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The expiration of the public health emergency COVID-19, which is likely to occur in January, will create significant complexity for schools that provide telehealth services to students.
Since 2020, the COVID-19 emergency — a federal declaration issued by the secretary of the Department of Health and Human Services — has led to a sharp spike in telehealth use among older Americans, thanks to regulatory exemptions and flexibility from the Centers for Medicaid and Medicare Service.
The same is true for the more than 33 million children and adolescents served by Medicaid, the state government program that helps pay for health care costs for people with limited incomes. While states have wide flexibility to determine whether to cover telehealth services under Medicaid, 49 states already have policies that allow reimbursement for at least one type of service when provided through telehealth in schools; 24 countries had similar policies before the pandemic. So while school telehealth is nothing new, the catalytic progress in implementing school telehealth was based on the widely shared goals of protecting the health and well-being of students, minimizing visits to local emergency rooms—already depleted by the pandemic and its financial impacts—and providing better care for children and adolescents to optimize personal learning.
This expansion was and remains an important opportunity for participation for students, families and schools. First, telehealth promises dramatically expanded access to and availability of various types of physical and mental health care, regardless of where the student lives. Second, telehealth can potentially reduce patients’ out-of-pocket costs due to inefficiencies in care, particularly in rural areas. Third, given widespread concerns about school staffing, telehealth presents an opportunity to maximize the impact of a capacity-constrained workforce. Perhaps most importantly, telehealth reduces the burden on families and students, for example by reducing transportation challenges that can impede access to care, resulting in more time spent in class.
Given the potential benefits of telehealth and the evidence that, in some conditions, such school-based care can improve the quality and efficiency of care, it would seem pointless to drastically scale back this service that has evolved during the pandemic.
However, there are remaining policy and programmatic concerns related to the delivery and management of telehealth in schools that must be addressed if it is to remain a viable health care model. For example, a recent report by the HHS Office of Inspector General concluded that approximately $130 million billed to Medicare in the first year of the pandemic for telehealth services involved practices considered high-risk. Medicare, of course, is not Medicaid. However, the provision of unnecessary services, waste, and fraud that have been documented in Medicare telehealth services likely exist in Medicaid programs at the state level—based on previous cases of large-scale fraud—and require additional safeguards if telehealth is to become sustainable in schools. It also has the potential for violations of the Controlled Substances Act. The providers were recently investigated by the Drug Enforcement Agency for improperly prescribing controlled substances. As many telehealth providers increasingly serve children and adolescents, the risks of inappropriate prescribing are worrisome.
The costs associated with steadily expanding Medicare coverage for telehealth pose another challenge. The Congressional Budget Office estimated that a two-year extension of Medicare flexibility for telehealth would cost $2.5 billion. Again, while Medicare does not serve the school-age population, it does matter for schools. Medicare’s market power is so significant that decisions surrounding Medicare and telehealth will likely affect how Medicaid and private insurers reimburse for school telehealth services. If Medicare coverage for telehealth ends next year, it is difficult to see Medicaid coverage for school services remaining in place without significant revisions to existing policies, well-funded and coordinated advocacy campaigns, or a significant change in the economic outlook. Given the current variability in Medicaid coverage across states, schools using telehealth rely on additional funding streams, including grants, private insurance, federal pandemic relief funds and other state sources. The formula schools put in place to pay for telehealth services will likely need to be changed, if not completely rethought.
The dynamics surrounding the extension of flexibility in the event of a COVID emergency remain uncertain. Proposed legislation circulating in Congress would expand them, but costs and policy concerns pose a serious challenge to any congressional action. Clearly, the Centers for Medicaid and Medicare Service and the US Department of Education should issue guidance to states, districts, and schools that outline the various public health emergency scenarios and actions required.
For now, district and school health leaders need to make sure they thoroughly understand the state of emergency waivers and the flexibility their organizations are using. They also need to reorient themselves to federal and state policies and procedures that were in place before the pandemic. They should similarly educate partner providers and school health personnel about the current uncertainty surrounding the expiration of the emergency and explain the potential need to rapidly implement new policies and procedures if the emergency is not extended. This work has significant budgetary implications. Finally, they must ensure that any additional requirements imposed on their organizations by non-expiring extraordinary flexibilities meet current regulatory requirements.
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