Telehealth Policy and Access to Care

Main Article Content

Charles M. Lepkowsky


The COVID-19 pandemic has highlighted limitations in access to healthcare. During the current public health emergency (PHE), Medicare, private insurers and state licensing boards have made policy changes liberalizing reimbursement for telehealth. Historically, Medicare and large private insurers (in the US) have presumed information technology (IT) fluency by patient populations. However, data demonstrate that there are numerous populations who demonstrate very limited utilization of IT for accessing healthcare, including older adults. These data demonstrate the importance of assessing IT utilization to make healthcare accessible to individual patients, and to better understand patterns of IT utilization among groups with historically low IT utilization. Under pressure from medical and consumer groups, Medicare and private insurers allowed reimbursement for telephone-only virtual visits during the PHE, but indicate that termination of the PHE will be coupled with termination of more liberal telehealth policies. In addition, Medicare and private insurers continue to seek loopholes allowing exclusion of various types of telehealth, which will make telehealth (and healthcare) inaccessible to the most vulnerable populations, including older adults. Recommendations are made for assessment of IT utilization as part of routine patient intake assessment, in order to make healthcare accessible, improve communication between patients and healthcare providers, and to improve treatment outcomes. Recommendations are also made for permanent telehealth policy changes that will make healthcare more accessible to at-risk populations.

Article Details

How to Cite
LEPKOWSKY, Charles M.. Telehealth Policy and Access to Care. Medical Research Archives, [S.l.], v. 10, n. 5, june 2022. ISSN 2375-1924. Available at: <>. Date accessed: 30 june 2022. doi:
Research Articles


1. Wesemann U, Hadjamu N, Willmund G, Dolff S, Vonderlin N, Wakili R, Vogel J, Rassaf T, Siebermair J. Influence of COVID-19 on general stress and posttraumatic stress symptoms among hospitalized high-risk patients. Psychol Med. 2020 Aug;14:1-2. doi:10.1017/S0033291720003165
2. Jakovljevic M, Bjedov S, Jaksic N, Jakovljevic I. COVID-19 Pandemia and public and global mental health from the perspective of global health security. Psychiatr Danub. 2020 Spring;32(1):6-14. doi:10.24869/psyd.2020.6
3. McGonagle KA, Kessler RC. Chronic stress, acute stress, and depressive symptoms. Am J CommunPsychol. 2020;18:681–706.
4. Mariotti A. The effects of chronic stress on health: new insights into the molecular mechanisms of brain-body communication. Future Sci OA. 2015;1(3):FSO23. doi:10.4155/fso.15.21
5. McEwen BS. Neurobiological and Systemic Effects of Chronic Stress. Chronic Stress (Thousand Oaks). 2017 Jan-Dec;1:2470547017692328. doi:10.1177/2470547017692328
6. Vyas A, Mitra R, Shankaranarayana Rao BS, Chattarji S. Chronic stress induces contrasting patterns of dendritic remodeling in hippocampal and amygdaloid neurons. J Neurosci. 2002 Aug 1;22(15):6810-8. doi:10.1523/JNEUROSCI.22-15-06810.2002
7. Peden CJ, Mohan S, Pagán V. Telemedicine and COVID-19: an observational study of rapid scale up in a US academic medical system. J Gen Intern Med. 2020 Sep;35(9):2823-2825. doi:10.1007/s11606-020-05917-9
8. Mann DM, Chen J, Chunara R, Testa PA, Nov O. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc. 2020 Jul 1;27(7):1132-1135. doi:10.1093/jamia/ocaa072
9. Wosik J, Fudim M, Cameron B, Gellad ZF, Cho A, Phinney D, Curtis S, Roman M, Poon EG, Ferranti J, Katz JN, Tcheng J. Telehealth transformation: COVID-19 and the rise of virtual care. J Am Med Inform Assoc. 2020 Jun 1;27(6):957-962. doi:10.1093/jamia/ocaa067
10. Ramaswamy A, Yu M, Drangsholt S, Ng E, Culligan PJ, Schlegel PN, Hu JC. Patient satisfaction with telemedicine during the COVID-19 Pandemic: Retrospective cohort study. J Med Internet Res. 2020 Sep 9;22(9):e20786. doi:10.2196/20786
11. Bokolo Anthony Jnr. Use of telemedicine and virtual care for remote treatment in response to COVID-19 pandemic. J Med Syst. 2020 Jun 15;44(7):132. doi:10.1007/s10916-020-01596-5
12. Farrugia G, Plutowski RW. Innovation lessons from the COVID-19 pandemic. Mayo Clin Proc. 2020 Aug;95(8):1574-1577. doi:10.1016/j.mayocp.2020.05.024
13. Julien HM, Eberly LA, Adusumalli S. Telemedicine and the forgotten America. Circulation. 2020 Jul 28;142(4):312-314. doi:10.1161/CIRCULATIONAHA.120.048535
14. Smith AC, Thomas E, Snoswell CL, Haydon H, Mehrotra A, Clemensen J, Caffery LJ. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020 Jun;26(5):309-313. doi:10.1177/1357633X20916567
15. Shah ED, Amann ST, Karlitz JJ. The Time Is Now: A guide to sustainable telemedicine during COVID-19 and beyond. Am J Gastroenterol. 2020 Sep;115(9):1371-1375. doi:10.14309/ajg.0000000000000767
16. Cubo E, Hassan A, Bloem BR, Mari Z; MDS-telemedicine study group. implementation of telemedicine for urgent and ongoing healthcare for patients with Parkinson's Disease during the COVID-19 pandemic: New Expectations for the Future. J Parkinsons Dis. 2020;10(3):911-913. doi:10.3233/JPD-202108
17. Keesara S, Jonas A, Schulman K. Covid-19 and health care's digital revolution. NEJM. 2020;382(23):e82. doi:10.1056/NEJMp2005835
18. Chang JE, Lai AY, Gupta A, Nguyen AM, Berry CA, Shelley DR. Rapid transition to telehealth and the digital divide: Implications for primary care access and equity in a post-COVID era. The Milbank Quarterly. 2021;99(2):340-368, doi:10.1111/1468-0009.12509
19. Centers for Medicare and Medicaid Services. Additional background: Sweeping regulatory changes to help U.S. healthcare system address COVID-19 patient surge. 2020. Accessed April 30, 2022.
20. Centers for Medicare and Medicaid Services. Billing for professional telehealth distant site services during the public health emergency — Revised. 2020. Accessed April 30, 2022.
21. Centers for Medicare & Medicaid Services. CMS-1744-IFC: Medicare and Medicaid programs; policy and regulatory revisions in response to the COVID–19 public health emergency. 2020. Accessed April 30, 2022.
22. Payán DD, Frehn JL, Garcia L, Tierney AA, Rodriguez HP. Telemedicine implementation and use in community health centers during COVID-19: Clinic personnel and patient perspectives. SSM - Qualitative Research in Health. 2022; 2:100054. ISSN 2667-3215.
23. Center for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): People who are at higher risk for severe illness. 2020. Accessed April 30, 2022.
24. Skillings J. Billing Update: New phone-only billing codes. 2020. Retrieved from:
25. U.S. Department of Health and Human Services. Telehealth was critical for providing services to Medicare beneficiaries during the first year of the COVID-19 pandemic. 2022.
26. Lepkowsky CM. Telehealth reimbursement allows access to mental health care during COVID-19. American Journal of Geriatric Psychiatry. 2020;28(8):898-899.
27., the official U.S. Government site for Medicare. 2018. Accessed 08/15/2018.
28. Centers for Medicare and Medicaid Services. Get started with Medicare. 2018. hellomedicare_launch_aug2018&ppc&google&nonbrand&medicare%20online&gclid=CjwKCAjw2MTbBRASEiwAdYIpsXeJvoRYuJYjaLAkO77rkUy4AxsT4s3tksmE-jXk8mWoC66G_v2_YBoC45QQAvD_BwE&gclsrc=aw.ds. Accessed 08/15/2018.
29. Health Care Partners. Choose the Medicare plan that’s right for you. 2018. Accessed 08/15/2018.
30. United Healthcare Insurance Company. AARP Medicare supplement plans. 2018. Accessed 08/15/2018.
31. Blue Cross Blue Shield. 2018. Internet. Available from: Accessed 08/15/2018.
32. United Healthcare. Welcome to United healthcare online. 2018. Accessed 08/15/2018.
33. Aetna. You don’t join us, we join you. 2018. Accessed 08/15/2018.
34. Health Net. We are your Health Net. 2018. Accessed 08/15/2018.
35. Humana. Changes are coming to 2018. Accessed 08/15/2018.
36. Sansum Clinic. MyChart login page. 2018. Accessed on 0815/2018.
37. Lovelace Health System. MyChart Lovelace. 2018. Accessed 08/15/2018.
38. Northwestern Medicine. 2018. Accessed 08/15/2018.
39. Washington University Physicians. MyChart BJC health care. 2018. Accessed 08/15/2018.
40. UTMB Health. MyChart. 2018. Accessed 08/15/2018.
41. Duke University. Duke MyChart. 2018. Accessed 08/15/2018.
42. Health Partners Park Nicolette. Welcome to MyChart. 2018. Accessed 08/15/2018.
43. Cleveland Clinic. MyChart. 2018. Accessed 08/15/2018.
44. Wellstar. MyChart. 2018. Accessed 08/15/2018.
45. U.S. Census Bureau. Measuring America: A digital nation. 2016. nation.pdf. Accessed 06/24/2017.
46. Dobransky K, Hargittai E. The disability divide in internet access and use. Information, Communication & Society. 2006;9(3):313-334. doi:10.1080/13691180600751298
47. Tanis ES, Palmer S, Wehmeyer M, Davies DK, Stock SE, Lobb K, Bishop B. Self-report computer-based survey of technology use by people with intellectual and developmental disabilities. Intellectual and Developmental Disabilities. 2012;50(1):53-68. doi:10.1352/1934-9556-50.1.53
48. Davies DK, Stock SE, King LR, Brown RB, Wehmeyer ML, Shogren KA. An interface to support independent use of facebook by people with intellectual disability. Intellectual and Developmental Disabilities. 2015;53(1):30-41. doi: 10.1352/1934-9556-53.1.30
49. Anthony DL, Campos-Castillo C, Lim CPS. Who isn't using patient portals and why? Evidence and implications from a national sample of US adults. Health Affairs. 2018;37(12):1948-1954. doi:10.1377/hlthaff.2018.05117
50. Lepkowsky CM. Functional Assessment of Comfort Employing Technology Scale (FACETS): A brief intake instrument to facilitate treatment planning and communication with patients. 2017; Psychology Behav Med Open Access J;1(1):9-13.
51. Lepkowsky CM. Technological diversity: A cost-saving, person-centered
alternative to systemic technocentrism and technological provider bias. 2017; Psychology Behav Med Open Access J;1(1):1-7.
52. Lepkowsky CM. Functional Assessment of Currently Employed Technology Scale (FACETS) 4.0: Update on a brief intake instrument to facilitate treatment planning and communication with patients. 2020; International Journal of Medical Science and Clinical Invention;7(5):4802-4809.
53. Niehaves B, Plattfaut R. Internet adoption by the elderly: employing IS technology acceptance theories for understanding the age-related digital divide. European Journal of Information Systems. 2014;23(6):708–726.
54. Vroman KG, Arthanat S, Lysack C. “Who over 65 is online?” Older adults’ dispositions toward information communication technology. Computers in Human Behavior. 2015;43:156-166. doi:10.1016/j.chb.2014.10.018
55. Anderson M, Perrin A. Tech adoption climbs among older adults. Pew Research Center: Internet & Technology. 2017. Accessed 06/24/2017.
56. U.S. Census Bureau. Computer and internet use in the United States: 2003. 2003. Accessed 06/24/2017.
57. Lepkowsky CM, Arndt S. The Internet: Barrier to Health Care for Older Adults? Practice Innovations. 2019;4(2):124-132.
58. Center for Medicare Advocacy. CMS report finds access to care problems for low-income Medicare beneficiaries. 2015. Accessed 08/15/2018.
59. Hoffman D, Novak T, Schlosser A. The evolution of the digital divide: how gaps in internet access may impact electronic commerce. Journal of Computer-Mediated Communication. 2000;5(3):JCMC534,
60. DiMaggio P, Hargittai E. From the 'Digital Divide' to 'Digital Inequality': Studying internet use as penetration increases. Center for Arts and Cultural Policy Studies. Working Paper #15. (2001).
61. Dimaggio P, Hargittai E, Celeste C, Shafer S. Digital inequality: From unequal access to differentiated use. Social Inequality. 2004:255-400. ISBN 0871546205, 9780871546210.
62. Payán DD, Rodriguez HP. Telehealth disparities. Health Affairs. 2021;40(8):1340. doi:10.1377/hlthaff.2021.00940
63. U.S. Census Bureau. Projections of the size and composition of the U.S. population: 2014 to 2060. 2015. Accessed 04/30/2022
64. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2016. Accessed 04/30/2022
65. Hayes SL, Salzberg CA, McCarthy D, Radley D, Abrams MK, Shah T, Anderson G. High-need, high-cost patients: Who are they and how do they use health care? A population-based comparison of demographics, health care use, and expenditures. The Commonwealth Fund. 2016. Accessed 04/30/2022
66. Health Care Cost Institute. 2016 Health Care Cost and Utilization report. 2017. Accessed 04/30/2022.
67. Centers for Medicare and Medicaid Services. NHE by Age Group and Gender, Selected Years 2002, 2004, 2006, 2008, 2010, 2012, and 2014. 2014.,%2Dage%20person%20(%247%2C153). Accessed 04/30/2022.
68. American Psychological Association Services, Inc. (2020). Phone only telehealth services for Medicare during COVID-19. Accessed May 1, 2022.
69. Haskard Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: A meta-analysis. Medical Care. 2009;47:826–834.
70. Vermeir P, Vandijck D, Degroote S, Peleman R, Verhaeghe R, Mortier E, Hallaert G, Van Daele S, Buylaert W, Vogelaers D. Communication in healthcare: a narrative review of the literature and practical recommendations. Int J Clin Pract. 2015 Nov;69(11):1257-67. doi: 10.1111/ijcp.12686
71. Hill R, Betts LR, Gardner SE. Older adults’ experiences and perceptions of digital technology: (Dis)empowerment, wellbeing, and inclusion. Computers in Human Behavior. 2015;48:415-423. doi: 10.1016/j.chb.2015.01.062
72. American Psychological Association. Guidelines for psychological practice with older adults. 2014. Accessed May 1, 2022.
73. Lepkowsky CM, Arndt SA. Functional Assessment of Currently Employed Technology Scale (FACETS): Reliability and validity. International Journal of Medical Science and Clinical Invention. 2018;5(9):4064-4068.
74. Cabeza R, Grady CL, Nyberg L, McIntosh AR, Tulving E, Kapur S, Jennings JM, Houle S, Craik FI. Age-related differences in neural activity during memory encoding and retrieval: a positron emission tomography study. J Neurosci. 1997 Jan 1;17(1):391-400. PMID: 8987764. Accessed may 10, 2022.
75. Burke S, Barnes C. Neural plasticity in the ageing brain. Nat Rev Neurosci. 2006;7:30–40. Accessed may 10, 2022.
76. Goh JO, Park DC. Neuroplasticity and cognitive aging: the scaffolding theory of aging and cognition. Restor Neurol Neurosci. 2009;27(5):391-403. doi: 10.3233/RNN-2009-0493. PMID: 19847066; PMCID: PMC3355626. Accessed may 10, 2022.
77. American Psychological Association. Telehealth after the pandemic: CMS outlines proposed changes. 2021. Accessed May 1, 2022.
78. American Psychological Association. Recent changes in CMS guidance for telehealth regarding the in-person visit requirement and place of service codes. 2022. Accessed May 1, 2022.
79. Centers for Medicare and Medicaid Services (CMS). CY2022 Telehealth update Medicare physician fee schedule. Accessed May 1, 2022.
80. Centers for Medicare & Medicaid Services. About Medicare. 2022. Accessed May 9, 2022.
81. Michigan Elder Justice Initiative. What is Medicare? 2022. Accessed May 9, 2022.
82. Centers for Medicare and Medicaid Services. Physician fee schedule. 2022. Accessed May 9, 2022.
83. Centers for Medicare and Medicaid Services. How is Medicare funded? 2022. Accessed May 9, 2022.
84. Centers for Medicare and Medicaid Services. Office of Financial Management. 2022. Accessed may 9, 2022.
85. Medicare Payment Advisory Committee. Report to the Congress. 2021. Access May 9, 2022.
86. The boards of trustees, federal hospital insurance and federal supplementary medical insurance trust funds. 2021 annual report of the boards of trustees of the federal hospital insurance and federal supplementary medical insurance trust funds. 2022. https://efaidnbmnnnibpcajpcglclefindmkaj/ Accessed May 9, 2022.
87. Berkowitz E. Medicare and Medicaid: the past as prologue. Health Care Financ Rev. 2005-2006 Winter;27(2):11-23. PMID: 17290633; PMCID: PMC4194925. Accessed may 9, 2022.
88. Glied SA. Financing Medicare into the future: Premium support fails the risk-bearing test. Health Affairs. 2018;37(7). Accessed May 9, 2022.
89. Cubanski J, Neuman T. Medicare’s finances have gotten much worse in recent years, foreshadowing tough choices for November’s winners. Kaiser Family Foundation. Policy Watch. 2022;. Accessed May 9, 2022.
90. Folliard ET. Medicare bill signed by Johnson: 33 Congressmen attend ceremony in Truman Library. Washington Post, Times Herald. July 31, 1965. Accessed May 9, 2022.
91. United States Census Bureau. Statistical Abstract of the United States: 1965. Accessed May 9, 2022.
92. United States Census Bureau. The population 65 years and older in the United States. 2018. Accessed May 9, 2022.
93. Centers for Medicare and Medicaid Services. NHE Fact Sheet. 2022. Accessed May 10, 2022.
94. Alemayehu B, Warner KE. The lifetime distribution of health care costs. Health Serv Res. 2004 Jun;39(3):627-42. doi: 10.1111/j.1475-6773.2004.00248.x. PMID: 15149482; PMCID: PMC1361028. Accessed may 10, 2022.
95. Cubanski J, Neuman T, Freed M. The facts on Medicare spending and financing. Kaiser Family Foundation. 2019. Accessed May 10, 2022.
96. Capretta JC. Rethinking Medicare. National Affairs, Spring 2022; 51. Accessed May 10, 2022.
97. Medicare FAQ. How the Medicare tax rate is changing. September 27, 2021. Accessed May 10, 2022.
98. Fontenot K, Brandt C, McClellan MB. A primer on Medicare physician payment reform and the SGR. 2015. USC-Brookings Schaeffer on health policy. Accessed May 12, 2022.
99. Clemens J, Veuger S. Repeal of the Medicare Sustainable Growth Rate: Direct and indirect consequences. AMA J Ethics. 2015;17(11):1053-1058. doi: 10.1001/journalofethics.2015.17.11.pfor1-1511.
100. U.S. Bureau of Labor Statistics. Inflation Calculator. 2022. Accessed May 10, 2022.
101. Roy A. Saving Medicare from itself. National Affairs. Spring 2022; 51. Accessed May 10, 2022.
102. Centers for Medicare and Medicaid Services. MACRA. 2022. Accessed May 10, 2022.
103. Payerchin R. Physicians spend 4.5 hours a day on electronic health records. Medical economics. 2022. Accessed May 10, 2022.
104. Yaraghi N. MACRA proposed rule creates more problems than it solves. Health Affairs Forefront. 2016. doi:10.1377/forefront.20161012.057043. Accessed May 10, 2022.
105. Boyle P. U.S. physician shortage growing. American Academy of Medical Colleges: Workforce. 2022. Accessed May 10, 2022.
106. The complexities of physician supply and demand: Projections from 2018 to 2033. American Academy of Medical Colleges. 2022. Accessed May 10, 2022.
107. Ochieng N, Schwartz K, Neuman T. How many physicians have opted-out of the Medicare program? Kaiser Family Foundation. 2020. Accessed May 10, 2022.
108. Yu J, Jena AB, Mandic PK, Golberstein E. Factors Associated with Psychiatrist Opt-out from US Medicare: an Observational Study. J Gen Intern Med. 2019 Nov;34(11):2460-2466. doi: 10.1007/s11606-019-05246-6. Epub 2019 Aug 16. PMID: 31420824; PMCID: PMC6848419.
109. Nordal K. Re: Request for information regarding implementation of the Merit-Based Incentive Payment System, promotion of alternative payment models, and incentive payments for participation in eligible alternative payment models. American Psychological Association. 2015. Accessed May 10, 2022.
110. Price S. States with the highest healthcare workforce shortages. ValuePenguin. 2022. Accessed May 10, 2022.
111. Claxton G. How private insurance works: A primer. Kaiser Family Foundation. 2002. Accessed May 10, 2022
112. 2021 employer health benefits survey. Kaiser Family Foundation: Health costs. 2021. Accessed May 10, 2022.
113. Jones SB. Medicare influence on private insurance: good or ill? Health Care Financ Rev. 1996 Winter;18(2):153-61. PMID: 10167855; PMCID: PMC4193643.
114. Lopez E, Neuman T, Jacobson G, Levitt L. How much more than Medicare do private insurers pay? A review of the literature. Kaiser Family Foundation: Medicare. 2022. Accessed May 10, 2022.
115. Houser, Douglas G. “Good faith as a matter of law: The insurance company’s right to be wrong.” Tort & Insurance Law Journal 27. 1992;3:665–77. Accessed May 9, 2022.
116. Kornblum GO. First Party Insurance Bad faith: A Defense perspective. Chicago, IL: Defense Research Institute; 1988.
117. Miller S. Health plan cost increases for 2022 return to pre-pandemic levels. Society for Human Resource Management. 2022. Accessed May 10, 2022.
118. U.S. Health Insurance Industry Analysis Report. National Association of Insurance Commissioners. 2022. Accessed May 10, 2022.
119. Uscher-Pines L, Arora N, Jones M, Lee A, Sousa JL, McCullough CM, Lee S, Martineau M, Predmore Z, Whaley CM, Ober AJ. Experiences of health centers in implementing telehealth visits for underserved patients during the COVID-19 pandemic: Results from the Connected Care Accelerator Initiative, Santa Monica, Calif: RAND Corporation, RR-A1840-1, 2022. As of May 04, 2022: Accessed May 10, 2022.
120. Equity in Telehealth: Taking Key Steps Forward. American Medical Association. 2022. Accessed May 10, 2022.
121. Maheu MM. Audio-Only Telehealth Update: A Classic Solution to a Modern Crisis. 2022. Accessed May 10, 2022.
122. American Medical Association. 2021 Telehealth Survey Results. 2022. Accessed May 10, 2022.