The recent sunset of telehealth flexibilities implemented during the COVID-19 pandemic has hospices concerned about health equity and patients’ access to care, particularly in rural areas.

Regulatory waivers that the U.S. Centers for Medicare & Medicaid Services (CMS) issued during the public health emergency expired on Sept. 30. Among the waivers was the ability to perform patient re-certification face-to-face encounters via telehealth. The flexibilities also widened the scope of practitioners eligible to provide telehealth while removing geographic requirements and expanding originating sites for these services, including federally qualified health centers and rural health clinics.

Underserved patient populations in rural regions came to depend heavily on telehealth services, according to Stephanie Adair Reed, vice president of hospice services at Liberty Homecare and Hospice. Reaching these patients without telehealth capabilities has brought on increased labor, financial and admission challenges, she stated.

“The end of telehealth waivers has been disruptive,” Adair Reed told Hospice News. “We had to hire additional nurse practitioners to assist our staff in meeting the face-to-face requirements. It’s a big issue. The biggest issue without telehealth waivers is that our admission process has slowed down, which has caused delays and concerns. Getting a visit done in person after hours has caused a financial burden, because we’re paying more for nurses when these could have been done by telehealth and not require us to pay for things like mileage reimbursement.”

Examining ripple effects

Liberty Homecare and Hospice provides hospice, home health and palliative care in North Carolina, South Carolina and Virginia. About one-third of the organization’s patient census is rural-based. Many of these patients require complex care management in the home, Adair Reed stated.

Telehealth waivers allowed Liberty Homecare and Hospice to respond to referrals within one hour at a rate of 90%. Any missed or delayed face-to-face patient visits can jeopardize a hospice’s ability to remain compliant with admission process requirements, Adair Reed said. The absence of telehealth flexibilities has reduced timely response rates and brought concerns related to the loss of operational efficiency, she indicated.

Telehealth services have helped to reduce clinicians’ travel time and stress levels while improving productivity, Adair Reed indicated. The regulatory changes have resulted in added administrative and clinician burden related to scheduling in-person visits and coordination of care.

Limitations in telehealth utilization could result in a significant gap of limited resources amid rising demand for hospice care, particularly among rural-based communities, according to Tiffany Hughes, nurse practitioner and chief clinical officer at PalliCare. The community-based palliative care provider is based in northeast Texas.

Changes in telehealth rules have been confusing and difficult for health care providers to navigate, particularly as prolific workforce shortages were exacerbated by the pandemic, Hughes indicated. Hospice and palliative care professionals are even more sparse, a growing concern among the nation’s swelling aging population.

Telehealth waivers allowed hospice and palliative care providers to serve more patients and improve clinical capacity not only across rural regions, but also nationwide, Hughes said. The issue isn’t only straining hospices, but also health care systems in rural regions. Scaling back regulations is challenging the ability to reach patients in a timely manner and avoid hospitalizations or emergency department visits, an issue that could result in increased staffing and health care costs, she noted.

“For those of us that are boots on the ground, there are not enough boots to go around. We need permanent telehealth rules passed!” Hughes told Hospice News in an email. “It truly impacts patient care and makes health care provider burnout even worse! The patients affected are the sickest of the sick patients who can’t or won’t go to a doctor’s office for care. It is not just a rural population problem; it is a seriously ill patient population problem.”

Calling for permanent resolution

Calls have grown louder among hospices, lawmakers and industry stakeholders to make the telehealth waivers permanent. Several legislative efforts have been made in this regard, though no bills have passed into federal law to date.

An increasing volume of recent research has found that telehealth utilization has been associated with improved quality of life, patient satisfaction and symptom management. However, geographic and regulatory barriers pose hurdles to further evaluation of telehealth’s efficacy.

The regulatory changes come at a time when CMS has focused on improved rural health care access and quality. The agency recently introduced a new $50 billion federal program designed to build more sustainable rural health care systems and improve outcomes.

“We were hoping that a permanent extension of some kind would be granted,” Adair Reed said. “One of the major concerns is it just seems like there’s a misalignment in CMS’ initiatives to reach rural and tribal communities. This lapse in telehealth waivers undermines a broader initiative to improve health care disparities in these areas. It just doesn’t make sense.”

Support for making the flexibilities permanent is bipartisan, but the recent federal government shutdown may stymie any progress, said Kyle Zebley, senior vice president of public policy at American Telemedicine Association (ATA) and executive director of ATA Action.

The expiration of telehealth flexibility creates a bigger barrier and “digital divide” for hospices that are losing access to underserved rural patient populations, Zebley said. Additionally, expanded virtual health care utilization allowed hospices to hone services that reach a more culturally diverse community.

Equitable access to quality end-of-life care will diminish in the near future without permanent telehealth regulatory action, according to Zebley.

“Unfortunately, we’re in a position of dysfunction and impasse during the current shutdown,” Zebley told Hospice News. “Losing telehealth flexibility hurts every American that is eligible for Medicare and magnifies the workforce scarcity in rural and tribal communities. It’s losing billing pathways, discouraging outreach and cultural and language continuity suffers. Access to culturally concordant clinicians and interpreters that would uniquely benefit rural and tribal Americans is less available and this undermines trust.”