As Healthcare Innovation Managing Editor Rajiv Leventhal reported on Wednesday, August 3, “President Trump signed an executive order on Aug. 3 to further expand access to telehealth services during the COVID-19 pandemic, especially in rural communities. Through this order, the administration is also taking action to extend the availability of certain telehealth services after the current public health emergency ends, via a new proposed rule. According to federal health officials, during the public health emergency, the Centers for Medicare & Medicaid Services (CMS) added 135 services such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services, that could be paid when delivered by telehealth. Now,” Leventhal wrote, “CMS is proposing to permanently allow some of those services to be done by telehealth, including home visits for the evaluation and management of a patient (in the case where the law allows telehealth services in the patient’s home), and certain types of visits for patients with cognitive impairments.”
Leventhal noted that CMS is seeking public input on which services to permanently add t the telehealth list beyond the public emergency in order to give clinicians and patients time as they get ready to provide in-person care again. CMS is also proposing to temporarily extend payment for other telehealth services such as emergency department visits, for a specific time period, through the calendar year in which the crisis ends.
“These proposals are part of numerous proposed policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues for the 2021 calendar year,” Leventhal wrote on Aug. 3. He also noted that “Federal officials pointed out that before the pandemic, only 14,000 beneficiaries received a Medicare telehealth service in a week while over 10.1 million beneficiaries have received a Medicare telehealth service during the public health emergency from mid-March through early-July. These statistics, and others, and others were touted in a recent Health Affairs commentary from CMS Administrator Seema Verma. That piece further noted that according to Medicare fee-for-service claims data, beneficiaries, regardless of whether they live in a rural or urban area, are seeking care during the pandemic through telemedicine services. In rural areas, 22 percent of beneficiaries used telehealth services, while 30 percent of beneficiaries in urban areas did so.”
In that context, Editor-in-Chief Mark Hagland this week interviewed Darryl Drevna, senior director of regulatory affairs at the Alexandria, Virginia-based American Medical Group Association (AMGA). As explained on its website, “AMGA is a trade association leading the transformation of health care in America. Representing multispecialty medical groups and integrated systems of care, we advocate, educate, innovate, and empower our members to deliver the next level of high-performance health. AMGA is the national voice promoting awareness of our members’ recognized excellence in the delivery of coordinated, high-quality, high-value care. More than 175,000 physicians practice in our member organizations, delivering care to one in three Americans.” Drevna spoke with Hagland about the implications of this policy moment for the senior executives of large medical groups, which AMGA represents in its advocacy and education efforts. Below are excerpts from that interview.
With regard to the activity taking place at CMS around telehealth, and this proposed rule, what are the most important elements in the rule and in the discussion, for physicians in group practice, from AMGA’s perspective?
I think that CMS is doing what it can to expand the availability of telehealth. I think they recognized early on that they needed to make telehealth as widely as possible, where their patients are. So they rolled out a bunch of waivers early on; and they’re pushing the envelope as far as they can to make telehealth as available as possible, but they’re running into statutory barriers.
The originating-site issue—where the patient is located—remains an important issue to resolve. Historically, the regulations were such that the patient had to be seen in a healthcare facility of some sort, with a clinician using the telehealth technology to talk with and communicate with a provider in a different facility. Now, under the public health emergency, the rules have been relaxed, and, understandably, Medicare is reimbursing providers for treating patients in their homes. The other issue is the geographic issue: typically, telehealth is urban-to-rural. And we’ve been arguing that those are obsolete restrictions on telehealth. If you’re in a big city and can hop onto your laptop, you should be able to do access care from an urban provider.
And with regard to those two areas of potential change, Congress will have to act to make permanent changes to those regulations, correct?
Yes, that’s correct, Congress will have to act. AMGA in October endorsed legislation called the CONNECT Act. “CONNECT” stands for “Creating Opportunities Now for Necessary and Effective Care Technologies for Health Act of 2019. [The bill, introduced on October 30, is being cosponsored by Senators Brian Schatz (D.-Hi.), Roger Wicker (R-Miss.), Ben Cardin (D-Md.), John Thune (R-S.D.), Mark Warner (D.-Va.) and Cindy Hyde-Smith (R.-Miss.). As AMGA noted at the time, “The AMGA-endorsed bipartisan legislation would address several gaps in Medicare’s current telehealth policy by providing the Secretary of Health and Human Services with the authority to waive telehealth restrictions when necessary; removing geographic and originating site restrictions for services like mental health and emergency medical care; allowing rural health clinics and other community-based healthcare centers to provide telehealth services; and requiring a study to explore more ways to expand telehealth services so that more people can access healthcare services in their own homes. Companion legislation has been introduced in the House of Representatives by Representatives Mike Thompson (D-CA), Peter Welch (D-Vt.), David Schweikert (R-AZ), and Bill Johnson (R-OH).”]
“The CONNECT for Health Act would:
> Create a bridge program to help providers transition to the goals of the Medicare Access and CHIP Reauthorization Act (MACRA) and the Merit-based Incentive Payment System (MIPS) through using telehealth and RPM without most of the aforementioned 1834(m) restrictions;
> Allow telehealth and RPM to be used by qualifying participants in alternative payment models, without most of the aforementioned 1834(m) restrictions;
> Permit the use of remote patient monitoring for certain patients with chronic conditions;
> Allow, as originating sites, telestroke evaluation and management sites; Native American health service facilities; and dialysis facilities for home dialysis patients in certain cases;
> Permit further telehealth and RPM in community health centers and rural health clinics;
> Allow telehealth and RPM to be basic benefits in Medicare Advantage, without most of the aforementioned 1834(m) restrictions; and
> Clarify that the provision of telehealth or RPM technologies made under Medicare by a health care provider for the purpose of furnishing these services shall not be considered “remuneration.”
Potential for cost savings:
> The bill includes requirements regarding cost containment, quality measures, and data collection.
> An Avalere analysis of three of the major provisions of the bill (first three bullets above) showed $1.8 billion in savings over 10 years.”]
We’re on the record as endorsing that legislation. CMS’s proposed rule—there’s only so much that they can do. If you dig into the reg, there’s a subset of codes—there’s a different law passed as part of CARES that allows for exceptions for substance abuse or mental health treatment. Those codes were on the telehealth list. But ultimately, CMS is signaling that they’d very much like to push this further and overcome some of those barriers, you could see that in the language of the presidential executive order. But congress will need to act.
Will Congress act?
I’d like to think so; you’d have to talk to someone in advocacy here. They’re focused right now on the COVID-19 relief package.
Long-term, what do you think will happen in this broad area?
I couldn’t speak to the timing, but I think that eventually, patient experience and demand, and provider experience and comfort, and further advances in technology, will force this forward. Patients have become accustomed to this during this public health emergency, and I don’t think they want to go back, and in some cases, can’t go back, to the way things were. And if patients are by and large happy with the care they’re receiving now, they’re going to be hesitant to go back to in-person visits on a routine basis. Of course, there will some services that will require in-person visits. But if patients and providers are comfortable sorting that out for themselves, eventually, Congress will recognize that.
How should providers prepare for the future, in the context of what we’ve been discussing here?
As providers are trying to navigate the pandemic and the potential practice procedures post-pandemic, it will require learning from your experiences during the pandemic and thinking forward around your plans for value-based care. This could provide an extra touchpoint for incorporating these types of models into population health management. So instead of having a diabetic come in every couple of months, can I get them on the phone every couple of weeks, to replace some in-person visits? It will involve rethinking care delivery models. And I think that collecting data and patient experiences and explaining patients’ stories to regulators and to policymakers on Capitol Hill, will help, and Congress will be informed in terms of thinking forward on policy into the future.