Prior to the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) did not provide reimbursement for telehealth services for physical therapists. However, this refund restriction was temporarily lifted during the pandemic-related public health emergency. The Expanded Telehealth Access Act of 2021 (HR2168/S3193), if passed, would permanently allow physical therapists and other CMS-designated providers to provide telehealth services under Medicare. This act has the potential to improve access to telehealth services, as CMS would provide reimbursement, thus allowing more providers to offer these services. This thesis is confirmed by what happened during the COVID-19 pandemic: when CMS began reimbursing telehealth services in the first part of the pandemic, the percentage of Medicare users who used telehealth services went from 7% in the first quarter of 2020 to 47 percent in the second quarter of 2020. Initially, this was likely due to reduced physical access to medical services during the lockdown; however, between Q3 2020 and Q1 2022, 16% to 28% of Medicare users continued to use telehealth services even after restrictions were lifted, suggesting more people used telehealth services following the reimbursement of these services.
If the Telehealth Access Act becomes law, it could help bring physical therapy care, through telerehabilitation, to people living in rural areas and alleviate the need for long, inconvenient or expensive travel. However, barriers such as limited broadband access in rural areas and interstate licensing limitations can limit the effective implementation of telerehabilitation. Furthermore, many questions remain unanswered regarding the effectiveness of telerehabilitation. The evidence is mixed, varies in quality, and is lacking for many conditions for which individuals receive telerehabilitation.
This article will review the existing evidence on the use of telerehabilitation, identify barriers to the effective implementation of telerehabilitation, and suggest potential areas that professional advocacy and policy can address.
Existing evidence to support the use of telerehabilitation
Telerehabilitation is the delivery of rehabilitation services, including physical therapy, over a videoconferencing platform. Research demonstrates that the effectiveness of telerehabilitation varies for adults with neurological, musculoskeletal, and cardiopulmonary conditions; further complicating matters is that the search ranges from high to low quality.
Several systematic reviews have investigated the use of telerehabilitation in subjects with neurological diagnoses. According to a Cochrane systematic review, treatment outcomes for activities of daily living, balance, health-related quality of life, upper extremity function, and depression showed no statistically significant differences between telerehabilitation and telerehabilitation therapy. person for people who have suffered a stroke, thus suggesting that telerehabilitation is not inferior. However, in contrast, a systematic review by Fary Khan and colleagues found that there is little evidence that telerehabilitation improves functional activities, fatigue, and quality of life in adults with multiple sclerosis.
For those suffering from musculoskeletal conditions such as arthritis and those seeking rehabilitation after elective orthopedic surgery, telerehabilitation has been shown to be effective in terms of improving physical function, and treatment provided solely through telerehabilitation is equivalent to face-to-face intervention. There is also moderate-quality evidence demonstrating that telerehabilitation leads to improvements in pain and functional mobility in people undergoing total knee replacement. However, in contrast, for people who have had total hip arthroplasty, there is very limited low-quality evidence showing no significant effects.
Finally, a systematic review of the use of telerehabilitation for people with chronic respiratory disease (99% diagnosed with chronic obstructive pulmonary disease) demonstrated that primary or maintenance pulmonary rehabilitation delivered via telemedicine achieves similar outcomes to face lung disease. face rehabilitation. No safety issues were identified, and participants were more likely to complete a telerehabilitation program (93%) than they were in-person (70%).
In conclusion, although studies of strong methodological quality exist to support the efficacy of telerehabilitation, under certain circumstances and for a few diagnostic groups, research gaps remain, for example for specific patient populations, such as children. More rigorous studies are needed to compare the effectiveness of telerehabilitation with face-to-face rehabilitation. The cost-effectiveness of telerehabilitation is also unknown due to the lack of randomized controlled trials. The ongoing investigation into the cost-effectiveness of telerehabilitation is critical to inform resource allocation to develop enduring telerehabilitation models.
Obstacles to the implementation of telerehabilitation
While CMS’s reimbursement policy has helped increase the use of telehealth among people living in rural areas compared to pre-pandemic levels, lack of access to high-speed broadband and the Internet have been identified as continuing barriers the use of tele-rehabilitation services. Medicare data for the first quarter of 2022 shows that 19.72% of Medicare users used a telehealth service in urban areas, but only 14.45% of Medicare users used a telehealth service in rural areas. Access to high-speed broadband has traditionally been limited in rural areas. The Federal Communications Commission (FCC) reports that 39% of rural residents lacked broadband service in 2016 and that number dropped to 17% in 2019. These statistics confirm that progress is moving in the right direction, but needs to continue at an accelerated pace to ensure that individuals in all geographic areas have equal access to this needed service. One way the FCC is supporting this event is through the Affordable Connectivity Program, which offers eligible households a monthly discount to help make broadband more affordable.
State broadband policy can have a significant impact on the availability of these services. State-level funding programs can facilitate wider broadband access, but restrictions on municipal or community broadband networks can limit the ability of public entities to own broadband access and provide these services at a more accessible. These restrictions vary and can include outright bans on municipal broadband infrastructure development or administrative hurdles that make it impossible to build a municipal network.
Interstate licensing also represents an obstacle to the effective implementation of telehealth services. Typically, to provide telehealth services, the physical therapy provider must be licensed in both the state in which they reside and the state in which the patient resides. Because obtaining licenses in multiple states can be a lengthy and expensive process, many physical therapists are licensed only in the state in which they reside. The American Physical Therapy Association (APTA) House of Delegates passed a motion in 2014 that supported the concept of a physical therapy licensing agreement, and in 2017, the Physical Therapy Compact (PT Compact) was developed by the Federation of State Boards of Physical Therapy. The PT Compact is an interstate agreement between member states to increase consumer access to physical therapy services by reducing regulatory barriers to transnational practice. To practice legally and be reimbursed in multiple states, therapists must first maintain a license in their state of permanent residence, which must actively issue and accept compact privileges. The therapist can then obtain a license to practice in another state that is also a member of the PT Compact and is actively issuing and accepting compact privileges. In this way, the PT Compact can extend telehealth access to patients in rural areas who may reside across state lines from providers. As of June 2022, 25 states are actively issuing and accepting compact privileges.
Areas for future action
Telerehabilitation has the potential to improve access and success rates for patients across the country, but there are areas for improvement. More research on telerehabilitation with various diagnoses, ages, and stronger methodology is needed to inform best practices. Continued rollout of broadband services in rural areas is needed with the support of government policy, both through increased government funding through grants and through the introduction of bills to ease municipal broadband restrictions. A professional advocacy is needed so all states can join the PT Compact to improve the ease with which patients can receive care across state lines. On an individual level, physical therapists can contact their APTA state chapters and let them know they are interested in having their state join the PT Compact and determine what steps can be taken to expedite the process.
The author would like to thank Dr. Shu-Fang Shih, Department of Health Administration, College of Health Professions, Virginia Commonwealth University, for her assistance in editing and reviewing the manuscript.