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By Sebastian Seiguer, CEO of emocha
During the 2020 campaign, the Biden campaign pledged to make healthcare more accessible and affordable through the preservation of the Affordable Care Act, the addition of a public option, and increased eligibility for programs like Medicare and Medicaid. The new administration has also signaled its support for telehealth expansion and an accompanying focus on interoperability, health information exchange, and value-based care. The strategies of the most recent CMS Administrators indicate that advancing digital health is truly a bipartisan issue.
With Medicare and Medicaid set to expand, the Biden-appointed CMS Administrator will need to rapidly address what telehealth has not yet been able to solve: the management of life-threatening, expensive chronic conditions. With medication spending at more than $350B per year in the United States, and waste of those same medications at similar levels, our healthcare system is fractured and inefficient: driven entirely by the incentives that CMS provides. Those incentives do not always result in optimal outcomes for patients.
The COVID-19 pandemic laid bare the inadequacies of the American healthcare system, but also demonstrated the federal government’s immense regulatory power in healthcare. Nowhere is this more obvious than in the field of telehealth. In 2020, the Centers for Medicare & Medicaid Services reacted quickly to adapt payment models: advancing flexibilities for remote patient monitoring, novel communication modalities, and telehealth. These changes accelerated a process that had been years in the making, bringing telehealth services to patients in the space of a few short months. In 2020, virtual care is expected to have accounted for more than 20% of all medical visits in the U.S., showing that telehealth enabled people to access care they might have otherwise delayed or skipped due to the COVID-19 pandemic. In the physician fee schedule for 2021, CMS added more than 60 services to the Medicare telehealth list which will continue to be covered after the pandemic has ended.
However, before a victory lap is taken, we must recognize that many of these changes were made to reimbursement schedules — an entirely “fee-for service” area of healthcare policy. These modernizations allow providers to bill for more telehealth services than they previously could, thereby increasing access to patients who access broadband internet easily. Yet that does not mean that healthcare outcomes will magically improve; on the contrary, while some patients navigated how to use telehealth, many of the most vulnerable patients dropped off the radar and will possibly have worsened health outcomes due to Covid-19.
What we need are radical changes to promote value-based care. False incentives create tax-payer sponsored gamesmanship with chronic disease patients and their health. Nowhere is this more evident than in the quality measures related to medication adherence. Having given up on the possibility that, one day, technology could be used to help patients actually take their medication properly, these incentive programs reward the refill of medication regardless of whether the patient takes them, or takes them properly. This is a boon to pharmaceuticals and creates artificial medication demand that does not necessarily correlate to a positive health outcome. It also results in confusion and medication errors. The lowest hanging fruit in all of healthcare may be the proper use and management of wasted wonder drugs, created by brilliant scientists at our academic medical centers. These inventions required trillions to get to market, much of which was funded by us as the taxpayer, and are a precious and critical tool in the management and cure of disease.
President-elect Biden’s published plans for healthcare and rural America demonstrate that the incoming president understands the value of virtual care and is committed to increasing funding and expanding access to telehealth, particularly in underserved rural areas. Concrete plans to achieve these goals include using federal loan and grant programs to build rural hospitals and mental health clinics with a focus on telehealth for mental health and specialty care, and increasing funding and expanding access to telehealth through the U.S. Department of Veterans Affairs, a major federal provider of healthcare. A crucial aspect of these plans involves expanding broadband access, without which telehealth services will remain out of reach for rural communities. President-elect Biden has committed to investing $20 billion in rural broadband infrastructure and making available federally-controlled assets like telecom towers, poles, and rights-of-way. Building durable broadband infrastructure and investing in clinics and hospitals will improve healthcare access and make permanent the shift towards telehealth as a means of reaching patients.
To scale and serve the patients that truly need help, telehealth must encompass all modalities, including those that are asynchronous. This does not necessarily encompass adding new codes to the PFS; rather, it means ensuring those modalities are acceptable means of communication under both national and federal regulations (see Massachusett’s newly-passed law redefining telehealth). Then, let value-based models drive health plans and providers to work with patients to determine the most effective and convenient channels for communication and healthcare delivery. The Direct Contracting Model has potential; in the future, and under the incoming administration, telehealth will not just be a stopgap measure for when doctor’s offices are unsafe to visit, but rather a multi-channel and affordable means of managing chronic conditions. Telehealth also has the potential to close health inequities by making health care more convenient for rural and underserved communities. But for telehealth to fulfill its potential, the Biden administration will need to make good on its promises to distribute grants effectively, invest in broadband infrastructure, and implement needed regulatory changes to provide the flexibility telehealth requires.
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