Title page

Contents

Highlights 2

Letter 6

Background 11

Medicare Provider Fees 11

Changes to Medicare Coverage of Telehealth in Response to the COVID-19 Pandemic 12

Beneficiary Privacy 14

Utilization of and Spending on Telehealth Services Increased Under Waivers; Services Were Concentrated Among 5 Percent of Providers and Beneficiaries 15

Utilization of and Spending on Telehealth Services Increased Post-Waivers, While In-Person Services and Overall Utilization Declined 16

Number of Beneficiaries Accessing Telehealth Services Increased Post-Waiver 17

Psychotherapy and Office Visits Were the Most Common Services Delivered under the Waivers, with 5 Percent of Providers Delivering 42 Percent of Services 18

CMS Identifies and Monitors Some Program Integrity Risks but Lacks Complete Data about Telehealth Delivery and Has Not Assessed Care Quality 22

CMS Took Actions to Monitor Some Program Integrity Risks, Including Investigating Potentially Problematic Providers and Identifying Long-Term Effect on Spending 23

CMS Cannot Fully Track Telehealth Visits That Are Audio-Only or Furnished in Beneficiaries' Homes Because of Billing Limitations 24

CMS Has Not Comprehensively Assessed the Quality of Services Delivered Using Telehealth 30

Patients May Be Unaware that OCR's March 2020 Telehealth Policy May Not Protect Patient Privacy 34

Stakeholders Believe Telehealth Waivers Enabled Access but Noted Limitations; Most Support Extension 40

According to Stakeholders, Waivers Enabled Access; Most Support Permanent Extension 41

Stakeholders Noted Telehealth Limitations for Services That Require Physical Exams; Beneficiary Groups Support Temporary Extension of Waivers 42

Stakeholders Indicated That Providers and Beneficiaries Relied on Audio-Only Technology to Access Telehealth 43

Stakeholders Indicated Expansion of Eligible Providers Enabled Service Delivery; a Few Noted Concerns when Providers Deliver Telehealth to New Patients 44

According to Stakeholders Equivalent Payment for Telehealth Services Enabled Access; Some Described Different Costs Related to Telehealth and In-Person Visits 44

Conclusions 45

Recommendations for Executive Action 46

Agency Comments and Our Evaluation 46

Appendix I: Objectives, Scope, and Methodology 52

Appendix II: Additional Information on Telehealth Utilization 59

Appendix III: Overview of Health Insurance Portability and Accountability Act of 1996 Privacy, Security, Enforcement, and Breach Notification Rules 63

Appendix IV: Comments from the Department of Health and Human Services 65

Appendix V: GAO Contact and Staff Acknowledgments 74

Table 1. Examples of Telehealth Coverage in Traditional Medicare, Before and Starting in or after March 2020 12

Table 2. Stakeholder Groups Interviewed 55

Table 3. Medicare Telehealth Utilization, by Service Type and Select Specialties, 2019 and 2020 59

Table 4. Medicare Telehealth Utilization, by Categories of Services, April-December 2019 and 2020 60

Table 5. Overview of HIPAA Privacy, Security, Enforcement, and Breach Notification Rules 63

Figure 1. Utilization of Medicare Services Delivered via Telehealth or In-person, by Month, April 2019-December 2020 17

Figure 2. Percentage of Medicare Telehealth Services, by Provider Specialty, for Selected Months in 2020 19

Figure 3. Percentage of Providers Delivering Medicare Telehealth Services Compared To In-Person Services, Post-Waiver April 2020-December 2020 20

Figure 4. Percentage of Medicare Telehealth Services Pre- and Post-Waiver, by Provider Location, April 2019-December 2020 21

Figure 5. Medicare Telehealth Services Pre- and Post-Waiver, by Service Type, April 2019-December 2019 and April 2020-December 2020 22

Figure 6. Use of Medicare Telehealth, by Beneficiary Characteristic, April-December 2020 62