December 4, 2018
Readers Respond: Telemedicine Poised for Expansion?
by Chas Roades
Despite growing consumer demand and widespread provider investment in virtual care, policy and reimbursement barriers have kept use rates low. However, the past year has brought a number of policy changes which could potentially break down barriers to telemedicine access. Health policy expert Julie Barnes responded to our questions about how these changes could broaden telemedicine access for millions of patients.
Julie Barnes is a health care policy expert who helps health care organizations navigate federal government activities that impact the health care system. With more than 20 years of experience as a health care attorney, policy analyst and Capitol Hill staffer, Ms. Barnes offers strategic advice to clients about the regulatory and legislative landscape. If your organization needs help understanding regulatory risk and how competitors are shaping policy in their favor, or requires strategic advice about the changing policy landscape, please reach out to Julie via email.
Gist Healthcare: How robust is telemedicine utilization today, and how is it poised to grow?
Julie Barnes: Despite lots of publicity and hype, telemedicine use rates today are much lower than many believe. A new report issued in November from the Centers for Medicare & Medicaid Services (CMS) said that 90,000 Medicare fee-for-service beneficiaries used over 275,000 telehealth services between 2014 and 2016.
Telemedicine is more popular with the non-elderly population—but the people who like it the most will be eligible for Medicare soon: younger Baby Boomers and “Generation X” consumers. FAIR Health, a non-profit organization that analyzed telehealth trends in recent years, released a study of its database of over 25 billion private claims showing that telehealth use has grown by 960 percent between 2011 and 2016, and the largest portion of this growth was from by people aged 41 to 60.
Telemedicine is more popular with the non-elderly population—but the people who like it the most will be eligible for Medicare soon, younger Baby Boomers and “Generation X” consumers
And while telehealth is still very uncommon—fewer than 7 annual visits per 1,000 people, compared to 313 physician office visits per 100 individuals— there is a marked uptick in use by people in bigger cities. While many policies have been adopted to support telemedicine as an access alternative for rural patients, a research letter published last month in JAMA reports that 83 percent of telehealth users lived in urban areas.
GH: Which Medicare payment changes in 2018 will have the greatest effect on telemedicine access for seniors?
JB: Given limited Medicare coverage, doctors have been reluctant to adopt telemedicine and jettison reimbursed in-person visits. Prior to this year, telehealth could only be reimbursed in rural areas under certain circumstances, and for patients who received care from providers in accountable care organizations (ACOs) who had “two-sided”, or downside, risk.
With the adoption of the 2019 Physician Fee Schedule (PFS), CMS will now pay doctors $14 for a five-minute “check-in” phone call with their patients. Of course, many physicians already do this for free. CMS says the idea is to help patients determine whether they need to come in for an appointment, but telehealth advocates say the virtual sessions could cover a broad array of services, including monitoring patients starting a new medicine or those trying to manage chronic illnesses, such as diabetes.
Here is a summary of other CMS moves to expand telemedicine coverage:
- Medicare will pay for virtual consultations between physicians, and evaluation of remote pre-recorded images and video. For example, a patient can now text a picture of a mole on their skin to a dermatologist for examination.
- The PFS now includes reimbursement for remote patient monitoring and CPT codes for telemedicine. Next year’s version will go even further, allowing for payment of two HCPCS codes (G2012 and G2010) so virtual check-ins and remote evaluation of recorded video and images sent by patients will be reimbursed.
- Medicare Advantage plans can offer telehealth services as a “basic benefit” (it is only allowed as a “supplemental benefit” now).
- Home health agencies will get paid for using remote patient monitoring for their Medicare patients.
- Dialysis patients can receive their monthly clinical assessments via telehealth, from their homes.
Congress may continue the trend if it passes the Reducing Unnecessary Senior Hospitalizations (RUSH) Act of 2018, which would pay skilled nursing facilities for using telehealth to reduce unnecessary readmissions to hospitals.
Telehealth services seems destined to continue to grow, and not just because Medicare is finally beginning to reimburse for it. Using technology from home is just an expected convenience of the modern age
GH: Medicare has lagged commercial payers and Medicaid plans in providing telemedicine coverage. What momentum are you seeing in other sectors to encourage telemedicine growth and adoption?
JB: Commercial payers and employers are increasingly interested in telemedicine as a value-added benefit, and states have bolstered Medicaid coverage, particularly to increase access for rural patients. Many state barriers to licensure are also loosening. Here are some updates:
- The share of large employers offering health plans that cover telemedicine expanded significantly between 2015 and 2018, according to the Kaiser Family Foundation’s 2018 Employer Health Benefit Survey. (However, a corresponding brief explains that most employees rarely take advantage of the offer.)
- Nearly all states provide some telemedicine coverage for Medicaid patients, and nearly 40 percent would be considered “progressive”, having expanded coverage across settings and relaxed licensure requirements. CMS also issued a pair of guidance documents urging Medicaid program directors to leverage telehealth as they address the opioid crisis.
- Growing patient demand and coverage has spurred provider investment in telemedicine platforms across the past few years. According to the American Hospital Association, 65 percent of U.S. hospitals can connect with patients and consulting practitioners at a distance through the use of video and other technology. HIMSS Analytics reports that the number of hospitals installing telemedicine has increased from 1,648 in 2014 to 2,140 facilities in 2018.
- The Federal Communications Commission (FCC) is establishing the Connected Care Pilot Program, directing $100M into a new telehealth pilot program to bolster locations with the infrastructure to support affordable broadband internet.
- Regulatory barriers to medical licensure across state lines are being streamlined by the Interstate Medical Licensure Compact making it possible for doctors to expand their practice through telemedicine.
Telehealth services seems destined to continue to grow, and not just because Medicare is finally beginning to reimburse for it. Using technology from home is just an expected convenience of the modern age. Increasing Medicare, Medicaid and commercial coverage will spur more provider investment. However, I’m betting that motivated consumers, particularly those with high deductibles, will increasingly seek out these services on their own, even if it means paying out-of-pocket.