In a virtual public meeting earlier this year, the Medicare Payment Advisory Commission (MedPAC) discussed a potential permanent expansion of telehealth in Medicare.
Before the COVID-19 pandemic started earlier this year, Medicare’s physician fee scheduled covered only a limited set of telehealth services in rural location. However, since that time, the Centers for Medicare and Medicaid Services (CMS) temporarily expanded that coverage so others could utilize telehealth services during the pandemic. The expansions helped non-rural patients access clinical care without having to leave their homes.
The future of telehealth and whether these emergency expansions are here to stay has been a hot topic of conversation. During the public meeting, the commissioners in attendance discussed the fee schedule for physicians and what services may be included in the future.
“Pandora’s box is open,” said Susan Thompson, BSN, of Unity Point in West Des Moines, Iowa. Ms. Thompson mentioned that patients value their time and don’t want to spend 2 to 4 hours getting to and completing an in-person visit, nor do they want to sit in waiting rooms.
MedPAC senior analyst Ledia Tabor points out both sides of the argument: on the one side, she says “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.” On the other hand, though, she mentions that telehealth has the potential to increase use and spending in a fee-for-services system and that it is important to balance “how to achieve the benefits of telehealth while limiting the risks.”
MedPAC senior analyst Ariel Winter brought up that Medicare could continue to cover most telehealth services for advanced alternative payment model-participating clinicians, while limiting the coverage and services for those not participating in A-APMs.
Audio-Only Telehealth
Another hot topic was audio-only visits. Winter voiced his concern that “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.”
On the other side of the argument, however, was Betty Rambur, RN, professor and Routhier Endowed Chair for Practice at the University of Rhode Island. Ms. Rambur did acquiesce that there are “concerns about additive services,” but that the audio-only visits can make telehealth services available to patients without smartphone/webcam technology, or those without broadband internet service. Those disadvantaged populations can sometimes need telehealth more than others.
Tabor acknowledged Rambur’s points, but instead of agreeing with allowing audio-only services, suggested that other federal agencies would need to step in and “continue to offer financial support to increase broadband connectivity and also just general access to technology.”
Lawrence Casalino, MD, PhD, professor of healthcare policy and research at Weill Cornell Medical College, also supported the idea of at least allowing some audio-only telehealth going forward, as he mentioned that chronic disease management can be done without the need for video, as providers can rely on portals, 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.
The Impact of APMs
Google Health Chief Health Officer Karen DeSalvo, MD, MPH, MSc, opined that “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,” which means that the focus 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.”
For those who do not participate in A-APMs, Tabor and Winter proposed several options, including limiting the frequency of which specific types of telehealth could be billed by a clinician for a given beneficiary or requiring an in-person visit before a clinician can order durable medical equipment or lab tests over a certain threshold.