NYHealth submitted the following comments in support of a proposed U.S. Department of Veterans Affairs rule to establish a telehealth grant program and exempt all telehealth services from copayment requirements:

January 10, 2025

The Honorable Denis R. McDonough
Secretary
U.S. Department of Veterans Affairs
810 Vermont Ave., NW
Washington, DC 20420

RE: File Code VA-2024-VHA-0027-0001; 8 CFR Parts 17 and 84; Telehealth Grant Program

Dear Secretary McDonough:

We appreciate the opportunity to provide comments on the U.S. Department of Veterans Affairs (VA) proposed rule to establish a telehealth grant program and exempt all telehealth services from copayment requirements. This proposed rule represents a significant step toward ensuring equitable access to vital telehealth services for veterans, particularly those in rural or medically underserved areas.

The New York Health Foundation (NYHealth) is a private, independent, statewide foundation committed to improving the health of all New Yorkers, especially people of color and others who have been historically marginalized. Through our Primary Care program, we advance policies and programs that expand and enhance primary care services and promote health equity across New York State. Our Veterans’ Health program advocates for policies and initiatives that improve the health of veterans and their families. Across programs, we have supported partners in expanding equitable access to telehealth through policy analysis, pilots of virtual access stations, and patient navigation programs. With our extensive knowledge of telehealth’s potential to enhance access to care, address mental health needs, and support underserved communities, we are well-positioned to offer insights and recommendations on this critical proposal.

Support for Eliminating Telehealth Copays
The VA’s decision to waive copays for telehealth services is commendable. Cost has long been a barrier to care, particularly for veterans in low-income and rural communities. By eliminating this financial burden, the VA is taking an essential step to make telehealth a truly viable option for all veterans. This change aligns with findings from a RAND needs assessment commissioned by NYHealth, which revealed that 15% of veterans in New York who recently separated from the military struggle to access and afford the care they need.[1] Exempting telehealth services—in all forms and settings—from copays will help ensure that veterans can receive timely and affordable care, improving both health outcomes and patient satisfaction.

By prohibiting copays in community settings, in addition to home and clinical settings, the VA would enable patients to receive virtual care in the locations that are most convenient and accessible to them—enhancing the likelihood of the telehealth grant program’s success. By codifying the practice of not imposing copays for phone visits, the VA would also take an important step in promoting equity in telehealth access in all modalities. Patients who are older, people of color, and/or low-income are more likely than younger, white, and/or more affluent patients to use phone rather than video visits for telehealth services.[2] The same barriers to telehealth video appointments likely exist for veterans from these same patient groups.

Support for Establishing Telehealth Access Stations
The proposal to expand telehealth capabilities through the creation of telehealth access stations in community-based locations is an innovative approach to making telehealth available to all veterans who want and need it. Many veterans, particularly those in rural or medically underserved areas, live far from VA facilities and face barriers to telehealth, such as inadequate broadband access, lack of appropriate devices, or limited private spaces for telehealth appointments. Community telehealth access stations can mitigate these barriers and increase access to care.

Importance of Connections to VA Care
We support the VA’s approach to launching this program by connecting veterans in community settings to remote VA health care professionals through telehealth access stations. The VA often leads the way in health innovation and spreading new models; using VA health care professionals will allow for rigorous real-time quality improvement and evaluation, leveraging data from the VA’s common systems. Given the VA’s history of delivering quality care and high patient satisfaction,[3] this approach will provide veterans with high-quality care in comfortable and accessible settings and ensure that veterans have more options. Over time, VA should consider how outcomes from the program can be used to inform expansion to additional providers and sites.

Endorsement of Training as a Permissible Grant Expense
Many veterans need support to effectively access and use telehealth. The VA’s “Bridging the Digital Divide” program serves as an example of how targeted initiatives can address barriers like connectivity. Through Digital Divide Consults, veterans are connected to social workers who assess their eligibility for programs that provide internet-connected devices or subsidized internet service. Additionally, the VA’s partnerships with major mobile carriers to eliminate data charges for telehealth appointments, as well as its ATLAS program, which provides private telehealth stations in communities, make telehealth more accessible to veterans facing connectivity challenges.

Veterans also need supports beyond a digital connection and devices to attend virtual care appointments. Our partners leading patient navigation programs have reported that patients—particularly those with low digital literacy, no devices, or no prior telehealth experience—benefited greatly from navigators’ technical assistance, visit reminders, and answers to their questions before and after telehealth appointments. Therefore, we appreciate that the VA proposes to allow grant funds to cover training programs and resources to help veterans understand how to access virtual care, including education on scheduling appointments, navigating telehealth platforms, and troubleshooting technical issues. Partnerships with community-based organizations can further strengthen these efforts, ensuring veterans receive hands-on technical support and guidance tailored to their needs.

Need for Deep Veteran and Community Engagement
We also appreciate the VA’s expansive and inclusive definition of community access points. Our partners have piloted telehealth delivery in various community settings, including banks, behavioral health clinics, family service agencies, libraries, local health departments, older adult service agencies, settlement houses, social service agencies, shelters, and supportive housing communities.

These partners’ experiences, while promising, have affirmed the need for deep patient and community engagement for community access stations to succeed. For instance, a pilot of kiosks in rural bank branches had limited uptake of telehealth visits in the first six months, despite strong organizational partnerships, operational plans, and clinical considerations. Although our partner conducted early marketing and outreach, it did not uncover patient resistance until surveys of non-users revealed that community members preferred other types of locations (e.g., pharmacies, grocery stores, gyms); had multiple concerns (e.g., location, privacy, cleanliness); and would have been persuaded if a health care provider recommended the kiosk.

For the VA’s access stations to succeed, veterans must be actively involved in planning and implementation processes. Veterans are uniquely qualified to identify the locations and settings where they feel most comfortable accessing care. Therefore, we encourage the VA to strengthen its scoring approach to assessing outreach plans (§ 84.25(b)(2)); applicants should not only detail how they would inform veterans about telehealth services, but also engage veterans in program design. We also stress the importance of scoring criteria related to organizational partnerships for outreach ((§ 84.25(e)). Community-based organizations, such as veteran service organizations and local, community-based health providers, should play a role in site selection and outreach to ensure that the stations are accessible and that veterans actually use them.

Need for Strategic Investment in Infrastructure and Staffing
Establishing access stations and waiving copays alone will not ensure the success of telehealth programs. Sustainable and stable reimbursement policies are essential to the effectiveness of any telehealth initiative. Successful telehealth services require significant investments in technology, infrastructure, and staffing to meet the growing demand. Without certainty about ongoing payment for telehealth services, providers and community-based partners alike will be reluctant to continue investing in virtual care, leaving the system at risk of falling short of its potential.

Conclusion
The VA’s proposed rule to establish a telehealth grant program and eliminate telehealth copays demonstrates a strong commitment to improving health care access for veterans. These measures have the potential to significantly reduce disparities in care, particularly for veterans in underserved communities. To maximize the impact of this initiative, the VA should:

  • Actively engage veterans in the planning and implementation of telehealth access stations.
  • Provide robust technology training and support for veterans.
  • Enshrine sustainable reimbursement policies and investment in infrastructure to ensure the long-term viability of telehealth services.

NYHealth stands ready to support these initiatives. Together, we can build a telehealth system that ensures every veteran has access to high-quality, affordable care.

Thank you for your leadership and for considering our comments. If you have any questions, please contact Ali Foti, program officer, at foti@nyhealthfoundation.org.

Sincerely,

David Sandman, Ph.D.
President & CEO
New York Health Foundation

 

 

[1] Ringel, J.S.; Lejeune, J.; Phillips, J.; Robbins, M.W.; Bradley, M.A.; Wolf, J.; and Timmer, M.J. (2024). Understanding Veterans in New York: A Needs Assessment of Veterans Recently Separated from the Military. https://nyhealthfoundation.org/resource/new-york-rand-assessment-veterans-2024/, accessed January 2025.

[2] Chen, K.; Zhang, C.; Gurley, A.; Akkem, S.; and Jackson, H. (2023). Patient Characteristics Associated with Telehealth Scheduling and Completion in Primary Care at a Large, Urban Public Healthcare System. Journal of Urban Health. 100(3), 468-477. doi: 10.1007/s11524-023-00744-9.

[3] Shekelle, P.; Maggard-Gibbons, M.; Blegen, M.; et al. (2024). “VA versus Non-VA Quality of Care: A Living Systematic Review,” Evidence Synthesis Program, Health Systems Research Office of Research and Development, Department of Veterans Affairs. VA ESP Project #05-226. https://www.hsrd.research.va.gov/publications/esp/quality-of-care-review.cfm, accessed January 2025.

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