By Tim Gronniger, Caravan Health, President and CEO
Telehealth quickly emerged as one of the few silver linings of COVID-19. Suddenly, the technology that had been promising for decades to improve access to care, streamline clinical workflows and boost patient engagement had the critical mass it needed to prove its mettle. At the end of 2019, just 10% of health care consumers had used any type of telehealth service. In April of 2020, telehealth visits accounted for nearly half of all Medicare primary care visits.
While there have been some hiccups along the way, providers and patients alike have generally praised the technology as a vital lifeline. Emergency federal action played a major role in telehealth’s success during the pandemic. Thoughtful, long-term legislation will be the key to its continued viability.
At the core of the issue are some of the restrictions on telehealth usage and the reimbursement rates that providers are paid by Medicare. Early in the pandemic, the U.S. Department of Health and Human Services removed many of the byzantine restrictions that had limited telehealth access in the past. Changes included paying physicians for telehealth services at the same rate as in-office visits and allowing patients in all settings – regardless of their zip code or distance from an outpatient facility – to receive telehealth services.
But those changes were only temporary. While the $900 billion coronavirus stimulus law enacted at the end of 2020 includes funding for broadband expansion and Medicare coverage for telemental health and telehealth at rural hospitals, it does not extend telehealth access and coverage provisions in place during the coronavirus pandemic. Recently, a bipartisan group of lawmakers re-introduced the Protecting Access to Post-COVID-19 Telehealth Act, which aims to make permanent many of the emergency telehealth access and coverage rules put in place last year.
While this bill addresses many of the issues that were a drag on telehealth adoption pre-COVID-19, such as geographic and originating site restrictions, it avoids the issue of coverage parity, meaning that there would still be no permanent guidance on how providers should be paid for telehealth services. And that is a problem.
If the last decade of evolution of value-based care and significant successes of the CMS Shared Savings Program have taught us anything, it is that alignment of payment incentives and outcomes is the most effective way to improve quality of care.
If Congress and CMS want to create real change in health care that leverages the improved access to care afforded by telehealth while also encouraging the highest quality of care, they will link permanent telehealth expansion to value-based payment models.
This is the only logical, permanent step forward for telehealth reimbursement: it must be tied to a provider’s willingness to access responsibility for the cost and quality outcomes faced by their patients. This approach would address most of the concerns that currently exist around a permanent expansion of telehealth.
First and foremost, there is the concern among public health and government officials that providing permanent parity between telehealth and physical office visits could encourage providers to abuse telehealth as a more profitable, time-saving service channel – even in cases where a physical office visit was warranted. Issues of fraud, waste and abuse around telehealth are a legitimate concern. In October of 2020, the Department of Justice charged 86 telehealth executive defendants – as well as many doctors and nurses – with $4.5 billion in telehealth-related fraud.
Clearly linking telehealth reimbursement to established value-based quality models would ensure that patients who receive telehealth services are receiving it because it is the best care for the situation, not because it is the most profitable service line. Accountable Care Organizations in the Medicare Shared Savings Program have already established proven best practices for integration of telehealth into longitudinal management of patient care as well as prevention, and this data can serve as a clear set of benchmarks and guidelines for value-based telehealth reimbursement.
The other major challenge involving sustained, long-term telehealth adoption is the cost of implementation on the provider side of the equation. Integrating telehealth in a meaningful way across a practice requires more than setting up a Zoom call with a patient. To execute telehealth well, a provider practice must buy technology, train staff, develop clear workflows and documentation protocols and integrate the technology throughout their practice. Many practices have resisted that investment due to uncertainty about reimbursement.
Here again, linking payment to outcomes would incentivize the adoption and integration of the right technologies as opposed to the stop-gap emergency solutions many practices put in place during the pandemic.
The COVID-19 pandemic will be remembered as one of the most pivotal learning experiences in the history of health care. It is critical that we take the lessons learned about patient behavior and engagement forward as we shape the future of health care in this country. Telehealth played a major role in that experience. We owe it to patients to get the numbers right so our providers are not forced to take a step back after taking steps forward and our patients can continue to benefit from the services that are best suited for them.
About the author:
Tim Gronniger is the President and Chief Executive Officer of Caravan Health, a leader in accountable care organization (ACO) development. He is the former Chief of Staff and Director of Delivery System Reform at the Centers for Medicare and Medicaid Services.