Accessing Healthcare Anywhere: Lessons For Liberalizing Telehealth

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Joe Selvaggi talks with Josh Archambault about the benefits of state policies to enable interstate telehealth that empowers patients to reach their healthcare professionals in other states, and for providers to offer service anywhere they are needed.


Josh Archambault is a Senior Fellow at the Cicero Institute. His work experience has ranged from work as a Senior Legislative Aide to a governor, Legislative Director for a state senator, to years working for think tanks operating in complex and highly political waters in thirty-five states, and in D.C. Josh has become a trusted adviser to Governors, state legislators, senior staff at the White House, and executive branch leadership as they navigate the policy issue of the decade. Josh’s health care policy work has been covered in outlets including the Wall Street Journal, USA Today, The New York Times, Fox News, NPR, MSNBC, Money Magazine, and National Review Online. He is also a regular contributor to the influential blog, The Apothecary. Josh holds a master’s in public policy from Harvard University’s Kennedy School of Government and a B.A. in political studies and economics from Gordon College. He and his wife enjoy raising four kids—a mix of biological, adopted, and children experiencing foster care.


Joe Selvaggi: This is Hubwonk. I’m Joe Selvaggi. Welcome to Hubwonk, a podcast of Pioneer Institute, a think tank in Boston. Among the most positive innovations necessitated by the COVID-19 pandemic was the use of telehealth to access medical expertise remotely, even out of state driven by fear of contracting disease at a hospital or office patients and professionals alike learn to meet from virtually anywhere for medical consultations on a wide range of services this power to see one’s own doctor while traveling or to reach an expert whose practices out of state reveal to patients a promise from better more convenient care now as the threat of severe COVID abates, policy experts and elected officials will need to examine telehealth interstate performance and then work to instantiate its most useful benefits into law. Which states have led the nation in empowering patients to reach providers beyond their borders? What were the problems if any were providers could offer services with little or no in-state registration? And what can states like Massachusetts that ended permission for interstate telehealth learn from these states that did not? My guest today is Josh Archambault, senior fellow at Pioneer Institute and senior fellow at Cicero Institute whose recent paper entitled “Few disciplinary issues with out-of-state telehealth” looked at the effects of Florida’s and Idaho’s decision to liberalize the use of interstate telehealth during and after the pandemic. His research examined how allowing access to out-of-state providers with little or no in state registration affected the quantity and quality of the healthcare provided. Mr. Archambault will share his views on the nature of the demand for Interstate telehealth and the benefits of liberalizing the restrictions on out-of-state providers and offer his recommendations to lawmakers in other states for helping patients find quality convenient care regardless of their or their providers location. When I return I’ll be joined by Pioneer Institute senior fellow in healthcare Josh archambeault. OK, we’re back this is Hubwonk, I’m Joe Selvaggi, and I’m now pleased to be joined by my Pioneer Institute colleague and senior fellow at the Cicero Institute Josh archambeault. welcome back to Hubwonk, Josh.

Josh: Thanks, Joe for having me.

Joe: All right. Now, you’ve been on the show before and we’ve talked about the COVID and the pandemic but we’re rapidly approaching the end of the public health emergency I think the official end date is May 11th which signals the end of all COVID related temporary government measures I’m sure listeners are delighted to have the pandemic in the rearview mirror but it’s uh the emergency has forced us all to develop new ways of communicating this this podcast is an example of that. So let’s we’re going to talk today about the adoption of telemedicine it’s been as you and I have discussed in the past a pretty good thing for those who didn’t want to go to the hospital and perhaps expose themselves to a contagious disease but I Iwant to take us through where we are now three years down the path you’ve done some interesting research on the uptake of telehealth and the uptake of telehealth between states so let’s start at the beginning what is telehealth for our listeners who haven’t heard our earlier podcast? And where within medicine have we seen its most enthusiastic adoption?

Josh: Yeah so telehealth is a broad term I mean most people think of what we are doing right now which is talking over a computer on a phone to do telehealth but telehealth is actually a broad term. It differs the definition actually slightly differs by state but it can be anything from text messaging to video chatting Skype, zoom-type calls to sending images you might get a scan of your knee or your ankle and that’s sent over the adoptions been pretty widespread during COVID somewhat out of necessity I do think that there’s been a massive expansion in the mental health and behavioral health space for two reasons, one there was a lot of technology companies that saw an opportunity to move into the space to treat patients when they couldn’t come into a facilities but also for mental health and behavioral health where there’s such a shortage of providers in certain parts of the country this is really the only option for patients, and so there’s been a massive interest both from the patient side and from the provider side to try to leverage this tool for that sort of delivery of care, and we started we started to see a downward plateau of sorts as people have returned back to how they use the healthcare system in general but telehealth seems to be here and sticking around and there’s definitely pockets of populations, and it’s not just by age there are older populations as well that continue to use telehealth at a far elevated rate versus pre-COVID.

Joe: So it’s been sticky you anticipated my next question which is to say when we’re no longer perhaps as afraid or no longer afraid at all of contracting COVID when we show up at a hospital one would expect that the the use of telehealth to fall off dramatically has have we seen that or has it been somewhat sticky?

Joseh: There’s been a dip but there’s definitely a stickiness to it and I think there’s for a couple of reasons .I mean we’ve talked about some of these and your listeners have probably experienced some of this too if you live in an urban area and you want to just avoid the traffic and you don’t need to actually have a provider’s hands laid on your body you’re doing a follow-up appointment you’re getting a second opinion you’re hearing about test results it is far, far easier to hop on and telehealth is it to avoid the traffic for the pollution for it’s sitting in a germy waiting room just to be able to get that information out relatively quickly, so there has definitely been a stickiness and I think we’re going to continue to see that what what’s very interesting about this is a great research opportunity to continue to get the question that you just asked what kind of care is best delivered over telehealth? What kind of specialties typically use it do we see it for primarily more for primary care for mental health do we see it for certain kinds of specialists in which they’re fully leveraging it as part of their pre operations check-in whereas before they used to make you come in each time that’s what I’m really really interested to watch over the next 5 to 10 years to see how technology now that all of us have it in our pocket or in our homes how often we’re going to see this as our preferred way to interact with the healthcare system.

Joe: Well we know that necessity is the mother of invention and it seems to be the case that telehealth somehow magically arrived at precisely the moment we needed it so that there’s been a huge uptake. Is it the case that it’s we use it now because we have it or you know why is it that you think that you know beyond COVID that this technology exploded I guess I’m asking if the pandemic hadn’t arrived would telehealth still be sort of a niche fringe concept or had its time arrived already?

Josh: Yeah I think it largely it’s time had arrived in COVID certainly gave it a leg up the technology was there companies were already in the space we wouldn’t have had we wouldn’t have as many companies as we do in this space which would certainly help the other thing that’s changed is there were a lot of providers that were resistant to using it before COVID and I think that necessity did yet many of them much more comfortable with it, see the convenience of it for certain kinds of care. So my view on this is pre COVID telehealth time would come but it probably would have been a decade from now instead of where we are today.

Joe: certainly there was some inertia from perhaps older providers who weren’t as familiar with the technology and they had to they had to figure it out. So, let’s uh let’s jump now to a paper you just released that I found very interesting this is some of the work you’re doing at Cicero Institute and you looked at the patterns of telehealth in two states but not just telehealth but interstate telehealth right people who are using providers in another state specifically you were looking at people users who were in Idaho and Florida and using the providers in presumably the other 48 states. Why did you choose those two states Idaho and Florida very very different?

Josh: Yeah so that’s part of the reason we chose them a separate size of the country very different in size and scope the other things that we want we’re looking for is Florida actually passed a law pre-COVID in 2019 that allowed for this a registration for out-of-state providers and what was different there is a couple things: One is it was pre COVID so they had a little bit of a jump start so we wanted to see could we see any movement pre-COVID on who was registering or not; they also allow it for all providers which is not the case in many states if a state allows for cross state line telehealth usually it’s only for MDs or for doctors and so we were very interested to see are there other provider types that registered. So that’s where we started we found some folks within their state government who are really interested to study it along with us and Idaho by contrast did it in a slightly different way they did it by executive order like many states did by the governors you know, pen to say that during COVID we’re going to allow for this flexibility now they didn’t have a registration requirement so we don’t have as much insight into all kinds of providers are providing those services but we wanted to see do we see a difference in the complaint rates so just for context this this is a massive debate in many states show going forward right now in state legislatures on whether they should continue or allow for this across state line and this is where there’s the fiercest opposition, this across state line telehealth. A number of other telehealth policy changes that are being debated but this is really the big one, because it does allow for patient in Boston to be able to access a provider anywhere else in the country, and that really opens up the possibility for competition accountability to access the best providers that maybe aren’t in your community, both rural and urban settings, where there are a shortage of certain kinds of specialists so this is really a big deal in the telehealth policy world and as you can imagine there are many groups who are fighting, it fighting it very hard and have successfully fought it for years. And so we wanted to understand what is the main argument against this reform, and it’s this concern that there’s going to be when you have a cross state telehealth a massive spike in the complaints, because the argument is that there’s going to be a huge dip in the quality of care from out-of-state providers, and so we said well, let’s look at that and these two states that have done this slightly differently did they see a big spike in complaints from across state line telehealth and then were they substantiated was their discipline on the other end of that? And jump ahead to the conclusion—we didn’t find that. We can pull that apart a little bit but really what we found was quite frankly a little surprising to us how how low some of the complaint levels were from patients and this is just one snapshot we grant that but it is something that’s definitely worth researching because this policy debate is raging right now.

Joe: Indeed I’m sure it is and you and I have talked about why a particular group may want to protect their business in a particular state but let’s do a little straw-manning and say well OK if we’re going to try to come up with some valid concerns we are very proud of our medical system here in Massachusetts we think we have the best doctors and hospitals in the country and the 48, 49 other states you know there’s there’s nowhere but down from our lofty heights is there a big difference amongst our 50 states given so you know we certainly have different laws in all states we need different laws in every state where you know we’re republican in our sort of form of government are there some Wild West states that just essentially allow anyone to hang a shingle and and aren’t properly vetted?

Josh: No, the short answer is, and noticing I mean there’s  a little bit of variation but when we comes to doctors and other kinds of very common provider types and these individuals are going to the same medical schools graduating together and going back home or staying or some moving they’re largely taking the same kinds of licensing tests they all many of them have to be licensed in their states have to be in good standing to even participate in these sorts of across state line thing there’s mild variation the radiation typically is in something called the scope of practice. What are they allowed to do for actually seeing their patients but the actual credentialing and the licensing and there is very minimal differences, and so the quality concerns I mean are not there. Now there’s another approach to get another policy approach to get at what we are studying here which is compacts. There are a number of states that have passed compacts and compacts in the medical world traditionally allow for somebody to more easily practice in two different states, but there’s some severe limitations to that. One the compacts only apply to one kind of provider so you may pass a compact for a medical doctors but no other provider can use that additional flexibility. They tend to be pretty expensive to go through the process you got to pay a licensing fee in every single state that you apply to it can take months for you to be able to actually get permission to practice in those other states. So you hear a lot of people in the medical and service industry said OK it’s better than nothing, but it’s not great, it’s not allowing for the flexibility that we would need and they analogy that Joe you and I have talked about it and for pilots we don’t assume that they across the state line and all of a sudden they’re not able to qualified to be able to take off, or they need a different license to take off from a different state—we assume those skills are transferable and that’s really what is important here going forward and so I think some of those quality arguments, well, certainly you want mechanisms to be able to catch them when you see bad apple providers providing care there does not appear to be a big difference in the kind of care. We don’t see we haven’t seen research where somebody moves and all of a sudden they become about an A problem doctor they were either a problem doctor in state one and in state two or they weren’t a problem doctor and they remain not a problem doctor going forward.

Joe: So, I wanna drill down more on the safety concerns that again I’m thinking about those listening to our podcast saying oh you guys haven’t thought of this if I’m getting a provider from another state and you mentioned Florida actually makes the doctors register and Idaho doesn’t. So they register but presumably they’re credentialed and certified in their respective state they’re just essentially putting their name on the list here I am I’m practicing in your state so at least we know they’re there in Idaho they don’t even have that how does it say if something goes wrong you know how do you know and I’ll follow that on with how does the individual consumer know if it can get again they’ve not been registered in your state that how do we know to scrutinize their practice.  I don’t you know if they hold their book diploma up to the screen I need you know more as a consumer to vet the professional and I’m not talking about the brain surgeons necessarily but perhaps lower level providers that may not have those elaborate credential systems how do I protect myself?

Josh: Yeah let’s start with the first part there so if something goes wrong in any state regardless of the state laws you can file a complaint and there’s always a a process that’s followed against medical providers to determine whether there’s substance to that complaint and frequently the board or whoever’s reviewing that complaint finds I mean pretty frequently like surprisingly high they find that there was not a complaint maybe it’s somebody just they didn’t click with their provider they said something that they found offensive but really it’s not like some malpractice nothing was done that was it should be called into question so that that’s the first thing: They absolutely need to be credentialed or licensed in their home state. And individuals actually can they have many different avenues in which they can pursue some sort of if there’s a problem not only can they file a complaint but they could file medical malpractice lawsuit against anybody and in fact across state line telehealth opens additional avenues for patients because it’s across state commerce and so there’s actually federal courts that you could access that you couldn’t for in-state providers when there’s a problem, so that that’s the first piece I would say. Oh, now the second thing I would say is we were curious about the in state complaint rate and disciplinary numbers versus the cross state because we wanted to see is there a difference in there absolutely are complaints filed for in state telehealth visits Florida tracks those and that’s in the paper we looked at those and there are complaints but again there’s very few disciplinary actions taken for those sorts of issues and they’re the same common complaints usually it’s they feel like the provider is not—they want them to prescribe something and the provider is saying no I can’t prescribe that—so they file a complaint and the board says well they can’t actually give that so no they’re not there’s no issue here and that’s very similar issues in state and out of state and so I think that’s it’s just important for people to remember there are consumer protections here whether the registration is there or not. What the paper I think illustrated to us is we wanted to know is the registration somehow fundamentally different? Do they catch more things? Do they see do they discipline more doctors or other provider types as a result? And the initial findings are no, the registration does not seem to catch more or result in more individuals having complaints filed or having disciplinary actions taken against them and so I think for policymakers it just begs the question there’s many ways to move forward whether it’s compacts or registrations or allowing just a more open-ended—if you’re licensed and in good standing in your home state a patient can choose to use that provider—again nobody’s being forced to use these providers that’s really important it’s just another option. Which is your second question Joe, which is I think we still are very early in stages of being able to help patients have tools to evaluate providers and how they will click with them or their expertise there are some quality metrics that are out there and tools that are out there I’d say they’re relatively rudimentary and there’s much more room to be done there. On the flip side though I would say really what we need to contrast this with is what the status quo is and the status quo is in many communities you simply don’t have access to some of these providers. So one could argue having access to a provider is better than access to no provider and that’s number one for us to keep in mind; #2 is telehealth allows your geography to no longer determine your medical destiny. You may live in a community and you know maybe you live in Western Massachusetts let’s say for example and you realize that either you’re going to have to drive to Boston to try to access somebody or you might know that there’s the world’s best expert for this whatever you’re dealing with in New York City and going to New York City would be a better option but you’re sick and so you’re trying to figure out but it’s maybe geographically closer for you to go to New York City doing a cross state telehealth makes more sense for you because it’s the world’s expert who lives in New York or in Cleveland or in Houston or wherever that expert might live and this allows you to access that provider. Anybody of any income would have the option and ability to access that provider; right now you have to have the resources and have the health to get on a plane pay for a hotel to be able to access that world class expert and across state line telehealth at least puts on the table the option for you to be able to access those which I think is really fundamentally different and I think we need to keep in mind as we’re discussing this issue.

Joe: Indeed you know you and I both value the power of markets to solve solution is you know create solutions for for needs now that you know I think you point out a very good point which is telehealth as a technology and COVID as a sort of a catalyst for that technology, are relatively new you don’t have many many years of data to compare given that it’s now possible to find a doctor out of state and given now that you have two states where doctors could in the case of Florida register., how have doctors reacted? Meaning are doctors eager? I mean we you said look patients need doctors elsewhere do doctors want to serve patients elsewhere have they decided to since being able to have they shown up and registered for instance in Florida?

Josh: S  that was one of the research questions that we were interested in and I should mention I did this with Doctor Tribe Harvard Medical School we pulled that apart we looked at OK and because Florida is requiring registrations what kind of providers are registering MD’s are by far the most so there’s about 14,000 additional providers who have registered and Empties make up a good percentage of those 40, 45% or so the next subcategory I’m going to lump together a few kinds of providers but it’s I would put into the mental health provider space so clinical social workers mental health counselors psychologists they’re they’re making up the next biggest bucket of providers that have moved forward and then we see like a hodgepodge of additional people who have registered dietitians, nutritionists, speech language pathologists, physical therapists those sorts of individuals there’s a handful of those thrown in and it’s going to be very interesting to see if that those trends continue overtime one of the trends we noticed was that they started pre-COVID but every single year since they’ve had significant increases in the amount of providers who are registering in Florida. I think the word’s just getting out and that this is a possibility for them to be able to see patients if you’re in the northeast and you have patients that snowbird down or in the Midwest this is way for you to stay in touch with your patients instead of not seeing him for six months out of the year if they run into any sort of medical issues. I think the other thing that we’re interested to see here Joe is the future in a lot of areas where those with chronic diseases is team-based care and what that means is a handful of different providers able to meet with the patient all at the same time. Well telehealth allows that in a way that is logistically much more challenging in other health settings and so I’m curious to see as hopefully more states allow for this across state line for more different kinds of providers you might have a nutritionist who lives in Texas but have your primary care Doctor who lives in your hometown meeting with your endocrinologist who lives in Ohio because they have worked together on patients and they’re able to be pulled together through telehealth while the patient sits at home versus before that team-based care might not have been possible.

Joe: That’s pretty powerful and essentially the proverbial death of distance in medicine it’s really profound have you noticed— you did have quite a few maps and charts in your paper—we’re looking at Florida again we know it’s a warm state destination for many folks retirees or snowbirds did you notice a pattern where are these doctors who are serving Floridians registering from which states are sort of exporters of telehealth?

Josh: Yeah so this is one of the things that we were very curious so we pulled the mailing addresses of the medical doctors to see where they were and New York State was by far the most the largest area for them but Texas wasn’t too far behind and there were a number of other kind of Midwestern states Michigan Pennsylvania even Massachusetts had quite a few MD’s who have registered and again I think this does get at that snowbirding dynamic. I think our working theory before we went in was that we actually expected there to be far more Georgia providers or Alabama or Mississippi providers thinking that oh there’s Florida residents who are you know crossing a state line previously to see a provider now this would allow that provider to stay in touch with the Florida patient while they’re in Florida. And we saw some of that but it’s not nearly as large as some of these other big states that are represented, and this needs further research I mean, what are there additional companies that are located in those two States and they’re helping their providers register? Or is it just that there’s just a lot more providers in those states who are interested or is it this whole theory that I have about their patients or snowbirding in Florida.

Joe: Now you reassured our listeners that you haven’t found substantial uptick in in complaints or problems with telehealth what’s a meaningful comparison are you comparing the incidence of complaints amongst in state telehealth versus out of state or are we looking at you know are you even in analyzing telehealth itself in other words how many complaints in the medical world for in-person versus telehealth. I mean where would we see a signal that says look maybe this telehealth thing is getting a little too Wild West and we don’t have enough proper guardrails to ensure patient quality yeah.

Josh: So  we took two different approaches just because of the quality of the data quality that was available to us so in Florida we looked at and they tracked in state telehealth visits versus across state line telehealth visits which felt relatively apples to apples to us. Now granted there is limitations to this the across state line telehealth visits are much fewer than in-state ones just as an a matter of where we sit right now but with that being said we didn’t see a measurable difference between those in-state telehealth visits versus the across state line ones. In Idaho what we had to do because they don’t have as much as robust data we simply looked at the complaints that were telehealth related complaints that were filed pre-COVID to post-COVID to see was there so pre-COVID would have been just in states providers because that was all that was allowed for telehealth and then during COVID now they allow for this across state line we didn’t see any significant difference in fact we found there were more complaints for in-state doctors than there were across state line doctors I think we’re cautious and don’t want to draw too many conclusions there and we’re not trying to say that in state doctors are lower quality but I think we’re just saying that there’s a many more visits that are happening in state whether it’s over telehealth or not and so therefore they are hovering more numbers of complaints but as a percentage or anything there’s not really a big difference between those two kinds, the delivery of care whether it’s across state line or in-state.

Joe: So I want to pull back from the the paper because as you know it’s just two states Idaho and Florida but every state has its own regime. In general if you have done any analysis of other states how does Florida compare with the other 49? Are other states approaching telehealth similarly and anticipating my next question is you know is there a pattern to who seems to embrace which states seem to embrace this technology and which seem to be reluctant to go there?

Josh: So the short answer is one of the reasons we studied Florida is because they’re a little bit farther ahead in our view Arizona also has passed legislation during COVID to allow for more across state line tell out for more providers but by and large that’s the extent of it. During COVID most states allowed it during it by emergency order by the governors but most states don’t have not continued to allow it with a few exceptions state of New Mexico, Utah, Minnesota have a little bit looser requirements for medical doctors to be able to see across state line providers, but Arizona and Florida are by far ahead of everybody else in terms of having a set of laws that are very clear for how any kind of provider can be able to see a patient or for a patient in reverse to select them as to see them for care. But for the most part well this this debate is raging it is not a settled issue and it is not a majority of the states that allow this and in an increasingly mobile society where people are moving around a lot we think this is something that needs to be addressed in the next couple of years.

Joe: So now you’re probably anticipating your next question we are one of those 50 states I count you I don’t think you’re in our state right now Josh but you you call us home I hope still so uh perhaps you look first for what Massachusetts has done we as you mentioned used an executive order our former governor Charlie Baker allowed this, you and I covered that in the past where are we now and where do we hope to be if we think we’ve enumerated benefits of allowing out-of-state presumably not allowing it is is is cause for some harm to some people in our in our great Commonwealth. So where are we and you know what do you think?

Josh: Yeah unfortunately it’s no longer allowed in Massachusetts after Charlie Baker rescinded some of the emergency orders it was discontinued and so no longer or is this allowed or people are quite frankly breaking the law if they’re continuing to see providers across state lines unfortunately. So  I’m optimistic and hopeful that the General Court at some point will take this back up they did do quite a bit in passing laws to liberalize some of our telehealth laws during COVID. This is one area that they did not touch and I think it was a huge missed opportunity and I hope that they do whether it’s even in just in New England given our geographic compactness, it makes a lot of sense to be able to have people from New Hampshire, Maine, Rhode Island, Connecticut, even New York be able to be a little bit more flexible going forward but this is not something that’s currently allowed in the Commonwealth.

Joe: Now I know you’re not an attorney but you did mention that it would be illegal if we continued our relationship our interstate telehealth relationship with our healthcare provider where I have move to or summer or winter in Florida I could maintain my relationship with my Massachusetts doctor while there? Again I don’t want to we don’t have to get into all the legal loopholes and I don’t want to commit you to anything but once one in you know how do the laws apply or attach is it where I’m sitting or where my health plan is or where my doctors you know how does this all work?

Josh: Yeah so it falls in most states it falls on what the laws are for practice for the provider so telehealth definitions are usually put into the code for those providers and so whatever the rules are or the laws there would apply for them for them to be able to stay in good standing as a result now with that being said there’s also in some states it’s put in the insurance code and so sometimes those requirements would apply to the insurance companies on what they’re allowed to pay for and not pay for. I think what’s happening in some cases is people just aren’t checking and so as a result they’re continuing to do what they did during COVID, and you know it’s just it’s just an issue going forward. For me it’s an innovation issue if you want to allow for flexibility and for companies to legally pursue these sorts of innovation and care models or continuation of care you want legal certainty and you do want to make it clear that this is something that we think is valuable and for them to explore and anytime that there’s either gray or black and white where a new entrant won’t enter the market because they feel like well it’s not probably not legal in probably get away with it for a little while but ultimately they have legal risk they’re not going to move down that pathway. And so that’s what I think what we’re really talking about at the end of the day Joe. It’s about patient care though if patients need to be able to stay in touch with their provider when they are crossing a state line then it matters I don’t think it should be whether the insurance company is allowed to pay for it or not we should simply say if the provider and the patient believe that this medically necessary covered service is something that would be helpful in their care then we should explore it, and again, compared to the status quo you go to another state you have to start over with a completely new provider who you don’t know and does not know you or your medical history I think the vast majority of people in the medical community would say yes, it makes more sense for somebody who’s known you for two decades and your health issues to be able to stay in touch once or twice when they’re away for the year, you know, living in a warmer climate perhaps,to be able to stay in touch to say yes actually no you need follow-up care given your history you need to go or for them to say no I think you’re fine why don’t you come see me once you get back to your home state.

Joe: So listeners who do rely on a provider out of state and want to continue that relationship ought to pick up the phone and contact their legislator and say please for everyone’s benefit, not just their own, but other people needing the same service could benefit from this it seems like a win-win-win for everyone. You and I have talked about the benefits of telehealth you know we’ve gone over them quite extensively here but one of them you mentioned the convenience of course you don’t want to have to drive into Boston park and getting parking ticket and all the other attending costs with this it’s also convenient for the doctor he needs a smaller office process staff and he doesn’t have to come in to see you I either. This is the cost of telehealth which let’s say the overhead costs seem to be far lower is that being reflected in the way one is billed and I’ll follow up question is might I as a consumer of healthcare if there were no restrictions on interstate telehealth, could I find a cheaper provider in Wyoming than in New York City you know again setting aside quality issues could I essentially shop around for the cheapest service in the country using telehealth and again everyone wins what would you say to that?

Josh: Yeah I mean in theory you can this is where the details matter though in which state because some states have called something called a payment passed a payment parity law which requires telehealth visits to be paid at the exact same rate as an in-person visit which kind of undercuts your entire possibility that you’ve just laid out there so that it depends on the state that you live in the challenge with that though is that for people with deductibles they’re paying the whole thing and so as we’ve seen survey data where you see fifty 60%, 70% of Americans saying they’re deleting delaying excuse me delaying medical care because over cost concerns I think there’s real questions on why you would mandate that they have to be the exact same rates going forward. When it comes to the price variation, that’s certainly possible that you could find a cheaper option but I would just say price is one of many factors that people are considering even over telehealth—rhat you know there’s a number of different companies that have different offerings some people value seeing the same provider each time, so you might not be want to just see you know the cheapest one you might want to say no I want to see Joe Smith every time I use telehealth, and so as a result that might be reflected in the price. Some people value no I just want to see the next provider doesn’t matter who it is just I’m dealing with this ailment and I want to see whoever can be on my screen within 5 or 10 minutes, that’s what I value. And so you are seeing some market differentiation in the telehealth world about what patients might want to see. I mentioned the team-based care going forward and so price is one of four or five or six different considerations that people are using to determine what sorts of providers they’re going to use long-term.

Joe: Wow it sounds like you’re giving agency to patients that’s a remarkable bit of confidence that I share your enthusiasm with the individual patient determines what is valuable to them and this is just one more tool in the toolkit.

Joe: We’re getting close to the end of our time together and I’m going to say if and when you do visit uh Massachusetts again and they call you into the governor’s office or into the legislators office and you say you know Josh we want to have an efficient system that serves our citizens we like telehealth we think we are a we have lots and lots of doctors what would you do what kind of legislation do we need now post-COVID to ensure that this technology sticks and we can all benefit from it?

Josh: Yeah, I think as you go through the political process there’s a few guardrails that have become common in the legislation that’s been filed which you know common sense to me you know I think the state should simply set up a very efficient process whether it’s just filing paperwork with the relevant board if you’re a medical doctor or if you’re a nurse or a mental health provider, that simply shows that you are licensed or registered or whatever is required for you in your home state, that you are in good practice, that you have not had a malpractice suit filed against you in the last five years or that it’s not outstanding, there’s not an outstanding disciplinary case that’s open in your home state and that you’re going to, there’s going to be some basic requirements for you to report back to the state when any of those factors are not met. If you have a disciplinary case opened that you need to alert the Massachusetts board within 10 days or 15 days or whatever timeframe makes the most sense. I think those sorts of common sense guardrails are very reasonable and I think most medical providers are willing to abide by them. For them it’s really just to say look when we find ourselves in a situation where a patient is needing medically necessary care and we know them we want to make sure there’s a quick way for us to be able to move forward to providing that care, and so anything that can shrink the time period in which an individual provider needs to provide that care is really important. You know two weeks a month three months is too long. Being able to put in that information and have it be verified overtime saying that if you put in the information we’re going to assume it is correct and you can go ahead and provide the care but we’re going to verify that information and give us a week to do so or something like that but you can start to provide the care because we’re trusting that you’re in good standing. The medical boards talk to each other across state lines so it’s not that unreasonable for them to just double check to say is this person in fact licensed in your state, are they in good standing? Great we can move forward. I think that’s what I would advise and I’m hoping that any resistance as there now will change over time because even in Massachusetts with many providers compared to other states there are still shortages in certain specialty areas and in primary care I think we’re just very short-sighted if we don’t entertain this as part of the solution.

Joe: Indeed and I think what I’m hearing you say is it should be comprehensive but it should be easy and quick because any delay any complexity anything that discourages that that registration in a sense hurts patients right for no reasonable purpose so that’s a great way so for the uh legislators and leaders listening uh let’s hope they take this to heart and we move forward with this again we’ve been very excited about telehealth from the day almost three years to the week from when this pandemic began if this is a bit of a silver lining I’m thrilled that have we been able to cover it so Josh thank you again for joining me on Hubwonk, you’re always a terrific guest.

Josh: Thank you for having me.

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