Alliance News2024-04-18T13:05:37-04:00

Alliance Applauds Inclusion of Major Telehealth Provisions in FY2023 Omnibus Appropriations Bill

The inclusion of a two-year extension of Medicare telehealth and commercial market telehealth flexibilities will make a huge difference to so many Americans. The Alliance for Connected Care has been calling for predictability for patients and clinicians while continuing to work toward permanent telehealth authorization. This gives us both.

The package includes a two-year extension of widely supported Medicare telehealth services that Congress enacted at the start of the pandemic. This extension will provide certainty to beneficiaries and health care providers, along with continued access to these critical virtual care services, while ensuring sufficient time is taken to analyze the impact of telehealth on patient care throughout the pandemic and beyond.  With the data currently pouring in, we are confident Congress will have the evidence needed to make telehealth permanent in Medicare two years from now.

The package also includes a two-year extension of the flexibility employers and health plans have to provide pre-deductible coverage of telehealth services for individuals and families with high deductible health plans coupled with a health savings accounts (HDHP-HSA). This policy is a game changer for the 32 million Americans who would otherwise have to think twice about out of pocket costs in accessing care.

Overall, a big win for America’s patients and caregivers. Bravo Congress.

Summary of Key Telehealth Provisions:

See here for bill text, press release, and Labor-HHS summary and explanatory statement. Below is a quick analysis of what was included in this package:

  • Sec. 4113: Advancing Telehealth Beyond COVID-19 (pg. 3714) – This section provides a two-year extension of the following Medicare telehealth flexibilities through December 31, 2024:
    • Removing Geographic Requirements and Expanding Originating Sites for Telehealth Services
    • Expanding Practitioners Eligible to Furnish Telehealth Services
    • Expanding Telehealth Services for Federally Qualified Health Centers and Rural Health Clinics
    • Delaying the In-Person Requirements Under Medicare for Mental Health Services Furnished Through Telehealth and Telecommunications Technology
    • Allowing for the Furnishing of Audio-Only Telehealth Services
    • Use of Telehealth to Conduct Face-to-Face Encounter Prior to Recertification of Eligibility for Hospice Care During Emergency Period
    • Study on Telehealth and Medicare Program Integrity
  • Sec. 4151: Extension of Safe Harbor for Absence of Deductible For Telehealth (pg. 3805) – This section provides a two-year extension of the flexibility allowing employers/plans to provide coverage for telehealth services pre-deductible for individuals with a high-deductible health plan coupled with a health savings account (HDHP-HSA) through December 31, 2024.

For a full summary of telehealth and related provisions in the FY2023 Omnibus package, click here or see below:

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December 19th, 2022|

Alliance Supports Members of Congress in Letter Pushing for Extension of HDHP Telehealth

On December 12, 2022, Reps. Schneider (D-IL), Steel (R-CA) and Lee (D-NV) led a bipartisan group of 30 House Members in a letter asking House leadership to extend critical commercial market telehealth flexibilities in the year-end appropriations package. The Alliance for Connected Care worked closely with the Congressional offices on this advocacy effort. 

The letter called on Congress to include the extension of the flexibility that allowed health plans and employers to provide pre-deductible coverage of telehealth services for individuals with a high deductible health plan coupled with a health savings account (HDHP-HSA). This provision was included in both the Primary and Virtual Care Affordability Act (H.R. 5541) and the Telehealth Expansion Act (H.R. 5981).

The Alliance has been a leading voice in advocating for the continued extension of this flexibility over the past several years. This policy has meaningfully expanded access to virtual care for a range of critical health services for the 32 million individuals with these plans. Without action by Congress, this flexibility will expire on December 31, 2022.

To read the letter, see below or click here.

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December 12th, 2022|

Diabetes Technology: Standards of Care in Diabetes—2023

Diabetes Technology: Standards of Care in Diabetes—2023

The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted.

December 12th, 2022|

Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial

Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial

Background: There is a paucity of evidence for dose and pace of up-titration of guideline-directed medical therapies after admission to hospital for acute heart failure.

Methods: In this multinational, open-label, randomised, parallel-group trial (STRONG-HF), patients aged 18-85 years admitted to hospital with acute heart failure, not treated with full doses of guideline-directed drug treatment, were recruited from 87 hospitals in 14 countries. Before discharge, eligible patients were randomly assigned (1:1), stratified by left ventricular ejection fraction (≤40% vs >40%) and country, with blocks of size 30 within strata and randomly ordered sub-blocks of 2, 4, and 6, to either usual care or high-intensity care. Usual care followed usual local practice, and high-intensity care involved the up-titration of treatments to 100% of recommended doses within 2 weeks of discharge and four scheduled outpatient visits over the 2 months after discharge that closely monitored clinical status, laboratory values, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations. The primary endpoint was 180-day readmission to hospital due to heart failure or all-cause death. Efficacy and safety were assessed in the intention-to-treat (ITT) population (ie, all patients validly randomly assigned to treatment). The primary endpoint was assessed in all patients enrolled at hospitals that followed up patients to day 180. Because of a protocol amendment to the primary endpoint, the results of patients enrolled on or before this amendment were down-weighted. This study is registered with ClinicalTrials.gov, NCT03412201, and is now complete.

Findings: Between May 10, 2018, and Sept 23, 2022, 1641 patients were screened and 1078 were successfully randomly assigned to high-intensity care (n=542) or usual care (n=536; ITT population). Mean age was 63·0 years (SD 13·6), 416 (39%) of 1078 patients were female, 662 (61%) were male, 832 (77%) were White or Caucasian, 230 (21%) were Black, 12 (1%) were other races, one (<1%) was Native American, and one (<1%) was Pacific Islander (two [<1%] had missing data on race). The study was stopped early per the data and safety monitoring board’s recommendation because of greater than expected between-group differences. As of data cutoff (Oct 13, 2022), by day 90, a higher proportion of patients in the high-intensity care group had been up-titrated to full doses of prescribed drugs (renin-angiotensin blockers 278 [55%] of 505 vs 11 [2%] of 497; β blockers 249 [49%] vs 20 [4%]; and mineralocorticoid receptor antagonists 423 [84%] vs 231 [46%]). By day 90, blood pressure, pulse, New York Heart Association class, bodyweight, and NT-proBNP concentration had decreased more in the high-intensity care group than in the usual care group. Heart failure readmission or all-cause death up to day 180 occurred in 74 (15·2% down-weighted adjusted Kaplan-Meier estimate) of 506 patients in the high-intensity care group and 109 (23·3%) of 502 patients in the usual care group (adjusted risk difference 8·1% [95% CI 2·9-13·2]; p=0·0021; risk ratio 0·66 [95% CI 0·50-0·86]). More adverse events by 90 days occurred in the high-intensity care group (223 [41%] of 542) than in the usual care group (158 [29%] of 536) but similar incidences of serious adverse events (88 [16%] vs 92 [17%]) and fatal adverse events (25 [5%] vs 32 [6%]) were reported in each group.

Interpretation: An intensive treatment strategy of rapid up-titration of guideline-directed medication and close follow-up after an acute heart failure admission was readily accepted by patients because it reduced symptoms, improved quality of life, and reduced the risk of 180-day all-cause death or heart failure readmission compared with usual care.

December 3rd, 2022|

Alliance Statement on Pandemic Response Accountability Committee Report on Telehealth Use and Program Integrity Risks During COVID-19

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On December 1, 2022, the Pandemic Response Accountability Committee issued a report on telehealth use and program integrity risks across selected health care programs during the first year of the COVID-19 pandemic. Given the debate on Capitol Hill about the permanent flexibilities in the Medicare program, we focus here on Medicare fee-for-service and Medicare Advantage, which HHS examined from March 2020 through February 2021, and the year prior from March 2019 through February 2020.

The report shared several impressive findings:

  • 37 million individuals used telehealth services across the programs of six federal agencies – an expansion from approximately 3 million individuals using telehealth in the prior year. Pre-pandemic, the vast majority of those telehealth visits were only available to veterans.
  • In Medicare, the expansion was huge – with over 80 times the number of individuals using telehealth in 2020.

The report identifies some potential areas of program integrity concern. While there will always be program integrity risks in federal programs, we urge policymakers to keep it in perspective. There is no evidence of a need for widespread concern related to telehealth in the Medicare program. In fact, the telehealth risks appear lower than in-person care.

HHS OIG Claim: “In total, Medicare paid over $5.1 billion for telehealth services for beneficiaries enrolled in Medicare fee-for-service. HHS OIG identified more than 300 Medicare providers who billed for telehealth services at the highest, most expensive level every time, totaling approximately $5.2 million.

  • Perspective:
    • The report identified 300 Medicare providers who billed for telehealth services at the highest, most expensive level every time was 0.1 percent of total Medicare payment for telehealth services for beneficiaries enrolled in Medicare fee-for-service. For 2020, Medicare spending was $829.5 billion for total Medicare services.
    • As context, the estimated Medicare total improper payment rate in 2020 was 6.27 percent, representing $25.74 billion in improper payments. Prior to the pandemic, the Medicare improper payment rate in 2019 was 25 percent. Other government watchdogs estimated $43 billion in FY 2020 for Medicare improper payments, accounting for over one-quarter of the total amount of improper payments made government-wide in fiscal year 2019.

HHS OIG Claim: “We identified over 1,700 providers whose billing for telehealth services poses a high risk to Medicare. Although these providers represent a small proportion of the approximately 742,000 providers who billed for a telehealth service, their billing raises concern.”

  • Perspective: An identification of providers who pose a high risk to Medicare does not indicate the presence of fraud – only that there are practices which should be monitored.
  • This point made by HHS OIG is out of context. OIG originally mentioned these providers in this report where they noted that more than half of those high-risk providers belonged to a medical practice that posed high risk billing to Medicare in general, not just telehealth. As such, the billing practices of these providers do not pose a risk solely as it relates to telehealth – they are risks to the Medicare program broadly that CMS should address.

HHS OIG Claim: “HHS OIG identified 138 providers who repeatedly billed both Medicare fee-for-service and a Medicare Advantage plan for the same telehealth service.”

  • Perspective: There are bad actors within the Medicare program, 138 providers is a low number for such billing practices to be occurring for the 28 million Medicare beneficiaries who used telehealth services and the $5.1 billion in spending on Medicare telehealth services during the first year of the pandemic.
    • In its September 2022 report on program integrity risks in Medicare telehealth services during the first year of the pandemic, HHS OIG noted that a total of 18,034 providers billed both Medicare fee-for-service and Medicare Advantage for the same telehealth service for the same beneficiary on the same date of service at least once. However, HHS OIG only classified providers as “high risk” if they billed this way for more than 20 percent of their claims and encounters – in this case 0.7 percent of providers who billed this way.
    • While OIG claims this could be an indicator of providers intentionally submitting duplicate claims to increase their Medicare payments, there is no concrete evidence to support this claim, nor is there an indication of the circumstances surrounding these claims (i.e., potential for practitioner error).
    • In 2018, OIG found that many of the disallowed payments for telehealth services were because of practitioner errors in understanding and meeting Medicare telehealth requirements. One of their recommendations was to offer education and training sessions to practitioners on Medicare telehealth requirements. Given that this was the case for the limited number of practitioners using telehealth in 2018, we have a hard time believing there were not many similar errors in 2020.

HHS OIG Claim: “HHS OIG identified 86 providers who billed for a high average number of hours of telehealth services per visit.”

  • Perspective: This again is a low number compared to the patients served and spending that occurred, and could be related to any number of factors such as practitioner error in codes used, the nature of the service rendered, or treatment of high-need patients.
    • In the same September 2022 report mentioned above, HHS OIG identified 86 providers that billed for an average of more than two hours of telehealth services per visit, compared to the median of 21 minutes of telehealth services per visit for all providers who billed for telehealth services. However, OIG does not note the types of services rendered for these longer visits, which is a critical data point necessary to make accurate comparisons to affirm whether there is call for widespread concern.
    • A visit with a psychotherapist who is treating a patient in crisis for a mental health or substance use disorder, for example, is going to require more intensive time and care compared to a visit for acute conditions. HHS OIG notes in a previous report that, during the first year of the pandemic, “beneficiaries used telehealth for 43 percent of behavioral health services, whereas they used telehealth for 13 percent of office visits.” Given the proliferation of telehealth for mental and behavioral health services in particular during the pandemic, this merits further analysis.

It’s important to note that this report recycles past policy recommendations made by HHS OIG. These recommendations include:

  • Strengthen monitoring and targeted oversight of telehealth services;
    • The Alliance has supported additional oversight to ensure bad actors do not undermine access to telehealth in Medicare.
  • Provide additional education to providers on appropriate billing for telehealth services;
    • The Alliance strongly agrees that provider education is useful, as accidental misbilling has in the past been interpreted as fraudulent. Similarly, HHS steps to simplify telehealth billing are welcomed.
  • Improve the transparency of “incident to” services when clinical staff primarily delivered a telehealth service;
    • The Alliance recognizes the importance of accurate data for analysis. We also stress the importance maintaining “incident to” services for healthcare practitioners unable to bill the Medicare program directly.
  • Identify telehealth companies that bill Medicare;
    • If a provider, including a virtual-only provider, wants to bill Medicare directly, they must enroll in Medicare, thereby giving CMS oversight of that provider. We don’t believe there is clear justification for singling out virtual-only providers, particularly when Medicare beneficiaries are overwhelmingly seeing providers that use telehealth services in addition to maintaining brick and mortar. Given that virtual-only is a new modality, limited steps to improve CMS’s understanding and oversight of these providers seems logical, and if it helps prevent limits on beneficiary access to telehealth, then we support it.
  • Require a modifier to identify all audio-only telehealth services provided in Medicare; and
    • HHS has already acted on this recommendation, with Alliance for Connected Care support.
  • Collect data on the use of telehealth in opioid treatment programs.
    • The Alliance recognizes the importance of accurate data for analysis and supports calls for additional data to further analyze this occurrence.
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December 1st, 2022|

Telehealth Expansion: What Does the Data Show?

Thanks to those who were able to join the Alliance for Connected Care and Healthcare Leadership Council for the Telehealth Expansion: What Does the Data Show webinar on November 17, 2022.

The Alliance for Connected Care and the Healthcare Leadership Council held a virtual discussion about telehealth data on November 17, 2022. Attendees heard from experts who discussed the implications of both their own and national telehealth data on our understanding of health care utilization, quality, and access.

The discussion on telehealth data supports the Alliance for Connected Care’s commissioned analysis on Medicare telehealth, which found no evidence that telehealth added to the total volume of Medicare services, and no evidence that patients initiating care who use telehealth had more E&M revisits for the same medical issue than patients with in-person visits.

Of significant note with respect to Medicare spending, the average per service cost of an E&M telehealth visit to the Medicare program is less than in-person services by approximately 20 percent. The reason for this difference was that telehealth clinicians generally billed shorted visit codes than in-person providers.

Find the slides from the webinar below or here.

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See notable telehealth research below or here.

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More information about the studies discussed at the webinar: 

Jackie Gerhart, MD
Jackie Gerhart, MDVice President of Clinical Informatics, Epic
Ethan Booker, MD
Ethan Booker, MDChief Medical Officer for Telehealth, MedStar Health
November 17th, 2022|

Alliance Signs Letter Urging Congress to Extend HDHP Telehealth Flexibilities

On November 15, 2022, the Alliance for Connected Care and more than 350 organizations signed a letter urging Congress to extend the telehealth provision that allows employers the flexibility to offer telehealth services pre-deductible to employees with a high deductible health plan coupled with a Health Savings Account (HDHP-HSA). The letter reminds congressional leaders that without legislative action, employers will be required to charge employees more to access telehealth services, creating a barrier to care, including telemental health.

Without action by Congress, this provision will expire on December 31, 2022. New action is needed to ensure Americans do not lose access to these important telehealth benefits again come 2023.

To read the letter, see below or click here.

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November 15th, 2022|

Alliance and Others Send Letter to DEA to Advance Proposed Rules on the Special Registration Telemedicine

Alliance and Others Send Letter to DEA to Advance Proposed Rules on the Special Registration Telemedicine

The Alliance for Connected Care and more than 300 participants sent a letter urging the DEA to advance the proposed rules on the Special Registration for Telemedicine under the Ryan Haight Act to the Office of Management and Budget (OMB). The proposed rule would enable a practitioner to deliver, distribute, dispense, or prescribe via telemedicine a controlled substance to a patient who has not been medically examined in-person by the prescribing practitioner. Without immediate action, there will be a gap between the finalization of the proposed rule and the imminent expiration of the COVID-19 public health emergency (PHE) flexibilities.

Read the full letter here and below:

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November 11th, 2022|

Results of a Remotely Delivered Hypertension and Lipid Program in More Than 10 000 Patients Across a Diverse Health Care Network

Results of a Remotely Delivered Hypertension and Lipid Program in More Than 10 000 Patients Across a Diverse Health Care Network

Importance  Blood pressure (BP) and cholesterol control remain challenging. Remote care can deliver more effective care outside of traditional clinician-patient settings but scaling and ensuring access to care among diverse populations remains elusive.

Objective  To implement and evaluate a remote hypertension and cholesterol management program across a diverse health care network.

Design, Setting, and Participants  Between January 2018 and July 2021, 20 454 patients in a large integrated health network were screened; 18 444 were approached, and 10 803 were enrolled in a comprehensive remote hypertension and cholesterol program (3658 patients with hypertension, 8103 patients with cholesterol, and 958 patients with both). A total of 1266 patients requested education only without medication titration. Enrolled patients received education, home BP device integration, and medication titration. Nonlicensed navigators and pharmacists, supported by cardiovascular clinicians, coordinated care using standardized algorithms, task management and automation software, and omnichannel communication. BP and laboratory test results were actively monitored.

Main Outcomes and Measures  Changes in BP and low-density lipoprotein cholesterol (LDL-C).

Results  The mean (SD) age among 10 803 patients was 65 (11.4) years; 6009 participants (56%) were female; 1321 (12%) identified as Black, 1190 (11%) as Hispanic, 7758 (72%) as White, and 1727 (16%) as another or multiple races (including American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, unknown, other, and declined to respond; consolidated owing to small numbers); and 142 (11%) reported a preferred language other than English. A total of 424 482 BP readings and 139 263 laboratory reports were collected. In the hypertension program, the mean (SD) office BP prior to enrollment was 150/83 (18/10) mm Hg, and the mean (SD) home BP was 145/83 (20/12) mm Hg. For those engaged in remote medication management, the mean (SD) clinic BP 6 and 12 months after enrollment decreased by 8.7/3.8 (21.4/12.4) and 9.7/5.2 (22.2/12.6) mm Hg, respectively. In the education-only cohort, BP changed by a mean (SD) −1.5/−0.7 (23.0/11.1) and by +0.2/−1.9 (30.3/11.2) mm Hg, respectively (P < .001 for between cohort difference). In the lipids program, patients in remote medication management experienced a reduction in LDL-C by a mean (SD) 35.4 (43.1) and 37.5 (43.9) mg/dL at 6 and 12 months, respectively, while the education-only cohort experienced a mean (SD) reduction in LDL-C of 9.3 (34.3) and 10.2 (35.5) mg/dL at 6 and 12 months, respectively (P < .001). Similar rates of enrollment and reductions in BP and lipids were observed across different racial, ethnic, and primary language groups.

Conclusions and Relevance  The results of this study indicate that a standardized remote BP and cholesterol management program may help optimize guideline-directed therapy at scale, reduce cardiovascular risk, and minimize the need for in-person visits among diverse populations.

November 9th, 2022|
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