Rebecca Canino is the administrative director at Johns Hopkins Telemedicine, which provides telehealth services across six hospitals, the medical school, its payer entity Johns Hopkins Healthcare, and more. During the early months of the pandemic, a number of state and federal flexibilities allowed telehealth providers to ensure access to care for their patients. However, some flexibilities are now being rescinded, although demand for remote care remains high.
In this Q&A, Canino discusses the state and local policy changes she hopes will address restrictions for telehealth providers—both in Maryland and across the Mid-Atlantic region.
Nicole Pasia: Demand for telehealth services has increased nationwide over the pandemic. How has COVID-19 impacted your work at Johns Hopkins Telemedicine?
Rebecca Canino: “Pre-pandemic … we were doing maybe 100 visits a month, and we were so excited. Then COVID hit in March 2020 and by April, we were doing 100,000 [visits] a month … It’s been really fascinating because COVID sparked [the rise in visits]. So it was not only to take care of patients, and to keep them from getting COVID by limiting exposure, but it was also to maintain wellness. We’ve seen telemedicine used in every single one of our departments. Probably our biggest user, and this is the same nationwide, would be behavioral health. But it’s followed by some really interesting [specialties].
Neurosurgery is a very high utilizer, and then you see it go all the way down to ophthalmology, which is probably our lowest utilizer. But it’s used in every specialty and they all use it differently. Some use it for new patients, some for established, some for surgical practice, follow up—but every department has figured out a way to use telemedicine to reach its patients.”
NP: What state and federal policy changes have ensured access to telehealth during the pandemic?
RC: “Prior to the pandemic, CMS only allowed telemedicine for patients who were in rural designated areas, which here in Maryland [are] extremely limited. I think we have two tiny pockets of folks that are in rural areas, so they were the only folks who could receive telemedicine. Everyone else could receive telemedicine only if they were in an approved site, which would be another hospital or a [federally qualified health center] or a health department or prison or school.
To even get telemedicine into those approved sites, you had to have clinical service agreements with those areas and your providers had to be credentialed in those areas. These are massive roadblocks. A patient who just needs care at home could not get it. Now, the [public health emergency] lifted those restrictions and said patients at home could receive that care … Governor Hogan, in the Preserve Telehealth Access Act, said telemedicine is available to Medicaid patients at home regardless of what happens with the public health emergency.
The second thing that happened with the Preserve Telehealth Access Act was that it paid for audio-only visits. This is huge. When the pandemic hit, and we started doing such a huge percentage of our visits via telemedicine, the disparities among our patients became glaringly obvious. Some of our data shows that if you are on a national payer, such as Medicaid or Medicare, you’re more apt to use the phone. Let’s say you’ll use the phone 30% of the time, because you do not have bandwidth … It takes about one gigabyte of data per hour of a telehealth visit, so a video visit uses up a huge chunk of your minutes.
Patients were finding out they either didn’t have a smart device, they didn’t have minutes, they didn’t have internet at all, or they just didn’t know how to use it … So early on in the pandemic phone visits weren’t being reimbursed, but providers were doing them anyway because it was the only way to reach their patients. So with the Preserve Telehealth Access Act that came into being, video or audio-only telemedicine visits are going to be reimbursed for two years, which is huge.”
NP: While those policies have worked well over the last 20 months, you previously mentioned that some flexibilities are now being removed. How are they impacting your work and the patients you serve?
RC: “During the PHE, one of the big things that you saw were all the states suspending licensure restrictions. Normally, to see our patients via telehealth, the provider needs to have licensure in the state where the patient is at the time of the visit. The state licensure waivers enabled a patient in a neighboring state here in the region to easily be able to follow up with their health care provider via telehealth regardless of licensure.
Let’s say that you live in Virginia, but your oncologist is a Maryland doc because they’re the only one who has a sub-specialty in your type of cancer. With the PHE, that physician could follow up with you via video in your home state. Now as the pandemic [has] wound on and on, states are putting those barriers back up. And now that oncology patient, who is immunocompromised, has to drive across state lines, park in a Walmart somewhere, and have a video visit with their provider because their provider only has a Maryland license. So this was an old restriction that has come back that is really limiting patients in who they can see and how they can see them.”
NP: Are there any policy changes currently in progress to work around those restrictions?
RC: “The Mid-Atlantic Excellence Zone, MEZ—we are trying to get that going. That would be a reciprocity compact between Virginia, Maryland, and D.C. and allow us to see our patients in those states, based on the provider’s home state licensure. Now, there are other compacts out there. IMLC, the Interstate Medical Licensure Compact that’s out there, provides a hub where providers can apply for licensure in one place with one set of paperwork, but they still have to pay for licensure in whatever 30 states they’re going to choose from.
There are other types of contracts like the nursing compact, which is a great one, which is true reciprocity among a huge amount of states, meaning that nurses can practice nursing in those states [through] their home licensure. This is really the type of compact that we want to see proliferate across the U.S. now … those licensure requirements that have to happen at the state level. You will see some examples of overarching [compacts], like the Veterans Administration … So it would be interesting to see if Congress said, ‘No, we’re going to have a national licensure [program]’ or not. But we haven’t seen that.
Another [federal] act that’s on the floor now that Hopkins has supported and sponsored, is the TREAT Act. That says, during a national emergency, you can see patients in any state during that emergency as part of the PHE. So it’ll be interesting to see if that goes into effect. It also [implements] a 90-day trail-off period that says when a public health emergency ends, there are 90 days where it remains in effect so that health systems and patients can get ready [to transition out].
What we’ve seen is with these abrupt stops of either a waiver or coverage, thousands of patients—effective between one day to the next day—suddenly can’t get care. We have patients scheduled months out, like everybody else. By adding this grace period, or this trail-off period, it allows people to get the care they need when they need it and to make plans in advance.”
NP: How do you stay hopeful to continue working to make sure that all of your patients get the care that they need?
RC: “I think it’s part of our mission to care for people here at Hopkins. I know all the other health systems feel the same. We’re going to do anything in our power to enable our providers to take care of their patients where and when they need it. So whatever we have to do, we’re going to do that. We work every day with the hope that Congress will act, [and] they will have some legislation in place that will allow our providers to see patients in their home. This is what our patients need, this is what they want. So we really are putting our trust out there that Congress will act in a timely manner.”
This interview was edited for clarity and length. Image: Johns Hopkins Telemedicine