Regulatory Changes Needed To Expand Medicare Telehealth Use

November 20, 2018 - A new report on Medicare telehealth between 2014 and 2016 shows increased utilization of telehealth services by Medicare beneficiaries but largely remains an untapped resource because of restrictive federal rules and regulations.

“Telehealth is being used primarily to treat beneficiaries with mental health diagnoses, with telehealth mainly used to provide office and other outpatient visits,” states the report. “While there is general consensus that rigorous evidence related to telehealth is still lacking for quality, health outcomes, and cost, there are promising results for certain geographic areas and certain conditions. There is very limited evidence specific to the Medicare population.”

According to the report, approximately 90,000 Medicare beneficiaries used more than 275,000 telehealth services as recently as 2016 — a 48.3-percent and 65.3-percent increase, respectively, over those figures in 2014. However, the overall totals represent a significantly small percentage of total beneficiaries who number 35 million individuals altogether. By and large, Medicare beneficiaries sought out telehealth services for mental health treatment and did so in mostly rural regions of the country.

Current Medicare payment policies must change in order for telehealth expansion to occur under the nation’s biggest health plan, the federal agency argues. Waivers have played an integral role in permitting the federal agency to test telehealth reimbursement.

“To date, based on current statutory restrictions, Medicare has primarily offered telehealth services to meet the needs of rural beneficiaries and has provided coverage for a select set of telehealth services required by statute or for which there is strong clinical evidence,” the report states.

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CMS identifies provisions of the Social Security Act, Section 1834(m), as the greatest barriers to Medicare telehealth expansion. Namely, the statute:

• prohibits Medicare payment for telehealth services to patients not located at particular health care settings, known as originating sites. Additionally, the provisions require originating sites to be located in a rural HPSA or a county outside of a Metropolitan Statistical Area, or a site participating in a specific Federal telemedicine demonstration project approved by, or receiving funding from, the Secretary as of December 31, 2000;
• limits the types of practitioners that can furnish telehealth services; and
• requires that Medicare pay for telehealth services at the same rates as in-person services

Additionally, CMS notes that the telehealth payment is limited to real-time interactions between providers and patients, with only two exceptions existing — one in Alaska and another in Hawaii — that allow for reimbursement of services rendered using asynchronous store-and-forward technology.

Barring significant change, the federal agency is unlikely to realize the full benefits of telehealth adoption, especially as it embraces more and more value-based payment.

“There is overwhelming agreement that telehealth can bring medical care into communities with limited access to health care providers, reduce wait times for patients, and be more convenient than travelling to a health care provider’s office,” the report states.

“Based on the experiences of multiple payers and health care providers,” the report continues, “it appears that telehealth could play an important role in achieving the goals associated with value-based models by providing clinically indicated, high quality, ‘anytime, anywhere’ care to patients. In addition, many health disparities in rural communities are related to poor access to care, and most evidence supports telehealth use in these communities.”

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In a recent speech at the Alliance for Connected Care Telehealth Policy Forum for Health Systems, CMS Administrator Seema Verma detailed increased efforts the federal agency is making to promote and expand telehealth use.

One is coverage for virtual check-ins. “As all of you know, many times a virtual check-in will resolve patient concerns in a convenient manner that gets them the care they need, and avoids unnecessary costs for the system. This is an incredible step in the right direction for our beneficiaries,” she said.

Another is virtual consultants. “For the very first time, we will also be paying for virtual consultations between physicians, and evaluation of remote pre-recorded images and video. For example, a patient could now text a picture of a mole on their skin to a dermatologist for examination,” she added.

Home health is also slated to receive a boost under Medicare. CMS will allow for the use of remote patient monitoring by home health agencies and Medicare patients receiving home dialysis will have the ability to receive monthly assessments using telehealth.

Lastly, Verma expressed optimism about efforts at the Center for Medicare & Medicaid Innovation (CMMI) to test care models with telehealth components.

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“When providers take accountability for healthcare costs, we want to give them more flexibility to innovate, so they don't have to come to CMS for permission to test a new approach to care delivery,” she said. “We’re particularly focused on using our waiver authority to spur innovation in the telehealth space.”

With much still depending on waivers, regulatory changes must be made in order to Medicare telehealth use to prove its worth.