Telehealth Advocates Respond to CMS ‘Virtual Visit’ Proposal

July 17, 2018
Telehealth advocates applaud a CMS proposal to pay for brief e-visits, but they ask whether providers are going to determine it is worth it to invest in telehealth systems.

Among all the proposed changes the Centers for Medicare and Medicaid Services (CMS) rolled out last week, ones related to telehealth drew considerable interest. Although it can’t use its regulatory power to change the laws that restrict telehealth services paid for by Medicare to rural settings, the agency has instead defined new “communication technology–based services” that could be used for virtual visits with established Medicare patients regardless of such patients’ location, effective Jan. 1, 2019.

In its proposed rule about virtual visits, CMS is seeking comment on whether telephone interactions are sufficient or whether interactions enhanced with video or other kinds of data transmission should be required. CMS also proposes to create a new code to permit separate Medicare payment for store-and-forward technology such as when a dermatologist examines an image of a patient’s skin asynchronously.

The CMS proposal brought a mix of enthusiasm and concerns from groups advocating for greater usage of telehealth. “What they have done is creative and brilliant, and it goes further than CMS has ever gone previously to ensure that seniors have services everyone else in the marketplace has,” said Krista Drobac, executive director of the Alliance for Connected Care. On the other hand, she expressed concern that CMS paying for brief e-visits is going to create an environment where providers are going to weigh whether it is worth it to invest in telehealth systems. “What they will probably find is that the reimbursement is not enough to transform their practice and make telehealth part of their work flow,” she said.

Drobac believes CMS has gone as far as it can go within the existing law. She said Congress needs to give the Secretary the authority to waive the telehealth restrictions on all provider codes. “On the one hand, I am excited about the progress; on the other hand, it makes me even more determined that Congress act. CMS has gone as far as any of us could have asked on a regulatory level.”

Drobac also noted that CMS has plans to make the program budget-neutral by cutting base payments for providers to counter increased spending on virtual visits. “The more this gets used, the lower those E&M code reimbursements might be,” she said.

Aside from actual proposal itself, Mei Wa Kwong, executive director of the nonprofit Center for Connected Health Policy, was intrigued by the reasoning CMS used for how they can make this proposal and not face the same limitations other telehealth services do. “That raises the question: are we creating two separate things, communication technology vs. telehealth. Are they going to be separate? They started down this path a few years earlier with chronic care management and remote patient monitoring,” she said.

The way the virtual check-in proposal stands now stands, providers would have to have a telehealth system set up. “But CMS asked for comments on whether they could be done on the phone, which I think would be a lot more common,” Kwong said. “The reimbursement for that proposal is $14 per check-in. People have asked me whether physicians would see that as worthwhile to go through the administrative tasks and I don’t have an answer. There are still a lot of questions.”

In its proposal, CMS noted that the virtual visit service could be used as part of a treatment regimen in follow-up visits for patients on medication-assisted therapy for opioid use disorders. “We have been very active on that issue on Capitol Hill,” Drobac said. “We have been an advocate for the e-TREAT Act, which is part of the Senate opioid bill. That would lift the telehealth restrictions for substance use disorders. It would give CMS even more authority to work in the substance use disorder area. We are pushing for Congressional action on that.”

Kwong said virtual visits could be very useful for patients, “but there are a bunch of policy complications related to medication-assisted therapy. It might not be as widely used as they hope.”

Overall, how the proposed rule is tweaked could make a big difference, she added. If the asynchronous store-and-forward service can be used for new patients, that would benefit the direct-to-consumer companies, she said. “Is CMS policy going to be that you can establish a patient-provider policy this way? If so, it could have a wider impact. Or if they allow the patient check-ins via phone, that could have a wider impact.”
Other provider organization and informatics group represenatives weighed in on the subtle nuances of the proposal:

“I think all types of patients can benefit from a policy like this, as it gives them an opportunity to touch base with a provider without having to schedule an office visit,” said Darryl Drevna, director of regulatory and public policy at the American Medical Group Association (AMGA). “Previously, the way that telehealth was paid was if an office visit was scheduled and then the payment would get wrapped up in that office visit. Here, you can look at the film or have a call with your patient, as sort of a triage, and if you don’t end up having to schedule an office visit, you’ll still get reimbursed for that. So, this is a positive; this is something that we’ve long supported, to expand the use of telehealth as a program.”

“Telehealth advocates have been clamoring for CMS to jump in with both feet on reimbursement of telehealth, and I think this proposal does that,” said Jeff Smith, vice president of public policy at the Bethesda, Md.-based American Medical Informatics Association (AMIA). “Whether or not they are jumping six feet in the water or have both toes in the water is up for debate. But I think telehealth advocates will score this as a major win, and it is a major win.”

“It’s always good when things like telemedicine are expanded and there are more options to treat patients, but what we’re going to be looking at with a proposal like this is: what are the criteria and what is the payment amount?” said Anders Gilberg, senior vice president, government affairs, for the Medical Group Management Association (MGMA). “Some of those additional flexibilities and additional codes for telemedicine can be quite useful, as long as the complexity and the rules and the hoops you have to jump through are not overwhelming so that the return on investment to even provide those [telemedicine services] is there.”