Alliance News

On Friday, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule regarding Medicare Part C and Part D benefits. The proposal is the next step in the implementation of the Bipartisan Budget Act which authorized Medicare Advantage (MA) plans to offer, as part of the basic benefit package, additional telehealth benefits beyond what is currently allowable in original Medicare.

After years of trying to convince CMS that telehealth services should not be considered separate clinical services, and that telehealth will not drive unnecessary utilization, the rule contains major progress for the telehealth community. However, in addition to these wins, there are a couple of areas we hope that CMS will consider modifications.

Telehealth Wins

Win 1: The biggest win is more of an existential one. For years, telehealth stakeholders have been bringing evidence to CMS to demonstrate that the use of telehealth will produce savings for Medicare. This evidence included avoided care in higher cost settings during acute situations, as well as use of telehealth for secondary prevention of chronic disease including post-acute care and medication management.

On Friday, CMS finally formally acknowledged this evidence. The CMS impact analysis of the proposed rule “assumes replacement of some face-to-face provider visits, and no additional increase in overall provider visits.” They also said that “increased coverage of the additional telehealth benefits will generally result in an aggregate reduction in use of emergency room visits and inpatient admissions because the relative increased ease of receiving healthcare services should improve health outcomes and reduce avoidable utilization that results in untreated conditions exacerbating illness.” They even acknowledged the value of telehealth in reducing patient travel time to the tune of $60-100 million.

Win 2: CMS’s proposal to allow MA plans to build their telehealth benefits “in a manner consistent with professionally recognized standards of health care” is consistent with the way MA plans treat other services. By declining to set up a prescriptive system to determine what is “clinically appropriate,” CMS implicitly recognized that telehealth is simply health care delivery by another modality. It’s not a separate service, and doesn’t need to be treated separately.

Win 3: CMS currently allows MA plans to engage in differential cost sharing for original Medicare benefits. This flexibility would be extended to additional telehealth benefits, meaning that MA plans could offer telehealth services for free should they so choose. This flexibility is crucial for enrollees and plans alike. Making telehealth services available with little or no co-pay facilitates it’s use.

Win 4: The proposed rule notes that CMS recognizes “the potential for additional telehealth benefits to support coordinated health care and increase access to care in both rural and urban areas.” This is exciting because in the past some have posited that telehealth may make care more disjointed. CMS sees the value that telehealth can bring to coordinating care.

Issues to Watch

Issue to Watch 1: MA plans want to offer telehealth services to increase access to care. CMS acknowledges this will happen. However, we need to ensure that telehealth services can be offered alongside in-person care without having to be classified as supplemental to in-person visits. In other words, we shouldn’t have exactly the same number of in-person providers as telehealth providers after network adequacy standards are met. MA plans should be able to add as many telehealth providers as they want after they have met their network adequacy standards.

Issue to Watch 2: The definition of technology in the rule is very broad. It’s good to have flexibility to allow for future technology innovation, but just like in the proposed Physician Fee Schedule rule, allowing secure messaging and phone to count as telehealth may simply mean paying for services that doctors already provide. We should have the same definition for telehealth in both original Medicare and fee-for-service for consistency. The fee-for-service definition is sufficiently broad to allow for technological innovation.

Overall, this proposed rule represents major progress for telehealth in Medicare, and will surely give seniors more access to care through technology.

This is the first of two blogs about the telemedicine provisions in the draft CY2019 Medicare Physician Fee Schedule published last week by the Centers for Medicare & Medicaid Services (CMS). I’ve summarized below what CMS is proposing, and I will follow up with some thoughts about the implications for telehealth coverage and adoption.

Each year, the Physician Fee Schedule addresses telemedicine. The annual rulemaking process is the mechanism by which CMS adds codes to the list of “telehealth services” allowed in Medicare, and also determines what is allowable for remote care.

But this year’s rule was different. It went beyond routine coding changes and clearly showed that CMS is committed to bringing virtual care to seniors. CMS used incredible creativity to get around some very restrictive statutory provisions. CMS Administrator Seema Verma expressed her commitment to telehealth early in her tenure, and this rule shows she was serious.

Telemedicine is generally divided into three modalities: real-time (live video or phone); remote patient monitoring (asynchronous monitoring); and store-and-forward (sending images via secure messaging). All are regulated differently, and this proposed rule addressed all three.

Physician-Patient Telehealth in Medicare
The CMS proposal getting the most attention is the addition of a new code for a “brief communications technology-based service,” or a virtual check-in (real-time) conducted by a physician or other qualified health care professional for 5-10 minutes of medical discussion. It’s meant to allow the provider “to assess whether the patient’s condition necessitates an office visit.” It can’t originate from a provider service offered within the previous seven days nor lead to a service or procedure within the next 24 hours or soonest available appointment. If either of those things is linked to the virtual visit, the virtual check-in gets bundled into the office visit and is not separately billable.

CMS is proposing to price this service at a rate lower than existing E/M in-person visits ($14 for the new service, compared to $92 for an in-person E/M visit) to reflect the “low work time and intensity.” This service could only be furnished to established patients.

The way the Medicare statute is written necessitated the creation of this new code because rural and site limitations apply to primary care and behavioral health codes that would be useful in treating Medicare patients remotely. By creating a new code, CMS got around the statutory limitation. They did as much as they can without Congressional action, but even with their clever approach we need Congress to change the law to fully allow real-time telehealth to take hold in Medicare (as will be discussed in more detail in my second post).

Remote Patient Monitoring
Remote patient monitoring, or the transmission of biometric information from patient to a medical provider asynchronously, is not considered “telehealth” under the Medicare statute. Therefore, it is not restricted by the same limitation applied to real-time telehealth visits. The newly created CPT codes related to remote patient monitoring – 990X0, 990X1, 93XX1 and 994X9 – were deemed by CMS to be “inherently non face-to-face” and therefore not telehealth services. So, these codes will simply be adopted as part of regular Medicare services under Part B in addition to CPT code 99091 which was unbundled from chronic care management (CCM) codes last year This is excellent news for patients with chronic illness who can benefit from a medical provider monitoring their disease state.

Remote Evaluation of Pre-Recorded Patient Information (“Store and Forward”)
Currently, store and forward, sending pre-recorded video or image technology to another provider for evaluation, is not permitted beyond Alaska and Hawaii. Like the virtual check-ins, CMS intends for store and forward information to be used to determine whether or not an office visit is warranted. It is mostly used in dermatology, radiology, pathology and ophthalmology.

CMS proposes to create a new code that would be separately billable as long as the review of a patient-submitted image or video does not result in an in-person office visit with the same physician, or originate from a service provided within the previous seven days by the same physician. In those cases, payment would be considered bundled into the in-person office visit.

CMS is seeking comment as to whether store and forward services should be limited to established patients, or whether there are certain cases where it might be appropriate for a new patient to receive these services.

Payment for Phone/Internet “Interprofessional Consultation”
CMS proposes to make a separate payment for interprofessional consultations undertaken “for the benefit of treating a patient that will contribute to payment accuracy for primary care and care management services.”

Interprofessional consultations include “assessment and management services conducted through telephone, internet, or electronic health record consultations furnished when a patient’s treating physician or other qualified healthcare professional requests the opinion and/or treatment advice of a consulting physician or qualified health professional with specific specialty expertise.”

Eventual Cuts to Base Rate to Achieve Budget Neutrality
CMS estimates that the usage of these new services will result in fewer than 1 million visits in the first year but will eventually result in more than 19 million visits per year, ultimately increasing payments under the PFS by about 0.2 percent. In order to maintain budget neutrality in setting proposed rates for CY19, CMS assumed the number of services that would result in a 0.2 percent reduction in the proposed base rate conversion factor.

Stay tuned for the second part of this series next week.

Over the past several weeks, the House of Representatives passed 58 opioid-related bills. The Senate is in the midst of considering their own legislation. The intent of congressional leaders in both chambers is to reconcile these legislative packages and send a final bill to the President this year. This effort is key to solving a major national problem and demonstrates that Congress can come together to support people, families and communities in need.

It also happens to be a significant step for Medicare reimbursement of telehealth. Telehealth supporters have long tried to overturn outdated statutory language that requires Medicare beneficiaries who are enrolled in traditional fee-for-service (FFS) to be in specific institutional sites in rural areas for their providers to qualify for Medicare coverage. About 80 percent of Medicare beneficiaries live in 1,200 metropolitan counties that are not considered “rural” under HHS’ definition, and making people go to a clinic or hospital to receive telehealth services defeats the purpose of the technology.

Our challenge as advocates has been assumptions by the Congressional Budget Office (CBO) that increasing access to telehealth for seniors will increase utilization without a subsequent decrease in utilization of other forms of care. In other words, they think people will use telehealth and also go to the doctor in person, thereby increasing costs. Studies showing that telehealth substitutes for in-person care, reduces re-admissions and increases preventive care have not convinced them, nor have the major investments that capitated insurers have made in telehealth services.

The opioid effort in Congress has changed the course of this debate. As a result of the dire need for behavioral health services to help mitigate the crisis, both the House and Senate have moved bills to lift telehealth restrictions in Medicare to enable more mental health and substance abuse providers to see patients via telehealth, and thereby expand access to care. The eTREAT Act (S. 2901) in the Senate would entirely lift Medicare’s originating site restrictions on reimbursement for patients suffering from substance use disorder (SUD). The Access to Telehealth Services for Opioid Disorders Act (H.R. 5603) in the House would give the Secretary of HHS authority to waive telehealth restrictions for opioid abuse disorder.

These bills, led by a powerful group of bipartisan lawmakers, have cracked the CBO code. They demonstrate what telehealth advocates have been trying for years to convey – allowing telehealth coverage in Medicare will not significantly impact the federal budget. According to CBO, the House version would cost a mere $11 million over 10 years. The Senate bill, which entirely lifts the restrictions, is only $14 million. That’s out of a program that will spend as much as $10 trillion over the same time period.

The relatively small price tag and bi-partisan support of these bills sets the stage for Congress to consider future legislation that would remove even more barriers to telehealth, and could pave the way for originating site restrictions to be lifted for all patients. In the meantime, Medicare patients with substance abuse disorders will be able to access care remotely. This is a huge step forward.