We're in a very sad, desperate state, to be honest with you, Richard, one that is deeply upsetting to me, deeply upsetting to our ATA and ATA action members. And most critically, we are in a place in time, three days into this shutdown where Medicare beneficiaries and patients are objectively losing out. Welcome to off the chart, a business and medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Littrell. I'm the Assistant Editor of Medical Economics, and I'd like to thank you for like to thank you for joining us today at 12:01am, on October 1, the federal government went into shutdown, and at the very same moment the pandemic era, Medicare care telehealth flexibilities expired. Those policies had allowed physicians to treat patients virtually and be reimbursed for those visits. With the shutdown in effect, coverage for telehealth and the acute hospital care at home program were reverted to pre pandemic rules that sudden change cut off access for millions of patients and created confusion for physicians across the country. In this episode recorded on October 3, Medical Economics Senior Editor Richard Payerchin spoke with Kyle Zebley, Senior Vice President of Public Policy at the American Telemedicine Association, and executive director of ATA Action, its advocacy affiliate, zebly, explains how this lapse happened, what it means for physicians and patients and what Congress can do to restore these critical programs. He also shares insights on the future of telehealth, rural access to care, and what physicians can do right now to make their voices heard. Kyle, thank you for joining us, and now let's get into the episode. You With me today is Kyle Zebley, Senior Vice President for Public Policy for the American Telemedicine Association and executive director of ATA action, the organization's policy affiliate. Thank you for joining us today. It's great to be here. Richard, thanks so much. And just to set the stage, we talked about this a moment ago, we are in the third day of the federal government shutdown here in early October 2025 just so that our audience is familiar with the some of the time elements we may be talking about, and just to get started on day three here, can you explain what is the current state of the telehealth, flexibilities and allowances for Medicare? Right now we're in a very sad, desperate state, to be honest with you, Richard, one that is deeply upsetting to me, deeply upsetting to our ATA and ATA action members, obviously extraordinarily disruptive in the ability to deliver care for Medicare providers across the country. And most critically, we are in a place in time three days into this shutdown, as of today, October 3, late of morning, we're at a place in time where Medicare beneficiaries and patients are objectively losing out. They have lost access to areas of care and appropriate treatment that they have been able to receive for the five and a half years preceding this telehealth shutdown that commenced 12:01am October one. That's unacceptable. It shouldn't have happened. It needs to stop as quickly as possible. The longer this goes on, the worse the pain is for the American people. It's a it's a great shame that we are here because we're popular, we're bipartisan. There's no one that's out there objecting to continuing these telehealth flexibilities in the acute hospital care at home program, and yet, because of the dynamics around this government shutdown and the fact that our latest extension came up for needing another extension, right at the same time as the dynamics around the shutdown were very much a victim of circumstance, and I wish that wasn't the case, but here we are. Definitely want to focus on the present and the future here, not to dwell too much on the past, but just to give a brief recap of some recent history, how would you explain or describe the evolution of telehealth in the last five years, both in Medicare and private insurance. And as much as we hate to think about it, the covid 19 pandemic, well, the covid 19 pandemic was absolutely transformative for our telehealth community and for the whole concept of telehealth, digital health and virtual care, in particular, the level of uptake, the level of Americans that were receiving care in this clinically appropriate manner, in a way that could be done through the use and advent of advancements in technology. It really hadn't existed much prior to. The onset of the pandemic five and a half years ago, after the pandemic, you know, came and after a set of policies at the federal level, at the state level, encouraged adoption the unique dynamics of the pandemic, the encouragement to keep people at home if at all possible, particularly in the early days of the pandemic, and the instinct to try to lessen pressure and alleviate concerns around capacity in our healthcare system and the brick and mortar centers of healthcare delivery, it all led to this dynamic that has vastly expanded the scope, breadth, reach, access to of telehealth. That's a great thing. It's unfortunate that that it took something as devastating as a global pandemic once in a century, pandemic, you know, made it unfortunate. But this was a silver lining of the pandemic, and on a bipartisan basis, starting with President Trump's first administration, through to the Biden Harris administration up now, until, unfortunately, just a few days ago, the covid 19 era, telehealth, Medicare flexibilities and the acute hospital care at home program had been maintained uninterrupted. Unfortunately, this is, this is very unfortunate interruption of the continuity of those programs that have been in place on that bipartisan basis. Like I mentioned, it's a great segway, and to bring it back into the present with the growth that has taken place over the last five years, can you give an idea about the current scope and scale of telehealth usage, both in Medicare and in private insurance? It is a magnitude of many times exponentially greater than it had been prior to the pandemic, prior to the start of this decade of the 2020s in the Medicare program, roughly one out of four Medicare beneficiaries use it in a given year. We're talking about about 7 million Americans who rely on Medicare fee for service, for telehealth access, and in terms of total visits that are virtual, the Medicare program is approximating about 13% of total visits that are reimbursed are virtual in nature. And if you look at commercial insurance, we're somewhere in that similar range, of course, with lots of variables based on types of payers and states and regions and also, of course, the types of services. But it's overwhelmingly increased from a negligible amount prior to the pandemic to become a sustained, integrated, dependable with a big caveat there aspect of our health care system, and given the timing that we're talking about, even right now, strictly speaking, is the expiration of the telehealth flexibilities directly tied to the federal government shutdown, or could one happen without the other? One could happen without the other, and it's an important distinction. Congress must authorize these extensions of the telehealth flexibilities and the acute hospital care at home program. They need to proactively do so through a policy language included in a piece of legislation. It could exist outside of any government spending bill. And so you could have a situation where we would have been extended and the government still shut down, or vice versa. You could have had a situation where we were left out and the government still was funded and there was no shutdown. The reason why we're in the position that where are we are where our kind of telehealth flexibilities and acute hospital care at home shutdown has occurred at the same time as our government spending shutdown. It's because Congress really ends up, in a given year only passing a small number of bills. They must do a few things over the course of the year, raise debt ceiling periodically, and, of course, keep the government funded and therefore popular, bipartisan items that are broadly supported that the Congress wants to keep in place and make sure it doesn't expire. Oftentimes, as I would frame it, hitch a ride on a must move piece of legislation, mostly that has meant that we're hitching a ride on government funding bills that's served us well so far in terms of making sure these flexibilities don't go away. Unfortunately, again, we were a victim of circumstance caught up in. In this drama. And again, it's very frustrating, because nobody's out to get us, nobody's opposed to us, everybody's on the record in support of us, and yet we still got caught up in these unfortunate dynamics. And a moment again, another great segue, because a moment ago, you had mentioned about the different congressional actions that will take place, at the risk of asking them maybe obvious question here ATA has endorsed making permanent the telemedicine flexibilities that were allowed during the pandemic and have that that have been extended since then. Why would that be the optimal solution? Well, it's very unfortunate. We haven't gotten to permanency. I think if things were operating and functioning as they should at the federal government level, we would have been made permanent long ago. That's not to knock anybody. It's a systemic issue that's built up over years, but the muscle memory of Congress is that they don't pass many standalone pieces of legislation. The legislation they do pass do not go through the so called regular order of committee consideration, markup, full consideration on a floor of either chamber, working through differences in a conference committee between the two chambers on a similar piece of legislation, then finally getting something to the President's desk into law, the regular order that I just described really no longer is able to occur and and so by by muscle memory, they are, in a way, stuck to doing this big, massive bills that often come out at the Last minute that everybody in town, as in Washington, DC, are trying to, again, catch a ride on to be included on a policy rider. And so that's the dynamic that we've been in. We've got great permanent legislation, legislation that would make permanent these popular programs. They are extremely well supported. Indeed, the Connect for Health Act, for instance, has over 60, well over 60 senators as co sponsors, 60 of the 100 senators. This is a filibuster proof majority. And yet these unfortunate dynamics that impede, you know, productivity, legislatively, have led us to these short term extensions that Congress tends to, unfortunately do by instinct and habit. You know, in our nation's capital, there's always a lot of debate about the best way to spend money. Part of that is going to involve healthcare spending. How likely is it that Congress will allow retroactive reimbursement for online or telephone medical visits that take place right now? I think it is likely. But as ever, as an advocate, as somebody that is working on behalf of our membership to get the best deal we can out of Congress, we've got to understand that they might not. The request that we are making is a reasonable one, and one that I think will find currency with our bipartisan congressional champions. And that request to your point is that Congress will reimburse and make whole those Medicare providers who are delivering care throughout the shutdown of services. It's the right thing to do for them, the providers. It's the right thing to do for the community, and my hope is that they will allow for a process to do so, but there is no guarantee, and we just have to keep on pushing. And nobody should trust that it will happen until it's there in black and white, in legislative text and getting a signature from President Trump. I I say, Keith, this is all well and good, but what if someone is looking for more clinical information? Oh, then they want to check out our sister site, patient care online.com the leading clinical resource for primary care physicians. Again, that's patient care online.com, I think that really begs the next question, then, what is the best advice for medical practices to follow at this time? Should they continue as normal, or should they try to shift as many visits as possible to be in person? Well, I cannot offer a one size fits all blanket piece of advice each organization has to look in within themselves. Has to consult with their folks that are doing operations and compliance, coverage and reimbursement issues, and they have to decide, are we going to roll the dice? Take the risk? Continue to offer these services at potential financial loss to them, and with the hope that they'll eventually get reimbursed retroactively, as we're pushing for, and which we hope and really expect to see. But there's no guarantees, like I said, or are you in a position where you do not have the financial wherewithal to last that long because it's an unanticipated timeline. Here. We don't know how long the shutdown will last, and therefore you're going to make the very difficult decision to not continue to offer care to Medicare beneficiaries via virtual means. It's a set of bad options, and it's one that each organization have to make an assessment on with a risk based approach. But I can't offer any clear guidance other than what we know. And what we know is the acute hospital care at home program is effectively suspended. There's no if ands or buts about that. And in regard to the Medicare, telehealth flexibilities, other organizations with armed with the same information, any of your you know, viewers and listeners have armed with that same information, many esteemed organizations across the country are continuing to offer the services with the hope that they'll be made whole later on. There are some maybe nuances associated with that. I'm going to save those a little bit maybe later in the discussion, just depending on time and availability. But I because there's a couple other things I definitely wanted to get to as well. But one of the things that has always been just really interesting and fascinating to me is the dynamic between that takes place between Medicare and then private insurance, because sometimes Medicare can be very influential to private insurance. Sometimes vice versa. Sometimes they go in different directions. And what I guess I want to ask here is, with the expiration of Medicare flexibilities, are you aware of any drastic changes in telehealth reimbursement policy that has taken place among private insurers, no, I'm aware of no major changes that have occurred outside the Medicare Fee for Service Program. And that means that, you know, for instance, Medicare Advantage plans, Medicaid plans, various commercial insurance plans, have not announced any major changes at all that was to be expected. These flexibilities are very targeted to Medicare fee for service. Medicare Fee for Service is tremendously impactful and important, and that includes whether or not you're offering care to Medicare beneficiaries as an organization. It's important, because Medicare Fee for Service still sets the floor of expectations for what other payers will cover as Medicare goes, so do other payers, by and large, by practice. And so I think that the real question is, how long will this, this impasse, last. How long will these programs remain lapsed, and what is the path forward there to get to a place where we're no longer in this period of prolonged uncertainty? That's why we really need to push for permanency, and if not permanency, the longest extension possible. That's why every day that goes by is a greater and greater concern to the entire health care system, and it's why we need to end it. It's why we need to make those providers whole. It's why we need to use this as a rallying cry for permanency, so that we don't see any delayed negative impacts on telehealth coverage in these other payers, and you've touched on this in our conversation, mentioning about how telehealth in Medicare, and I think even among private payers generally, has enjoyed pretty strong bipartisan support in Congress and the White House. Do you foresee one party or the other might try to use it as a bargaining chip in the budget negotiations taking place. We haven't seen this yet. Both the House Republican plan and the Democratic counter proposal included in baked in an extension of Medicare telehealth flexibilities. We welcome that and we appreciate that, and again, it's a sign of our broad based support. But you know, you can never rule out anything. I would hope and expect that we continue to maintain our bipartisan posture, that we don't get caught up into partisan squabbling, we have seen remarkable, sustained bipartisan support that really consists of broad stated support and endorsement of these services, most folks. In Congress want to see them made permanent. President Trump's been a transformative, visionary leader on these issues, going back to his first administration and and we want to keep it that way. My membership expects us to work in good faith with both parties to get the best deal possible for patients across the country that have come to rely on these necessary services. And I think, in my mind, that definitely means that we have to keep ourselves as much as possible, as far away as possible from any hint of partisanship we've been talking in some fairly broad terms, and there are, like I said, some different nuances that come into play based on, you know, the type of care, the services that are needed for patients. And as I understand it, there may be some key differences right now in using telemedicine visits for mental health care versus using it for physical health care. Can you explain what those are, and should they be treated the same way? Well, couple of things in response there, at the end of 2020, the Congress did come together, and they made permanent telemental health as a permanent part of the Medicare program, regardless of an extension of flexibilities. We do have permanency for this important suite of services. That's good. The bad news is that comes encumbered with a clinically inappropriate, mandatory barrier to care in the form of in person requirements. And what that means is you've got to find, if we were in a period of time where the flexibilities are no longer persisting as we are now, you've got to find this unicorn of a telemental health provider that will see you periodically in person and then continue to deliver that care virtually. That doesn't make sense, doesn't allow for the full advantage of telehealth. It needs to be repealed. It needs to be precedent, never to be repeated. And one of the things that our extensions have done is forestall the implementation of this in person requirement. The Centers for Medicare, Medicaid services, to their great credit, have said if you already have an established relationship via telehealth, even post expiration, theoretical expiration of these flexibilities that have become all too real, you can continue to receive care from that previously established relationship. However, their hands are tied for new relationships moving forward during this period of the lapse, and again, that makes it significantly more complicated. So again, it's a bit of a tangled web of issues that are important to highlight now in terms of whether or not that was the right thing to do, or telemental health should be treated differently than other areas of care. We are of the belief that we all are wanting to empower all healthcare providers to apply the standard of care consistent with the terms of their state based license for their profession, to determine for themselves what can and can't be done appropriately via telehealth. And that's held us in great stead. It's about empowering our healthcare professionals to make the right determination on behalf of their patients as to what can and can't be done via telehealth. All areas of appropriate care should be covered and reimbursed by payers such as Medicare. At minimum, what we should never be in a position of is in this day and age where there are too few mental health providers to have in person requirements only for telemental health services as we look towards permanency, rather than for other services. That is a gross distortion of fairness. It's not clinically necessary, as I keep hammering and and we should be in a situation where all these services have a level playing field and are appropriately covered and getting reimbursed. Hey there. Keith Reynolds here, and welcome to the p2 management minute in just 60 seconds, we deliver proven, real world tactics you can plug into your practice today, whether that means speeding up check in, lifting staff morale or nudging patient satisfaction north. No theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom. They come from. You got a clever workflow. Hack an employee engagement win or a lesson learned the hard way. I want to feature it. Shoot me an email at K Reynolds at mjh life sciences.com with your topic, a quick outline or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count. Together. Thanks for watching, and I'll see you in the next p2 management minute. I think that, I think that appropriate coverage for physician and clinical autonomy number one is certainly going to resonate with our audience. So that's that is a, definitely an important point, and another thing I wanted to ask about, because you've mentioned it in Converse it in conversation, I had it on my list of questions here that I wanted to get to is regarding the acute hospital care at home program. It seems as though, and maybe I'm just not reading the right sources, but I feel like that program has been kind of existing and generally positive, but maybe a little under the radar regarding the acute hospital care at home program, maybe to ask a spiral question here, why is that program so important for telehealth, and why is telehealth so important for that program? Well, this program is extraordinarily important. It's an example of a creative policy makers doing the exact right thing at the right time. This program allowed for patients that were on their recovery journey to open up a hospital bed, leave that hospital setting, get hospital level care through the use of technology and hybrid care and some in person visits from hospital health care teams gets them back home where they want to be with their loved ones in the comfort of their own home, and allows for them to still receive clinically appropriate care. This is a visionary program that's the exact right direction that our healthcare system should be going. It opens up capacity, it increases patient satisfaction. It's done in a clinically appropriate way. What's not to like, but telehealth is intrinsic in the delivery of the program, synchronous. You know, video calls, remote. Physiologic monitoring devices that are still being then, you know, data that's produced by the patient that is being reviewed by the care team. It's done in hybrid care in a really effective way. So we think it's a very robust, appropriate program. We have over 400 participating hospitals in the program. It's worked. Unfortunately, we are in a situation now where it has been also, of course, caught up in these other broader dynamics that led to the shutdown of Medicare telehealth services. And like I had said, it's very cut and dry, the Office of Management and Budget has put forth guidance leading up to this shutdown, saying all patients need to either be discharged or brought back to a hospital setting effective 12:01am, October one. So it's a devastating impact for our community, and it's dragging us backwards prior to the onset of the pandemic, when all these positive advancements have been made and sustained. I'm frankly, really curious to see how hospital at home is going to develop, and I know that there is a segment of our audience, both like from the clinical side and the business side that is there. I don't want to say dabbling in it. That's not quite the right word. But I think they're really, really curious about how that's going to, you know, evolve as a both a business model and a clinical model. So we'll have things to talk about for that. One of the flexibilities that I wanted to ask about involves allowing rural health clinics and federally qualified health centers to serve as distant sites for telehealth. How important is that for rural health care? It's extraordinarily important. We are very supportive of our federally qualified health centers, rural health clinics, being able to cover and get reimbursed for telehealth services by its very design and nature, FQHCs and RHCs are on the front lines, physically and and rhetorically in terms of the delivering of services to underserved communities that are oftentimes isolated from other areas of care access. So they're a fundamental, important, critical part of our healthcare system, and they have benefited from these Medicare telehealth flexibilities. And of course, as much as possible, wherever possible, we need to make sure that various flexibilities are being used to the max in order to maintain as much access to care as possible, so and then, so far as they would be used as distance site clinics, so that it would suffice for geographic and originating site needs and requirements during in particular, this period of the overall lapse. It's absolutely critical and fundamental that we do all we can to support. For that being the case and main being maintained moving forward for however long the duration of this lapse is one of the things we always like to focus on is, is solutions, of course, and provide news you can use so to speak to our audience. Ata has created a grassroots advocacy tool for physicians, patients, or anyone to express their support for telehealth programs. Is that still online? And can you explain how people can access that? It sure is online. It's readily accessible via the various ATA newsletters that ATA members have access to, and it's something that is critical for the American people to get involved. It's a very simple tool that we continue to update as an appropriate including since the shutdown of these services. It's an easy way for you to send a written communication to your congress person and your representative, as well as your two senators. It's a way that you could send a written communication. It's a way that also could very easily, readily connect you via phone to call direct to those two senators and your member of Congress. You know, often have said to folks that you know politics and public policy is not a spectator sport, particularly if you care, particularly if you're fighting for yourself or your loved ones to continue these needed services, you got to get off the sidelines. You got to play ball and and that means making sure that your elected representatives, your congressional delegations hearing from you and that your message is clear, the shutdown of these services of the acute hospital care at home program is unacceptable. It is hurting people now. It's hurting people worse and worse with every hour and every day that goes by without these flexibilities and this program being back into effect, and so it's a great way to get involved with the different legislation. Frankly, I wanted to ask about some of that, but we can, if I may. I'd like to reserve some time, maybe when something goes through committee or comes to a vote in Congress, that I think would be a great time to catch up. Maybe just to close out, a question I always like to ask. Of course, our main audience is primary care physicians. What would you like to say to them? Or what would you like them to know? Well, I delivered a similar message to them in the past. Again, it's that there are few messengers more important than our physicians that are present in communities across the country, they're credible with their patients. They're credible messengers in the community. They deliver clear messages to their elected representatives, and when they speak, particularly as much as possible, when they speak with one voice is extraordinarily powerful. And so there's a lot of different competing priorities for the time of your of your membership and listeners and those that view the work that you do. But I think that this is an extremely important time again to get involved, to use that credibility that they have in their communities to good effect by weighing in with their elected representatives, with their senators, and saying, Stop the insanity and bring back these Popular, bipartisan programs that really increase access to care in a clinically appropriate way, and that lessen the overwhelming burden and stress and strain that exists now in our US healthcare system. I'm Richard Payerchin reporting for medical economics. My guest today has been Kyle Zebley from American Telemedicine Association and ATA action. It's been a great conversation, and thank you so much for taking the time with us today. It's great to be here. Richard, thanks so much. You again, that was a conversation between medical economics senior editor Richard Payerchin and Kyle Zebley, Senior Vice President of the American Telemedicine Association and executive director of ATA Action. My name is Austin Littrell, and on behalf of the whole Medical Economics and Physicians Practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode. Be sure to check back on Monday and Thursday mornings for the latest conversations with experts, sharing their strategies, stories and solutions for your practice. You can find us by searching off the chart wherever you get your podcasts. Also, if you'd like the best stories that Medical Economics and Physicians Practice published delivered straight to your email six days of the week. Subscribe to our newsletters at medicaleconomics.com and physicianspractice.com Off the Chart: A Business of Medicine Podcast is executive produced by Chris Mazzolini and Keith Reynolds and produced by Austin Littrell. Medical Economics, Physicians Practice and Patient Care Online are all members of the MJH Life Sciences family. Thank you.