducted by the University of Houston—Downtown showed promising results. When surveyed, 86 percent of officers answered that the clinician/psychiatrist helped safely de-escalate the individual in distress. Ninety-three percent said the clinician/psychiatrist helped them decide what course of action to take.

The CORE program has also been effective at avoiding transportation to emergency rooms and criminal detention facilities. Approximately 42 percent of CORE calls in 2019 were resolved on scene. Officers indicated that, in the absence of CORE, these calls would have likely resulted in transportation to an emergency room. Only two calls resulted in transportation to a jail or detention center.

More recently, police departments in Florida and South Dakota have adopted similar programs. In Florida, the Largo and Belleair police departments have adopted the Telehealth Remote Access to Crisis Evaluation (TRACE) program. Since November 2020, the number of involuntary psychiatric holds initiated by the Largo Police Department has decreased by 50 percent. Similarly, twenty-three counties in South Dakota began the Virtual Crisis Care pilot program in July 2020.

If telehealth programs continue to produce such promising results, other municipalities should consider implementing similar approaches. While in-person models may prove to be more effective, telehealth could nonetheless be another tool to address mental-health-related interactions with police. Given the complexity of the problem, policymakers should ultimately seek to provide law enforcement and mental health professionals with as many options as is practicable.

Of course, these types of policing reforms are only part of rethinking the punitive treatment of mental illness in the United States. Additional measures are required to provide treatment before mental health issues reach the point of crisis.

The post How Telehealth Services Can Help Address Mental Health Issues and Police Reform Efforts appeared first on Reason Foundation.

A patchwork of regulations normally limits the use of telehealth in states across the country. However, emergency actions in Louisiana and several other states have allowed telehealth use to increase dramatically throughout the pandemic.

As Eric Peterson and I explain in a new report published by Reason Foundation and the Pelican Institute, there are many ways to improve Louisiana’s telehealth laws and ensure that telehealth remains a viable option for patients and health care providers after the pandemic subsides.

One of the principal benefits of telehealth is the fact that it enables patients to connect with providers across vast distances. Unfortunately, outdated state licensing schemes often prevent health care professionals from providing telehealth services across state lines. In 2008, state lawmakers passed legislation that allowed out-of-state physicians to practice telemedicine without obtaining full Louisiana licensure. The legislation directed the Louisiana State Board of Medical Examiners to issue special “telemedicine licenses” to physicians licensed in other states.

Similar reforms in 2014 allowed other licensing boards, such as the Louisiana State Board of Nursing, to establish telehealth rules–including rules that would allow out-of-state non-physician health professionals to provide telehealth services to patients in Louisiana. However, the legislation merely provided licensing boards the option, rather than the mandate, to issue rules related to telehealth. Consequently, only seven of the 25 provider types mentioned in the act have any rules governing the practice of telehealth. Of those, only Speech-Language Pathologists and Audiologists have an out-of-state registration process.

Rather than allowing greater flexibility, the lack of rulemaking means that there is little guidance on telehealth for most providers. This creates an uncertain environment for those seeking to provide services in the state and unnecessarily limits patients’ access to care. Additional legislative action is required to provide clarity and expand out-of-state registration to all providers.

New applications of telehealth are constantly emerging, but regulation often fails to keep pace with innovation. In Louisiana, outdated rules and definitions limit the range of telehealth services available to patients and providers. Louisiana law distinguishes between the terms “telehealth” and “telemedicine” even though the terms are often used interchangeably. In general, the state uses the term telemedicine in reference to services provided by physicians. Telehealth, on the other hand, refers to services provided by non-physician health professionals such as nurse practitioners. Combined with a delegation of rulemaking authority, this unnecessary distinction has resulted in overly complicated telehealth policies that create significant disparities between health care providers.

Louisiana’s telehealth policies also present barriers to the use of telepharmacy and important asynchronous store-and-forward technologies.

The state currently allows prescription dispensation through telepharmacy dispensing sites staffed by pharmacy technicians who are overseen by a central pharmacy through telecommunications technology. These sites expand access to pharmacy services in areas without an adequate supply of pharmacists. However, Louisiana law prohibits telepharmacy dispensing sites from operating within 15 miles of another pharmacy. This restriction allows the use of telepharmacy dispensing sites where they are needed most but may unnecessarily limit access in some areas.

Asynchronous store-and-forward technology refers to the digital transmission of health data or information—such as x-rays, MRIs, or photos of skin conditions—between patients and health care providers. Importantly, these interactions do not need to happen live. A patient can send or upload documents for later review by their care provider. Right now, Louisiana’s differing definitions of telehealth and telemedicine complicate the use of store-and-forward technologies. The state’s definition of telehealth includes asynchronous store and forward but the state’s definition of telemedicine includes the “transfer of medical data,” through the use of two-way video and audio transmissions. As a result, non-physician providers are able to use asynchronous technologies, but physicians in Louisiana may not.

Telehealth use has skyrocketed during the COVID-19 pandemic, but its value isn’t limited to times of crisis. Telehealth has the potential to expand access to care and reduce costs, particularly in rural areas and underserved communities. Unfortunately, outdated regulations may hamper the use of telehealth going forward.

Louisiana could improve its telehealth policies by increasing clarity, eliminating disparities between physician and non-physician providers, reducing barriers for out-of-state providers, and recognizing all potential forms of telehealth. Adopting such reforms would ensure that telehealth remains a valuable tool for providing care to those in greatest need.

Full Policy Brief: Medicine in a Digital World—Ensuring Permanent Access to Telehealth Care in Louisiana 

The post Telehealth Reforms Could Expand Access to Health Care in Louisiana appeared first on Reason Foundation.

In early 2020, total outpatient visits declined dramatically nationwide, but the increased use of telehealth made up for some of the gaps in care. The shaded area in Figure 1 below reflects this increased use of telehealth. In Florida, total weekly visits declined by 24 percent last year between May 20 and June 16. Over that same period, telehealth visits accounted for 17.4 percent of total visits in the state.

A patchwork of state and federal regulations normally governs interactions between health care workers serving their patients via telehealth. But emergency actions by the federal government, as well as temporary changes to various state laws, have temporarily eliminated or reduced regulatory barriers to the use of telehealth across the country during the pandemic.  Prior to these actions, varying definitions of telehealth, onerous licensing restrictions, and other outdated regulations limited telehealth adoption by patients and care providers.

Fortunately for Floridians, lawmakers in the Sunshine State recognized the potential tradeoffs associated with health care regulation before the coronavirus pandemic began. In 2019, the Florida legislature enacted a significant improvement to Florida’s telehealth policies. The reforms created a unified definition of telehealth, altered rules around insurance coverage of telehealth services, and authorized a wide range of health care professionals to engage in telehealth services.

The 2019 reforms also required licensing boards to create a telehealth registration process for out-of-state providers. The registration process allows providers licensed in other states to practice telehealth in Florida without obtaining an additional Florida license. Allowing out-of-state providers to practice telehealth in Florida will help offset the growing demand for health care services as Florida’s population continues to grow and age.

Yet, as Sal Nuzzo and I explain in a new report published by Reason Foundation and the James Madison Institute, there are many ways to improve Florida’s telehealth laws.

Registered out-of-state telehealth providers are required to work within their scope of practice (SOP) as provided by Florida law––even if they are licensed in a less restrictive state. Scope of practice refers to the range of services that a health care professional may provide. This creates an unnecessary burden for out-of-state providers who must maintain knowledge of SOP provisions in their state and in Florida. Short of expanding SOP requirements in Florida, allowing these providers to practice within the SOP provisions of their state of residence would reduce this burden and expand access to care.

There are many technologies through which patients can access telehealth. Decisions regarding how telehealth services are delivered are best left to the discretion of patients and their providers. Therefore, definitions of telehealth should be broad and allow for future innovation.

For example, Florida’s definition of telehealth explicitly excludes audio-only phone calls, emails, and facsimile (fax) transmissions. Including these and other common forms of remote communication would provide greater flexibility to patients and care providers.

While telehealth services are covered for most Florida Medicaid beneficiaries, Florida’s Medicaid fee-for-service (FFS) delivery system provides more limited telehealth coverage than the Statewide Medicaid Managed Care program. Reimbursements through Florida Medicaid should be expanded to include all potential forms of telehealth.

Regarding private insurance, Florida’s current policy strikes the right balance between promoting the use of telehealth and preserving its cost-savings potential. Some telehealth advocates suggest that requiring private insurance companies to reimburse for telehealth services at the same rate as in-person services would incentivize more providers to adopt telehealth. Lawmakers should resist the pressure from telehealth industry advocates and avoid interfering with negotiations between providers and private insurers.

Finally, lawmakers should avoid preemptively restricting the uses of new technologies as they emerge.

Consumer electronic devices are increasingly capable of collecting health data and providing information to patients and their health care providers. For example, wearable devices like smartwatches can gather information about patients’ fitness, activity levels, and heart rates––and even more complex measurements like blood oxygen levels. Emerging technologies like this promise to bring patients closer to their care providers, but their potential could be thwarted by misguided rules and restrictions.

The COVID-19 pandemic has demonstrated the value of flexibility and innovation in the health care sector. Unfortunately, outdated and overly restrictive regulations may limit the potential of telehealth after the public health crisis subsides.

Improvements to Florida’s telehealth policies that increase flexibility, expand choice, and allow for permissionless innovation would ensure that telehealth continues to expand access to care in Florida.

Full Report: Expanding Access to Telehealth in Florida 

The post How to Improve Access to Telehealth in Florida appeared first on Reason Foundation.

In Florida back in March 2020, Gov. Ron DeSantis issued Executive Order 20-52, which declared a state of emergency in Florida and allowed health care workers licensed in other states to provide care to Floridians affected by the crisis. Those licensing exemptions came with the caveat that their services “be rendered to such persons free of charge and … under the auspices of the American Red Cross or the Florida Department of Health.”

Later that month, an emergency order from the state surgeon general, Scott Rivkees, further expanded licensing exemptions for out-of-state health care workers for a period of 30 days. That order has since been extended until the end of Florida’s state of emergency, which expired on Jan. 2.

These temporary actions could go a long way toward addressing the current crisis, but another long-term threat requires permanent reform. Florida had a huge problem with not having enough medical professionals even before the pandemic. According to the Association of American Medical Colleges, the U.S. is expected to experience a shortage of up to 139,000 physicians by 2033. In Florida, there are already 279 designated primary care health professional shortage areas covering a population of more than 6.66 million Floridians. An additional 1,793 physicians are required to fill the existing need in those areas. Projections from the Department of Health and Human Services estimate that the shortage of primary care physicians in Florida will more than double to 4,671 by 2030. (See graph.)

Residents of Sarasota already feel the bite of these shortages as new residents struggle to find doctors, especially specialists, willing to take new patients.

Fortunately, Florida has been leading the way on reforms to address the looming physician shortage. In 2019, the Florida legislature took substantial steps toward clearing the way for telehealth providers to operate in Florida. Telehealth services allow health care professionals to provide care remotely through telecommunication or other digital communication technologies. Florida’s recent reforms allow health care professionals licensed in other states to provide telehealth services in Florida without obtaining a separate Florida license. However, they are still required to register as a telehealth provider in the state of Florida.

In 2020, Florida passed comprehensive scope of practice reforms to expand the role of nonphysician providers. Scope of practice refers to the range of services a health care professional is allowed to provide under state law. Florida’s recent reforms will allow nurse practitioners to practice autonomously without the supervision of a physician. Nurse practitioners are also now allowed to sign documents that would otherwise require the signature of a physician. Pharmacists in Florida can now test for common illnesses, such as strep throat and the flu. In most other states, pharmacists are allowed to administer vaccines but may not provide tests for those common illnesses.

Although these reforms are meaningful, the scale of the looming shortage requires further action. First, temporary measures allowing out-of-state providers to practice in Florida should be made permanent.

Florida already belongs to the Interstate Nurse Licensure Compact (NLC), which provides a streamlined process for registered nurses licensed in other compact member states to obtain a Florida license. However, Florida is not a member of the Interstate Medical Licensure Compact (IMLC) or the Advanced Practice Registered Nurse (APRN) Compact, which would create similar streamlined processes for physicians and APRNs licensed in other states.

Florida should join the IMLC and APRN Compact, but interstate compacts are not the best available solution. For one, compacts only affect one group of health care professionals at a time. Although there are compacts for physicians, registered nurses (RNs) and APRNs, there are no such compacts for pharmacists or physician assistants. Moreover, compacts rely on widespread adoption to be effective. The Nurse Licensure Compact (NLC) has been adopted by 33 states and the IMLC currently includes 29 states. However, the APRN Compact has not been adopted by any states.

Much better would be to simply recognize all licenses issued by other states provided that health care professionals obtain appropriate liability coverage in Florida. Other states including Arizona, Pennsylvania, New Jersey, and Montana have already passed universal license recognition laws to allow medical professionals — and all other licensed workers — to more easily obtain a license.

Second, Florida should embrace innovative technologies in the health care industry and avoid policies that could prevent such innovation from taking place. For example, a growing body of evidence suggests that artificial intelligence is capable of diagnosing some diseases as well or even more accurately than physicians. Although this technology is a long way off from replacing physicians, it could become an essential aid to physicians in the near future and help them be more productive and help more patients. Florida should be cautious to avoid limiting the potential of new technologies in health care settings.

State responses to the COVID-19 pandemic have highlighted the drawbacks of state-by-state medical licensing regimes. Although temporary suspensions of these licensing rules have helped alleviate staffing shortages during the current crisis, the looming shortage of physicians poses a longer-term threat to Florida’s health care workforce. Florida lawmakers should therefore consider permanent reforms to allow out-of-state health care professionals to more easily practice in Florida and embrace the potential of technological innovations.

A version of this column previously appeared in YourObserver.com. 

The post Florida’s Response to COVID-19 Shows How It Could Address the Looming Physician Shortage appeared first on Reason Foundation.

In a recent policy brief published by the James Madison Institute, my coauthor, Sal Nuzzo, and I discuss several state-level policy measures to address provider shortages, expand access to care, and lower costs for patients. 

The U.S. Department of Health and Human Services has already designated 282 primary care Health Provider Shortage Areas (HPSAs) in Florida, which cover a population of more than six million Floridians. An estimated 1,636 additional primary care physicians are required to remove existing HPSA designations. The shortage is projected to grow to over 3,000 physicians by 2025 and up to 4,671 physicians by 2030. 

States are beginning to embrace telemedicine as a tool to address the looming physician shortage. Indeed, telemedicine is one of many emerging trends in health care delivery with tremendous potential to expand access and achieve cost-reductions, but it should not be perceived as a panacea for issues in the health care industry. Addressing the growing physician shortage will require states, including Florida, to expand the scope of practice for non-physician providers, pursue comprehensive licensing reform, eliminate certificate of need requirements, and embrace future technological innovation.

Expanding Scope of Practice for Non-Physician Practitioners

In contrast to physicians, the supply of non-physician providers including advanced practice registered nurses (APRNs), physician assistants (PAs), and pharmaceutical workers is growing rapidly. However, scope of practice laws prevent these workers from practicing to the full extent of their training and education by limiting the range of services they are allowed to provide or requiring them to work under the supervision of physicians.  

Fortunately, wide variation in scope of practice laws and supervision requirements across states suggests that there is ample room for reform without compromising the quality of care. In fact, the vast majority of research on the subject suggests that expanding the role of non-physician providers improves access with no negative effects on quality.

A report from the Institute of Medicine strongly recommended expanding the role of APRNs to meet the growing need for primary care providers. The report specifically cited the importance of nurses in expanding access and improving the quality of care.

The Florida legislature is currently considering legislation (HB 607) that would allow APRNs and PAs to practice independently and expand their scope of practice by authorizing them to sign documents that otherwise require the signature of a physician. Another bill (HB 389) under consideration would expand pharmacists’ scope of practice to include testing and initiation of treatment for influenza and streptococcal pharyngitis.

Removing Barriers for Out-of-State Telehealth Providers

The terms telehealth and telemedicine broadly refer to the delivery of health care services via telecommunication or digital communication technologies. Widespread adoption of these technologies would help address physician shortages by allowing patients to receive care without the physical presence of a health care provider. However, the patchwork of licensing requirements for out-of-state providers limits the potential impact of telemedicine.

In 2019, Florida lawmakers passed significant reforms to allow for wider use of telemedicine. The legislation created a registration process that allows out-of-state providers to provide telehealth services in Florida without obtaining a license in the state. While allowing providers licensed in other states to practice telemedicine is a major step in the right direction, registration still presents an unnecessary barrier to out-of-state providers. 

Rather than create new requirements, Florida and other states could join interstate licensure compacts to reduce the burden of receiving licensure in multiple states. If a practitioner receives a license in any member state, they are able to receive licensure in all other member states with little or no additional effort. However, there are no existing compacts for physician assistants or pharmacists, and the compacts that do exist rely on widespread adoption to be effective. 

Alternatively, states could recognize licenses from other states. Such a policy would not be detrimental to the quality of services as licensure standards for health care providers are largely comparable across states. In fact, many states, including Florida, already have license reciprocity programs to recognize out-of-state licenses held by veterans, active-duty service members, and military spouses. Expanding out-of-state license recognition to all new residents and out-of-state providers would increase competition, expand access, reduce costs, and promote the adoption of telemedicine by expanding the health care labor market. 

Eliminating Certificate of Need Requirements and Bans on Specialty Hospitals

Certificate of need (CON) laws require health care providers to demonstrate an unmet need before constructing new facilities, expanding existing ones, or offering new services. The 1974 National Health Planning and Resources Development Act mandated states to implement CON programs for many facilities and services under the theory that unregulated competition would lead to over-investment in facilities and equipment. However, ample research has found that CON laws actually increase costs and reduce access to care by limiting competition and supply. Consequently, several states have eliminated their CON programs following the repeal of the federal mandate in 1987.  

Florida repealed most of its CON laws in 2019 but maintained requirements for nursing homes, skilled nursing facilities, hospice programs, and intermediate care facilities for the developmentally disabled. The legislature also stopped shy of eliminating Florida’s ban on specialty hospitals that restrict their services to cardiac, orthopedic, surgical or oncology care. Florida lawmakers are currently considering legislation (HB 6059) that would eliminate this ban. 

Considering that a shortage of physicians will raise costs and limit access to care, policies such as certificate of need laws that unnecessarily exacerbate these problems should be eliminated. CON laws for nursing homes and hospices are particularly detrimental in Florida given the relatively high elderly population in the state. 

Embracing Innovative Technologies

Technological innovation has the potential to transform the health care industry and reduce the impact of physician shortages, but our laws are often slow to respond to change. While it is impossible to know what innovations lie around the corner, technologies including artificial intelligence (AI), unmanned aerial vehicles (UAVs), and telepharmacy services are already demonstrating their potential. Rather than trying to force compliance with outdated regulatory schemes, states should embrace these technologies and avoid limiting future innovation through excessive regulation. 

A growing body of evidence suggests that artificial intelligence could be used to diagnose a variety of diseases more accurately than physicians. For example, an algorithm developed by Google researchers outperformed six radiologists at screening for lung cancer in a study published by Nature Medicine. While this technology is a long way off from replacing physicians, it could become an essential aid to physicians in the near future. States should be cautious to avoid limiting the potential of AI in health care settings through overregulation. 

UAVs, or drones, could be useful for delivering medical supplies to remote areas, especially during natural disasters. In fact, they are already being used in some developing countries to deliver blood, vaccines, and other life-saving medical supplies. However, deploying UAVs in the United States is more complicated because of the patchwork of laws and regulations governing airspace and will likely require collaboration between federal, state, and local authorities. Nevertheless, states like Florida should be leaders in coordinating with federal and municipal authorities. 

Telepharmacy technologies could expand access to care, particularly in rural communities, by allowing patients to interact with pharmacists remotely. There are several types of telepharmacy services including remote consultation, remote dispensing, and automated dispensing machines. In a remote counseling setting, a pharmacist provides guidance to patients via a video or audio link to ensure the safe and proper use of medications. Remote dispensing is another option, wherein a pharmacist manages several remote sites staffed by pharmacy technicians. This model allows for wider access in rural areas where traditional pharmacies staffed by in-person pharmacists may not be feasible. Finally, automated pharmacy dispensing machines, allow pharmacists to interact with patients and remotely dispense medications via video or audio link. The machines are typically stocked with common prescriptions (non-narcotics) and provide 24-hour access to pharmacy services without significant labor costs. The Florida legislature is considering legislation (HB 57) that would allow certain hospitals to place these machines in their emergency departments for use by patients upon discharge.  

As the country’s population continues to grow and age, the demand for health care services will outpace the supply of physicians. States can address the looming shortage by pursuing a broad range of reforms to expand scope of practice for non-physician providers, eliminate certificate of need laws, recognize out-of-state licenses, and embrace future technological innovations. Taken together, these measures would alleviate the growing strain on our health care resources, expand access to care, and reduce costs for patients. 

The post How State-Level Reforms Could Alleviate the Looming Physician Shortage appeared first on Reason Foundation.