The regulatory flexibilities related to telehealth that the U.S. Centers for Medicare & Medicaid Services (CMS) implemented during the COVID-19 pandemic have expired.

This includes the ability of hospices to perform patient re-certification face-to-face encounters via telehealth. Also expiring are waivers that expanded the scope of practitioners eligible to provide telehealth services, as well as flexibilities that removed geographic requirements and expanded originating sites for telehealth services, including federally qualified health centers and rural health clinics.

The government’s failure to extend or make permanent the telehealth re-certification waiver is a “grave mistake,” according to Tom Koutsoumpus, CEO of the National Partnership for Healthcare and Hospice Innovation (NPHI). 

“Allowing the hospice face-to-face telehealth recertification flexibility to expire would be a grave mistake that puts some of our most vulnerable patients at risk,” Koutsoumpus told Hospice News in an email. “For almost five years, this commonsense flexibility has ensured that hospice providers can spend more time caring for patients and families rather than navigating unnecessary, administrative red tape.”

Hospices and other health care providers have heavily leveraged virtual services during the past five years of the telehealth waivers, particularly to reach patients in rural and remote locations with limited resources.

Telehealth has allowed hospices to reach more patients during a time of rising demand and staffing shortages that were exacerbated by the pandemic. Providing virtual services have additionally aided in the ability to offer more layers of support to patients and caregivers, helping hospices to avoid unnecessary home visits and balance clinician workload.

“If telehealth extenders are not enacted, hospices, including our nonprofit and mission-driven provider members, will be required to conduct face-to-face requirements in-person,” Katy Barnett, director of home care and hospice operations and policy for LeadingAge, told Hospice News in an email. “Telehealth has become an integral part of care delivery in hospice, and the loss of this option would represent a substantial setback for the health and safety of hospice patients who have come to rely on it, especially those in rural areas.”

The provision of telehealth is a helpful complement, but not a replacement for in-person care, according to Empassion Health co-founder and CEO Robin Heffernan.

“Repeated evidence suggests that while telehealth can complement in-person care, it rarely substitutes for the relational depth and nuanced observation possible during home visits — particularly for patients in their final year of life,” Heffernan told Hospice News in an email. “This is especially critical for cancer patients nearing end-of-life, where physical presence in the home allows providers to assess environment, family dynamics and unmet needs that would otherwise remain hidden.”

Despite the clear benefits, telehealth is not a panacea. A 2022 Cancer Medicine study found that non-White race, Medicaid coverage, limited English proficiency and lower income were all negatively associated with use of virtual care.

In addition, some palliative telehealth visits are billed under complex Chronic Care Management (CCM) codes, costing the system as much as $395 or more per encounter, according to Heffernan.

The future of telehealth remains uncertain. Though they have now lapsed, CMS or Congress could restore the flexibilities. CMS Administrator Dr. Mehmet Oz in his Senate confirmation hearing indicated that expanding telehealth utilization is a “major focus” for the agency. 

“Congress has a responsibility to extend telehealth widely throughout the nation, and as it was during COVID …” Oz said. “It is a major focus of mine, and if confirmed, it’s one of the areas I think we’ll be able to make major inroads, because there are no opponents to this.”

However, no CMS action on telehealth has materialized to date. Also, as of Oct. 1, the federal government has shut down due to Republicans’ and Democrats’ failure to agree on a continuing resolution to keep it funded.  

In February, Reps. Carol Miller (R-West Virginia) and Jared Golden (D-Maine) reintroduced the Hospice Recertification Flexibility Act. If enacted, the bill would allow hospices to conduct face-to-face recertification visits via telehealth. But thus far the bill hasn’t moved toward a vote.

The waivers’ expiration will make life more difficult for hospice providers, according to the National Alliance for Care at Home.

The expiration of the telehealth flexibility forces providers to handle substantial logistical challenges and workforce issues. Hospices must make difficult decisions about how and when to shift physicians and practitioners away from direct patient care to complete the face-to-face encounters.

“This puts pressure on the ability of hospices to make sure that they can meet the needs of their patients, but it also risks impacting access to care in rural and underserved areas where workforce issues are more acute,” the Alliance indicated in a statement shared with Hospice News. “Hospices may not be able to admit a new or transfer patient entering their third or later benefit period timely, or hospices may be forced to discharge existing patients about to enter their third or later benefit period due to issues with being able to perform these encounters in person.”