The American Telemedicine Association (ATA) released a statement this week saying it appreciates that the Medicare Payment Advisory Commission (MedPAC), in its March 2021 report to Congress on Medicare payment policy, recognized the importance of telehealth during the COVID-19 public health emergency (PHE) and the need for policy changes to ensure access to telehealth post-PHE. However, the association did disagree with the federal agency’s recommendation that only “some” elements of the government’s telehealth expansion during the crisis be permanently extended.
In its report, MedPAC, an independent, non-partisan legislative branch agency headquartered in Washington, D.C., referenced several telehealth benefits, including “improved access to care for those with physical impairments, increased convenience from not traveling to an office, and increased access to specialists outside of a local area.” The report also cited MedPAC’s annual beneficiary survey, stating that “over 90 percent of respondents who had a telehealth visit reported being ‘somewhat’ or ‘very satisfied’ with their video or audio visit, and nearly two-thirds reported being ‘very satisfied.’”
As the report noted, during the PHE, Congress and CMS have temporarily expanded coverage of telehealth services, “giving providers broad flexibility to furnish telehealth services to ensure that beneficiaries continue to have access to care and reduce their risk of exposure to COVID-19. Hospitals, physicians, and other providers have responded by rapidly adopting telehealth to provide continued access to medical care for their patients.”
Indeed, according to MedPAC’s analysis of fee-for-service (FFS) Medicare claims data, during the first six months of 2020, 10.3 million beneficiaries in FFS Medicare (32 percent of the total) received at least one telehealth service, compared with 134,000 beneficiaries during the first six months of 2019.
Without legislative action, however, many of the changes will expire at the end of the PHE, MedPAC noted. Although temporary telehealth expansions affect virtually all settings of care, most of the changes affect the services paid under the physician fee schedule (PFS), the agency added. Before the PHE, Medicare paid for a limited number of telehealth services and only if they were provided to beneficiaries in a clinician’s office or facility in a rural area. What’s more, most telehealth services were paid at the lower PFS rate used to pay clinicians providing care in facilities, rather than the higher rate used to pay office-based clinicians, because the practice expenses associated with furnishing telehealth services were presumed to be lower, the report explained.
MedPAC pointed to several flexibilities that were granted around telehealth during the PHE:
- Clinicians may bill for telehealth services provided to Medicare beneficiaries in any location, including their homes and in urban as well as rural areas.
- CMS has added over 140 PFS services to the list of services it will pay for when delivered through telehealth. Clinicians can bill for some of these services if they are provided using audio-only interaction, and CMS also added new codes for audio-only evaluation and management visits.
- CMS pays the same rate it would have paid if the service had been provided in person.
- Clinicians may reduce or waive beneficiaries’ cost-sharing obligations for telehealth services.
What happens next?
While it is expected these telehealth expansions will remain in place throughout the PHE, there is ongoing debate on whether the expansions should be made permanent. MedPAC believes that “policymakers should temporarily continue some elements of the telehealth expansions for a limited duration of time—one to two years after the PHE—to gather more evidence about the impact of telehealth on access, quality, and cost, and they should use that evidence to inform any permanent changes.”
- During this limited period, MedPAC contends that Medicare should temporarily:
- Pay for specified telehealth services provided to all beneficiaries regardless of their location,
- Cover certain telehealth services in addition to services covered before the PHE if there is potential for clinical benefit
- Cover certain telehealth services when they are provided through an audio-only interaction if there is potential for clinical benefit
“After the PHE ends, Medicare should return to paying the fee schedule’s facility rate for telehealth services and collect data on the cost of providing those services. In addition, providers should not be allowed to reduce or waive cost sharing for telehealth services after the PHE,” MedPAC said in its report. It's also noteworthy that the agency recommended that CMS should continue to temporarily cover select services that the agency determines have the potential for clinical benefit. “We favor this approach instead of permanently covering all of the telehealth services that are temporarily covered during the PHE,” MedPAC said.
The ATA, in its statement, did take issue with the report calling for an extension of “some” elements of the telehealth expansion, rather than permanently covering telehealth services. “We strongly believe that, rather than a temporary extension of flexibilities, Congress should permanently remove existing statutory barriers to ensure Medicare recipients are able to receive care where and when they need it. The ATA looks forward to continuing to work with CMS and Congress to enact commonsense Medicare reforms to ensure beneficiaries continue to access telehealth post-PHE,” said Ann Mond Johnson, CEO, the ATA.
The ATA and others have been at the forefront of advocating to make permanent these government-granted flexibilities during the PHE. Importantly, as noted in a report last fall from the Taskforce on Telehealth Policy, statutory restrictions within the Social Security Act and that the authorities granted to HHS and CMS are limited to the COVID-19 public health emergency period, meaning that “Congress must act to ensure that the Secretary has the appropriate flexibility to assess, transition, and codify any of the recent COVID-19-related telehealth flexibilities and ensure telehealth is regulated the same as in-person services.” Payment-focused telehealth changes are under the authority of Congress rather than HHS and CMS.
“Importantly, MedPAC rightly advises that Congress should give CMS the authority to pay for telehealth services provided to all Medicare FFS beneficiaries regardless of geographic location, including those at home. We also applaud MedPAC for identifying audio-only interactions with a healthcare provider as an appropriate way to deliver care,” said Mond Johnson.
However, the ATA did take issue with another assertion in the report, specifically around “inaccurate assumptions about legitimate telehealth services.” As stated by MedPAC, “Expanding telehealth services also raises program integrity concerns. Telehealth companies have been involved in several large fraud cases, resulting in several billions of dollars in losses for Medicare.” The report specifically pointed to a case in which the Department of Justice (DOJ) recently charged defendants—including telemedicine companies—with submitting false and fraudulent claims worth more than $4.5 billion to federal health programs and private insurers.
As such, MedPAC asserted that “Telehealth technology might make it easier to carry out fraud on a large scale because clinicians employed by fraudulent telehealth companies can interact with many beneficiaries from many parts of the country in a short amount of time. In addition, if telehealth is expanded and beneficiaries become more comfortable receiving care through telehealth, they might become more vulnerable to being exploited by companies that pretend to be legitimate telehealth providers. For these reasons, Medicare has historically been cautious about covering telehealth services. In considering a permanent expansion of telehealth, a key issue is how to achieve the benefits of telehealth while limiting the risks to beneficiaries and the program.”
In response, Mond Johnson said, “It is essential, as recently pointed out in a statement from the HHS Office of Inspector General (OIG), that we must differentiate ‘telefraud’ and telemarketing schemes and legitimate telehealth services in order to dispel concerns around the safety and effectiveness of telehealth.”
