Some of the temporary telehealth flexibilities implemented during the pandemic will soon expire while others have been recently extended. These evolving regulations have hospices concerned that a lack of virtual access to their services could have significant impacts on quality and health disparities.

Temporary telehealth flexibilities granted during the pandemic have opened up discussions around the future of technology in health care delivery, said Dr. Michael Fratkin, board president at the Institute for Rural Psychedelic Care. Fratkin is also a palliative care specialist at Humboldt Center for New Growth.

“We’ve inherited a kind of accelerated movement toward a new normal during the pandemic,” Fratkin told Hospice News. “And since then, we’re trying to reconcile previous legislation with the realities of health care delivery before and after the pandemic.”

A few of the flexibilities have been extended, though not all. The U.S. Drug Enforcement Administration (DEA) and the U.S. Department of Health and Human Services (HHS) recently announced the extension of telemedicine flexibilities for the prescribing of controlled medications until Dec. 31, 2025. These waivers were initially set to expire on the same date in 2024 and were extended to allow more time to outline future telemedicine regulations, the DEA and HHS indicated.

The decision has many in the hospice community weighing the potential ripple effects on other telehealth waivers, including the flexibility allowing for virtual face-to-face recertifications, which are separate from the DEA extension.

The telemedicine extension reflects a growing recognition of the critical role telehealth plays in ensuring timely access to care, particularly in the hospice setting, said Madison Summers, public affairs professional at the National Alliance for Care at Home (the Alliance).

“While we deeply appreciate the extension of DEA flexibilities, we strongly advocate for policymakers to make both the DEA and [face-to-face (F2F)] provisions permanent — or, at the very least, to ensure hospice providers have specific exceptions moving forward,” Summer told Hospice News in an email. “Given the proximity to expiration, failing to extend these policies would be irresponsible and could create unnecessary chaos for patients and providers alike.”

Navigating regulatory complexities

Industry stakeholders and providers alike have urged Congress to extend face-to-face recertification via telehealth or make these waivers permanent, including the Alliance, LeadingAge and the American Academy of Hospice and Palliative Medicine, among others.

For now, the future of telehealth in hospice remains uncertain, though providers can look to some regulatory aspects for clues as to where it may be heading.

While the content of the telemedicine flexibilities has not changed since the waivers were initially established, all mentions of COVID-19 were removed from the temporary rule, except for the title. This could be interpreted as a signal of interest in retaining some of these flexibilities into the future, according to Katy Barnett, director of home care and hospice operations and policy at LeadingAge.

LeadingAge recently penned a letter to Congress requested a two-year extension of the temporary hospice recertification rule, along with several other Medicare telehealth waivers including the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2023 and the Telehealth Modernization Act of 2024.

“If Congress does not extend provisions such as allowing the home to be an originating site of care, removing the geographic restrictions, and more flexibility in the types of providers that can bill for telehealth, the result – i.e., reverting to the pre-COVID status quo on these provisions – would be detrimental to hospices and other of our members that provide Part B services,” Barnett said.

Congress currently is mulling a bill, the Preserving Telehealth, Hospital, and Ambulance Access Act, that proposes to extend the expiration of regulatory flexibilities tied to telehealth through 2026. It also includes some exceptions. If a hospice is undergoing a period of enhanced oversight by the U.S. Centers for Medicare & Medicaid Services (CMS), they would not be able to recertify via telehealth. Also, clinicians who are not enrolled in Medicare or who validly opted out would likewise be prohibited.

If enacted, the bill would represent a two-year extension, though some lawmakers expressed a will to make the flexibilities permanent. However, the legislation seems to have died in committee.

Hospices are navigating a complex web of both telehealth and telemedicine uncertainties that are impacting their ability to provide quality care, according to Summers. Patients and their families may bear the brunt of potential negative effects, she stated.

“If these flexibilities are set to expire, which we strongly oppose, it is essential that hospices are given sufficient time to adjust operations and avoid disruptions in patient care,” Summers said. “Losing F2F recertification flexibility would complicate efforts to maintain continuity of care for patients in remote or underserved areas. To safeguard access and support patients and families, we urge policymakers to extend both the DEA and F2F flexibilities permanently.”

Telehealth’s quality, access impacts

To become permanent, telehealth regulations may need to solidify certain aspects, including establishing rules around oversight and quality measures to ensure safe, effective and ethical practices, Fratkin said.

But regulators may be behind the proverbial curve of innovative technology utilization and how it has impacted patient outcomes, family experiences and sustainable avenues for end-of-life care delivery, he added.

“The future of health care includes the use of telehealth technologies that meet people where they are and [also] saves a lot of money,” Fratkin told Hospice News. “There’s some really responsible telehealth-enhanced programs that have accelerated and advanced appropriate use of health care resources, especially to address the needs of homebound, very sick people. It seems like there’s no stopping the use of tele-technologies to serve people.”

Telehealth flexibilities have allowed for more timely access to hospice among some of the most vulnerable and underserved patient populations across the country, Barnett stated. The waivers have widened opportunities for providers to reach patients sooner in their illness trajectories, particularly those in rural and frontier regions with sparse resources nearby, she added.

Researchers have found mounting evidence pointing to the benefits of telehealth utilization among serious and terminally ill patient populations. Some research efforts have explored the potential for telehealth to be as effective as in-person care delivery and ways that these services have eased care transitions among pediatric and adult patient populations alike.

A recent study of telehealth billing claims found that these services have led to improved access to caregiver support in rural regions while also providing a cost-effective model for providers.

Another study examining the past decade of utilization found that telehealth has been associated with improved quality of life, patient satisfaction and symptom management, particularly in home-based settings. Telehealth services were also tied to reduced caregiver burden and greater care coordination for remote, rural and underserved communities, the research found.

Rural-based hospice providers have leveraged telehealth to improve access for patients while boosting caregiver support and resources. Being able to virtually recertify hospice patients has also helped providers to balance clinical capacity amid rising demand and prolific workforce shortages, Barnett indicated.

“Hospices have adapted their workforces to being able to do this visit via telehealth and focus these high level clinical resources (physicians and nurse practitioners) more effectively and efficiently — a benefit of telehealth, given the clinical workforce shortages,” she said.