Labeling telehealth as “increasingly vital” to the healthcare delivery system, the American Hospital Association (AHA) urged the Committee on Energy and Commerce to reduce Medicare’s financial and technological barriers to remote care. The letter, addressed to Chairman Fred Upton,follows a report on the growing promise of telehealth to address care disparities, reduce costs, and ease packed calendars for physicians who can easily diagnose and treat certain low-level conditions without the need to see a patient face-to-face.
“Despite recent expansions in covered services, Medicare is behind the private sector and many state Medicaid programs in promoting telehealth,” writes AHA Executive Vice President Rick Pollack. While many states have established parity laws that require Medicaid to cover telehealth services in the same way as private payers do, Medicare has not embraced video and telephone consults in the same way. “Medicare Advantage plans are beginning to provide telehealth benefits that are not covered under Medicare fee-for-service (FFS) rules, leaving the 70 percent of those utilizing FFS with limited access to these technological advances,” Pollack points out.
The expansion of telehealth faces several distinct obstacles, including geographic restrictions that dictate where a patient must be located in order to qualify for telehealth care. Currently, patients must live in a qualified rural Health Professional Shortage Area, which ignores the needs of urban populations that make up the majority of Medicare beneficiaries. In 2013, patients in 97 counties lost access to Medicare’s telehealth services when their areas were redefined as “metropolitan” instead of rural.
“We know that urban areas (particularly inner cities) can also suffer physician shortages, and access to certain specialties (such as psychiatry) can be limited in all geographic areas,” Pollack says. “Further, the almost ubiquitous use of communications technology in American life today has created growing consumer expectations that, where safe and appropriate, health care services also can be accessed remotely, regardless of where the individual is located.”
Medicare also narrowly defines what technologies and services will be covered for reimbursement. It will not pay for store-and-forward technology, nor will it provide reimbursement for many common treatment options. “In 2015, only 75 individual service codes out of more than 10,000 physician services covered through the Medicare physician fee schedule are approved for payment when delivered via telehealth. This constrained list stands in stark contrast to the private payers operating in telehealth parity states,” the letter says.
A discussion draft outlining potential ways to improve Medicare’s telehealth structure does not go far enough in reducing these obstacles, the AHA says. The draft proposes that Medicare expand its telehealth services only if doing so would not add costs to the system, which may not take into account future savings generated by better primary care and sustained patient engagement with the healthcare system. The draft does not address the technology limitations inherent in the current rule structure, and may not be able to adapt and evolve as quickly as the technology is currently doing.
The American Telemedicine Association has also weighed in on the draft, and sees similar problems with the cost containment strategy. “We understand the present political requirement that proposals must not cause a net increase to Medicare spending and do not object to the inclusion of some form of it,” writes ATA CEO Jonathan Linkous. “However, we are concerned that the no spending increase test and process of certifying could be too rigorous to ever be conclusive and result in an endless economic debate and no action.”
“You might also consider alternative means, such as to create a role for Congress’s Medicare Payment Advisory Commission in certifying that any use of telehealth generates no additional costs or offsetting savings,” Linkous adds.
“In conclusion, the AHA strongly agrees with your goal of expanding coverage of telehealth services in Medicare, and appreciates the specification of a mechanism for doing so,” Pollack said. “However, given the growing body of evidence that telehealth increases quality, improves patient satisfaction and reduces costs, we believe a more global approach to expanding Medicare coverage of telehealth is warranted.”