With COVID-19 raging throughout the country with restrictions on face to face interactions and encouragement of social distancing, telehealth has come to the forefront. Recent actions by Congress and the Department of Health and Human Services (HHS) are attempting to increase access to telehealth services while reducing the need for in-person visits during the public health emergency. They also give providers mechanisms to continue treating patients while their typical face-to-face caseload is diminished. These temporary changes could serve as a valuable case study and potentially lead to permanent changes.
Telehealth Changes
The Centers for Medicare and Medicaid Services, in particular, has released a number of changes. CMS announced that it would permit Medicare Advantage (MA) plans to waive cost-sharing for telehealth services. It also announced that MA plans could expand the scope of services that they currently offer via telehealth. HHS Secretary Azar also waived requirements for physicians or other health care professionals to hold licenses in the state in which they provide services with respect to Medicare and Medicaid services for the duration of the public health emergency.
CMS further implemented the telehealth provisions of the Coronavirus Preparedness and Response Supplemental Appropriations (CARES) Act and expanded telehealth with an 1135 waiver. Under the waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth regardless of geography. Providers may reduce or waive cost-sharing for telehealth visits paid by federal health care programs. Visits provided by telehealth are considered office visits and are reimbursed at the same rate as regular, in-person visits. First visits may be provided through telehealth for the duration of the public health emergency. CMS emphasizes that no federal approval is needed for state Medicaid programs to reimburse providers for telehealth services in the same manner or at the same rate that states pay for face-to-face services.
CMS also noted that federal financial participation (FFP) is available for “telephonic services” provided by FQHCs and RHCs, subject to limitations of the state plan. In addition, FQHC and RHC services may be provided offsite, also subject to limitations of the state plan. CMS also encourages states to adopt the same telehealth flexibilities they offer in fee-for-service in their managed care contracts and clarifies that states may retroactively adjust capitation rates based on such a change.
Additionally, CMS released a pair of telehealth toolkits (general and ESRD) to assist general practitioners and those working with patients with end-stage renal disease. These toolkits do not contain new policy but do provide a list of resources for providers to use. It also reiterates CMS’ intention to not enforce policy on the use of consumer video conferencing technologies for telehealth services for the duration of the crisis and provides information about other CMS telehealth policies to providers that may use such flexibilities.
CMS also issued an interim final rule in which the agency identified over 80 additional services that may be provided via telehealth, including nursing facility initial and discharge visits, home visits, and evaluation services. A complete list of newly payable telehealth services can be found in the IFR. Additionally, CMS is temporarily eliminating frequency limitations and other requirements associated with particular services furnished via telehealth and clarifying several payment rules that apply to other services that are furnished using telecommunications technologies that can reduce exposure risks.
Providers will be allowed to evaluate beneficiaries who have audio phones only, and CMS is allowing telehealth to fulfill many face-to-face visit requirements for clinicians to see their patients in inpatient rehabilitation facilities, hospice and home health. During the pandemic, individuals can use commonly available interactive apps with audio and video capabilities (such as Skype or FaceTime) to visit with their clinician. Home Health Agencies will be able to provide more services to beneficiaries using telehealth, so long as it is part of the patient’s plan of care and does not replace needed in-person visits as ordered on the plan of care. The rule also implements CARES Act provisions permitting federally qualified health centers (FQHC) and Rural Health Centers (RHC) to provide telehealth services to beneficiaries in their homes. Virtual Check-In services, or brief check-ins between a patient and their doctor by audio or video device, will be offered to patients that had an established relationship with their doctor and new patients. Clinicians can provide remote patient monitoring services for patients during the crisis, regardless of if it is for the COVID-19 disease or a chronic condition.
The Federal Communications Commission (FCC) has also got involved, with its Chairman Ajit Pai looking to use $200 million from the economic stimulus package to expand telehealth services across the country. The CARES Act earmarks the funds for the FCC to help healthcare providers offering telehealth. “As we self-isolate and engage in social distancing during the COVID-19 pandemic, telehealth will continue to become more and more important across the country. Our nation’s health care providers are under incredible and still increasing, strain as they fight the pandemic,” Pai said. If adopted by the commission, the program would offer qualified healthcare providers full funding to buy “telecommunications services, information services and devices necessary to enable the provision of telehealth services during this emergency period.”
Importance of the Changes
Taken as a whole, these are major wins for the telehealth industry and its providers. As described by Fierce Healthcare, many physician practices, forced to cancel routine patient visits to keep patients home and avoid potential exposure to the coronavirus, said they were swamped with phone calls from patients. While they could offer advice, they were typically not paid by CMS for these calls with Medicare and Medicaid patients. Losing revenue from regular patient visits to their offices, some doctors worried they would not be able to keep their doors open.
As reported, the American College of Physicians (ACP), the American Medical Association (AMA) and the American Academy of Family Physicians (AAFP) were among the groups commending CMS for making the changes. “We are glad that CMS heard our concerns about physician practices. The changes announced by CMS yesterday will help practices by providing them with revenue to keep their practices open as the move away from in-person visits to virtual ones,” said Robert McLean, M.D., ACP president.
This is also important to note because it may be a predictor of the future of medicine. Dr. Subha Varahan wrote the following in a post on KevinMD: “The innovations in telemedicine and relaxations of CMS’s policies have created an atmosphere in which health care providers are thriving and doing what we do best: taking care of our patients. Health care providers should implore the Department of Health and Human Services (HHS) and the Trump administration to continue the current CMS telehealth guidelines after the calamity has resolved. They should set an example for commercial insurance companies and lead the way for facilitating patient care. For a large majority of patients, this is the future of medicine, and I foresee this technology becoming mainstream and more widely expected by patients, insurance companies, and used throughout the medical field. This is the new reality in our current dystopian world. And telemedicine is here to stay.”