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.”
In that context, Leventhal wrote on Wednesday, “CMS said that it is also seeking public input on other services to permanently add to the telehealth list beyond the public health 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. This will also give the community time to consider whether these services should be delivered permanently through telehealth outside of the emergency, officials believe. 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.”
On Wednesday evening, Blair Childs, senior vice president for public policy at the Charlotte-based Premier Inc., spoke with Editor-in-Chief Mark Hagland regarding this new set of developments, and its implications for federal healthcare policy developments in the coming months. Below are excerpts from that interview.
Can you share your perspectives on the CMS announcement from yesterday evening, per the telehealth component of that announcement?
With regard to the proposed rule overall, there’s still a lot that’s unknown. I thought it was interesting that they released this element of a new rural payment model. It appears to be a risk-based model, though we haven’t seen its details yet. We’ve been talking to CMS for between one and two years on a new rural payment model, and they’ve been insisting that everything has to be risk-based based. So I think it may be based on a blend of the Pennsylvania model and the AIM model—the ACO Investment Model. Pennsylvania has rolled out what is essentially a capitated model: they pay the critical access hospitals in that state a fixed fee, so it’s a fixed budget they have to operate within. It’s a little bit like what they did in Maryland, with similar kinds of approaches.
The call that the White House held last night involved different groups, talking about what they were releasing, and one of the speakers was Theo Merkel, from the White House Council of Economic Advisers—someone very fiscally conservative. He was talking, in terms as general as possible, was saying that they want to move to some kind of risk-based model in order to—the issue is that if you have telehealth without the provider being at risk, the provider will do the telehealth visit and then have the patient come in for an in-person visit; there’s an increased potential for that to occur. So that’s why the thinking is that you need to make providers accountable for the total cost of care, which a capitated model does.
Can CMS, through its own authority, create permanent payment parity for telehealth-based visits, long-term or would the agency need congressional approval for that?
Here’s what I think will happen: CMS has a level of authority such that, under risk-based models, they can give providers a lot of flexibility, using CMMI [the Center for Medicare and Medicaid Innovation]. If they broadly expand telehealth, they need congressional action, because you can’t change the original site of care provisions of the law; you would need statutory change to address that issue.
In that regard, what are the chances of congressional action?
I think that they’re high. But I think that what Congress is going to do, is that it will say, yes, you can expand the originating-site definition. Right now, it’s limited to a provider setting. Through congressional legislation, you could change the site of care to the home, and allow additional types of physicians and providers to make use of telehealth, on a permanent basis. Congress would give CMS the authority to do that, and then CMS would set the rules.
Many providers are concerned that, once the public health emergency ends, that the de facto payment parity for telehealth-based visits could go away. What are your thoughts on that?
Payment parity is the correct term to use, because they did create greater parity under the public health emergency rules. So Congress will give them that power, but they’ll say, in risk-based models, you can have the higher payment, but for people staying in fee-for-service, they’ll very gradually expand your telehealth options, so you could do a telehealth visit, but, for example, they might constrain the frequency of patient visits, to perhaps once in a three-month period, for example. That would be with regard to fee-for-service-based care delivery. I think they’re going to incentivize providers to go into two-sided risk arrangement.
So you approve of what you saw last night in the CMS telephone conference with providers, overall?
Oh yes, I think it’s great. We’ve been pushing hard for expanded telehealth; this is a priority for our members. And many of our members are in two-sided risk, and will be able to take full advantage of this, being in a risk-based model. And we could have a change in administrations, and could see a different approach to alternative models, but I actually don’t expect considerable change to the models. In the future, you’ll see more and more providers take the incentive to do telehealth, because the payment will be better, and will give them much more flexibility from a care delivery standpoint.