April 27, 2022

The Joint Legislative Committee on Access to Healthcare and Medicaid Expansion convened this week to discuss telehealth policies in North Carolina. Although this week’s meeting was the final one before the start of the legislative short session on May 18th, the committee will likely continue work later this summer or early fall to develop a Medicaid expansion plan and to propose other healthcare reforms for the legislature to consider.

The committee first heard from Naomi Lopez, Vice President of Healthcare Policy at the Goldwater Institute, who spoke on Arizona’s recent telehealth reform. Arizona’s telehealth policies focus on a patient-centered approach and is based on the idea that patients should have better options for medically appropriate care via telehealth. The new law requires providers to be reimbursed at no less than the rate for an in-person visit, unless the service is provided on the insurer’s telehealth platform. Lopez referred to the policy as a “parity light” approach, and pointed out many benefits of Arizona’s policy including increased access to specialty providers in rural areas and decreased costs. Telehealth policies drastically expanded during the pandemic due to various federal and state waivers, and Lopez warned of the “telehealth cliff” once the public health emergency ends and states revert back to pre-pandemic reimbursement policies – shutting the door on progress that has been made over the last two years.

Dr. Scott Rissmiller, Executive Vice President and Chief Physician Executive at Atrium Health presented on Atrium Health’s success with ramping up telehealth services during the pandemic. Dr. Rissmiller explained that increased use of telehealth was a silver lining of the pandemic, and that the state needs policies in place to stabilize reimbursement for these services moving forward to build on the progress made. Atrium providers have been able to provide telehealth services across a variety of service lines, reaching patients in rural and underserved areas across the state. Dr. Rissmiller highlighted several successful telehealth programs at Atrium, including Hospital at Home, School-Based Virtual Care, and Virtual Behavioral Health Integration. Patients saw improved health outcomes, fewer ED visits, and higher Patient Experience Scores.

The committee also received a presentation from Josh Archambault, Senior Fellow at the Cicero Institute and President of Presidents Lane Consulting, on telehealth best practices for a pro-patient and provider landscape. A recent report from the Cicero Institute rated the best states for telehealth and provided a toolkit to help policymakers take the next step toward a more quality-oriented, affordable, and innovative health system by ensuring that their state laws on telehealth remove deleterious barriers that have historically discriminated against those in certain geographies, such as those living in rural communities or in underserved urban areas. Archambault outlined best practices across state lines, including simple & quick registration for all, clean licensing and certification processes, clear pathways for discipline, a basic legal framework in place, and commonsense exemptions.

The report encourages states to:

  1. Support “Modality Neutral” Options – Allow all kinds of telehealth (i.e., live video, remote monitoring, or recorded messages) to be used to establish a patient-provider relationship, and on whatever device is
    best for the patient and provider.
  2. Support Access to Care – Allow all kinds of providers to utilize telehealth to allow for more team-based care and prohibit facility fees from being charged for services that can be delivered from anywhere.
  3. Support Provider Access to Telehealth – Allow across-state-line telehealth with a simple registration for those holding a license or registration in good standing to help with the continuation of care and increase access in rural communities.

The report said states should avoid:

  1. Arbitrarily Limiting Provider Tools – Requiring in-person visits before using telehealth or requiring certain technology methods (e.g., real-time video) when the clinical situation does not necessitate limits patient care.
  2. Mandating Coverage for Everything – Passing insurance coverage parity mandates that require paying for all services, since research has shown mixed outcomes for certain services over telehealth, can lead to wasteful spending. A mandate also inhibits innovation in care delivery.
  3. Mandating Payment Rates in Law – Passing a payment parity mandate that requires all telehealth visits to cost as much as an in-person visit hurts vulnerable patients as they pay more, and small businesses as large companies are not subject to these mandates.

Chris Evans, Vice President of Public Affairs at Blue Cross NC, provided the committee with an overview of Blue Cross NC’s view on telehealth policy mandates in North Carolina. For more than two decades, Blue Cross NC has covered telehealth for its members, including evaluations for common health concerns, behavioral health services, diabetic counseling, genetic counseling, inpatient/outpatient counseling, and provider-to-provider consultations when the member is present. At the start of the pandemic, Blue Cross NC began covered all services provided via telehealth at both coverage and payment parity.

Blue Cross NC warned that telehealth is evolving, with providers and patients still adapting and learning what services are effective through virtual mediums and how to value it, and that telehealth isn’t appropriate for all care. The presentation outlined barriers and challenges with telehealth, including quality of care, technology and broadband limitations, and outdated payment models – claiming that parity laws would take us back towards fee-for-service models that are no longer financially sustainable. Blue Cross NC has historically been opposed to a one-size-fits-all telehealth mandate for insurers. Evans argued that mandates force coverage of unwanted or clinically inappropriate services across the board, remove needed oversight of untested services without proper guardrails to ensure patient safety, slow innovation and reduce the impact in areas where it is needed the most, and put the cost burden on small businesses and families since state mandates apply only to fully-insured plans.

In closing, Evans offered the following comments for policymakers to consider:

  1. Address the rising cost of health care. High health care costs
    create a barrier to access, and cost impacts should always be top of mind.
  2. Consider the entire supply chain and the impacts of regulation/unintended consequences.
  3. Health care is more dynamic than ever – innovation and disruption are occurring at breakneck speed – government regulations get in the way.
  4. Two thirds of customers are small businesses, families, and individuals. These are the customers whose insurance is subject to the health care regulations you pass, not self-funded large employers which make up ~60% of the market. Increasing pressures on the fully insured population is causing hardships for individuals, families and small businesses.

Connie Wilson, Lobbyist for the North Carolina Orthopaedic Association, presented on the importance of telehealth licensure reciprocity. The use of telehealth increased dramatically as a result of the COVID-19 pandemic, and licensure reciprocity between states was a key component. With many executive orders across the country expiring, states are reverting back to pre-pandemic licensure regulations on telehealth. States like Florida and Texas have enacted telehealth licensure reciprocity legislation for out-of-state providers to offer telehealth services, and several proposed bills in the North Carolina General Assembly would offer the same benefits.

Wilson said the North Carolina Orthopaedic Association supports HB 868: Telehealth Licensure Reciprocity and SB 380: Interstate Medical Licensure Compact. HB 868 would create an avenue for out-of-state providers to provide telehealth services to patients in North Carolina. SB 380 develops a streamlined process to allow physicians to become licensed in multiple states participating in the Interstate Medical Licensure Compact. The process complements the existing licensing and regulatory authority of state medical boards to encourage medical license portability for providers to practice in North Carolina physically or via telehealth.

Switching gears from telehealth, the committee received a presentation from David Smith, Vice Chair of the Legislative Action Committee for the NC Association of Health Underwriters, on a Medicaid voucher program. Smith explained that Medicaid Expansion in North Carolina should target those who are not otherwise eligible for subsidized coverage through the Health Care Marketplace. States like Indiana and Arkansas have similar programs, where individuals and families purchase their own coverage through the Marketplace in lieu of expanding enrollment in the state’s Medicaid system. Those households earning less than 100% of the Federal Poverty Level would be given premium vouchers to buy the policy that best suits their family’s needs with very low out of pocket costs. If they earn 100-150% PFL or more, Marketplace options would cover most if not all of their premium costs with low out of pocket costs. Smith explained that expanding Medicaid by taking advantage of the Marketplace through a voucher program will maximize the existing premium subsidies within the ACA, and will teach those enrolled on the program to better shop for coverage.

The committee meeting concluded with a presentation from Heather Korbulic, Senior Policy and Strategy Lead at GetInsured, on state-based marketplaces. GetInsured currently runs state-based exchanges in seven states and is adding Georgia next year. A state-based health insurance exchange is an insurance marketplace where the state provides the technological infrastructure, the website, and the customer support for individuals to access financial assistance to purchase state-based plans. Korbulic explained that state-based marketplaces can increase cost savings, lower premium growth rates, encourage better control and access to state data for planning purposes, and allow for greater state autonomy and policy flexibility.