On August 4th, U.S. Senators Chris Murphy (D-CT) and Roy Blunt (R-MO) introduced Senate Bill 4421: the Temporary Reciprocity to Ensure Access to Treatment (TREAT) Act. As stated by Murphy’s and Blunt’s press releases, this bill “allows any health care practitioner or professional in good standing with a valid practitioners’ license to render services—including telehealth—anywhere for the duration of the COVID-19 pandemic.” This is the latest example of how the pandemic is going to have lasting permanent changes to the U.S. healthcare system.
Where is the current gap in care?
Prior to the pandemic, the provision of telehealth services across the healthcare continuum was limited. This was likely a result of telehealth services being reimbursed lower than the same service provided face-to-face as well as confusing rules and regulations. Some large medical centers had begun to support expansion of telehealth programs, however, there remained gaps in optimizing the use of telehealth. A big gap was in the rules and regulations that limited access to telehealth services, such as the fact that providers must be licensed in every state a patient is receiving telehealth services in, regardless of where that provider is practicing from.
Then the pandemic hit and we saw our healthcare system upended as we began to prepare for potential surges and spikes in cases. In the first months, primary care offices were unable to practice in the way that they always had. They were canceling appointments and patients did the same out of fear of risking themselves to an exposure. 98% of primary care offices saw a decrease in revenue and there was concern that many would close, further limiting access to care, especially for those that live in rural or medically underserved communities.
Recognizing the potential long-term negative therapeutic consequences as a result of lapses in care, which could have further economic ramifications, CMS passed emergency rules and waivers to better compensate providers for telehealth services. This resulted in a boom in the utilization of telehealth by patients across the country. Some larger practices reported that their weekly percentage of telehealth visits before and during the pandemic went from 0% to 8.2%. Experts have predicted that telehealth will remain a more substantial piece of the healthcare marketplace in a post-COVID world. We have already begun to see this becoming a reality with the signing of executive orders and proposed rules from CMS to make expansions allowed during the public health emergency (PHE) permanent (read more about these expansions and how they apply to pharmacists here).
Despite these expansions, there remain issues with the provision of telehealth services. One of the biggest issues identified is that it matters where the patient and professionals are physically located when providing services.
How will this bill fill this gap?
The TREAT Act does a few things that are notable and need to be discussed. Of course, the biggest is that it will allow for healthcare professionals to provide telehealth services to any patient as long as both of them are physically in the U.S. It specifically clarified that services can be provided regardless of if there is a prior relationship between the patient and the healthcare professional.
From the perspective that this will be able to increase access to care, there are a lot of positives to this bill. Instead of being limited to your geographical area, healthcare professionals would have the ability to provide care to patients across the country. This would be incredibly important, especially for those that live in rural or medically underserved areas that previously may have had to travel a long distance to receive healthcare and may have been limited to utilizing telehealth services only if there was a previously established relationship.
Another huge positive to this bill is not in what the bill does but in how the bill is written. Any health policy geek out there knows that when bills are typically written regarding what healthcare professionals can do, the term “healthcare professional” is often defined as referring back to the Social Security Act. We have already discussed that national provider status efforts essentially aim to add the pharmacist to this list of healthcare providers. What is different about the TREAT Act is that healthcare professional is broadly defined as an individual who “has a valid and unrestricted license or certification from, or is otherwise authorized by, a State, the District of Columbia, or a territory or possession of the United States, for any health profession, including mental health”. The all-encompassing language of how “healthcare professional” is defined means that this bill applies to pharmacists as well!
Where does this bill miss the mark?
Although there are positives to this bill, we have some logistical questions and are concerned with what is missing from the language. Despite the positives regarding access issues, what are the long-term hopes for the types of provider-patient relationships that may result from a completely virtual care experience? Will only acute services be offered that do not require an in-person physical examination? What if labs need to be drawn? A provider in Maine caring for a patient in Texas may not be familiar with local labs and the burden of those logistics may fall on the patient. If the patient is unable to solve such questions by themselves, this could result in providers making medical decisions without all the information they need. What if a referral is needed to be placed to a specialist? Providers often utilize their professional networks with local practitioners that they have referred to previously. This may be another logistical concern. Although these are some gaps, there would be plenty of opportunities for the private sector to step in to solve these issues through a lab/specialist referral interface. Although his bill would only be applicable during the current PHE, we have seen so many rules and laws planned to be expanded beyond the PHE and this could have the potential of doing the same if it ends up being signed into law. Long term solutions to these concerns should be addressed from the beginning of implementation.
Where else this bill misses the mark is in how it could impact the setting in which healthcare professionals practice. If bills such as the TREAT Act pass and telehealth continues to expand, some healthcare professionals may worry that their practice setting may resemble more of a call center rather than what they are traditionally used to. Although some healthcare professionals may not prefer this setting, healthcare businesses such as SinfoniaRx have embraced this model and use it to provide patient care to thousands across the country. Some healthcare professionals may not like the idea of practicing in a call center, but we should recognize that at the end of the day, we need to do what is in the best interest of the patient. If evidence supports that it means where we practice begins to change, then we should embrace what better helps our patients, not fight it because of personal preferences.
An obvious exclusion from this bill is any discussion on payment. This is likely because payment rules and executive orders for telehealth services are already in place and will likely remain in place following the lifting of the PHE. A gap remains for healthcare professionals that are included in the TREAT Act but are not listed under the Social Security Act (such as pharmacists), and thus still will not be able to directly bill for their services.
How can you advocate for or against this bill?
The TREAT Act has been referred to the Senate Committee on Health, Education, Labor, and Pensions. Currently the bill only has two cosponsors, but given the bipartisanship of those cosponsors, it has the potential to get some attention from other Senate members. At the time of the writing of this post, no pharmacy associations had come out in support or opposition of the bill, however, many other healthcare organizations had spoken out in support of it. Below is a selected list of supporters:
- American College of Physicians
- American Hospital Association
- American Medical Group Association
- Association of American Medical Colleges
- American Psychological Association
- Many of the Nation’s leading academic medical centers
- National Organization for Rare Disorders
Also, if you feel that the profession of pharmacy should take a stance on this bill, contact the elected leaders of the associations you are members of and ask for them to review the TREAT Act.