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WHEN WILL TELEHEALTH SIMPLY BE ‘HEALTH’? SOME EXPERTS SAY SOONER RATHER THAN LATER

Published Friday, June 14, 2019
by Rajiv Leventhal

In the southeastern U.S., Georgia has a rural healthcare crisis. Local news stories from the past year noted that seven rural hospitals have closed in the state since 2010, while others face financial challenges. Meanwhile, 64 of 159 counties have no pediatrician; 79 have no obstetrician/gynecologist; and nine simply have no doctor, according to one report from the Atlanta Journal-Constitution.

For some folks, getting medical care services far away from home might not be a major issue, but for many others, the struggle is real. To this end, an analysis from the Georgia Department of Public Health recently revealed that when the state’s public health nurses would refer patients to specialists in more populated areas of the state, many of them ended up skipping their appointments.

“When we asked the patients why, several of them said they didn’t have transportation, couldn’t take off work, or didn’t have funds to get to their specialty appointments, most of which are in the metro-Atlanta area,” says Suleima Salgado, director of telehealth, telemedicine, and rural health initiatives for the Georgia Department of Public Health. “Most of our patients in remote areas were having to drive anywhere between three to six hours to get to their specialists. And they just couldn’t get there.”

That’s when the public health agency decided to further develop its telehealth network. Although the infrastructure was already in place to allow for video conferencing and other services, “we realized that some of our rural counties were already using telemedicine because it’s all they had available. So we went into our local counties, [communicated] the plan to them, and that’s how we expanded,” Salgado says. What started off with only four specialty services offered is now up to 25 that are directly connected to the state’s public health department, and the expanded telehealth network now has access to more than 400 specialists throughout the state, reports Salgado. “Having access through a telemedicine counter is now seamless in the state,” she adds, noting that all 159 of its counties are connected via the telehealth network.

Of course, Georgia is hardly alone in its struggle to improve access to care for local patients. But more and more, telehealth is being seen as an impactful solution for being able to tighten access gaps while lowering costs by keeping patients out of doctors’ offices and emergency rooms as much as possible.

And gradually, physicians are buying in to the idea of adopting telehealth as a standard way of practicing care. A recent survey from telehealth company American Well found that 22 percent of 800 surveyed U.S. physicians said they have used telehealth to see patients, up 340 percent from 2015 when only 5 percent of physicians reported having ever used telehealth. And 69 percent of physicians said they would be willing to use telehealth, up 12 percentage points from 57 percent in 2015.

At the same time, each of the experts interviewed for this feature agree that this sub-sector of healthcare will not reach peak levels of growth until a number of barriers are removed: most notably, that constraints around practice and payment policies significantly loosen. For instance, historically, there have been several restrictions regarding reimbursement for telehealth services under Medicare, such as patients may only be located at certain clinical sites or within certain rural areas, and only Medicare-defined physicians and practitioners can provide telehealth services.

But increasingly, telehealth bills that remove some of these barriers continue to get introduced and work their way up in Congress, while other federal regulations evolve. Through the CONNECT for Health Act, within the Bipartisan Budget Act of 2018, for instance, Medicare has slowly incorporated additional telehealth services into their reimbursement models, including telestroke and teledialysis.

More recently, the Centers for Medicare & Medicaid Services (CMS) published the final rule for the 2019 Physician Fee Schedule, introducing a new code: virtual check-ins, officially titled “Brief Communication Technology-Based Service,” enabling doctors to get paid for certain virtual visits with patients to determine if they need an in-person office visit. The code is worded this way because federal law forbids Medicare from paying for telemedicine services that replace in-person office visits, except in certain rural areas.

For providers to qualify for the reimbursement, the service they provide must be to an established patient who has seen the treating provider within the past three years, and it may not be related to a service provided within the past seven days nor lead to a service or procedure within the next 24 hours or soonest available appointment. Essentially, Medicare wants the virtual check-ins to be quick, for one-off medical questions and condition assessments, rather than for a follow-up or triage that leads to an office visit, according to the Alliance for Connected Care, an organization devoted to promoting telehealth as a standard of care.

For the most part, telehealth advocates are applauding the new CMS regulation. “We think it will significantly increase the number of people we serve and make [care] more convenient, while allowing for more flexibility into those types of encounters. And you may see an uptick in different kinds of health conditions [telehealth could be used for] just because we can address and assess more people. For us, it’s a win,” says Salgado.

Back in Georgia, lawmakers recently pushed ahead with a pair of telemedicine bills that would enable providers outside of Georgia to deliver virtual care in the state, while mandating that payers cover telehealth services at the same rate as in-person services. Salgado says that the public health department is heavily prioritizing addressing the issue of statewide broadband availability as well, by making sure there is broadband access for everyone in the state, regardless of where one may be. “That has not been the case in the past,” she asserts.

Indeed, state-to-state differences in laws and reimbursement policies have only made things more confusing. Something as simple as how states define telehealth versus telemedicine, for instance, could vary. In Florida, there isn’t even a clear definition about what telehealth is, says Lauren Faison, service line administrator for population health and telemedicine at Tallahassee Memorial Healthcare System. “You don’t want to overregulate something, but you want to feel comfortable about what it is and why it’s a great opportunity for people in Florida to get the care they need at home. We need to take those federal regulations [from CMS] and make them applicable in each state,” she says.

For some providers, obtaining licenses across state lines has long been a challenge, as they have historically had to apply for and pay for licenses in those states—a costly and time-consuming process. In 2017, the Interstate Medical Licensure Compact officially began accepting applications from qualified physicians who wished to obtain multiple licenses from participating states. While the Compact is expected to expand access to healthcare—especially to those in rural and underserved areas of the country—nearly half of U.S. states have yet to join the agreement. Some state boards have also sought to prevent or limit the expansion of telehealth, citing patient safety concerns.

As explained by Jay Backstrom, digital imaging and telehealth practice leader at the Illinois-based consulting firm Impact Advisors, in some states there are even requirements that a physician who is providing the virtual service has to have an office in that state.

Arkansas, for one, has a ways to go to improve its telemedicine policy. It’s one of the last states to comfortably allow a telehealth visit with a new patient to take place before an in-person one does. Recently, the state shot down a bill that would have permitted healthcare providers to meet with new patients via an audio-only phone; those against the legislation argued that at the least, an audio-visual virtual care platform be leveraged. So any provider doing telehealth with Arkansas patients has to have an Arkansas medical license, as Arkansas has not yet joined the Interstate Medical Licensure Compact. “You can’t have a hub of telehealth service providers outside of that state,” says Backstrom.

Will reimbursement move the needle enough?

Although stakeholders seem pleased with some of the latest changes Medicare has made to reimburse providers for telehealth services, some questions still remain about how much this specific policy will drive change. For the virtual check-ins that CMS will now be paying for, providers will be reimbursed at a rate of $14 per visit in the first year. But this is compared with $92 per visit for the corresponding established patient visits, said CMS in its nearly 2,400-page physician fee schedule final rule. The agency noted in its rule, “Because of the low payment rate relative to that for an office visit, we are assuming that usage of these services will be relatively low.”

What’s more, CMS also wrote in its final rule that it expects the financial impact of paying for the communication technology-based services will be an increase in Medicare costs since it predicts “the number of new or newly billable visits and subsequent treatments will outweigh the number of times that communication technology-based services will be used instead of more costly services.”

The agency stated, “We estimate that usage of these services will result in fewer than 1 million visits in the first year but will eventually result in more than 19 million visits per year, ultimately increasing payments under the PFS [physician fee schedule] by about 0.2 percent.” And because the agency has to maintain budget neutrality, CMS will be decreasing some other Medicare physician payments.

It should also be noted that patients would also be required to pay a 20 percent cost-sharing charge for these visits. CMS stated, “We are aware that coinsurance can be a barrier for some beneficiaries, but we do not have the statutory authority to waive the coinsurance requirement.”

Nonetheless, Sean Sullivan, an attorney in the healthcare practice group of Atlanta-based law firm Alston & Bird, does believe that over time, the reimbursement changes, and the uptick in telehealth use that will result from them, will reduce overall healthcare costs in the U.S. “I’m positive of that,” says Sullivan, who points out that the cost of a patient going to the ER even once or twice a year can be exorbitant.

And as Nathaniel Lacktman, a partner with the law firm Foley & Lardner LLP, and chair of the firm’s telemedicine industry team, points out, every Medicare Part B service is subject to a 20 percent patient copay fee, and unlike Medicaid, Medicare is a benefit that is not contingent on a beneficiary’s financial situation. “We are talking about 20 percent of a $14 charge, which comes to less than $3. In return, the patient doesn’t have to take off work to [physically] walk in and get care. The patient can also get rapid feedback from his or her treating physician for less than what Starbucks charges for a cup of coffee. I think that is a stellar value,” Lacktman asserts.

He also contends that for those physicians who don’t believe that $14 is enough of a reimbursement to move the needle, raising it to $24 or $34 would likely not change their minds either. Lacktman believes that there is a bigger picture to see anyway: although these new virtual visit codes sometimes pay providers less than in-person codes, it will free up more time with the patients who truly need the in-person consultations.

Nowadays, “physicians get double and triple booked every day, spend half their time typing in the EHR [electronic health record], and might only have 5 to 10 minutes with each patient. It is not the experience they hoped for when in medical school,” says Lacktman. “These new modalities and virtual care options that offer direct third-party reimbursement are a great thing for physicians. Virtual services can help reduce burnout and manage their throughput of patient volume. Plus, the patients are likely to be much more satisfied with the overall experience,” he adds.

What’s more, for some providers, the reimbursement piece for every single telehealth encounter isn’t necessarily a deal breaker. Tallahassee Memorial’s Faison notes that her hospital has created certain workarounds such as including telehealth visits in bundled pay services. This way, there isn’t provider dependence on getting paid for each individual telehealth encounter, since they would already be incorporated into what the doctors are billing toward anyway, she explains. “The rules and regulations around reimbursement, and the operational aspect in general, could become too much of a headache to even try it. So for us, it was about finding opportunities where some of those barriers would not come into play,” says Faison.

A new path for remote patient monitoring

As the industry continues along its value-based care path, hospital and health system leaders are realizing that keeping their high-utilization patients—who often have multiple chronic conditions—out of the ER by leveraging virtual technology has a great promise to lower costs. Recently, KLAS Research partnered with the American Telemedicine Association (ATA) to examine remote patient monitoring (RPM) programs at different healthcare organizations, including hospitals, payers and home health agencies. As part of the report, KLAS Research spoke with 25 organizations using products from seven remote patient monitoring vendors about their experiences.

On Jan. 1, CMS went live with three new CPT codes for remote patient monitoring—a sub-sector of homecare telehealth that allows patients to use mobile medical devices and technology to gather their own data such as vital signs, weight, blood pressure and heart rate and send it to healthcare professionals—that now permit physicians to get reimbursed for certain instances in which they are collecting and interpreting this patient-generated health data.

And according to the KLAS/ATA report, the potential for RPM to improve health outcomes is quite apparent, with heart disease and chronic obstructive pulmonary disease (COPD) being the leading use cases. The research found that 38 percent of respondents said their RPM program reduced hospital admissions; 25 percent said it reduced hospital readmissions; and 25 percent said it reduced ER visits.

What’s next?

The telehealth experts interviewed for this piece firmly believe that both patients and providers are motivated to make virtual care a bigger part of their lives. In Florida, Faison says that “every year there has been an increase in the amount of providers participating and the amount of [virtual care] claims being processed. And I think it will keep growing because consumers are catching on. They are saying I don’t have to take off work to get a service; maybe I can just log onto my cell phone and get that same [care].”

Salgado, who notes that throughout the U.S., there are a very limited number of infectious disease specialists—which has led to the state’s public health department’s telehealth network being heavily utilized for consultations for hepatitis A, HIV, and tuberculosis—says she heard lots of discussion during the ATA Annual Conference in April about new and different ways telehealth can be utilized, from behavioral healthcare to dermatology services, to name a few.

“I think you will see even more dibbling and dabbling in the next year or two, and in the next three to four years, I think telemedicine will be seen as another standard model of care, rather than a different way of delivering medicine,” she predicts.

In the end, patients and providers are getting increasingly comfortable and familiar with using virtual technology for the delivery of healthcare, says Lacktman, who believes that regulators are also becoming more comfortable with it. Many realize it’s arbitrary to restrict physicians’ use of a specific technology, as telehealth is simply a tool through which physicians provide care.

“What we should really care about is maintaining standards of care in the quality of medical services, not the technical modality through which medical services are delivered,” he says. “Indeed, we are seeing more medical boards become less proscriptive in their definitions and use cases for telemedicine. Everyone wants to maintain patient safety—that is paramount—but we also need to foster an environment in which physicians feel comfortable and confident to innovate, developing new and better ways to deliver healthcare.” Alston & Bird’s Sullivan adds, “The stigma of using technology and not being able to see your doctor face-to-face is starting to go away.”