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SEPTEMBER 9, 2020

The COVID-19 pandemic, and the corresponding need for social distancing, has catapulted telehealth into the mainstream. According to some estimates, the proportion of ambulatory patient visits using telehealth (video, phone, or e-visit) increased from 10 percent before the pandemic to more than 90 percent during the pandemic. These shifts have been buttressed by temporary policy changes introduced by the Centers for Medicare and Medicaid Services (CMS), including a marked increase in telehealth reimbursement rates. Before the pandemic, a 2019 survey reported that nearly 77 percent of physicians raised reimbursement as a serious obstacle to telehealth adoption. The rapid rise in adoption rates suggest that the CMS policy changes have been welcomed and are effective for providers.

On August 3, the Trump administration signed an executive order directing the Department of Health and Human Services to extend these temporary measures beyond the public health emergency to make them permanent. CMS immediately announced changes in the 2021 physician fee schedule that will make the new telehealth billing codes permanent, allowing Medicare providers to bill for home-based telehealth visits and for an expanded suite of telehealth services. While these telehealth policy changes are critical to promoting telehealth adoption, policies now need to move beyond reimbursement rates to help providers integrate telehealth into routine care.

From April to July 2020, in partnership with the New York City Department of Health and Mental Hygiene’s Bureau of Equitable Health Systems (BEHS), we conducted six repeated surveys of primary care providers working in mostly small independent practices (across the survey waves, an average of 54 percent of respondents reported working in a practice with  three or fewer providers) in New York City, an early US epicenter, to track their adoption of telehealth during the pandemic. The average survey response rate was 5 percent from an internal BEHS listserv of 5,300 primary care providers, and 84 percent of those who accessed the survey responded with the highest response rate in Wave I (491 responses). Their responses confirmed the role of timely regulatory changes in facilitating telehealth adoption, and their hope for these changes to “stay permanently for better primary care delivery.” However, their responses also called attention to five additional action items for policy makers and insurers to support to achieve a seamless integration of telehealth into primary care (exhibit 1). What follows are five specific recommendations for further action: 

Exhibit 1: Recommendations for policy makers and insurers to support telehealth use by primary care providers, and representative responses

RecommendationsRepresentative Open-Text Survey Responses
Harmonize the reimbursement criteria “Some insurance companies are paying less than in-person visits for telehealth visits from Day 1. Small practices, like usual, have been left to themselves for the most part.”“Primary care is extremely challenging with the constant change in protocols, the uncertainty and enormously confusing insurance schemes.”
Create billing codes or payment models for the additional work required to offer telehealth “Insurance companies not reimbursing telephone visits at a rate that supports the level of work done on a telephone visit.”“Elderly patients have no access or are unable to access virtual – more work, have to teach them how to take BP, some hard of hearing, etc.”“I am more stressed out doing telehealth, as we spend time to fix internet, video, and voice. There are calling issues, so it’s more time consuming.”
Provide coverage for at-home monitoring devices “I need blood pressure cuffs and glucometers covered by insurance for home monitoring.”“I will do tele health… provided patients have equipment.”“Patients lack thermometers, blood pressure cuffs, and pulse oximeters.”
Incentivize the development of and access to, patient- and provider-centered telehealth technology“Telehealth information technology platform is NOT user friendly.”“Difficult to properly diagnose with telehealth. Have been using photos from patients to supplement but still not really sufficient.”“Our patients are low-income with language barriers. Requiring third party interpreter by speaker phone takes extra time and reduces quality of care.”
Review, revise, and communicate telehealth malpractice policies “I am not going to practice telehealth; it is not reliable and may increase malpractice cases.”“I’m very concerned about being sued for managing the patients over telehealth especially since many are requesting opioids.”“Malpractice premiums are a major barrier for telehealth.”

Harmonize The Reimbursement Criteria

First, despite the increased telehealth reimbursement rates announced by CMS and commercial insurers, there was widespread confusion due to the plethora of variables determining the reimbursements, such as the HIPAA compliance of the platform, duration of the tele-visit, tele-visit modality, originating site, coverage parity, and payment parity for video versus phone versus in-person office visits. Moreover, these variables differ by states and insurers. When asked if they have been reimbursed for telehealth services, more than a third of our respondents reported that they “don’t know.” Nearly 55 percent of respondents reported that “uncertain reimbursements” were a barrier to using telehealth. Small independent practices, which made up a large proportion of our survey respondents, often do not have the necessary administrative resources to sift through a long variable list. To promote integration of telehealth, policy makers and insurers will need to reduce the existing heterogeneity of payments to mitigate confusion and uncertainties around billing for telehealth.

Create Billing Codes Or Payment Models For The Additional Work Required To Offer Telehealth

Second, fee-for-service reimbursements for telehealth fail to account for the time practices are spending to coordinate telehealth visits and help patients access these services. In our survey, providers reported a number of activities that are not reimbursable and hence not incentivized in the fee-for-service system, including: coordinating tele-visit schedules, creating materials and providing one-to-one sessions to help patients download and use video conferencing platforms for tele-visits, and having dedicated staff call patients in advance of their appointments to test their video and audio capabilities. Given the significant adjustments and workflow changes required for telehealth use, value-based or population-based capitation models can better account for the expenses associated with these team-based and technology-enabled models of care.

Provide Coverage For At-Home Monitoring Devices

Third, to do remote monitoring providers rely on patients being able to measure their health indicators at home, which requires patients to have access to appropriate devices and equipment. Remote monitoring is critical for effective telehealth. In their suite of supportive measures for telehealth, the 2019 CMS final rule announced coverage for remote patient monitoring in the form of three CPT billing codes. However, these codes pay for provider-level expenses in the initial setup of monitoring devices and for the ongoing monitoring of physiologic parameters, rather than for the compatible equipment required by the patients. Some of the large health care systems provide equipment free of charge to their patients to facilitate remote monitoring. However, such a cost is not easy for independent primary care practices to absorb. The great majority (77 percent) of our survey sample of mostly small independent practices reported that their patients bought the devices on their own. Some patients may not have the means to purchase the devices on their own, which can affect the quality of telehealth being delivered and in turn increase the likelihood of adverse health outcomes for these patients. There is a clear need for insurers to support patients’ access to and training in the use of monitoring equipment at home.

Incentivize The Development Of And Access To Patient- And Provider-Centered Telehealth Technology

Fourth, providers reported several flaws in telehealth technology that impacted its usability for patients from different socioeconomic backgrounds and for providers in different practice settings. Providers proposed several examples of necessary improvements in telehealth technology, including: a user-friendly platform for patients to share images of body parts and exchange diagnostic information, platforms with built-in language translations to enhance communication with populations with limited English proficiency, electronic health records (EHRs) that allow appropriate telehealth documentation and are compatible with telehealth billing codes, and EHRs that are interoperable with health monitoring apps for information exchange. More than a third of providers also indicated that their patients lacked access to reliable internet, which was a barrier to using telehealth, particularly the video component. Some health systems have begun to incorporate language interpreters into their video platforms and provide low-cost internet access to their patients. However, independent primary care practices often lack the capacity to garner such resources and will need policy-level support to address these barriers. Financial incentives and national payment policies can support the needed advancement in digital health applications and revamp its clinical value and quality for providers and patients. Financial incentives for telehealth vendors are needed to accelerate the building of improved telehealth platforms to address these flaws. National payment policies for telehealth use can also help increase demand on the provider and patient side, which can stimulate telehealth vendors to respond.

Review, Revise, And Communicate Telehealth Malpractice Policies

Lastly, providers raised concerns about malpractice claims related to telehealth. Despite growing advocacy for telehealth, related malpractice policies are largely undeveloped. A multitude of factors explain why several carriers of liability insurance coverage have not embraced telehealth. For example, providers licensed to practice in one state could be subjected to liability laws from another state if they deliver telehealth services to patients across state borders. There is also limited information about the standards of care or damage caps, and patients might be more likely to sue providers they have not met in person. The consequence is often an exclusion of telehealth services from the malpractice insurance policies, creating concerns among providers about telehealth use. Regional health departments should give providers more guidance on legal liabilities related to telehealth. This is particularly true for independent practices that do not work within larger systems, and thus lack the capacity to address the complexities of malpractice policies.

Conclusion

There is an urgent need for strategies to support the integration of telehealth into primary care. The recent executive order and CMS policy extension indicate that telehealth is no longer a short-term fix but is fast becoming a core and enduring function in primary care delivery. The extension of the telehealth policies holds promise in expanding access to high-quality care. However, access is classically defined as having five domains: affordability, availability, accommodation, accessibility, and acceptability. The present telehealth policies address only the first two domains, which is not enough to fully integrate telehealth into routine care delivery. Other policies, as recommended above, can optimize telehealth access and quality by promoting “accommodation,” “accessibility,” and “acceptability” for telehealth, to complement increased reimbursements. Failing to address these barriers—which affect the least resourced primary care practices that are primarily serving the most vulnerable patients—will only serve to widen patient-level disparities in access to quality telehealth care. These gaps offer actionable opportunities for public and private insurers and policy makers to intervene and improve the integration of telehealth into primary care.

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