The American Academy of Family Physicians says proposed changes to Medicare Advantage plans will improve members’ access to telehealth, but they may also support direct-to-consumer channels at the expanse of the primary care provider.

By Eric Wicklund

December 28, 2018 – The national organization representing family physicians is pushing back against proposed changes to Medicare Advantage plans, saying the proposal supports direct-to-consumer telehealth at the expense of primary care providers.

“When considering utilization of telehealth services, it is important for patients to maintain a continuous relationship with their primary care physician for proper care coordination,” American Academy of Family Physicians (AAFP) Board Chairman Michael L. Munger, MD, says in a letter to Centers for Medicare & Medicaid Services Administrator Seema Verma. “Responsible care coordination is necessary to ensure patient safety and continuity of care for the immediate condition being treated, and it is necessary for effective longitudinal care.”

“The most effective coordination is when the patient’s primary care physician or practice performs the telemedicine service,” Munger adds.

The letter comes in response to CMS’ Nov. 1 proposal to expand telehealth access for members in Medicaid Advantage plans. Public comment on the proposed changes is due to end at the end of this year.

CMS is proposing to eliminate geographical restrictions on telehealth access in MA plans by 2020, enabling those in urban areas to use connected health technology, and give members more locations to access care, including their own home.

Increasing access to connected care services is a good thing, Munger points out, but some proposals tilt the scales toward DTC telehealth over the member’s primary care provider. That, he says, interrupts the continuum of care and could create service silos that negatively affect long-term care management and coordination.

This is especially true, Munger says, in CMS’ proposal to allow telehealth providers to count toward an MA plan’s network adequacy requirement.

“The AAFP opposes this approach unless the telehealth provider is a physician that is also providing in-person care in the payer’s network,” he argues. “If a provider is only available to provide care virtually, then they are not truly ‘available’ to meet all potential care needs for a patient in the payer’s network within the applicable medical specialty.”

“The AAFP urges CMS to protect Medicare Advantage beneficiaries from an encroachment of direct to consumer telemedicine not coordinated with the beneficiaries’ usual source of primary care,” he adds. “Patients need access to longitudinal, comprehensive primary care, and stand-alone telemedicine is inadequate for patients. If the telehealth physician/provider is also providing in person care in the network, then they should count toward fulfillment of network adequacy thresholds.”

Munger says the organization does agree with one proposed change in MA plans: the provision that, if the plan covers a Part B service as an additional telehealth benefit, it must also access to that service through an in-person visit. This, he says, would boost access to telehealth in the home and give health plans the freedom to offer telehealth services not otherwise available to Medicare beneficiaries.

The AAFP’s letter offers an example of a long-standing challenge to DTC telehealth, which some say will become more commonplace as groups like Amazon, Google and Apple continue their push into the healthcare market. Those channels offer access to quick and convenient primary care services, while creating new pathways to care that might bypass a consumer’s primary care provider.

“Available technology capabilities as well as an existing physician-patient relationship impact whether the standard of care can be achieved for a specific patient encounter type,” Munger says in his letter. “Telehealth technologies can enhance patient-physician collaborations, increase access to care, improve health outcomes by enabling timely care interventions, and decrease costs when utilized as a component of, and coordinated with, longitudinal care.”

“(R)esponsible care coordination is necessary, and the most effective coordination is when the patient’s primary care physician or practice performs the telemedicine service,” he concludes.

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