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Should expanded payments and relaxed regulations for telehealth during the COVID-19 pandemic eventually come to an end?

That's the question that the Medicare Payment Advisory Commission (MedPAC) debated last week, with commission members noting that walking back telehealth could prove challenging.

"Pandora's box is open," said member Susan Thompson, BSN, of Unity Point in West Des Moines, Iowa, adding that patients value their time and don't want to spend 2 to 4 hours getting to and completing an in-person visit, nor do they want to sit in waiting rooms with other potentially contagious patients.

Lawrence Casalino, MD, PhD, of Weill Cornell Medicine in New York City, agreed, while also noting that the majority of clinicians -- even those who once felt threatened by telemedicine -- now see its benefits.

But other members of MedPAC, which makes recommendations on Medicare payment policies, expressed concerns about the burden on taxpayers, maintaining a reasonable ratio of telehealth to in-person visits, and pushing the "digital divide."

Telehealth Transforms

In January, the Department of Health and Human Services declared the novel coronavirus a public health emergency (PHE), and telehealth use skyrocketed after Congress granted the Centers for Medicare & Medicaid Services (CMS) the authority to expand the types of services and provider types eligible for reimbursement.

CMS also relaxed longstanding restrictions on where beneficiaries can conduct a visit to ensure access to care, and lessen exposure to the virus. Pre-pandemic, telehealth services were covered only in rural areas or at an originating site, with the exception of certain remote physiological monitoring tools, MedPAC's technical staff explained.

During the pandemic, clinicians can provide direct-to-consumer telehealth services to beneficiaries who do not live in rural areas, and to beneficiaries in their homes.

CMS implemented several other changes:

• Reimbursing telehealth visits for at least 80 new services
• Expanding provider types eligible for reimbursement to include physical, occupational, and speech therapists
• Reimbursing clinicians for audio-only telehealth visits
• Reimbursing telehealth services at the same rate as in-person services
• Eliminating penalties for healthcare providers for noncompliance with the Health Insurance Portability and Accountability Act (HIPAA)
• Allowing clinicians to reduce or waive cost-sharing for telehealth visits

Many of these concessions were meant to incentivize the use of telehealth, according to MedPAC's technical staff, but lifting barriers to access might also drive up the volume of services unnecessarily, and make the program more vulnerable to fraud.

MedPAC staff have now proposed limiting the expansion of telehealth for most fee-for-service (FFS) clinicians, while preserving telehealth flexibilities in advanced alternative payment models (A-APMs).

A-APMs hold clinicians accountable for the quality and cost of care that beneficiaries receive. MedPAC staff reasoned that the models are less likely to drive up spending. Additionally, the increased flexibilities could encourage more clinicians to join A-APMs.

MedPAC's technical staff also suggested:

• Continuing to allow clinicians in A-APMs to conduct telehealth visits with patients in non-rural areas and with patients from their homes
• Continuing most telehealth services offered under the PHE or A-APMs and continuing select services for FFS on non-A-APM clinicians
• Potentially capping the number of telehealth services that could be billed each month
• Ending reimbursement for audio-only visits and lowering payment for telehealth visits
• Reducing payment for telehealth services from the higher nonfacility rate paid during the PHE to the facility rate

Staff then asked commissioners for their perspectives on which telehealth services and providers should remain eligible for telehealth payments; what rates should be applied; and whether clinicians should be required to comply with HIPAA post-pandemic.

Also, because audio-only visits prevent clinicians from visually examining patients, staff asked whether such services ultimately increase program spending. Services delivered by telehealth are also unlikely to require the same practice costs as those delivered in person in a physical office, so continuing to pay for telehealth services at the same rate as in-office services could "distort prices" and cause providers to favor telehealth over in-person services, stated Ariel Winter, MPP, a principal policy analyst for MedPAC.

Access Versus Cost

MedPAC member Marjorie Ginsburg, BSN, MPH, of Sacramento, California, said she was concerned that increased visits would increase the burden on taxpayers and ultimately beneficiaries. She suggested that a study could be done to see if telehealth offers "greater benefit to patients" and whether it "lowers costs to the system."

Member Brian DeBusk, PhD, of DeRoyal Industries, in Powell, Tennessee, raised concerns about Medicare Advantage where "incremental visits ... could be used ... for the purpose of collecting and driving risk scores."

DeBusk said he favored reducing telehealth payments to the facility rate, and limiting "the frequency" or "the ratio of telehealth to in-person visits."

Karen DeSalvo, MD, MPH, of Google Health in Palo Alto, California, said she worried about exacerbating the "digital divide" by pushing forward technologies that beneficiaries are not capable of, or interested in, using.

She cited a recent that found 72% of beneficiaries over age 85 have barriers to telehealth, such as lack of technology, hearing impairment, cognitive impairment, or they "don't trust the system."

But Thompson championed the advantages of telehealth, such as its value in helping patients manage chronic illness through increased engagement, that could improve outcomes and reduce costs.

Thompson pointed out that patient access to care has been a significant concern, and that the MedPAC discussion was focused on fear of access that is too convenient.

"Do we seriously and intentionally want to make healthcare less accessible for the Medicare beneficiary to keep costs down?" she stated.

Thompson acknowledged that any new technology has risks, but telehealth is a tool -- and not a service -- so the same protections in place to monitor fraud and abuse for in-person services could be used for online visits.

"Let's take the leap into what may be a key to improving beneficiary engagement, improving quality, improving our outcomes, and reducing our costs," she said.

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