One of the largest randomized clinical trials to directly compare telehealth and in-person care has found that they are equally effective in improving quality of life in patients seeking palliative care—specialized care focused on managing the symptoms of serious illness.
The use of telehealth surged at the height of the COVID-19 pandemic through waivers that expanded Medicare coverage for a wide range of medical services. These flexibilities are set to expire by the end of 2024 unless Congress takes action to extend them—and many private insurers follow Medicare’s lead. While advocates argue that telehealth improves accessibility, policymakers have expressed concerns about quality of care, costs, and the potential for fraud.
This study is really important for providing Congress with the evidence that they need to support the concept of extending waivers.
Lee Schwamm, MD
Now, a multi-site study involving 1,250 patients with advanced lung cancer across 22 U.S. sites has found that those who received early palliative care via telehealth reported quality-of-life scores that were equivalent to those who received in-person care. The findings highlight the importance of keeping telehealth accessible to patients, the study’s authors argue. They published their study in JAMA on September 11. The study adds to growing evidence that telehealth provides comparable quality of care to in-person visits across specialties.
“Medicare has to make some big decisions about whether or not to continue the waivers that allow telehealth visits to be reimbursed,” says Lee Schwamm, MD, associate dean for digital strategy and transformation at Yale School of Medicine and a co-author on the research. “This study is really important for providing Congress with the evidence that they need to support the concept of extending waivers.” The outcome will impact nearly all individuals who seek medical care, but especially those with chronic and/or disabling conditions.
Telehealth skyrocketed during COVID-19
Before the COVID-19 pandemic, Medicare offered very little reimbursement for telehealth. Many commercial insurers follow Medicare’s lead, and patients typically only received coverage for virtual visits if they lived in rural areas. The patients also had to attend these visits from a Medicare-approved facility, such as a rural health clinic, rather than from their home.
But with the pandemic, Medicare relaxed these restrictions, granting millions of Americans access to virtual services. Telehealth visits skyrocketed—from 5 million among Medicare recipients between April and December 2019 to over 53 million in the same period in 2020. Furthermore, a national study following 36 million individuals with private insurance found that telehealth visits increased by 766% during the first three months of the pandemic.
Advocates argue that these changes have substantially benefited patients—especially those who must travel long distances to see their providers, suffer from disabling and/or chronic illnesses, or are being treated for behavioral health disorders that require weekly visits. “Telehealth has become such an important part of medical care,” says Dmitry Kozhevnikov, DO, director of ambulatory palliative care at Yale New Haven Hospital-Smilow Cancer Center, who was not involved in the new study. “It has really increased access to the patients who need it the most.”
Now, the Subcommittee on Health of the U.S. House of Representatives Committee on Energy and Commerce is reviewing 15 bills related to Medicare telehealth access. The American Telemedicine Association has referred to these deliberations as the 2024 telehealth “Super Bowl.” Lawmakers are debating whether to extend the waivers temporarily or make permanent changes to telehealth reimbursement policies for ambulatory care.
Many providers are worried about the implications if Congress decides against extending telehealth flexibilities. “If the renewal of the waivers is not passed, it will have a huge impact on medicine,” says Eric Winer, MD, director of Yale Cancer Center, who also is not affiliated with the study. “At a time when we’re trying to make health care more convenient, providing a number of different approaches for clinician-patient interactions is very important.”
In-person and virtual visits led to equivalent outcomes
In their recent study, Schwamm and colleagues affiliated with Harvard Medical School, where he formerly was on the faculty, investigated whether conducting palliative care through telehealth was as effective as in-person care in improving patient quality of life. They enrolled 1,250 patients diagnosed with non-small cell lung cancer — the most common form of lung cancer. The average age of participants was 65.
The researchers ran the trial at 22 cancer centers across the United States and trained the providers at each center on the technology needed to conduct a virtual visit. They assigned half of the participants to receive telehealth after an initial in-person palliative care visit. The other half received care entirely in the doctor’s office.
To assess quality-of-life outcomes, the team used a questionnaire called the Functional Assessment of Cancer Therapy-Lung (FACT-L). They found that there was no significant difference in quality of life between the two groups.
Interestingly, the study also revealed that caregivers were less likely to participate in virtual visits than in-person, perhaps pointing to the greater independence telehealth allows patients. For instance, many patients depend on their caregivers to drive them to and from appointments, but with telehealth, they can speak to their providers from their own homes without needing to arrange for transportation. “There’s more flexibility and freedom for patients who may typically rely so much on their caregivers to receive care,” says Kozhevnikov.
Furthermore, other factors including caregiver quality of life, patient and caregiver satisfaction with care, and mood symptoms were equivalent across groups. “That’s really reassuring,” Schwamm says. “For patients with advanced lung cancer, this was an effective way to deliver palliative care.”
Telehealth could help reduce health disparities for a range of conditions
Palliative care doctors are in short supply. According to the World Health Organization (WHO), only 10% of those in need of palliative care globally receive it. “They tend to be concentrated at academic health systems,” Schwamm explains, “So, there’s a tremendous geographic disparity in who can access a palliative care doctor.”
Telehealth has the potential to dramatically expand the number of patients who can obtain care while still providing quality treatment. “When it comes to palliative care, in-person visits are quite difficult because it’s forcing some of our sickest and compromised patients to make trips into a hospital setting,” says Winer. “Telemedicine allows patients to have the same benefit of in-person care without having to travel.”
Beyond palliative care, clinicians can apply telehealth to an endless number of physical and mental health conditions. It even can be beneficial in acute, life-threatening situations such as stroke care, research has shown. In fact, prior to the COVID-19 pandemic, Congress passed the FAST Act of 2018, which permanently expanded telehealth coverage for acute stroke care in recognition of these benefits beyond only rural areas. “The same concept applies—telemedicine for stroke care allows patients to have access to a neurologist and get treated,” Schwamm says. “This is a substantial opportunity to reverse disability and improve outcomes.”
Researchers argue in favor of Medicare reimbursement
Based on its findings, the research team hopes that Congress will support Medicare reimbursement of telehealth visits. “Policymakers have concerns that the quality of care that is delivered by telehealth is not as good as care delivered in person,” says Kozhevnikov. “I personally have found so many times that the quality of telehealth-delivered palliative care and medical care is quite strong, so I don’t think those concerns are well-founded — especially in light of these new results.”
In April, Schwamm testified in front of the Subcommittee on Health. Beyond quality of care, policymakers have also expressed concerns regarding fraud or abuse. But a 2022 report from the U.S. Department of Health and Human Services (HHS) found that telehealth fraud during the pandemic was rare. “And we already have mechanisms in place to monitor for those kinds of activities,” Schwamm argued.
Policymakers also have concerns about cost. For example, the Congressional Budget Office has projected that the bipartisan bill, the Telehealth Expansion Act (H.R. 1843), would cost over $5 billion over a ten-year period. During the April subcommittee hearing, experts debated how much Medicare should reimburse for telehealth services. To reduce costs, some argued in favor of Medicare reimbursing telehealth visits at a rate below in-person visits.
However, others including Schwamm argued that setting telehealth reimbursements too low would discourage its use. Adopting a permanent hybrid model of care—which combines both virtual and in-person services—will require significant initial investments from health care systems, including repurposing in-person infrastructure and implementing appropriate technology for video visits.
So, Schwamm advocated for a phased approach in which Medicare gradually reduces its payments for telehealth services as new infrastructure becomes established and virtual visits become less expensive over time. “We need to give health systems a year or two of a runway and then slowly ramp the payment down in conjunction with permanent waivers, so that they can really start to rebuild the health system around that capability and lower their cost of care,” he says.
Other medical providers are also calling for Congress’s support of telehealth expansion. “We have to advocate for patients and families to have access to these services,” says Kozhevnikov. “Especially among those who live too far away to be able to logistically travel to a clinic or are too ill to get out of the house—those patients and caregivers still deserve high-quality care, and telehealth is one way we’ve been able to deliver that.”