Telehealth: An Important Tool in Achieving the Goals of the ACO Program and Why Restrictions Should Be Lifted in Final ACO Rule
Congress adopted the ACO concept as part of an effort to optimize healthcare delivery by incentivizing Medicare providers to furnish more integrated, better quality, and cost-effective care. Specifically, its stated purpose is to: “promote accountability for a patient population and coordinate items and services under parts A and B, and encourage investment in infrastructure and redesigned care processes for high quality and efficient service delivery.”2 As part of the program, ACOs are required to: “…define processes to promote evidence-based medicine and patient engagement…and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies.”3
In the proposed rule, CMS acknowledged that telehealth “could allow ACOs to realize cost savings and improve care coordination.” They also acknowledged that Congress explicitly cited telehealth as an enabling technology that can assist in the coordination of care.
The challenge for ACOs in adopting telehealth has been section 1834(m) of the Social Security Act, which restricts Medicare reimbursement to a limited number of Medicare Part B services furnished through particular telecommunications systems to only those beneficiaries able to reach an “originating site” located in a rural Health Professional Shortage area or a county outside of a Metropolitan Statistical Area (MSA). Specifically, “originating sites” only include physician offices, hospitals, critical access hospitals, skilled nursing facilities, and Federally Qualified Health Centers (FQHCs).4,5
Telehealth can only be used in facilities in rural areas, which limits the ability of medical providers to reach patients in their homes and communities. As a result, the number of Medicare beneficiaries accessing telehealth is miniscule. According to CMS data analyzed by the Center for Telehealth and eHealth Law, in 2011, CMS spent less than $5 million on telehealth services for seniors.6 This is out of an overall budget of more than $500 billion.
The 1834(m) restrictions create a disincentive for the vast majority of ACO providers—many of whom are located in urban and suburban areas—to use this type of technology, and exclude a broad swath of Medicare beneficiaries from being able to access the benefits of telehealth. ACOs that do not receive reimbursement for telehealth services are faced with the difficult decision of assuming financial risk by providing the care for free. For many physician-led and smaller ACOs, assuming that risk is not financially feasible.
Data shows the consequences of these restrictions. A recent survey of ACOs conducted by Premier, Inc and the eHealth Initiative reports that more than 90% of ACOs have concluded that the cost and return on investment for health IT is a “crippling concern.” This is consistent with additional findings showing that ACOs have low technological capabilities and lack the necessary infrastructure to support connected care. Few respondents reported being able to use secure messaging (38%), phone-based telemedicine (34%), or video-based telemedicine (26%).7
The Affordable Care Act granted the secretary of the department of HHS the authority to waive Medicare requirements as necessary to carry out the implementation of the ACO program. With the proposed rule, CMS opened the door to use of that waiver authority. In fact, they acknowledged they have the authority to waive the restrictions: “A waiver of certain Medicare telehealth requirements could be supported by section 1899(b) (2)(G) of the Act in that is gives the use of enabling technologies, such as telehealth, as an example of a process to coordinate care.”1
The comment period for the proposed rule is 60 days, and we should all respond to CMS’s request for “information from ACOs and other stakeholders about the use of such technologies to coordinate care for assigned beneficiaries.”
The body of evidence demonstrating that telehealth contributes to the achievement of all of the goals set forth by Congress and CMS is extensive. In addition to evidence collected by individual ACOs using telehealth, there is much published literature on the benefits of telehealth in a system of accountability and coordinated care. The Journal of the American Medical Association has published 7 articles just this year on telemedicine, while Health Affairs dedicated its entire February 2014 edition to telemedicine evidence. The Journal for E-Health and Telemedicine is continually publishing studies, including a collection of randomized controlled studies of COPD, CHF, and stroke, 3 conditions very prominent in the Medicare population.
Most of the evidence published to date focuses on cost, quality, and access, exactly what Congress and CMS are trying to impact. The American Telemedicine Association has an excellent synopsis of data demonstrating the positive impact of telehealth on cost and quality.8 Overall, the findings demonstrate that telehealth enables providers to reduce unnecessary in-person care (emergency care and preventable inpatient admissions), while increasing patient access to timely primary care. Telehealth also allows providers to connect patients with appropriate specialists and coordinate care across clinical settings.
Telehealth can and will help ACOs achieve the cost, quality, access, and patient engagement goals they are striving for. It is time to lift the section 1834(m) restrictions on the coverage and reimbursement of telehealth services so ACO providers can have another important tool in realizing the new care delivery models envisioned.
1. CMS, HHS. Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations. Proposed Rule. 42 CFR Part 425. Page 231. http://www.ofr.gov/OFRUpload/OFRData/2014-28388_PI.pdf.
2. The Public Health and Welfare. 42 USC. Page 3260, SEC. 1395jjj(a)(1), Shared savings program. http://www.gpo.gov/fdsys/pkg/USCODE-2010-title42/pdf/USCODE-2010-title42-chap7-subchapXVIII-partE-sec1395jjj.pdf.
3. The Public Health and Welfare. 42 USC. Page 3261, SEC. 1395jjj(b)(2)(G), Shared savings program. http://www.gpo.gov/fdsys/pkg/USCODE-2010-title42/pdf/USCODE-2010-title42-chap7-subchapXVIII-partE-sec1395jjj.pdf.
4. The Public Health and Welfare. 42 USC. Page 2550, SEC. 1395m(m)(4)(C), Shared savings program. http://www.gpo.gov/fdsys/pkg/USCODE-2010-title42/pdf/USCODE-2010-title42-chap7-subchapXVIII-partB-sec1395m.pdf.
5. Centers for Medicare & Medicaid Services, HHS. Page 409, SEC. 410.78(b)(4), Telehealth services. 42 CFR. http://www.gpo.gov/fdsys/pkg/USCODE-2010-title42/pdf/USCODE-2010-title42-chap7-subchapXVIII-partB-sec1395m.pdf.
6. Sprang R. How much does Medicare reimburse for telehealth? the real story. CTeL website. http://ctel.org/2012/09/how-much-does-medicare-reimburse-fortelehealth-%E2%80%94-the-real-story/. Published September 7, 2012.
7. eHealth Initiative (eHI) and Premier, Inc. The landscape of accountable care and connected health: results from 2014 national survey of accountable care organizations. http://www.ehidc.org/resource-center/surveys/doc_download/451-survey-the-landscape-of-accountable-care-and-connected-health-results-fromthe-2014-national-survey-of-accountable-care-organizations. Published September 2014.
8. Examples of research outcomes: telemedicine’s impact on healthcare cost and quality. American Telemedicine Association website. http://www.americantelemed.org/docs/default-source/policy/examples-of-research-outcomes—telemedicine'simpact-on-healthcare-cost-and-quality.pdf. Published April 2013.
This article is featured on www.ajmc.com.
Commentary: Time for Congress to make payments for telehealth happen
December 12, 2014 | Krista Drobac, Executive director of the Alliance for Connected Care
The reason that telehealth usage among seniors in Medicare is almost non-existent is because the rules were written at a time when telehealth was used primarily to provide access to care for rural patients. To access a physician remotely, Medicare beneficiaries have to be in a rural area and in an “originating site” defined as a hospital, doctor’s office or clinic. This defeats the purpose of today’s telehealth offerings, which are providing access to primary care in the home, office, retail clinic, or wherever.
The telehealth market is growing by double-digits with people in urban and suburban areas accessing care through technology as part of their employer or health plan offerings. Starting in 2015, some Medicare Advantage beneficiaries will even have access to medical providers using telehealth because it is a supplemental benefit in Medicare Advantage. Most seniors enrolled in Medicare fee for service will not have that option.
It’s time to update the payment rules for telehealth and give all seniors access to technology that is increasing access to high-quality primary care. One policy challenge is that the conventional wisdom among policy makers has been that telehealth will increase costs to Medicare. It is said that lifting the rural and originating site restrictions so Medicare beneficiaries can experience telehealth like commercially-insured patients will cause a huge increase in utilization, and therefore costs.
Today, we know that conventional wisdom is wrong. Data from the commercial market shows that access to telehealth does not create excessive use among beneficiaries, particularly those who would otherwise have done nothing. And, if structured as a substitute to in-person care, telehealth can even save money.
The Alliance for Connected Care commissioned a study from Dale Yamamoto, an actuary with 30 years of experience and stellar credentials. He aggregated data from five companies using telehealth in the commercial market — Teladoc, Doctor on Demand, Anthem, American Well and Optum. What he found demonstrates that if we reimburse for telehealth in Medicare when the telehealth visit substitutes for an in-person visit, we may actually save money by averting ER and urgent care visits.
Furthermore, the study dispels concerns that the convenience and accessibility of telemedicine will lead to overutilization and addresses questions about quality of care, finding that:
- Despite their convenience, commercial telehealth services are not used excessively. The average number of telehealth visits across vendors was 1.3 visits per patient per year.
- Telehealth visits are used to treat fairly routine, non-emergent conditions. This study found that the most common diagnoses during a telehealth visit are sinusitis, followed by cold/flu/pertussis and urinary tract infections.
- Medicare could realize savings by replacing in-person acute care services with a telehealth visit reimbursed at the same rate as a doctor’s visit. The study found that replacing in-person acute care services with a telehealth visit reimbursed at the same rate as a doctor’s office visit could save the Medicare program an estimated $45/visit.
- “Induced utilization” by those people who use telehealth services instead of forgoing care altogether is unlikely to result in increased total costs to the Medicare program. Medicare will only realize losses as a result of making telehealth services available if the percentage of Medicare patients utilizing telehealth who would have otherwise “done nothing” increases to more than 32.8 percent. This study found that this is unlikely given that this population is currently approximately 13 percent in the commercial market.
Telehealth is increasingly becoming part of the spectrum of care patients are receiving in the commercial marketplace. Medical providers are using telemedicine to treat primary care conditions, coordinate care and monitor patients. Studies, including one commissioned by the Alliance for Connected Care in the spring, show that telehealth is important to the bottom line issues of quality, patient satisfaction and cost. All Medicare beneficiaries should have access to it.
This study shows that if structured as a substitute for in-person care, telehealth could even save money.
Now it’s time for Congress to make it happen.
This article is featured on www.govhealthit.com
Actuarial Study Shows Medicare can Save with Telehealth
New Study Highlights Savings Likely from Payment of Telehealth in Medicare
Washington, DC, Dec. 12, 2014 – The Alliance for Connected Care is pleased to release a new actuarial study showing that telehealth can help achieve savings in the Medicare program. The study combined the data of five telehealth companies in the commercial sector and extrapolated the likely impact of telehealth payment on Medicare expenditures. [more…]
Can telemonitoring reduce hospitalization and cost of care? A health plan’s experience in managing patients with heart failure
Can telemonitoring reduce hospitalization and cost of care? A health plan’s experience in managing patients with heart failure
Telemonitoring provides a potentially useful tool for disease and case management of those patients who are likely to benefit from frequent and regular monitoring by health care providers. Since 2008, Geisinger Health Plan (GHP) has implemented a telemonitoring program that specifically targets those members with heart failure. This study assesses the impact of this telemonitoring program by examining claims data of those GHP Medicare Advantage plan members who were enrolled in the program, measuring its impact in terms of all-cause hospital admission rates, readmission rates, and total cost of care. The results indicate significant reductions in probability of all-cause admission (odds ratio [OR] 0.77; P<0.01), 30-day and 90-day readmission (OR 0.56, 0.62; P<0.05), and cost of care (11.3%; P<0.05). The estimated return on investment was 3.3. These findings imply that telemonitoring can be an effective add-on tool for managing elderly patients with heart failure.
Clinical- and cost-effectiveness of telemedicine in type 2 diabetes mellitus: a systematic review and meta-analysis
Clinical- and cost-effectiveness of telemedicine in type 2 diabetes mellitus: a systematic review and meta-analysis
Emerging telemedicine programs offer potential low-cost solutions to the management of chronic disease. We sought to evaluate the clinical effectiveness and cost effectiveness of telemedicine approaches on glycemic control in patients with type 2 diabetes mellitus. Using terms related to type 2 diabetes and telemedicine, MEDLINE, Cochrane, EMBASE, and CINAHL Plus were searched to identify relevant studies published through February 28, 2014. Data from identified clinical trials were pooled according to telemedicine approach, and evaluated using conventional meta-analytical methods. We identified 47 articles, from 35 randomized controlled trials, reporting quantitative outcomes for hemoglobin A1c (HbA1c). Twelve of the 35 studies provided intervention via telephone, either in the form of a call or a text message; 19 studies tested internet-based programs, employing video-conferencing and/or informational websites; and four studies used interventions involving electronically transmitted recommendations made by clinicians in response to internet-based reporting by patients. Overall, pooled results from these studies revealed a small, but statistically significant, decrease in HbA1c following intervention, compared to conventional treatment (pooled difference in means=-0.37, 95% CI=-0.49 to -0.25, Z=-6.08, P<0.001). Only two of the 35 studies included assessment of cost-effectiveness. These studies were disparate, both in terms of overall expense and relative cost-effectiveness. Optimization of telemedicine approaches could potentially allow for more effective self-management of disease in type 2 diabetes patients, though evidence to-date is unconvincing. Furthermore, significant publication bias was detected, suggesting that the literature should be interpreted cautiously.
Implant-based multiparameter telemonitoring of patients with heart failure (IN-TIME): a randomised controlled trial
Implant-based multiparameter telemonitoring of patients with heart failure (IN-TIME): a randomised controlled trial
Background: An increasing number of patients with heart failure receive implantable cardioverter-defibrillators (ICDs) or cardiac resynchronisation defibrillators (CRT-Ds) with telemonitoring function. Early detection of worsening heart failure, or upstream factors predisposing to worsening heart failure, by implant-based telemonitoring might enable pre-emptive intervention and improve outcomes, but the evidence is weak. We investigated this possibility in IN-TIME, a clinical trial.
Methods: We did this randomised, controlled trial at 36 tertiary clinical centres and hospitals in Australia, Europe, and Israel. We enrolled patients with chronic heart failure, NYHA class II-III symptoms, ejection fraction of no more than 35%, optimal drug treatment, no permanent atrial fibrillation, and a recent dual-chamber ICD or CRT-D implantation. After a 1 month run-in phase, patients were randomly assigned (1:1) to either automatic, daily, implant-based, multiparameter telemonitoring in addition to standard care or standard care without telemonitoring. Investigators were not masked to treatment allocation. Patients were masked to allocation unless they were contacted because of telemonitoring findings. Follow-up was 1 year. The primary outcome measure was a composite clinical score combining all-cause death, overnight hospital admission for heart failure, change in NYHA class, and change in patient global self-assessment, for the intention-to-treat population. The trial is registered with ClinicalTrials.gov, number NCT00538356.
Findings: We enrolled 716 patients, of whom 664 were randomly assigned (333 to telemonitoring, 331 to control). Mean age was 65·5 years and mean ejection fraction was 26%. 285 (43%) of patients had NYHA functional class II and 378 (57%) had NYHA class III. Most patients received CRT-Ds (390; 58·7%). At 1 year, 63 (18·9%) of 333 patients in the telemonitoring group versus 90 (27·2%) of 331 in the control group (p=0·013) had worsened composite score (odds ratio 0·63, 95% CI 0·43-0·90). Ten versus 27 patients died during follow-up.
Interpretation: Automatic, daily, implant-based, multiparameter telemonitoring can significantly improve clinical outcomes for patients with heart failure. Such telemonitoring is feasible and should be used in clinical practice.