Telemedicine in the Era of Covid-19
Policymakers implemented many changes to facilitate telemedicine use.
- Telemedicine visits can be provided to patients in their homes
- All out-of-pocket costs are waived for telemedicine visits
- Payment is mandated for audio-only telephone communications
- Visits are no longer limited to rural residents
- Licensure requirements waived
- Types of providers that can deliver a telemedicine visit expanded
- Sense of urgency given continued uncertainty about long-term plans has deterred investments by providers.
- Government and health plans leery of covering telemedicine visits permanently.
- Convenience, key strength of telemedicine, may be viewed as its Achilles heel.
- Concern that in a fee-for-service system there will be “overuse” of telemedicine.
Key Policy Considerations
- Telemedicine ≠ video/audio visits
- No single telemedicine policy
- Need for simplicity
- If providers at risk, should there be any limitations?
- How to address overuse?
- Limitations by patient, condition, provider
- Relative cost difference – should there be parity?
- Should there be coverage of phone calls?
Delegate Ariana Kelly: Could you expand on your point about payment parody? Could you walk me a little bit more on what that might look like?
Dr. Ateev Mehrotra: A doctor may come to you and say when I do my telemedicine visit I spent 15 minutes and my in person visit could only be 15 minutes, so why would you pay differently? When we pay a provider for an outpatient visit we are not paying just for the time. We are also paying for the rent, the overhead, the medical assistant, and the equipment. All of those costs go into that visit. Because telemedicine allows us to reduce those overhead costs, that’s why I believe in the long term it will be less costly for a provider and therefore the payment should reflect that.
Delegate Karen Lewis-Young: Can we design policies that will address the 3-5% of the population that will abuse the system? On any medical issue there are always going to be outliers, so do we address the policy to the general population or to the exceptions?
Dr. Ateev Mehrotra: One area where the exceptions come up is the issue of fraud. We have concerns and some experience already unfortunately. We may need to ensure that we make those investments to address that kind of fraud.
Delegate Susan Krebs: I’m concerned about the appropriateness of a telemedicine visit. How do we ensure that we’re not missing out on things that would have been picked up on during an in person visit?
Dr. Ateev Mehrotra: There is a variation. While there is a lot of evidence that in many clinical circumstances a telemedicine visit is an equal to an in person visit. We should not expand upon that and say all telemedicine is appropriate in all circumstances, some of that is obvious.
Delegate Susan Krebs: As we are crafting policy how in the weeds do we get with this?
Dr. Ateev Mehrotra: That would be almost impossible for you to set up policy that you would specify you can use it for this, but you can’t use it for this. In that particular case I think it should go back to the professions and our malpractice structure to enforce that we use professionalism to ensure we’re providing the right care.
Delegate Bonnie Cullison: Do you have any sense that at the federal level they are beginning to look at some guidelines around telehealth beyond Medicare, but in general or if this will really be left to the states?
Dr. Ateev Mehrotra: To date it has been very much under our federal system but the states have been given tremendous deference in terms of developing policies. On the federal level there is limitations on what they can do.
David Sharp, Director, Center for Health Information Technology and Innovative Care Delivery, Maryland Health Care Commission
Telehealth – MHCC’s Role
Telehealth is an important strategy to improve access take care and reduce health care costs, three key initiatives:
- Assess barriers to adoption and propose solutions to address barriers
- Foster technology adoption and meaningful use
- Educate providers and consumers on value and best practices
Supporting Telehealth Policy Development
The MHCC Is planning to conduct an impact evaluation of telehealth in 2021; key questions include:
- Has telehealth improved access to care, particularly for more vulnerable patients?
- Has telehealth induced new demand for services or offset in-person care?
- What is the financial impact of widespread use of Tele health on Maryland’s Total Cost of Care Model?
- Does telehealth reduce emergency department utilization?
- How can new components of telehealth, such as remote patient monitoring, be integrated into the course of care and systems of reimbursement?
PHE and Regulatory Relief Propels Telehealth
Enabled by Executive Orders from Governor Hogan and waivers from the federal government; waivers were time limited, however, many have been extended to the end of the public health emergency (PHE)
- Telehealth waivers (some variance across payors):
- Patient location (originating site) – lessening of geographical restrictions
- Licensing – greater flexibility is to practice across State lines
- Patient-provider relationship – redefined what constitutes a treatment relationship
- Eligible providers – expanded provider types that can deliver telehealth services
- Types of services covered – increased the number of services payable when furnished via telehealth
- Cost-sharing – patient obligation eliminated or reduced
- Technology – use of popular non-public facing applications temporarily permitted to deliver telehealth services
- The Office for Civil Rights is exercising enforcement discretion and not imposing penalties for noncompliance with the regulatory requirements under HIPPA Rules for the good faith provision of telehealth
Telehealth Adoption Pre-Covid-19
Adoption in Maryland informed by data:
- 11% – practices
- 96% – hospitals; diffusion limited to certain departments, 4% planning to implement
- 12% – nursing homes
- 27% – home health agencies; limited to remote patient monitoring
- 4% – dentists
Telehealth Adoption in Response to Covid-19
*Adoption in Maryland based partly on anecdotal information:
- 70% – practices
- 100% – acute care hospitals; expansion to most departments
- 45% – nursing homes
- 65% – home health agencies; limited to remote patient monitoring
- 6% – dentists
Telehealth Virtual Resource Center
- Featured information:
- Payor policy changes and reimbursement
- Web-enabled Telehealth Readiness Assessment Tool
- Technology vendor selection guidance
- Privacy and security considerations
- Best practices for patient engagement and virtual care
- Resources are continuously added, reflective of stakeholder’s inquiries and requests.
Consumer Awareness Building
- Educational materials highlighting the utility of telehealth, answers to frequently asked questions about virtual care, and safety tips during the PHE.
- Podcasts highlighting the telehealth experience.
- Telehealth public service announcements
Telehealth Adoption Grant
- A technology grant awarded to three State-Designated Management Service Organizations (MSOs) to assist small practices with telehealth implementation.
- Coaches work with practices to complete specific milestones
- Practice activity as of September 2020:
- 150 – expressed interest in working with an MSO
- 72 – provided with adoption support
- 52 – attested to using telehealth in care delivery
Post Covid-19 Planning
- Momentum increasing nationally to make some telehealth policy changes permanent; a complete post COVID-19 telehealth policies are not yet clear.
- Payors have signaled that some dialing back will occur at the end of the federal/State PHE.
- Audio only, first contact telehealth visits, telehealth from within same site.
- Getting the prices right – Medicare will use the annual physicians fee schedule update as a vehicle for making changes to the scope and fee levels for Medicare telehealth services.
- Medicaid federal and State collaboration on scope and payment with possible State budget impact.
- Policymakers – need to address inequities in access to telehealth.
- The MHCC is convening a Telehealth Policy Workgroup to discuss policies and potential future legislation alignment opportunities.
- Over 60 different stakeholders consisting of payors, providers, consumers, and technology vendors, among other.
- Virtual kick-off held September 30th, meetings are planned through the end of this year.
- An information brief is targeted for release in 2021.
Delegate Bonnie Cullison: Regarding expanding the accessibility and use of school based health centers. Would you be supportive of us seeing if we can find a way to make sure that can be facilitated?
David Sharp: About a year ago we were asked by the Senate Finance Chair if we would convene a work group related to school based telehealth and make some recommendations. We convened stakeholders and developed a report and identified a number of areas in which school based telehealth could be advanced in the state. Typically for the Commission to support legislation, that’s a decision made by the Commission itself. There has been a lot of support around advancing school based telehealth.
Delegate Karen Lewis-Young: Regarding students with special needs. What other things can be done to address the special needs of certain students?
David Sharp: There are school based health centers which are run by nurse practitioners or physicians and a small staff in the state. There is also school health nurses or school health services which typically include a registered nurse, that either are site specific or have several sites. With remote learning by students these health nurses have been filling the gap because they’re working with students and their families via telehealth. We’ve done some education on awareness for best practices for using telehealth.
Kathleen Birrane, Commissioner, Maryland Insurance Administration
David Cooney – Associate Commissioner – Life and Health
- Expansion of telehealth systems and platforms eligible for coverage – any “non-public facing” commercial applications (e.g. FaceTime, Skype, Zoom)
- Increased scope of services eligible for telehealth coverage (conditions/services/specialties)
- Telehealth coverage of phone-only consultations
- Waiver of member cost-sharing for telehealth visits
- Provider reimbursement parity between virtual consultations and in-person consultations
- Extension of accommodations to self-funded clients