In a virtual public meeting this past Friday, members of the Medicare Payment Advisory Commission discussed how – and whether – to permanently expand telehealth in Medicare.
Before the pandemic, Medicare’s physician fee schedule covered a limited set of telehealth services in rural locations. During the public health emergency, the Centers for Medicare and Medicaid Services temporarily expanded that coverage – for example, allowing clinicians to provide services to patients in their homes and in non-rural settings.
Although the pandemic shows no signs of slowing in the United States, questions around the future of that coverage have continued to swirl. During the meeting, the 15 commissioners present weighed the ideal fee schedule for physicians and what services might be included in the future.
“Telehealth has played a key role in delivering health care to patients during the pandemic, which has raised many questions about its future role in the healthcare system after the pandemic,” said MedPAC senior analyst Ledia Tabor.
Tabor noted that, while advocates claim telehealth can expand access to care and reduce costs, others say it has the potential to increase use and spending in a fee-for-service system.
“A key issue is how to achieve the benefits of telehealth while limiting the risks,” said Tabor.
Tabor pointed out that under the Quality Payment Program, CMS designates alternative payment models, including accountable care organizations, episode-based payment models and primary care-focused models.
“The Commission has long supported the movement of Medicare payment policy from fee-for-service to value-based payment such as A-APMs,” said Tabor. “Allowing clinicians who participate in A-APMs more flexibility to provide telehealth services could be another incentive for more clinicians to move into these models.”
Senior Analyst Ariel Winter argued that after the public health emergency period ends, Medicare could continue covering most of the telehealth services offered during the PHE for A-APM-participating clinicians, while limiting services for those not in A-APMs.
Presenters also zeroed in on audio-only services.
“Because clinicians are unable to visually examine patients during audio-only visits, it is possible that they will lead to new services instead of substituting for existing ones and, therefore, could increase program spending,” said Winter.
“Therefore, policymakers might want to consider not covering audio-only services after the PHE, even when provided by clinicians who are in A-APMs,” he continued.
Betty Rambur, RN, professor and Routhier Endowed Chair for Practice at University of Rhode Island, noted that such audio-only visits can make telehealth services available to underserved populations, those without smartphone or webcam technology or those without broadband.
“I understand the concern about additive services, but I was just a little curious about those disadvantaged populations,” said Rambur.
“One concern with not covering audio-only visits would be that six-some people would be at a disadvantage,” acknowledged Tabor. “So I guess we’d encourage other kinds of federal agencies to continue to offer financial support to increase broadband connectivity, and also just general access to technology.”
Dr. Lawrence Casalino, professor of healthcare policy and research at Weill Cornell Medical College, pointed out that chronic disease management can be done without the use of video. Instead, he said, providers can rely on portals, the phone or email.
“If you have a patient accurately check their blood pressure, you’ve had them bring their device into the office and check it, or they can accurately check their blood sugars and record that, those [kinds] of things, traditionally physicians have had patients come back into the office,” said Casalino.
“And with patients you know, that is probably a waste of a lot of patients’ time … So patients love to do that kind of thing over the phone in many cases,” said Casalino. Winter and Tabor also proposed that telehealth technology and services should be required to comply with HIPAA after the PHE.
“Enforcing HIPAA would help protect patient privacy and reduce the risk of identity theft,” said Winter.
For clinicians who are not in A-APMs, Tabor and Winter proposed a few options: limiting the frequency specific types of telehealth could be billed by a clinician for a given beneficiary and requiring clinicians to provide a face-to-face visit with a patient to order durable medical equipment or lab tests over a certain amount.
“It sounds a little lofty for telehealth, but I think telehealth is one of the tools in the toolbox that alternative payment model-type systems, especially ones that are more global budgeted, have as an opportunity,” said Google Health Chief Health Officer (and former national coordinator for health IT) Dr. Karen DeSalvo.
The focus then, she said, “is less on the nuances of the fee schedule, which are important, I understand, for those beneficiaries and providers that rely mostly on traditional Medicare, but I do like the pathway of trying to push people more towards value-based care models.”
Some commissioners objected to the idea of limiting telehealth to A-APMs, saying it could deepen the digital divide and worsen access for those in need.
“I can see reasons for doing this, but I think it would be premature at this stage to let this just become the wisdom of the Commission,” said Casalino.
Many also emphasized the importance of virtual care as a community care augmentation.
“We don’t have to go entirely back to where we are, and I don’t think it has to be the same for every category. Just as I’m asking for a principle of simplicity, I’m asking for a little complexity as we think about which providers we want to pay,” said DeSalvo.
Other commissioners pointed out the need for continuous monitoring of the situation.
“It’s going to be really important going forward to study and adjust … I don’t think we need to view this as one bite of the apple,” said MedPAC chair Michael Chernew.
“This is going to be a process that we’re going to put in place, but I do think we’re going to have to deal with payment and cost sharing to control potential overuse,” Chernew continued.
“There are three core risks in the chapter around telehealth,” summarized Sue Thompson, chief executive officer at UnityPoint Health.
“Number one, increasing volumes will drive increased cost. Number two, concerns for integrity, worrying about inappropriate telehealth practices. And last but not least, large-scale fraud. I fear we have become so constipated in our fear about rampant increase in utilization that we’re no longer thinking about what’s right to do for our beneficiaries,” she said.
“We profess our commitment to keeping the beneficiary at the center of our policy discussion, and I believe that includes access to healthcare. And telehealth is a tool to improve access 13 and engagement, while an opportunity to reduce cost,” she argued.