How Govt. Shutdown Affects Telemedicine

Mark Masselli (00:04)
Telemedicine took a big leap forward during the pandemic, but supporters say a lot is at risk if policymakers do
not act soon.

Kyle Zebley (00:12)
The stakes are enormous. we're talking about millions of Americans, through the Medicare program, having
access to telehealth services, or benefiting from, the Forward Reaching Visionary Program, the acute Hospital
Care at Home program, benefiting from these, items that will lose out. starting, just early tomorrow morning.

Margaret Flinter (00:37)
Our guest is Kyle Edley, the Senior Vice President of Public Policy for the American Telemedicine Association.

Kyle (00:44)
It's very clear that not everything can nor should be done, via telehealth. Is it one out of four healthcare
encounters, maybe on its way to one out of three or one out of two in the next few, years to decades?
Absolutely. I think that absolutely could be the case.

Margaret (01:02)
This is Conversations on Healthcare.

Mark (01:14)
Well, Kyle, welcome to Conversations on Healthcare.

Kyle (01:18)
Great. Thanks so much. It's an honor to be here. Really appreciate you asking me to come on and talk with you.

Mark (01:23)
Well, we have so much to talk about with you, and lots is happening in Washington, but I think before we get
there, maybe you could give our listeners an overview of the American Telemedicine Associate. What are your
goals and who do you represent?

Kyle (01:37)
Absolutely. Well, the American Telemedicine Association, ATA, has been around since 1993. we're an
association of organizations at the end of the day, over 400 organizations that represent the width and breadth of
the healthcare system. That includes healthcare systems, hospital systems, academic medical centers, virtual
only providers, commercial insurance payers. We've got pharmaceutical manufacturers, medical device
manufacturers, advisory firms, law firms, and just about everything else you can think of in between. So, very
big tent, broad based membership. At the end of the day, what we're trying to do is, is make healthcare better
through the use of technology, to break down geographic barriers to care, to make the most of what technology
can do now in the 21st century in terms of making sure people can live longer, better, healthier lives.

Margaret (02:32)
Well, Kyle, that's, pretty interesting that you go back to 1993 because I think for a lot of people in this country,
telemedicine began with the COVID Pandemic in 2020 and, and everything has happened in the past five years.
So we're looking forward to hearing more about all of this. I wanna ask you another question first. I know that
you have a, or ATA has a “principles of practice”, “telehealth as an imperative” modality of care. Tell us about
the key points our audience should know about that.

Kyle (03:01)
Well, most importantly, what really underpins the viability, of telehealth and virtual care and digital health is
this whole, concept that it has to be clinically appropriate in its use. It has to meet the standard of care as
determined by a licensed medical professional. That I think is a really critical component. We have to make sure
that the public trusts that the care they're receiving is high quality and it has to be appropriate. Therefore, we
really want to apply very well understood, really, time honored practices, in terms of empowering licensed
medical professionals to deliver that care through the use of technology more than anything else, I think that's
the most important principle of practice, that we are asking policymakers. We're asking, both the federal
government and the state government to allow for our healthcare professionals to really use their best judgment
through the use of technology and delivering care to patients.

Mark (04:15)
You know, Kyle, we're talking to you here on September 30th. it's sort of D-Day, across the country as people
wait, what's gonna happen in, with, budget, and, whether or not there can be some compromise, to continue the
budget, for some period of time. But you have an urgent deadline, right? The Medicare Telehealth flexibility
and Acute Hospital Care at Home program expires, today, which is, something that I'm sure your organization is
very focused in on. What, what are the implications of this is not, continued?

Kyle (04:57)
Well, no pressure Mark. certainly, you laid out the stakes quite well. right now we are, oh, about 14, 15 hours
away from the expiration of those Medicare telehealth flexibilities, and the acute hospital care at home program
items that have been in place at the federal level since, the beginning of the decade since, before really the
COVID-19 pandemic hit the United States in a major way early in 2020, these flexibilities, the acute hospital
care at home program were put in place by President Trump, have been kept in place, ever since the beginning
of the pandemic on a bipartisan basis through the Biden Harris administration have already been renewed once
by President Trump and his second stint in office. we are deeply concerned that, even though we're not a
spending provision, we have been attached to spending bills, that we are gonna lapse for that first time since the
onset of the pandemic. The stakes are enormous. we're talking about millions of Americans, through the
Medicare program, having access to telehealth services, or benefiting from, the Forward Reaching Visionary
Program, the acute Hospital Care at home program, benefiting from these, items that will lose out, starting, just
early tomorrow morning, right around 12:01 AM and thereafter, it's a tremendous setback for our community.
It's all the more disappointing because these are popular bipartisan provisions. I think it is an, unfortunately,
emblematic of the dysfunction that we've seen, in Washington DC now, for many years running, as I often have
said, it's everybody's fault. It's nobody's fault, right? these are really good men and women, we're honored, and,
and don't take for granted the fact that our, our program's priorities are bipartisan and popular. but if we, in
particular in this rarefied space of clear agreement, are in a position where we're only hours away from
expiration, something is deeply wrong with how Congress and, and the federal government operate. And it's a
real shame. And I say that as somebody that's, you know, been in Washington DC and always been honored to
do so, for 16 years. But it's a real shame that it's come to this. But we're not…

Mark (07:32)
You said earlier, though, that President Trump, I think in January, did an extension of, of this act. Does CMS
have any abilities, if Congress shuts down, can CMS on its own extend this or continue payments and the like?

Kyle (07:49)
That's a great question. we believe based on interpretation of statute and law, that CMSs hands are tied barring
congressional action, that gets a bill to the President's desk. That being said, there are fantastic, smart, capable,
creative men and women at, HHS and at the Centers for Medicare Medicaid Services that, might have
something up their sleeve. I don't know if that's the case. and we will certainly, probably have to find out now
because, I don't see a way out of this likely impending shutdown. but we'll see what, what those, those smart
folks, are, are thinking.

Margaret (08:34)
Well, Kyle, it's, it's always interesting to, make it real for people. I think, of everything that we've mentioned,
the acute care hospital home is probably very familiar to those who've experienced it directly and totally not on
the radar of those who have not. That's, to use a bad analogy, you can't just flip the switch on something like
that, you know, that is lifesaving if that is really being used, at home. And on the other side, perhaps of the
spectrum are what we're seeing around behavioral health and psychiatric services. there's been an exception for
behavioral health to continue with telemedicine, but psychiatry may be in more of a gray zone because it's
medical as well. I wonder if you could tackle maybe those two things, how your membership and your
leadership in your organization working with your members is, is really thinking about how to protect really the
health of people who've come to rely on telemedicine and telehealth.

Kyle (09:32)
Well, it is devastating, what, what we, expect to occur, and we're gonna do our best to mitigate the
extraordinarily negative impact and precedent, that is about to transpire in terms of the Acute Hospital Care at
Home program, unfortunately, we already have guidance from the Office of Management and Budget, to let
folks know to, disenroll and bring back into physical hospitals. Any individual patient that is benefiting from the
acute Hospital Care at home program now that allows them to, leave the hospital free up that hospital bed,
increase capacity and go back home where they want to, through the use of technology and hybrid care, to, to
continue their convalescence at home, that'll end, in just a few hours, unless Congress, does something before

then in terms of Telemental Health, you are right at the end of 2020. Telemental Health was made a permanent
part of Medicare program. It unfortunately, became encumbered with a mandatory ongoing in-person
requirement that we've, never seen implemented. We want it to be repealed. It's a bad precedent, and it will take
effect, if, if Congress doesn't extend these waivers again. but for those patients that have already established
provider patient relationships via telehealth prior to, the end of today, they'll be able to continue to have those
services reimbursed in terms of the technicalities between psychiatrists and psychologists. We're in an uncharted
area. We'll see what kind of regulatory interpretation and guidance that CMS puts out. Our hope is, of course,
they'll maximize their flexibility when it's a, it's a regulatory gray zone and air on the side of continuing to allow
for patients to receive clinically appropriate care in a reimbursable way.

Mark (11:30)
You know, Margaret, we see in our practice, the value of telehealth, telemedicine. but I'm wondering if you
could Kyle, frame up for our listeners the cost benefit, of telemedicine so that they can get a good sense of it.
And it really reaches beyond the simple things that we think about, goes all the way over to just saving people,
driving time and the environmental impact that it has. But walk, walk through what you've learned so far, and
what research maybe you've all done, to, to lay, bear, the value of these, services.

Kyle (12:12)
Yeah, and, and, and I'll just say, as I had mentioned, a few minutes ago, all of the benefits that we can talk about
would be kind of null and void if, if licensed medical professionals, professional societies, and, and an enormous
amount of academic research didn't prove the point, that telehealth is clinically appropriate in a whole host of
circumstances, and that digital health technology can underpin successful care treatment plans. If that wasn't so,
all of the other benefits wouldn't be worth anything. But luckily, our licensed medical professionals from across
the country are resoundingly overwhelmingly, essentially unanimously saying that high quality care can be
delivered via the, via, via the use of telehealth to break down geographic barriers to care. But what are some of
these other benefits? Well, patients like to receive it, in this manner for a whole host of circumstances. it's really
important for them to receive care in their home that works better with their schedule. It avoids them fighting,
you know, to, to go across the state, go across the city. regardless of whether or not they're in rural America,
suburban America, urban America, all Americans stand to benefit from the ease of use, of, of telehealth. And
while telehealth in and of itself cannot increase whole cart, the, the, the supply of healthcare professionals, what
it obviously can do is better meet the supply with the demand. we have too few healthcare professionals. We've
got a, a great burnout, that we're still reeling from, in the healthcare community of so many folks that have left
voluntarily the healthcare force. We've got the demographic trends of, the baby boomer generation increasingly
retiring out of the healthcare workforce. We just don't have enough healthcare professionals in the pipeline. And
so you can't solve this capacity problem of too many Americans, too many patients needing too much care for
many ongoing chronic conditions, for instance, without maximizing use of telehealth to increase the, the
available, supply. Given this huge demand, telehealth can help do that. It can break down these geographic
barriers and, and really right-size, some of these demand factors. These are some of the primary benefits. you
know, the healthcare system, I think it's fair to say, has not served the American people well in a whole host of
areas. We don't get value for money in terms of the percentage of our GDP that we pay as compared to our peers
in other developed nations. telehealth is a clear way that it can help address some of these systemic issues that
have left too many populations behind. That's not gonna solve all of our problems. But you can't solve these
problems in healthcare without the use of technology.

Margaret (15:09)
Well, Kyle, we've talked quite a bit about food as medicine, on our program, and certainly this is something that,
many of the academies of the clinical disciplines are looking at. And I was very interested to see, it might not
have been as obvious to me, right away, that, telemedicine has an interest in this as well. So tell us about, I
think, what you've termed virtual food care and also the Enhanced Medical Nutrition Therapy Act.

Kyle (15:37)
Absolutely, and it's a great point. What is somebody that's talking, about all the things that can be done virtually
through the use of, of telehealth and technology? What, what am I doing talking about virtual food care? what
we did is, of course, if we consider telehealth as part of the healthcare system, and then we examine ways that it
can improve healthcare for Americans across the range of varied needs. and we agree of course, that food is
medicine, and that in order to, live healthier lives through preventative care or to mitigate ongoing challenges of
chronic diseases, you need a healthy, balanced diet. We did think that there was a lot there that we could make a
difference on through the advocacy work that we do in ATA action. So we have endorsed a variety, of policy
principles and policy priorities that really are all about meeting two sides of this, this series of opportunities and
challenges, that virtual food care presents. One is in terms of our food support programs, that are there like

SNAP and WIC, to meet the needs of underserved communities, impoverished Americans, we believe there
needs to be online access points for it. We believe that there needs to be home delivery of medically nutritious
meals, so that they're not going towards cheaper, options that are, calorie rich, nutrition poor, in terms of their,
their food that they're receiving. So that's one component of it. And the other component is to make sure all
payers are covering for nutrition, guidance, nutrition, treatment, nutritionists, dieticians, that can help really
empower the individual patient regardless of where they live, regardless of their socioeconomic background.
Empower them with the skills they need to make the right choices for themselves. this is the right thing to do in
terms of making sure these, the, the everyday Americans are living healthier, longer, happier lives like we've
been talking about. But it's also the right thing, to do if you're just looking at it from a, a pure pragmatic
perspective as a policymaker, how are we gonna save the healthcare system money? How are we going to
increase productivity? and one of the best ways to do that, of course, is empowering folks to make the right
choice for themselves, and preventative care in treating their own ongoing chronic conditions.

Mark (18:09)
I'm thinking about, saving the healthcare system money and wanted to talk maybe a little bit about the
regulatory barriers that exist there, maybe at the state level as well. We had Dr. Mitch Katz on, who heads up the
New York Health and Hospital system recently. He was talking about all the challenges. and I think you were
alluding to this before. We have a lot of people retiring. We need to grab providers from all across the country,
and yet there are many at the state level, regulatory barriers for licensure. is your association looking at those
issues as well? And is, is there anything on the horizon that might give some relief?

Kyle (18:51)
Well, and, and, and Mark and Margaret, you know, this extremely well. while federal policy issues, might, you
know, take up most of the, the headline space, and ma might make the most, in terms of, being attention seeking
from the average, observer of healthcare and, and, and do we even led talking about the impact of, major federal
policies right at the beginning of the conversation? Don't sleep on safe governments. the United States is very
unique as compared to other developed nations. We're highly federalized in the way that, healthcare and the
practice of medicine have developed over the course of the last century and a half or so. and, we essentially have
50 different, state governments, the District of Columbia territories, that have tremendous authority to determine
all types of issues, so important to the delivery of healthcare. And if you think about telehealth and its ability to
break down geographic barriers, the ability of, for instance, a Florida provider to deliver clinically appropriate
care to an Alaska patient, it really becomes a potential major impediment to the successful ability to deploy,
healthcare across state lines around the United States. A licensure is one of the very biggest issues. You are not
licensed federally in the United States. You are licensed on a state-by-state basis across the healthcare
professional classes. And, some states, make it very, very difficult for you to operate within their borders, and
deliver care to their patients, without going through a lot of hoops. and, and most importantly, for kind of legal
precedent purposes in, in terms of the delivery of telehealth, and almost every circumstance, you've gotta be a
license. And in good standing in the state in which the patient is located, providers would love it if it was only
the state where they were physically located, but that's not how it works. And so there are lots of different ways
to break down those, geographic barriers to care. There are licensure compacts, including a physician's compact,
nurses compact, many other healthcare professionals have their own compacts. that, that kind of tries to
hopefully make it easier. Not all of those compacts are created equal. some, do some handholding and make it
easier to go through all the re regulatory requirements. but, you know, it's better than nothing, but not a lot better
than that, in my opinion. And I say that to all of our friends that are supportive of the interstate medical licensure
compact. The gold standard is the nurse's compact, which is a driver's license model. You 40 states and
territories have adopted the nurse's compact. You're good to go as a nurse to deliver care in any of those 40
states. If you are, registered and licensed in one of those, 40 states and territories. There is a role for the federal
government to play here. they can encourage states and have done that in a whole host of circumstances in
healthcare and beyond. and we're actually right now working with our ATA policy council to try to come up
with some new original ways to get the federal government involved in some commonsense areas that would
offer some exceptions to the strict enforcement of state-based licensure. So more to come there, and I'm very
excited to continue this work and make progress here.

Margaret (22:08)
Well, that's great. And, Kyle, I wanna, let's sort of, tip this a little bit and say, we've been talking about, many of
the benefits that people see to telemedicine, and of course, there's always a countervailing position on the part
of, some folks, and I know, there have been questions raised about, the limitations, right? The limitations of,
perhaps the physical exam. Although there's technology, you know, for some of that devices like TAL Care and
the like, but in diagnosing complex, cases, maybe, on the heavy reliance that's inherent, in self-reporting, of the
patient of their, conditions. How, how do you respond? And I would imagine there's a research agenda within,

the association and, and within the professions that's always looking at these factors. What, what are you
learning and how would you respond?

Kyle (23:00)
Well, a couple of things. One is we embrace and welcome, academically sound, and rich and diverse research.
and, and any community and industry that doesn't open itself up to such research, you know, it would seemingly
have something to hide. We have nothing to hide. We welcome it. I think that the research has overwhelmingly
been in the favor of increasing access to care and overwhelmingly underpin the idea that we haven't taken full
advantage enough of the use of technology to do all these wonderful things that we've been talking about today.
That being said, and as far as we've come in the year 2025, and a whole host of things, that can be done via
telehealth, it's very clear that not everything can nor should be done, via telehealth. Is it one out of four
healthcare encounters, maybe on its way to one outta three or one out of two in the next few, years to decades?
Absolutely. I think that absolutely could be the case. However, for the foreseeable future, for the rest of my
lifetime and the rest of the lifetime, and probably everybody I know, there's going to be a need for our
healthcare professionals to lay hands on patients at some point during the care Jo journey that every person takes
through their life. nobody questions that, nobody doubts that. It's really all about what's the right mix to do, and
what's the right mix to consider. And, I think, again, we're only starting to tap the potential of all the various
services and modalities and technologies, that telehealth and virtual care, digital health, will allow us to do. And
we haven't even touched upon, what AI in healthcare is going to mean for us, as human beings in this unique
moment in time where there's a galloping leap forward in terms of all the things that we can finally do, for
instance, with the massive amounts of data that can be produced for individual patients, that's gonna lead to
more bespoke and individualized care. But even with all these advancements, we still need to have a robust
healthcare system that has capacity and has capabilities and the knowledge and the understanding and the
workforce to deliver care in person. And no advocate of telehealth should pretend otherwise.

Mark (25:23)
Yeah. And, and yet we know that telehealth is a force multiplier. One of the programs that we operate is con
confirm med, which provides e-consult, support to primary care providers with a couple hundred specialists in
the background, really helps them focus their attention, on the patient in front of them. So often the data has
shown that they send a referral to a specialist, the patient can't come, or the specialist when they get there say,
oh my God, you should have done these simple tests. So we've seen the value, but not everybody sees the value
in telehealth. And I would really go to the insurance industry opposes, mandated parody, which requires
telehealth to be reimbursed at the same rates as in-person visits. Talk to us a little bit about what's happening
there and the, the work that you're doing to try to, have people understand the value proposition, particularly,
our colleagues in the insurance world.

Kyle (26:19)
Well, we, we love our colleagues in the insurance world, and, and they are part of the, the big tent of the, ATA
and they were deploying telehealth, and, and allowing for it to be covered and reimbursed in a much more
flexible dynamic way than frankly. For instance, Medicare fee for service was prior to the onset of the
pandemic, so we should give them their due. And they've also massively increased the degree to which they're
covering and reimbursing for telehealth services. Of course, since the last few years, post pandemic, it might
surprise you, but maybe not because of what I just laid out. We're not saying that we are all in on pay parody.
what we have said is that we're coverage, parody and fair reimbursement. And what, what we mean by that is
we, we really need and want our payers to be robustly covering telehealth services. And in terms of pay, it must
be reasonable enough to have the, incentive in place for our providers to use, these services and do it virtually,
or else we're gonna have, this robust sector atrophy, and it won't be to anybody's benefit. And we won't see, in
particular, the, the ability to increase capacity in the healthcare system, take hold. there are about 25 of R 50
states that have adopted, varieties of pay parity measures at the state level, that have forced commercial payers
to reimburse at the same rate. By all accounts, there has not been an enormous disparity in the quality or
quantity of care delivered in states that have pay parity laws versus those states that do not for what that is
worth. but it's a huge issue. Many of our members are for pay parity. They want to have that inducement to use
telehealth. Other members, including virtual only providers, want to have a competitive advantage, against,
against some of their peers and want market forces to, allow them to win out in terms of arrangements with
payers or healthcare systems, through more competitive pricing. So it's a, it is actually more of a, a controversial
issue than you might assume, for the ATA to wade into and take a position on.

Margaret (28:38)

Well, speaking of current and, and controversial issues, in the public domain, certainly ongoing legal and
political debates over the use of telemedicine for abortion services across state lines. Does the association take a
position on this? Can you share what that position is?

Kyle (28:56)
Yeah, so, we believe that you must abide by the laws of the state in which the patient's located. and, that's really
important in this dynamic because states need to trust each other to hold each other account if something goes
awry on behalf of the patient. That gets very tricky, of course, with this issue, we don't second guess or weigh
into individual medical treatments. but we do need to ensure that the good forward positive momentum that's in
red states and blue states, and across, you know, political parties, both Republican and Democratic at the federal
level, we need to make sure that positive momentum for telehealth and breaking down these geographic barriers
to care, breaking down these boundaries continues unabated. And despite what, you know, some of us had
feared post the overturn of Roe v Wade, that there would be a total collapse in interstate trust, that hasn't come
to pass. And I think it's for good solid, reasons, and it's because of, advocates, like the ATA and ATA action or
advocacy arm trying to, be as reasonable as possible to keep the momentum ongoing.

Mark (30:15)
Well, Kyle, we wanna thank you for joining us. I think we could, stay here for another half an hour.

Margaret (30:18)
Exactly.

Mark (30:19)
This is a fascinating conversation, and thank you to our audience for being here. Just a reminder to be sure to
subscribe to our videos on YouTube and find us on Facebook and X. You can also share your thoughts and
comments about this program. Take care and be well. Thank you again, Kyle.

Margaret (30:39)
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