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 reimbursement restriction was temporarily waived during the public health emergency related to the pandemic. The expanded Telehealth Access Act of 2021 (HR2168/S3193), if approved, would permanently allow physical therapists and other providers designated by CMS to provide telehealth services under Medicare. This act has the potential to improve access to telehealth services, as CMS would provide reimbursement, thus allowing larger numbers of providers to offer these services. This thesis is borne out by what happened during the COVID-19 pandemic: When CMS began reimbursing for telehealth services in the early part of the pandemic, the percentage of Medicare users who used telehealth services rose from 7 percent 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 lockdown; however, between the third quarter of 2020 and the first quarter of 2022, 16 percent to 28 percent of Medicare users continued to use telehealth services even after restrictions were lifted, suggesting that more individuals used telehealth services as a result of these services being reimbursed.
If the Telehealth Access Act becomes law, it may help bring physical therapy care, via telerehabilitation, to individuals living in rural areas and alleviate the need for time-consuming, uncomfortable, or expensive travel. However, barriers such as restricted broadband access in rural areas and limitations in interstate licensing may restrict the effective implementation of telerehabilitation. Furthermore, many questions remain unanswered regarding the effectiveness of telerehabilitation. Evidence is mixed, varies in quality, and is lacking for many conditions for which individuals receive telerehabilitation.
This article will review 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 video-conferencing platform. Research demonstrates that the effectiveness of telerehabilitation varies for adult individuals with neurological, musculoskeletal, and cardiopulmonary conditions; further complicating matters is that the research ranges from high to low quality.
Several systematic reviews have investigated the use of telerehabilitation in those with neurological diagnoses. According to a Cochrane systematic review, treatment outcomes for activities of daily living, balance, health related quality of life, upper limb function, and depression showed no statistically significant difference between telerehabilitation and in-person therapy for individuals who have suffered a stroke, thus suggesting that telerehabilitation is not inferior. However, in contrast, a systematic review by Fary Khan and colleagues found there is little evidence of telerehabilitation improving functional activities, fatigue, and quality of life in adults with multiple sclerosis.
For those with musculoskeletal conditions such as arthritis and people seeking rehabilitation after elective orthopedic surgery, telerehabilitation has been shown to be effective in terms of improved physical function, and treatment delivered solely via telerehabilitation is equivalent to face-to-face intervention. There is also moderate quality evidence showing telerehabilitation results in improvement in pain and functional mobility in people undergoing total knee arthroplasty. However, in contrast, for individuals who have undergone total hip arthroplasty, there is very limited low-quality evidence that shows no significant effects.
Lastly, a systematic review on the use of telerehabilitation for individuals with chronic respiratory disease (99 percent with a diagnosis of chronic obstructive pulmonary disease) demonstrated that primary or maintenance pulmonary rehabilitation delivered via telehealth achieves outcomes similar to those of face-to-face pulmonary rehabilitation. No safety issues were identified, and participants were more likely to complete a program of telerehabilitation (93 percent) compared to in-person (70 percent).
In conclusion, although studies of strong methodological quality exist to support the effectiveness of telerehabilitation, in certain circumstances and for a few diagnostic groups, gaps in the research remain—for example, for specific patient populations, such as children. More rigorous studies are needed to compare the effectiveness of telerehabilitation to face-to-face rehabilitation. The cost-effectiveness of telerehabilitation is also unknown due to a lack of randomized controlled trials. Ongoing investigation of the cost-effectiveness of telerehabilitation is critical to inform allocation of resources to develop long-lasting models of telerehabilitation.
Barriers To The Implementation Of Telerehabilitation
Even though CMS’s reimbursement policy has helped increase the use of telehealth among people who live in rural areas compared to pre-pandemic levels, lack of access to high-speed broadband and the internet have been identified as ongoing barriers to the use of telerehabilitation services. Medicare data from the first quarter of 2022 demonstrate that 19.72 percent of Medicare users used a telehealth service in urban areas, but only 14.45 percent of Medicare users used a telehealth service in rural areas. High-speed broadband access has traditionally been limited in rural areas. The Federal Communications Commission (FCC) reports that 39 percent of rural residents lacked broadband services in 2016, and that number fell to 17 percent in 2019. These statistics support that progress is moving in the right direction, but it needs to continue at an expedited pace to assure that individuals in all geographic areas have equal access to this necessary service. One way that the FCC supports this happening is through the Affordable Connectivity Program, which provides eligible households with a monthly discount to help make broadband more affordable.
State broadband policy can have a significant impact on availability of these services. State-level funding programs can facilitate wider broadband access, but municipal or community broadband networks restrictions can limit the ability of public entities to own broadband access and provide these services at a more affordable price. These restrictions vary and may include banning the development of municipal broadband infrastructures altogether or administrative obstacles that make it impossible to create a municipal network.
Interstate licensing is also a barrier to effective implementation of telerehabilitation services. Typically, to provide telerehabilitation services, the physical therapy provider needs to be licensed both in the state in which they reside and the state in which the patient resides. Since obtaining licenses in multiple states can be a lengthy and costly process, many physical therapists only hold a license 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 license compact 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 among member states to increase consumer access to physical therapy services by reducing regulatory barriers to cross-state practice. To legally practice and obtain reimbursement in multiple states, therapists must first maintain a license in their home state of permanent residence, which must be actively issuing and accepting 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 be residing 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 practice. Continued implementation of broadband services into rural areas with support of government policy is necessary, both through increasing state funding through grants and introducing bills to ease municipal broadband restrictions. Professional advocacy is required so that all states might join the PT Compact to improve the ease with which patients can receive care across state lines. At 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 help in editing and revising the manuscript.