Nurses Advancing Telehealth Services in the Era of Healthcare Reform

Joelle T. Fathi, DNP, MN, BSN, RN, ANP-BC; Hannah E. Modin, MHA, B.A; John D. Scott, MD, MSc, FIDSA


Online J Issues Nurs. 2017;22(2) 

In This Article

Policy Considerations

Given the potential of telehealth, especially with rapidly developing ICT and established need for services, policy considerations are important to continue the evolution of quality, accessible services. Just as important is the need for nurses to become informed and support initiatives in telehealth in this era of health care reform. This section will discuss telehealth policy considerations such as the demand for providers; the role and contribution of nurses; challenges and feasibility of delivery and reimbursement; and future considerations.

Policy Impact on Demand for Providers

With the intent to create a healthier population, the ACA (2010) established provisions that incentivize patients to access primary care and preventive health services (Davis, Abrams, & Stremikis, 2011). Calling for the elimination of out-of-pocket costs for preventive services such as cancer screenings and annual wellness physicals, the legislation placed new pressures on an already stressed primary care network across the country. Coupled with increasing numbers of insured individuals, this has resulted in a greater demand for primary care providers (Heisler, 2013).

Many rural areas especially lack reasonable numbers of and appropriate ratios of health professionals (e.g., primary and dental care, mental health) to persons offer reliable access to safe and quality healthcare. Such areas are identified as Health Professional Shortage Areas (HPSAs) (Heisler, 2013). This shortage of healthcare professionals significantly determines access to healthcare, or lack thereof, and thus the health of communities. Professional isolation for healthcare providers in these remote HPSAs also poses a serious challenge. Telehealth provides a unique opportunity to address these shortages and effectively provide care to patients and support to providers, primarily nurses and doctors, in areas of provider and resource constraints. This shortage of primary care providers is well documented, and the deliberate inclusion of nurses as a solution is a natural conclusion to continued calls for innovation to meet health needs of all patients.

Nurses as Critical Partners in Telehealth Services

Nurses are educationally and professionally prepared to provide a broad scope of skills and services across the continuum of healthcare (Bleich, 2011). The nursing workforce has doubled since 1980, and is now the largest contingency in the U.S. healthcare workforce (Committee on the Robert Wood Johnson Foundation Initiative, 2011) with 3.6 million registered nurses (McMenamin, 2016). This number includes 208,000 nurse practitioners, who are board certified to deliver specialty services and primary care (American Association of Nurse Practitioners, 2017) with a similar scope of practice as primary care physicians (Bleich, 2011).

There is an unending need for healthcare professionals, including nurses, to initiate appropriate and timely use of telehealth services to ensure Americans receive the care they need. Providers must collaborate to strengthen the infrastructure of clinical practice; delegate tasks to broaden the spectrum of caregivers; and develop care delivery pathways and models in telehealth to address quality and reimbursement requirements. Collaborative practice is key to building effective healthcare teams (Joel, 2013); improving delivery and experience for patients via telehealth technology services; and optimizing efficiencies of healthcare.

Nurses are often the only consistent, frontline healthcare providers present in communities; critically positioning them to support all aspects of the telehealth continuum, with the greatest impact on patient care. As clinicians, educators, researchers, advocates of policy, and as transformational leaders, nurses need to practice at the fullest extent of their education and training in order to derive their professional potential for all involved. Nursing practice, at its full scope, must include continued reform to develop and deliver telehealth services.

The Intersection of Telehealth and Healthcare Reform

The 2009 American Recovery and Reinvestment Act included billions in funding to update healthcare IT systems, research, and facilities (LeRouge & Garfield, 2013). The National Broadband Plan, in 2010, identified and directed funds for further development and use of information technology by expanding the infrastructure for high speed internet access aiding in the establishment of telemedicine and remote monitoring (Federal Communications Commission, 2010; The White House: President Barack Obama, 2016). In 2010, the ACA became a driver of healthcare delivery and payment reform, and aspects of the legislation focused on improving care quality, value, transparency, and health information technology.

Telehealth is a means to achieve many aims of healthcare reform, particularly goals to improve value and deliver affordable care with high quality outcomes, while reversing rising healthcare costs (Rosenfeld, 2015). In the Accountable Care Organization (ACO) model, a product of the ACA, health systems are responsible for the care of a defined population, which requires seamless cooperation of multiple facilities and providers across the care continuum. The ACO model creates an ideal testing environment for novel models of care delivery like telemedicine, focused on better coordination and efficiency (National Advisory Committee on Rural Health and Human Services, 2015).

In the Centers for Medicare and Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CCJR) program, hospitals are financially responsible for quality and cost of the entire care episode for Medicare beneficiaries receiving hip and knee replacements, including 90 days post discharge. As part of the CCJR program, CMS waived certain geographic reimbursement requirements for telehealth, encouraging the use of telehealth to care for patients during the episode of care, especially as they transition out of the hospital (CMS, 2017; mHealth Intelligence, 2016).

Now, value-based programs including the Medicare Access and Chip Reauthorization Act (MACRA), which will replace Meaningful Use in 2017, and the Delivery System Reform Incentive Payment Program, openly invite expansion of virtual services as a means to provide timely and cost-effective care (Becker's Health IT & CIO Review, 2016). The new payment tracks under MACRA will affect over 700,000 clinicians in 2017, including payments for nurse practitioners, clinical nurse specialists, and certified registered nurses (Advisory Board, 2017).

Challenges and Feasibility of Delivery and Reimbursement

Increasingly, healthcare providers are driving innovation with intent to deliver care, promote wellness, and keep people healthier in new and cost effective ways, such as telehealth. However, there remain many evolving and unresolved challenges of telehealth, such as the determination of permissible practice environments; ethical considerations; licensing and credentialing; and interstate compact agreement statutes. Patient privacy and information security are other concerns. For example, telehealth provision must adhere to Health Insurance Portability and Accountability Act (Public Welfare, n.d.) requirements and always ensure patient privacy. This may require extra steps for providers (e.g., entering a business associate agreement) to ensure protection of patient health information (Center for Connected Heath Policy, 2017b). Services rendered electronically may be vulnerable to hackers and other security breaches, requiring the utilization of software encryption features and advanced protocols for security (Telehealth Resource Centers, 2017b).

Engaging in telehealth, in practice, also depends on identifying specific services that can be rendered; practical development and implementation; and determination of the feasibility of reimbursement. Reimbursement for telehealth services varies amongst Medicare, Medicaid, and private payers (Center for Connected Heath Policy, 2017a; Robert Wood Johnson Foundation, 2016). In 1997, Medicare was one of the first payers to acknowledge and promote reimbursement for telehealth services as part of the Balanced Budget Act (Telehealth Resource Centers, 2017a). However, Medicare has coverage restrictions for telehealth services, and traditionally only reimburses synchronous telehealth services for designated rural and underserved areas.

Expansion of reimbursement for other telehealth services has been slower amid concerns it will incentivize an increase in unnecessary utilization and drive Medicare expenses up (Galewitz, 2016). In 2000, The Benefits Improvement and Protection Act expanded Medicare coverage for telehealth, and today CMS only reimburses for a select number of services, and restricts payments to specific areas (Telehealth Resource Centers, 2017a). Although Medicare has covered some iteration of telehealth services for two decades (National Advisory Committee on Rural Health and Human Services, 2015), fewer than 1% of Medicare beneficiaries use it (Galewitz, 2016). Nurses have a critical opportunity to promote acceptance and adoption of telehealth services, advocate for nonrestrictive telehealth benefits, and educate patients on the care available through telehealth.

Medicaid reimbursement for telehealth is administered by respective states, and as of January 2016, 48 states provide some form of Medicaid reimbursement for live video telehealth services with drastically fewer states providing Medicaid coverage for store-and-forward and remote monitoring (Center for Connected Heath Policy, 2015). Medicaid reimbursement for live video is more prevalent in most states, rather than reimbursement for store-and-forward and remote patient monitoring (Telehealth Resource Centers, 2017c).

Individual states are able to establish requirements for private payers, mandating coverage for telehealth services (National Conference of State Legislatures, 2016). As of 2016, 32 states had a private payer legislative policy in place (National Conference of State Legislatures, 2016). A study reviewing hospital adoption of telehealth (Adler-Milstein, Kvedar, Bates, 2017) found that uptake of telehealth is directly impacted by state policies on reimbursement and licensure. States with private payer reimbursement for telehealth, and particularly policies requiring payment parity, were associated with a greater number of hospitals choosing to adopt telehealth technologies (Adler-Milstein et al., 2017). Such policies drive reimbursement for telehealth services, including payment parity, where legislative policy require payers to reimburse at the same rate for the same services provided in person or via telehealth (Center for Connected Heath Policy, 2015). Payment parity encourages healthcare systems and providers to deliver telehealth services, and allows providers to make necessary investments in infrastructure to support new approaches in care delivery.

Nurses as Key Contributors and Informants

As noted previously, the 2010 landmark IOM report strongly recommended an increased role for nurses in the transformation of healthcare. This report outlined a future in which nurses work at the top of their license and training, achieve higher levels education through improved education systems, and work as partners with other healthcare professionals, including physicians. The report called for effective workforce planning and better data collection and information infrastructure (Bleich, 2011). Fostering essential interest and uptake of telehealth services by healthcare professionals, including nurses, demands integration of telehealth curriculum and practical training into academic programs (Ferguson, 2006). Such curriculum will enhance nurses' ability to demonstrate proficiency to conduct telehealth visits and advocate for such services through health policy.

The Josiah Macy Jr. Foundation (2016) published recommendations for the increased role of nurses in primary care. Given current stresses on the primary care system, new practice models that include nurses in critical roles are needed to meet demand and achieve the Institute for Healthcare Improvement (IHI) Triple Aim of improved patient experience, health of populations, and per capita cost of healthcare (IHI, 2016; Josiah Macy JR Foundation, 2016). An advanced role for nurses, and redesign of primary care practices, can provide an opportunity for nurses to participate and actively lead telehealth integration in the future.

As telehealth continues to move from theory to practice, legislation that ensures comparable reimbursement and favorable conditions for practice of telehealth services will be critical. This telehealth legislation remains a significant need in healthcare reform. Such health policy cannot occur unless healthcare providers partner with local government officials, and actively drive telehealth initiatives. Advocacy and awareness of critical legislation is also important, such as the Nurse Licensure Compact which allows nurses a multistate license to practice (National Council of State Boards of Nursing, 2017) Without this legislation, telehealth becomes an expensive venture requiring licensure in each state where telehealth care is delivered. As key informants on the front line of clinical healthcare, nurses should not underestimate the power of their individual and collective voices to advocate for changes to health policy in their practice states.

The Future for Telehealth

In 2017, amid rising pressure of increasing health insurance costs, breakdowns in state health insurance marketplaces, and working to fulfill a campaign promise, Republicans introduced legislation to move towards repeal and replacement of the ACA. The House of Representatives voted to pass the American Health Care Act in May of 2017. The bill now moves to the Senate. For now, the ACA remains in place, but the long-term future of this legislation remains unknown. The extent to which the law will be modified or overhauled, and how healthcare coverage will be financed in the future, remains a highly polarized, partisan issue.

Meanwhile, advancements in telehealth policy continue to emerge. In spring 2017, a bipartisan bill was introduced to the U.S. Senate to expand Medicare coverage of telehealth services. The bill is aimed at increasing access for rural patients, however, opponents raise concerns regarding the potential for increased utilization, leading to greater overall Medicare costs (Arndt, 2017). Akin to the fate of healthcare reform, the future of the bill is yet to be determined in the politically charged and polarized environment of Washington DC.