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Dr. Roslinde Collins-Gibbard consults on critically ill patients from Dartmouth Health\u2019s Telehealth hub. Photo courtesy of Dartmouth Health<\/p>\nDr. Roslinde Collins-Gibbard consults on critically ill patients from Dartmouth Health\u2019s Telehealth hub. Photo courtesy of Dartmouth Health<\/p>\n
For many of the patients served by the Montpelier community health clinic All Brains Belong, being able to access health care through virtual and telehealth care appointments during and after the Covid-19 pandemic was a game changer.<\/p>\n
When telehealth care became more widespread, \u201cmany patients were able to access health care that worked for them for the first time,\u201d said Mel Houser, the founding physician of All Brains Belong, which focuses on providing care for\u00a0patients with long Covid, chronic conditions or neurodevelopmental differences.<\/p>\n
Even for the region\u2019s large, mainstream providers, the broader flexibility for telehealth has proven crucial to many of their rural patients.<\/p>\n
Dartmouth Health, among New England\u2019s largest health care providers, has seen its online consulting with network specialists grow exponentially under new reimbursement rules that quickly became the norm for public and private insurers during the public health emergency.<\/p>\n
But those federal rules changed overnight on Oct. 1, as some of the pandemic-era flexibilities that allowed Medicare to cover virtual appointments<\/a> lapsed with the new federal fiscal year. Health care providers\u2019 advocates nationwide have lobbied for years to make them permanent, and had at least hoped to see Congress approve further extensions as part of the next federal funding bill.<\/p>\n Now, with that funding bill still stalled \u2014 and large portions of the federal government shut down \u2014 the telehealth practices of small Vermont clinics and large hospital networks alike remain in limbo, along with the Medicare patients they serve. Nearly a quarter of the state\u2019s population<\/a> is on Medicare \u2014\u00a0158,3600 individuals in 2025.<\/p>\n Separately, the lapse in authorization also means video or telehealth appointments can no longer count as the face-to-face encounters that Medicare requires for patients to be eligible for home health or hospice care.<\/p>\n Vermont state law<\/a> requires that in-state insurers cover telehealth services to the same extent as they would cover the equivalent in-person services. But as a federal program, Medicare \u2014 the country\u2019s health insurance program for people age 65 and older and those with certain disabilities \u2014 is not subject to that law.<\/p>\n Now that authorizations have reverted to pre-pandemic rules, Medicare covers telehealth \u2014 both audio-only and video interactions \u2014 only for mental health or substance use disorders, acute stroke treatment, or end-stage renal disease dialysis. For these conditions, updated rules allowing reimbursement for virtual care have been approved already through previous federal legislation.\u00a0<\/p>\n But outside those specific kinds of treatments<\/a>, telehealth visits are currently not eligible for Medicare coverage at all in metropolitan areas, which in Vermont means in and around Chittenden County. In the rural parts of the state, telehealth visits will be covered only if they occur in designated Medicare \u201coriginating sites<\/a>\u201d such as a local clinician\u2019s office.<\/p>\n That rule negates many of the accessibility benefits<\/a> telehealth opens up, Houser and other providers point out.<\/p>\n Many of her patients rely on the at-home format for a variety of reasons, she said. Some patients are thankful for the freedom from the risks of catching a virus in the clinic. Others appreciate avoiding sensory overload of visiting the office that can overwhelm some people with sensory issues. For another group, virtual visits remove the stress of needing to find or pay for transportation to the office.<\/p>\n Though commercial insurers may follow the standards Medicare sets, both insurers who sell plans on Vermont Health Connect, the state\u2019s Affordable Care Act marketplace \u2014\u00a0Blue Cross Blue Shield of Vermont and MVP \u2014\u00a0are continuing to cover most telehealth care, spokespeople for each insurer confirmed to VTDigger. Vermont Medicaid coverage for telemedicine is also not changing.<\/p>\n At All Brains Belong, nearly half of the 350 patients her small clinic serves are on Medicare or Medicaid, Houser said.<\/p>\n While Vermont Medicaid and private health insurers are continuing to reimburse for virtual and telehealth services, Houser said she is now unable to bill Medicare for the care. For now, those patients can self-pay for the service, tapping into the sliding scale costs the clinic is able to offer with a mutual-aid Community Health Access Fund<\/a>, or cover the cost of services with the clinic\u2019s unique bartering service-exchange program.\u00a0<\/p>\n \u201cWe are trying to catch people in the gaps,\u201d Houser said. Still, for a small clinic, the loss of cashflow is substantial, she said.\u00a0\u00a0<\/p>\n Banking on a solution<\/p>\n The two largest providers for the state, Dartmouth Health and UVM Health, are continuing to provide telehealth services to Medicare patients and hold onto the bills, rather than seek other payments from Medicare patients. They are banking on the possibility<\/a> that Congress will eventually act to expand the rules and approve the treatment retroactively.<\/p>\n Dartmouth Health has a broad range of telehealth care for patients in and out of the hospital, said Kevin Curtis, the medical director of Dartmouth Health\u2019s Connected Care program. The network sees about 500 visits per week from Medicare beneficiaries using telehealth to their home, Curtis estimated. Nearly 200 of those patients are Vermont residents, he said.\u00a0<\/p>\n At UVM Health, the Network has nearly 40,000 Medicare-related telehealth visits per year, said the network\u2019s spokesperson Annie Mackin.<\/p>\n
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Dr. Kevin McAvoy remotely provides neurological care to Dartmouth Health patients in the hospital. Photo courtesy of Dartmouth Health<\/p>\n