Recent Growth

To understand telemedicine’s growth, its pre- and post-pandemic use, and how it impacted doctors and patients, we need to understand what it constitutes. Telemedicine is the practice of medicine via remote online meetings, either through phone calls or video chats, that allow patients to connect with doctors without needing in-person visits. Telemedicine services can be synchronous, asynchronous, or through remote monitoring. Telehealth Systems.

Telemedicine’s growth remained quiet until March 6th, 2020, when the COVID-19 pandemic began and the US Congress passed many telemedicine bills to limit  in-person meetings between doctors and patients to control the spread of the disease. While telemedicine had been gradually growing before March 2020, its integration into common hospital practices was rare. Oftentimes, patients or providers who desired to use it faced deficient reimbursement for services, problems with location, issues with the type of method for communication, and costly privacy regulations. Telemedicine providers were also limited from offering their services to patients in other states due to interstate licensing restrictions, prescription rules, and the types of patients that were or were not eligible for telemedicine. However, the spread of COVID-19 removed many of the obstacles to telemedicine as most people were quarantined in their homes. In March 2020, Congress passed the CARES Act, which permitted telemedicine to be conducted from any site, for physicians to conduct telemedicine from home and provide their services to patients in different states, allow for audio-visual or audio-only meetings, expand the number of approved platforms, and reimburse all telemedicine meetings as if they were performed in-person. As a result, according to a study done by the National Center for Biotechnology Information, telemedicine encounters increased 766% in the initial 3 months of the pandemic, going from 0.3% of interactions from March to June 2019 to 23.6% of interactions in the same months of 2020. The State of Telehealth Before and After the COVID-19 Pandemic.

Medicaid and Medicare—the government’s health insurance programs – also had a dramatic increase in the use of telehealth. Government Accountability Office's analysis of Centers for Medicare & Medicaid Services (CMS) data in Arizona, California, Maine, Mississippi, and Missouri, reported changes in telehealth use among Medicaid beneficiaries and found that the number of telehealth services in those states increased dramatically—15x the pre-pandemic level. Beginning March 2020 to February 2021, 32.5 million services were delivered via telehealth to about 4.9 million beneficiaries in the selected states, in contrast with 2.1 million services delivered to around 455,000 beneficiaries in the 12 months before the pandemic. In a report, the GAO also found that the use of telehealth in Medicare increased from about 5 million services in 2019 to about 53 million services in 2020. Telehealth in the Pandemic—How Has It Changed Health Care Delivery in Medicaid and Medicare?.

As for the healthcare workers during the pandemic, even though many studies describe problems related to stress and anxiety due to the consequences of national lockdowns that promoted remote work, Consequences of COVID-19 on Employees in Remote Working: Challenges, Risks and Opportunities An Evidence-Based Literature Review, interviews conducted by the National Center for Biotechnology Information of primary care physicians from July to August 2020 analyzing their thoughts on working remotely during the pandemic,found many benefits for both patients and physicians: patients could receive safe care, remote visits were more convenient and comfortable for patients, physicians were equally paid for telemedicine meetings, and telemedicine promoted the physician’s work-life balance. Doctoring from home: Physicians’ perspectives on the advantages of remote care delivery during the COVID-19 pandemic.

According to research by the Doximity online medical networking service, 20% of all US healthcare meetings in 2020 were conducted through telemedicine, and the number of health workers practicing telemedicine as an active skill doubled in 2020, from 20% to approximately 40%. State of Telemedicine Report: Examining Patient Perspectives and Physician Adoption of Telemedicine Since the COVID-19 Pandemic. Nowadays, telemedicine use has greatly increased and is used mostly by doctors treating patients with chronic diseases who require constant monitoring, which can be done through video calls. Telemedicine is also coming to be seen as a relief valve for physician shortages, specialty care, and service to rural communities. Telemedicine: Filling In The Hospital Care Gap In America.

However, while the use of telemedicine appointments increased during the pandemic and solved the medical requirements of millions of people, there are many concerns surrounding the quality of healthcare patients receive, the lack of sufficient patient data for continuous care, privacy concerns, difficulty to provide effective physical therapy, and whether telemedicine services are truly accessible to everyone. 7 Telemedicine Concerns and How to Overcome Them.

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Case Studies

In the post-COVID era,, the government was at the forefront of preventative measures by passing large-scale policies in an attempt to curb the spread of the pandemic. Specifically, a raft of measures, including Medicare Part B, Medicaid, and CHIPs were either implemented or revised. Looking at the successes and failures of these preventative measures can be instrumental in gaining an understanding of telehealth during COVID-19. 

Established in 1965, Medicare Part B covers outpatient services, medical care not covered by Medicare Part A, and primarily focuses on office visits, consultations, mental health services, chronic disease management, and remote patient monitoring. Prior to the Covid-19 pandemic, strict rules required patients to visit approved healthcare facilities for care. However, these restrictions were relaxed significantly during the COVID-19 pandemic to address overburdened staff and healthcare systems. 

Successes:

Improved Access: Patients could access telehealth services from home, eliminating the need for travel to healthcare facilities. This was crucial for vulnerable populations who needed to avoid COVID-19 exposure.

Broader Coverage: Telehealth services were expanded to include primary care, routine visits, mental health services, and preventive care, such as cancer and cardiovascular screenings, physical therapy, and rehabilitation.

Relaxed Geographic Restrictions: Temporary removal of the requirement for patients to reside in rural or underserved areas to qualify for telehealth services allowed urban and suburban populations to benefit, easing the burden on families with limited access to healthcare facilities and specialists.

According to the National Institutes of Health, this program benefited nearly 80 million families in the U.S., with a 500% increase in telehealth visits during the pandemic compared to pre-pandemic numbers.

Failures:

Inconsistent Reimbursement Policies: Many states did not offer payment parity, meaning telehealth services were reimbursed at lower rates than in-person care. This reduced financial incentives for healthcare providers to offer telehealth services as compensation did not cover the cost of virtual care.

Privacy Concerns: Telemedicine raised significant privacy issues, especially when handling sensitive health information via digital platforms. Data breaches or unauthorized access can compromise patient confidentiality, making compliance with privacy regulations like HIPAA a challenge for both providers and technology platforms.

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Children’s Health Insurance Program (CHIP)

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CHIP provides healthcare coverage to children in low-income families, which has become an essential component in expanding access to pediatric care in recent years.

Successes: 

Improving Access: In states like Montana and North Dakota with vast rural populations, pediatric care has expanded through increased investments and improvements in telehealth infrastructure, which effectively facilitate remote health checkups. This swift adoption, fueled by the COVID-19 pandemic, allowed for the implementation of rapid emergency telehealth policies that benefit millions of families in these regions. 

Health Equity and Focus: States like New Mexico and Alaska have used telehealth emergency protocols to specifically  reach minority and indigenous populations, allowing pediatric patients within these communities to attain quality care. 

Failures:

Waiting Periods: Due to large numbers of applicants, children were left uninsured for longer periods of time due to lock outs in some states, such as in West Virginia and Mississippi. Higher cost-sharing requirements, through the CHIP program,  have also  diminished access to healthcare.

Limited Technological Access: In states with high applications, technological literacy of families has been the primary issue. Many low-income households lack access to the necessary devices or the technical knowledge to effectively engage with telehealth platforms.

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Telehealth in Private Networks: Companies and State Successes

Private companies have played a critical role in the expansion of telemedicine, especially through their partnerships with Medicare Advantage plans, Medicaid, and large healthcare providers. Telehealth platforms like Teladoc, Amwell, and MDLIVE have seen variable success depending on state infrastructure, healthcare policy, and demographic needs.

Successes:

Teladoc in Florida and Pennsylvania: Teladoc has emerged as a leader in states with high Medicare enrollments, such as in Florida and Pennsylvania. Telemedicine is impactful and, thus, heavily demanded in these regions with a large elderly population who require telehealth options. 

Amwell in California and New York: Amwell has found success in states like California and New York, whose environment is defined by stringent regulatory requirements for telehealth implementation and robust broadband access. 

MDLIVE in Texas: MDLIVE expanded in Texas during the COVID-19 pandemic by partnering with major insurers and employers to provide non-emergency telemedicine services. Its success is due to its ability to serve both urban and rural populations with flexible healthcare solutions.

Failures:

Inconsistent Reimbursement Policies: In states like Alabama and South Dakota, inconsistent telehealth reimbursement policies, where virtual care is reimbursed at lower rates than in-person visits, have hindered widespread adoption. This disparity reduces financial incentives for both providers and patients, making it difficult for telemedicine services to grow.

Patient Reluctance and Technological Barriers: In states with robust infrastructure like Arizona and Ohio, patient reluctance, especially among older adults, has slowed telehealth adoption. Cultural preferences for traditional care and challenges in using telemedicine platforms have limited the reach of virtual healthcare services despite available resources.

Current Challenges

Telemedicine has advanced in recent years, offering new opportunities for care through digital platforms. However, its rapid expansion also brings to light several critical challenges. Understanding these difficulties is essential for improving the quality, delivery, and accessibility of telehealth services.

First, location-based and monetary factors contribute to the problems in telemedicine availability. Urban areas benefit from a higher rate of telemedicine coverage, with 40.2% of urban residents utilizing these services, whereas rural regions face a significant gap, with only 29.7% having access. This dissimilarity results from differences in technological proficiency. Metropolitan areas inherently have faster internet because investing in high-speed infrastructure is more economically necessary, coupled with higher competition among service providers. Socioeconomic status further exacerbates these struggles as low-income individuals are more likely to encounter barriers, such as inadequate internet access and the inability to afford necessary devices. Unfortunately, 18%—nearly 1 in 5 people living below the poverty line—cannot afford the cost of the internet, let alone a device for making phone calls. The combined effect of poor infrastructure and financial constraints hinders the outreach of digital health services.

The requirement for telehealth providers to be licensed in the state where their patients are located, which affects 30 states, also introduces notable inefficiencies. Furthermore, state-specific licensing necessities force providers to manage multiple licenses, increasing operational costs and burden. Costs of obtaining and maintaining these licenses vary significantly, from as low as $35 or as high as $1425 in Nevada, making it financially onerous to some. Additionally, managing licensure in different states involves fervent ongoing commitment. Each state imposes its own distinct set of fees, requirements, and procedural nuances. Therefore, navigating the array of regulations, which often include varying application processes, renewal timelines, and continuing education mandates, is time consuming. High expenses and intense regulatory demands can further disincentivize providers from acquiring licenses in multiple states, leading to a reduced number of telehealth professionals and an inability to meet growing demand. Consequently, the current system thus limits the accessibility and growth of telehealth services.

In this context, quality of care in telemedicine presents a mixed picture when compared to traditional in-person visits. According to a questionnaire completed by 1,226 participants, 71% favored in-person visits, whereas 29% preferred telemedicine. This data suggests that while telemedicine is a valuable alternative, it has not yet achieved the same level of satisfaction and perceived quality as in-office care. This gap is particularly noticeable in specialties that rely heavily on detailed physical assessments including orthopedics, neurology, and cardiology. Such restrictions make remote evaluations less efficient and accurate for health care providers. Moreover, telemedicine presents obstacles in emergency and urgent care situations. The potential for delays in delivering critical treatments via calls raises concerns about its productivity in promptly addressing pressing medical needs.  

Concerns surrounding privacy and security have also proved to be  genuine worries in telecare. 70% of healthcare security professionals have experienced cyberattack incidents, with phishing attacks leading at 57%, followed by credential harvesting at 21%, ransom and malware at 20% each, and other issues like thrift, web attacks, and insider activity. Ensuring that patient information remains confidential is necessary, but breaches and data leaks have severe repercussions for both individuals and healthcare organizations. Growing sophistication of cyber-attacks means that telemedicine systems must continuously adapt to safeguard against threats.

As telemedicine becomes more deeply integrated into America’s healthcare system, acknowledging its limitations is crucial. Geographic and socioeconomic disparities, inconsistent quality of care, and privacy concerns all require targeted solutions.  

Current Policy and Initiatives

The emergence of telehealth has significantly changed the delivery of healthcare, especially following the COVID-19 pandemic. Numerous policies have been enacted at both state and federal levels to facilitate and govern telehealth services, resulting in their broader incorporation into the healthcare system.

The COVID-19 pandemic prompted an immediate need to keep healthcare services available while minimizing the spread of the virus. In March 2020, the federal government declared a national emergency and employed several temporary measures to broaden access to telehealth. The Centers for Medicare & Medicaid Services (CMS) played a pivotal role in this effort by easing various restrictions associated with telehealth services. 

For instance, CMS allowed healthcare providers to deliver a broader array of services remotely, including routine check-ups, mental health counseling, and chronic disease management, which had traditionally required in-person visits. Furthermore, the agency authorized the use of audio-only telehealth visits, which proved essential for patients lacking access to video technology, thus widening the scope of telehealth service to those in rural and underserved areas.

In addition, CMS permitted providers to utilize non-HIPAA-compliant communication platforms including Zoom, Skype, and other conferencing tools. This decision was crucial in minimizing barriers to care, as it allowed healthcare professionals to connect with patients more easily. The flexibility granted by these changes aimed to encourage both patients and providers to engage in telehealth solutions without the usual administrative burdens.

Also, state-level regulations have evolved to assist telehealth services across state lines, especially during the pandemic. During the time, many states temporarily removed barriers that restricted healthcare providers from offering services beyond their home states. 

For instance, numerous states have adopted interstate compacts, such as the Interstate Medical Licensure Compact (IMLC) and the Nurse Licensure Compact (NLC). The IMLC simplifies the licensing procedure for physicians, allowing them to practice in various states through a single, streamlined application. In similar fashion, the NLC enables registered nurses and licensed practical nurses to work across state borders with just one multistate license. These advancements improve patient access to timely healthcare and address workforce shortages by permitting providers to reach a wider patient population without the hindrance of obtaining multiple licenses.  

Alongside state-level initiatives, private insurers have recognized the critical role of telehealth. Many states have introduced legislation that requires private insurance providers to cover telehealth services at rates equivalent to those of in-person visits. These telehealth parity laws aim to bridge gaps in healthcare access and motivate individuals to seek timely medical attention through virtual means. By mandating insurers to reimburse telehealth appointments comparably to traditional office visits, these laws foster equity in access to care and incentivize patients to utilize telehealth services without fear of higher costs. Consequently, insurance companies are more inclined to invest in the development and enhancement of telehealth capabilities, further promoting the growth of these services.

Future Policy

It is clear that telemedicine has a place in modern society because it was already on a slow, upward trajectory pre-pandemic. By 2018, 76% of American hospital systems used some form of telemedicine in a variety of medical fields including radiology, psychiatry, and cardiology. Due to COVID-19, the government removed several  telemedicine restrictions, causing telemedicine encounters to increase 766% in the first 3 months of the pandemic. Additionally, telemedicine encounters constituted 23.6% of all medical interactions from March to June 2020 compared to 0.3% of such interactions during that same period in 2019. Therefore, it is no surprise that most patients have viewed telemedicine favorably before, during, and after the pandemic. The reasons these patients have cited include: ease of use, low cost, better communication and no travel time. However, physicians were more likely to have divided opinions about telemedicine as 50% of doctors surveyed who used both telehealth and in-person visits felt that telemedicine was inferior to in-person visits. Physicians who were hesitant about using telemedicine altogether, expressed concerns about lack of training, inadequate reimbursement and accuracy of care.

As of now, the main issue of telemedicine is its accessibility. People of color, the elderly, the disabled, and those below the poverty line are the least likely to use telemedicine. For telemedicine to be widespread, there must be readily available digital literacy programs to ensure that users know how to operate the software and hardware required to access telemedicine. There is also the issue of data security and privacy.

Telehealth companies are aiming to address their shortcomings through the following:

• Patient Privacy: Physicians should advise patients to find a suitable private room for the telehealth sessions (e.g. for a video conference) and to use headsets to protect sensitive information. If that is not possible, the session should take place via chat or text. 
• Cybersecurity measures: Telehealth companies should invest in the appropriate cybersecurity measures to prevent hacking, data loss, and viruses. Patients should only access their appointment through a secure website which requires a secure password for all virtual sessions. Physicians should also verify the patient’s information prior to the beginning of the virtual appointment. Furthermore, devices on both sides of the telehealth session should remain updated with the appropriate antivirus software. Adequate encryption and privacy modes should be activated when using telemedicine while public Wi-Fi and commonly shared devices should be avoided.
• Training: Adequate training should be provided for medical staff to ensure that they are well-trained to fully meet a patient’s needs through telemedicine. Patients should also be required to watch short tutorial videos before their first telehealth session to ensure that they are well-prepared for the encounter. Finally, telehealth equipment and devices should be integrated in the organization’s security management plan and annual security risk assessment to protect against potential data breaches. 
• Reimbursement: Insurers’ coverage determinations for telehealth services should be checked when arranging visits to mitigate potential fraud or identity theft. At the beginning of each session, a patient’s name, address, government photo ID, and device location should be verified. The names and jobs of all participants of the telehealth session should also be documented and proper consent must be obtained. 

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   As the benefits of telehealth have become more and more clear, the American Medical Association has advocated for Congress to remove restrictions and expand  access to telehealth services. Examples of this bipartisan effort include:

• The Creating Opportunities Now for Necessary and Effective Care Technologies for Health Act (“CONNECT Act”) was introduced in the Senate in 2021. This act would permanently remove the geographic restrictions under Medicare, allowing patients to access mental telehealth services from their residence rather than an approved location. 
• H.R. 2903 (a companion bill to the CONNECT Act) amends the Social Security Act to expand access and reimbursement of telehealth service.

Due to the pandemic, the telehealth process has been demystified and examples of telehealth services that have been increasing in popularity include:

• Amwell: Formerly known as American Well, Amwell is a leading telehealth platform that supports individual providers, clinics, and even government agencies. It offers a wide range of specialties, including family medicine, psychiatry, pediatrics, and psychotherapy, providing on-demand services through video consultations. Amwell has been ranked highly in patient telehealth satisfaction and is recognized for its ease of use and flexible scheduling for providers and patients alike.
• MDLIVE: MDLIVE is an established telehealth service offering 24/7 access to healthcare providers via phone or video consultations. It focuses on urgent care, primary care, dermatology, and mental health services. MDLIVE is known for its convenience and accessibility, making it a popular choice for both insured and uninsured patients.
• Doctor on Demand: A part of Included Health, Doctor on Demand offers flexible telehealth solutions for both patients and providers. It covers a wide range of services, including psychiatry, psychology, urgent care, and preventive health. The platform emphasizes easy access, on-demand consultations, and broad specialty coverage.
• PlushCare: This platform provides virtual primary care and mental health services through video consultations. It connects patients with experienced doctors from top U.S. medical schools and integrates with most major insurance providers. PlushCare is also known for its user-friendly interface and affordability for self-pay patients.
• 98point6: 98point6 is unique in its text-based approach to offering primary care and mental health services. It allows patients to have discreet, anytime access to medical professionals through messaging, catering to those who prefer written communication over video or phone calls.
• Wysa: An AI-driven mental health support platform, Wysa offers immediate assistance through AI-led conversations and human coaching. It provides an anonymous and stigma-free environment for mental health support, catering to a range of mental health needs through digital tools.
• HealthTap: HealthTap provides quick access to medical professionals through same-day appointments, video chats, and follow-up messages. It focuses on making healthcare affordable and accessible, with low-cost consultations and a straightforward user experience.
• Fruit Street: Specializing in chronic disease management, particularly for diabetes prevention, Fruit Street offers a comprehensive program that combines technology, dietitian coaching, and group classes to help patients manage their conditions through lifestyle changes.

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Conclusion

This brief explores the evolving role of telehealth and telemedicine in America. The history and current use of this system before and after the pandemic is discussed. Current case studies and legislation supporting the use of telehealth and telemedicine are explained in detail.  The challenges of this system and the potential in its future use are also evaluated.

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Acknowledgment

The Institute for Youth in Policy wishes to acknowledge Anagha Nagesh, Anoushka Swaminathan, Nolan Ezzet, and other contributors for developing and maintaining the Policy Department within the Institute.

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