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What Will End of COVID Public Health Emergency Mean for School-Based Telehealth?

Ramirez & Buher: How states, districts & Washington can ensure that students will continue to have access to this valuable public health resource

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The expiration of the COVID-19 Public Health Emergency, 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 driven a surge in telehealth utilization among older Americans, enabled by regulatory waivers and flexibilities from the Centers for Medicaid and Medicare Service.

The same is true for the over 33 million children and adolescents served by Medicaid, the state-run government program that helps pay health care costs for people with limited income. While states have broad flexibility to determine whether to cover telehealth services under Medicaid, 49 states now have policies that allow for the reimbursement of at least one type of service when provided via telehealth in schools; 24 states had similar policies prior to the pandemic. So while school-based telehealth is not new, catalytic advances in school-based telehealth implementation were based on the widely shared goals of protecting student health and well-being, minimizing visits to local emergency rooms — already stretched thin because of the pandemic and its financial impacts — and providing better care to children and adolescents to optimize in-person learning.

This expansion was, and remains, an important equity opportunity for students, families and schools. First, telehealth holds the promise of dramatically expanded access to, and availability of, different types of physical and mental health care, regardless of where a student lives. Second, telehealth can potentially reduce out-of-pocket costs for patients due to inefficiencies in care, particularly in rural geographies. Third, given the widespread concerns around school staffing, telehealth represents an opportunity to maximize the impact of a capacity-limited workforce. Maybe most critically, telehealth decreases burdens on families and students, for example, by reducing transportation challenges that can hinder access to care, resulting in more time spent in class.  

Given the potential benefits of telehealth and evidence that for some conditions, such school-based care can improve the quality and effectiveness of care, it would seem nonsensical to dramatically scale back this service that matured during the pandemic.

There are, however, lingering policy and programmatic concerns relative to school-based telehealth delivery and governance that must be addressed for it to remain a viable health care model. For instance, a recent HHS Office of Inspector General report concluded that approximately $130 million billed to Medicare during the first year of the pandemic for telehealth services included practices deemed high risk. Medicare is of course, not Medicaid. That said, the provision of unnecessary services, waste and fraud that have been documented in Medicare telehealth services likely exist in state-level Medicaid programs — based on previous occurrences of large-scale fraud —and necessitate additional safeguards if telehealth is to become sustainable in schools. Additionally, there is the potential for violations of the Controlled Substances Act. Providers have recently been scrutinized by the Drug Enforcement Agency for prescribing controlled substances improperly. As many telehealth providers are increasingly serving children and adolescent populations, the risks of inappropriate prescribing are concerning.   

The costs associated with a permanent extension of Medicare telehealth coverage pose another challenge. The Congressional Budget Office estimated that a two-year expansion of Medicare telehealth flexibilities would cost $2.5 billion. Again, while Medicare does not serve school-age populations, it has implications for schools. Medicare’s market power is so significant that decisions around Medicare and telehealth will likely impact how Medicaid and private insurers reimburse school-based telehealth services. If Medicare coverage for telehealth ends next year, it is difficult to see Medicaid coverage for school-based services remaining in place without significant revisions to existing policies, well-resourced and coordinated advocacy campaigns or a significant change in the economic outlook. Given the current variability in Medicaid coverage across states, schools using telehealth have relied on additional funding streams including grants, private insurance, federal pandemic relief money and other state sources. The formula schools have put in place to pay for telehealth services will likely need to be altered, if not entirely rethought. 

The dynamics around an extension of COVID emergency flexibilities remain uncertain. Proposed legislation circulating in Congress would extend them, but the costs and policy concerns pose a severe challenge to any congressional action. What is clear is that the Centers for Medicaid and Medicare Service and the U.S. Department of Education need to issue guidance for states, districts and schools that outline the various Public Health Emergency scenarios and requisite actions. 
For now, district and school health leaders should ensure they deeply understand the status of emergency waivers and the flexibilities that their organizations are utilizing. They should also reorient themselves with federal and state policies and procedures that were in place before the pandemic. They should similarly educate partner providers and school-based health staff on the current uncertainty around the emergency’s expiration and explain the potential need for swift implementation of new policies and procedures should the emergency not be extended. This work has significant budget implications. Finally, they should ensure that any additional requirements imposed on their organizations by the emergency flexibilities that are not expiring meet ongoing regulatory requirements.

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