Q&A: Texas e-Health Alliance’s Nora Belcher on the evolution of telemedicine

Nora Belcher is the executive director of the Texas e-Health Alliance. In a session with numerous telehealth-related bills, she has been busy at work advocating on behalf of bills that would expand telemedicine services for Texans.

In this Q&A, Belcher tells State of Reform about the continually evolving area of telemedicine, what the future of remote medical services looks like and the key legislation the Texas e-Health Alliance is supporting.


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Eli Kirshbaum: The pandemic has clearly shifted the health sector’s perception of telemedicine. Can you describe the telehealth transformation you’ve seen in the past year?

Nora Belcher: “Where I’d start is that, from looking at the claims data, we think that one in five future visits will be virtual. What that means is that office visits, follow ups, mental health — all sorts of things are going to stay virtual for a lot of clients. Not for everybody, not for every service, but it [telehealth use] peaked last year as about 40% of visits, and then that peak actually dropped off, so I think it’s going to be, in the long run, one in five. That’s a pretty big shift.

What that means is a couple of things. We’ve got to keep it in place for purposes of continuity of care. We have a lot of people now who have been seeing the same doctor for a year, virtually. We’ve got to make sure they continue to see them. So a lot of the discussions I’ve been having have been around, ‘How do we make sure that we get to that continuity of care for the new models and new ways people have started doing things so they’re not started over again because telemedicine gets taken away after it’s been established?’”

EK: As we transition into a “post-COVID” world with more vaccines going into arms every day, how much of this focus on telehealth will diminish? How much of it is here to stay?

NB: “I think it’s here to stay. Here’s the analogy that I’ve been using. There was a time when not everyone in America had an email address — it was a thing not that long ago. America Online literally sent everyone a CD at home, and that was America’s first sort of mass exposure to the internet. COVID, to me, is the America Online event of telemedicine. You are not going to tell working class people, ‘Sorry, we’re taking away your virtual business, you’ve got to miss three hours of work to go to the doctor’ — that’s not going to be a thing. Patients are going to go to places where they can get care that’s more convenient for them. I can’t tell you how many stories I’ve heard from people saying, ‘Sorry, I have to miss two hours of work to have a fifteen minute chat with my doctor.’ And they never knew there was another option.

I was outreached to by a group called the Texas Rare Disease Coalition … and they were telling me how telehealth is keeping these children safe, because the doctors visits require the mom to put the child in the van, put the van on the road, take the child to the waiting room — and these are kids with compromised immune systems. We still make them go to their health care. Sometimes you still have to go, so there’s the flip side.

Medicine has not been customer service friendly, and the public really hasn’t been exposed until now, in a mass way, to other ways of doing things, and they’re not going to go back. For some things they’ll have to go back because that’s what’s clinically appropriate, but [things like] surgery follow ups — I’ve gotten in my car when I was not completely healed and had to be driven to have a discussion. Why do we do that? We don’t have to do that anymore.

If care is not convenient, [patients] are going to seek out convenient sources of care. So, smart doctors are going to make this [remote visits] part of their practice and offer that availability or offer it as a wrap-around service, and I think it’s going to build loyalty with their patients because now their patients know there’s another way to do things. Even two years ago, I would not have been able to make that argument, but I certainly think I can make it now.”

EK: Let’s talk about the telehealth bills currently in the Legislature. Can you describe HB 4 (SB 412), and what its legislative trajectory looks like?

NB: “In Texas, the Speaker and the Lieutenant Governor pick the smallest thirty numbered bills. So the budget’s always [number] one, and normally they get the number based on when you get filed, so if you file early you get a small number, if you file late you get a big number. They get to reserve one through 30 for their priority. So when you see a single-digit bill, that means that elected official has designated that bill as a high priority for his or her administration.

For a telemedicine bill to be House Bill 4 is unprecedented in Texas. Nothing like this has ever happened. Health care bills are rarely [that low], much less telemedicine bills. So we are delighted that the Speaker of the House understands how important this issue is.

This particular bill is around Medicaid and public benefit programs, and making all of the flexibilities of COVID current to those populations. There is universal agreement, the bill has tons of support, no opposition that we’re aware of, we’ve been having great hearings, and we fully expect to be able to pass it and send it to the Governor … So that is the bill that has the broadest support.”

EK: What about HB 522 (SB 412), which aims to establish payment parity for telehealth visits?

NB: “We actually have [around] twelve payment parity bills between the House and the Senate. My association is neutral on the issue of payment parity for antitrust reasons. We have a very strict policy about discussing what people get paid for using our equipment, so we are not engaged in payment parity because my group views that as out of bounds.

What I will tell you is that while it’s very popular with ambulatory providers, if you watch the SB 412 hearing, you will hear the Texas Hospital Association say that they are opposed to payment parity … The problem with parity, for some of the providers, is it locks you in — you can’t go up, you can’t go down. It locks you out of value-based purchasing, and it locks you out of incentives.

With the hospitals not being in agreement with the doctors, that makes [HB 522] really hard to pass.”

This interview was edited for clarity and length.