Telehealth: Onward and Upward

By Matt Fisher, General Counsel, Carium
Twitter: @matt_r_fisher
Twitter: @cariumcares
Host of Healthcare de Jure#HCdeJure

It should be well known at this point in time that telehealth achieved rapid adoption and expansion throughout the course of the COVD19 pandemic. The adoption and expansion was the result of many emergency orders though that will only remain in place while a public health emergency declaration is in place. As a potential light at the end of the COVID tunnel can be seen, what will happen next? Optimistically, the answer is stabilization at the current point and growth.

What has Happened?
The federal government, specifically the Centers for Medicare and Medicaid Services (CMS), took as much regulatory action as may be possible through finalization of the 2021 Medicare Physician Fee Schedule (2021 PFS). The 2021 PFS added several new permanent telehealth codes for coverage and reimbursement. Included in the expansion was clarification around how remote patient monitoring will be covered, which is a particularly effective tool for clinicians and care teams to engage with patients outside the traditional walls of a healthcare institution.

Late 2020 also saw CMS launch a hospital at home demonstration model that encouraged hospitals to care for patients in their own homes while still providing the same amount of reimbursement as given to typical inpatient care. Hospital at home is a concept with a decent amount of evidence-based history of helping to improve outcomes while also controlling costs. If CMS’s new demonstration model gets to the same result, then it could be possible to see hospital at home a more permanent part of the care delivery landscape.

States have also been active on the legislative front. As already noted, the vast majority of, if not all, states used public health emergency declarations to require coverage along with increasing reimbursement for telehealth. States are also somewhat quietly and with growing momentum making those changes permanent. The list of states taking action since the COVID pandemic began include Massachusetts, Maine, New Hampshire, Texas, and Washington among others. Many of those changes focus solely on commercial coverage (meaning private health insurance plans) though. Addition of teleheath requirements to state Medicaid plans may not be so consistent or expansive.

What is Coming Next?
The next steps for telehealth are multifold and will need to approach a number of different angles. First, a legislative press needs to continue, in particular at the federal level. A telehealth coverage bill was reintroduced with the start of the 117th Congress that is meant to keep the emergency changes in place, at least for some period of time, and examine how best to incorporate telehealth for the longer term into Medicare and other government coverage. The legislation also tries to address clinician licensure issues as well as other geographic based restrictions, such as where the patient needs to be located.

States are also continuing to introduce new legislation to make telehealth coverage permanent. Bills are pending in some states that would keep the emergency changes. While it is not know if the bills will pass yet, it is certainly positive that legislation is being considered.

In considering the various forms of legislation, it will be essential to not just require coverage. Coverage just means that an insurance plan may be required to include telehealth in the scope of services that a plan member can access. Coverage is separate and distinct from reimbursement though. Many arguments may be presented for full payment parity, which has largely been the case during the emergency. Parity means plans would pay for telehealth services at the same level as in-person services. Arguments can be presented on both sides of the coin as to what level of reimbursement is appropriate. However, no matter the outcome of the debate, reimbursement should, at a minimum, be set at a level where utilization of telehealth is not discouraged because the money coming in is too low. If reimbursement undercuts the use of telehealth by pinching the financial health of an organization, then no one will benefit.

Another component for the growth of telehealth is development of evidence around the actual impact of service delivery through telehealth. The evidence should focus on the quality of care delivered, impact on workflow, and impact on cost. Positive outcomes may be expected on all fronts, though the impact on cost will be one of the most important data points for expansion. Presumptive arguments claim that telehealth just drives up service utilization along with cost because patients and clinicians can use so easily. However, if a telehealth visit could be viewed as preventing a complication or not driving up utilization, then cost would not necessarily increase and the case for telehealth is strengthened.

Another key area for legislative attention on telehealth use will be licensure of the clinicians who can deliver telehealth services. Currently, a clinician is typically required to be licensed in the state where the patient being treated is located. That is giving rise to the state of some clinicians holding 50 or more licenses, a cumbersome process and management requirement at best. During the pandemic, some states granted emergency licenses, recognized licensure in another state, or created telehealth specific licenses. Regardless of the specific solution, easing the licensing process would certainly have a beneficial impact. There is also a growing argument that medicine is practiced the same in all states, which raises the question as to why each state has a different licensing requirement. While a single solution is unlikely, some change will be necessary to make the process clearer.

Connection to Value Based Care
The COVID pandemic has frequently been cited as a driver for increasing the adoption of value based care models. If that is true, then telehealth will become even more essential. Being able to easily interact with patients and promote preventative care ties directly into the processes necessary for succeeding in value based care.

Beyond the presumed video based visit, remote patient monitoring and other engagement solutions, which are all forms of telehealth, will also factor into the value based care discussion. Helping patients lead healthier lives and detecting potential complications earlier should have a positive impact on the overall cost of care delivery along with patient satisfaction and community benefit. An almost limitless number of potential benefits could be identified, but commitment will be necessary to seeing it bear out.

The Takeaway
It may sound like a broken record, but it is really important for all interested parties to keep up the pressure and attention to telehealth expansion and incorporation. Legislation is absolutely required to keep all of the changes made during the pandemic in place. Sliding backwards is not a good option. Instead, the focus must be onward and upward.

This article was originally published on The Pulse blog and is republished here with permission.