On 28 April 2021 I sat in front of the House Ways and Means Health Subcommittee and was asked, in effect, what should happen to telehealth now that the emergency was ending. I testified on behalf of myself, of Prism Health North Texas where I was then Chief Behavioral Health Officer, and of the Texas Medical Association.
I had been working in telehealth for eighteen years by that point. I have spent most of my career trying to get the right care to people who are difficult to reach — incarcerated juveniles, the military, the elderly, people living with substance use disorders and with HIV. So I did not want to argue about reimbursement codes. I wanted to offer some framings, in the hope that they would outlast the moment.
Three of them, and they are all about journeys.
The path is broadband
Every journey travels along a path, and for telehealth the path is broadband. That much is obvious. What I wanted the subcommittee to hear is that our broadband problem is not only a coverage problem.
Parts of the country genuinely have no service. But for the quarter of Medicare beneficiaries who live in urban areas, the issue is under-utilization rather than access. The wire is on the street. It is not being used. A strategy that only builds network misses those people entirely — and it also misses that broadband carries commerce and education alongside healthcare, which makes a collaborative approach far more sensible than a healthcare-only one.
Telehealth is a skill to be mastered
Journeys need orienteering. Ours has a destination — value-based care — but value is more than one thing, and telehealth on its own does not deliver it.
What I believe telehealth actually is, is this: the right doctor with the right information at the right time. Most of our delivery failures trace back to people waiting until a problem becomes a crisis, which costs more and works worse. Technology-enabled care is a way to get in front of that. But only if the right doctor — your doctor, the one who knows you — is skilled at it. Having your own physician fluent in telehealth improves the odds that they can be with you when you most need them.
Prism Health is the clearest example I have. It is the largest community health center in North Texas specialising in HIV treatment and prevention, and it stood telehealth up in 2020 hoping simply to hold onto a trusted source of care. Within about a month it had restored visit volume to pre-pandemic levels and reduced no-show rates. It went on to earn Patient-Centered Medical Home designation with a distinction in behavioral health.
But the number I keep coming back to is a quieter one. Over time, completed telehealth visits settled at roughly 30% of the total. Claims data across Texas put it closer to 20%. When your doctor is skilled with telehealth, they reach for it when it is indicated and not otherwise. It is neither a replacement for conventional care nor simply added on top of it. It finds its own level.
Guardrails, not a separate road
Regulation exists to keep people safe. The trouble is that telehealth was treated for years as "something else" — a distinct thing needing its own rulebook — and that separateness is precisely what held it back. Then the pandemic relaxed the rules, and years of progress happened in months. One of my patients called that a gift from the pandemic. The question I was there to help answer was: what now?
I pointed the committee at Texas, because Texas had already done the work in three unglamorous steps:
- 2017 — telemedicine is medicine. Questions about telemedicine were referred back to existing guidance on medicine, including demonstrating a therapeutic relationship. No parallel rulebook.
- 2019 — service parity. Payers may cover any service, on the understanding that how it is delivered does not matter so long as regulatory expectations are met.
- 2021 — payment parity. A covered service should be paid at the same rate whether it is delivered conventionally or by telehealth.
The lesson is not that Texas is special. It is that the long road to regulatory guidance can be walked without reinventing the wheel, and that simple is preferable. Returning to pre-pandemic complexity around rules and reimbursement would be like detouring a traveller onto a dirt road. Nobody would choose that route, and most of the benefit would be lost along the way.
There were other concerns raised that day — fraud, over-utilization, licensure. Fraud is not unique to telehealth. The rest, I think, can be worked through with the framings above rather than against them.
Why this still matters to me
I closed by asking the subcommittee to help create an environment where telehealth provides timely, informed care, extends a physician's reach, and is proactive rather than reactive.
Geste Health is, in a sense, me taking my own advice. It is a practice built on the assumption that being reachable is itself a form of care — that the right doctor, with the right information, at the right time, is not a policy abstraction but something a single practice can actually deliver. The journey framing was not just for the committee. It is more or less how I think about the work with every person I see.