Telehealth can’t succeed without expanding access to affordable broadband internet, witnesses told the Senate Committee on Commerce, Science, and Transportation on Thursday.

But extending the regulatory flexibilities around this access granted under the public health emergency, which are slated to expire when the COVID-19 pandemic subsides, is also critical, they said, stressing that the benefits of telemedicine can’t be understated.

Brendan Carr, commissioner of the Federal Communications Commission (FCC), described how innovations like a “smart emergency room” on the Pine Ridge Reservation in South Dakota allows a team of emergency department specialists in Sioux Falls, hundreds of miles away, to guide generalists through complicated procedures when there’s no time to transfer patients to a more specialized facility.

And in the realm of behavioral health, in one Indian Health Service area near Billings, Montana, telemedicine allows clinicians to provide behavioral health care to patients in their homes, which has resulted in a 40% decline in no-show rates compared with clinic visits, said Deanna Larson, CEO of Avel eCARE.

These services were made possible by funding that was included in the COVID telehealth program, she added.

In addition, remote monitoring can give clinicians a “window” into patients’ lives, said Sanjeev Arora, MD, founder of Project ECHO and a professor of internal medicine at the University of New Mexico in Albuquerque.

For example, if an elderly woman who’s wearing a wireless remote device has difficulty with her gait, that device can send a message to alert clinicians that she is unsteady, potentially avoiding a fall and a hip fracture. As seen in Carr’s Pine Ridge example, “telementoring” is another aspect of telemedicine that benefits patients. Multidisciplinary teams of providers can help to “upskill” clinicians in more remote areas, or areas that lack specialists, through case-based learning and mentor-mentee relationships.

But a “prerequisite” to leveraging any one of these telehealth models in rural areas or underserved urban areas is access to high-quality, high-speed broadband connectivity, Arora said.

Making these broadband internet services affordable is key to narrowing the digital divide, some witnesses agreed.

Sterling Ransone, Jr., MD, president of the American Academy of Family Physicians, said that the cost to providers who want to leverage telehealth technologies can be “prohibitive.” Telemedicine vendors can charge setup fees of up to $3,000 on top of “recurring subscription and transaction fees,” he noted.

He urged Congress to ensure that small physician practices are supported either by making sure facilities are eligible for funding through existing FCC programs or by developing new ones.

In his opening statement, Carr spoke about the Connected Care Pilot Program that launched in April 2020. The initiative directs up to $100 million from the Universal Service Fund over 3 years to approved participants and pays for 85% of the costs of providing “connected care services” to patients, including broadband connectivity, network equipment, and information services. The FCC has awarded $58 million to date, he said.

The CARES Act also provided the FCC with an additional $200 million in funding from which the commission stood up a COVID-19 telehealth program similar to the Connected Care model. The FCC awarded all of the funding from that bill by July 2020, at which point Congress funnelled another $250 million, of which $80 million has been allocated.

“I think the most important challenge at the moment is implementation, because we have a lot of dollars … already spread out across the departments of Agriculture, Commerce, Education, [and] Treasury,” said Carr. “We got to make sure we move in a coordinated way, so we’re not putting money on top of other dollars, or wasting it, because this issue is just too important … to not fully coordinate on this.”

Larson, who applied and received COVID relief funding for her company, said that she and her colleagues used the monies to set up telemedicine in more emergency settings and skilled nurse facilities, as well as in in-home settings.

“The funding worked really well for us,” she noted. While her company was able to get equipment where it was needed quickly, reimbursement took 12 months. Larson said they did not apply for a second time because “there were a lot of unknowns” and they weren’t sure when the reimbursement would arrive.

However, she stressed her appreciation for the program. “We were able to impact hundreds and hundreds of lives through the funding we received,” she added.

“It seems like we ought to be able to improve on a 12-month reimbursement rate, even for organizations as inefficient as the federal government,” said Sen. Todd Young (R-Ind.) in response to Larson’s concerns.

Witnesses also underscored the importance of preserving the telehealth flexibilities and funding granted during the pandemic, which are expected to expire after the COVID-19 public health emergency ends.

Prior to the pandemic, only about 15% of family physicians provided telehealth services, said Ransone. But about 6 weeks after the pandemic began, more than 90% of family physicians were providing care using telehealth.

He worries what will happen if that funding were to vanish. For years, Ransone saw patients in their home to keep them out of the hospitals; now, telehealth has allowed him to expand his house call services.

“When we can … monitor our patients closely, we can keep them from going downhill and we can keep them out of the hospital, so continued funding is incredibly important,” he said.

Ransone in particular stressed the need to continue funding audio-only services. When doing video visits, he said he rarely sees any of his geriatric patients alone; there’s always a younger person in the room. Many of his patients over 80 rely on audio-only telemedicine, which he uses to monitor patients who may not have younger family members or friends to help them.

“I think keeping that availability of audio-only telemedicine services and funding there is incredibly important to help me take good care of my patients,” he added.

Larson said that telemedicine can be a solution to workforce problems, but regulatory and licensing issues can get in the way.

It’s important to think about having a network of providers who can work across states lines, she noted. For example, a child in rural South Dakota should be able to access specialist care remotely from a clinician in another state.

“There’s no reason for a pediatric rheumatologist to be in South Dakota. There’s not enough patients for him or her to take care of. But in a neighboring state, maybe two or three of those states in the Midwest, they could do a great amount of care,” she continued. However, barriers to licensure and other bureaucracies can limit clinicians’ ability to provide care across states.

For a busy physician to provide all of the information that individual states require — some of which ask for clinicians to come to the state to be fingerprinted — is difficult, and often duplicative, Larson noted.

“I have … emergency physicians who are appointed in 200 locations across the U.S., [which means] 200 different sets of bylaws that they have to be accountable to, achieve and accomplish, and keep up in 200 different facilities. That’s just the governance at the local site that’s required by the conditions of participation,” she said.

Sen. Roy Blunt (R-Mo.) said he supports the TREAT Act, which authorized the provision of interstate telehealth care, with the aim of helping to mitigate some of the challenges with licensure.