Telehealth Access Challenges in Vermont after Medicare Changes

For many patients at All Brains Belong, a community health clinic in Montpelier, accessing care through virtual appointments has been transformative, especially during and after the COVID-19 pandemic.

As telemedicine becomes more commonplace, Mel Hauser, a founding physician at the clinic, noted that many patients are able to receive personalized care for the first time. The clinic primarily serves those facing long-term COVID-19 symptoms, chronic illnesses, or neurodevelopmental challenges.

Even in larger healthcare setups, the flexibility of telehealth has been crucial for numerous rural patients. Dartmouth Health, one of the biggest health providers in New England, has seen a significant rise in online consultations due to new reimbursement policies that public and private insurers adopted during the health crisis.

However, a shift occurred on October 1, when pandemic-related rules reverted. Advocates for healthcare have urged Congress to make these telehealth reimbursements permanent, anticipating approval in future federal funding discussions.

While that funding bill has stalled—leaving many telehealth practices in limbo—about a quarter of Vermont’s population is enrolled in Medicare, raising concerns for both small clinics and larger hospital networks.

The change in rules also means that telehealth visits now no longer count towards the in-person appointments Medicare requires for patients eligible for home health or hospice services.

Though Vermont state law mandates insurers to cover telehealth services equivalent to in-person ones, Medicare, the federal program for individuals over 65 and certain disabled groups, does not follow this requirement.

Now, Medicare only covers telemedicine for specific conditions such as mental health or substance use disorders, acute stroke treatment, or end-stage renal disease dialysis. The newly reverted rules were authorized by prior federal legislation.

Outside of these areas, telehealth interactions are currently not covered by Medicare in urban regions, such as Chittenden County. In rural sectors, coverage for telehealth is limited to specific “designated Medicare starting sites.”

This reversal undermines the potential benefits of telemedicine, as highlighted by Hauser and other healthcare providers.

She mentioned that many of her patients appreciate the option to avoid potential COVID-19 exposure in clinics. Others find telehealth helps them manage sensory overload that can accompany office visits, while for some, virtual appointments alleviate the stress of transportation.

Despite Medicare’s stance, private insurers like Vermont Blue Cross Blue Shield and MVP continue to cover most telehealth services, as confirmed by their representatives. Vermont Medicaid coverage for telehealth remains unchanged.

At All Brains Belong, about half of the 350 patients rely on Medicare or Medicaid. Even though these services are still reimbursed by Vermont Medicaid and private insurance, Hauser mentions she currently cannot bill Medicare for her services. For now, patients can pay out of pocket or through a sliding scale, or utilize a barter service offered by the clinic.

“We’re trying to bridge the gap,” Hauser expressed, though the financial impact on small clinics is considerable.

Focusing on Solutions

Dartmouth Health and UVM Health, Vermont’s largest healthcare providers, are working to offer telehealth to Medicare patients while withholding bills rather than pursuing separate payments. They remain hopeful for Congress to expand the rules retroactively.

Kevin Curtis, who directs Dartmouth Health’s Connected Care Program, mentioned that their network conducts around 500 telehealth visits a week for Medicare patients, with about 200 of those in Vermont.

UVM Health performs nearly 40,000 Medicare-related telehealth visits annually. Data suggests that around 6.7 million Medicare beneficiaries may use telemedicine by 2024, despite varying usage rates over the past few years.

Both Curtis and Hauser emphasize that continuing telehealth access is fundamentally about equity and access. For individuals who struggle to attend in-person appointments—such as those with mobility issues—telehealth offers critical support.

In remote areas of New England, receiving specialty care can require a long drive. Curtis noted that for some patients, in-person visits can even pose risks, especially for those with certain health conditions.

Moreover, Dartmouth Health views telemedicine as an essential way to tackle many challenges in the local healthcare system, ensuring that people can connect with specialists more easily.

Healthcare providers have adjusted their office layouts to accommodate for this hybrid model, complicating shifts back to standard practices. “We can’t just bring in 40 patients a day; there’s no space for them,” Curtis remarked.

Barriers to Home Care

The reversion to pre-pandemic rules also adds challenges for home health and end-of-life care in Vermont. For Medicare to cover home health visits and hospice care, an in-person meeting is now a requirement, which could have previously been conducted via telehealth.

Eric Covey, interim director of Vermont VNAs, pointed out that homebound individuals without transportation may delay or skip necessary visits. Not addressing chronic conditions can lead to more serious health issues and higher hospital costs later on.

Patients often get referred to home health or hospice care upon leaving the hospital. However, the absence of remote options for certain patients could complicate their care pathway.

“It’s not just about the numbers; it’s about individual needs for access to care,” Covey emphasized. Dr. Curtis echoed this sentiment, noting the importance of each patient’s unique situation, recognizing that behind every statistic is a real person who requires support.

“There are still 500 individuals each week who need to be cared for by any means necessary,” Curtis concluded.