“I get paid for this if I do it in person.”
That’s how current Medicare rules on telehealth force physicians to think. It’s a counterintuitive and frankly, outdated way to care for patients. In an era when most physicians could use telehealth to improve access and quality, and lower costs—and CMS has a roadmap tying half of all Medicare payments to quality-based models by 2018—this policy needs to change.
The CONNECT for Health Act will push Medicare, and hopefully the rest of the market, in the right direction.
Currently section 1834(m) of the Social Security Act (42 U.S.C. 1395m) restricts utilization of and reimbursement for telehealth in the traditional Medicare fee-for-service program by narrowly defining conditions around eligibility for coverage. As a result, the benefits offered by these advanced technologies are limited to people who live in a rural area and willing to go to a specific site determined by HHS.
Why CONNECT matters
Because of this existing Medicare policy, there is no coverage for about 80 percent of Medicare beneficiaries who live in the 1,200 metropolitan counties not included in the definition of “rural.” Patients don’t need to be in rural environments to benefit from telehealth. Take a stroke victim, as an example.
When it comes to high-acuity, critical situations like stroke, minutes, even seconds matter. The patient should be treated in the fastest and most effective way possible, never mind if they’re located in New York City or in rural South Carolina. With the nationwide shortage of neurologists, the best and fastest treatment option is increasingly facilitated by telehealth.
Even in cases that aren’t critical, patients in metropolitan areas can have access to a specialist via telehealth and avoid unnecessary trips outside of their regular communities. Keeping patients close to home and with greater accessibility to care increases compliance and adherence to care plans, especially for patients with complex chronic conditions.
Unfortunately for patients, current Medicare policy does not cover
- “Store‐and‐forward” services (such as transmission of medical images) for the 43 million beneficiaries who live outside of Alaska and Hawaii.
- Services originating from a beneficiary’s home (even for the “homebound”), a hospice and other common non‐medical locations from which a beneficiary seeks service.
- Otherwise covered Medicare services of physical therapy, occupational therapy, speech‐language pathology, audiology and some other practitioners.
- Most health procedure codes, precluding the best judgment of physicians and other practitioners about the medical needs and other circumstances of beneficiaries.
What’s stopping reform
The major barrier to the CONNECT Act has been the way costs are calculated and analyzed by the Congressional Budget Office. The CBO has traditionally looked only at the costs added by expanding telehealth coverage for Medicare, and not at the expected savings.
This is a flawed approach—as a patient treated via telestroke won’t also need to have the same treatment in-person.
There’s also a concern that patients will over utilize telehealth services, particularly for primary care and other low-acuity visits. Or, that patients who previously would have forgone care altogether will use telehealth instead—raising costs.
But, according to estimates by the Alliance for Connected Care, Medicare costs will only increase if the percent of Medicare patients using telehealth who would have otherwise “done nothing” increases to more than 32 percent. This is unlikely—the same proportion of patients in this category is just 13 percent in the commercial market.
Change is coming
Both consumer and physician mindsets toward telehealth are changing. Greater integration of technology in both parties’ lives are increasing both acceptance and use. These changing perceptions, coupled with CMS’ commitment to shift heavily toward value-based care, requires a new baseline. One that considers the advancements of the last decade, new data and evidence, and the evolving health care ecosystem.
The new baseline needs to eliminate the originating site geographic requirements, lift restrictions on store-and-forward technologies and expand the list of providers eligible to treat patients via telehealth. Passing the CONNECT Act for Health will be a big step in the right direction.