Evaluating the Present & Future of Medicare Coverage of Telehealth Services 

Announcer:
Welcome to Perspectives with the AMA on ReachMD, produced in partnership with the American Medical Association. Here’s your host, Dr. Charles Turck.

Dr. Turck:
Welcome to Perspectives with the AMA on ReachMD. I'm Dr. Charles Turck. And joining me today to discuss current and future Medicare coverage of telehealth services are Ms. Sandy Marks, Ms. Kim Horvath, and Mr. Kyle Thomson. Ms. Marks is a Senior Assistant Director of Federal Affairs at the AMA. Ms. Marks, welcome to the program.

Ms. Marks:
Thank you for having me.

Dr. Turck:
And Ms. Horvath and Mr. Thomson are both senior legislative attorneys with the AMA. Ms. Horvath, Mr. Thomson, thank you both for being here.

Ms. Horvath:
Great to be here.

Mr. Thomson: 
Thanks for having us. Excited to talk today.

Dr. Turck:
To start us off, Mr. Thomson, can you tell us what the present landscape for Medicare coverage of telehealth services looks like here in the context of the COVID-19 pandemic?

Mr. Thomson:
You have to first understand where coverage stood prior to the pandemic for Medicare. And typically, prior to the public health emergency, Medicare is prohibited from covering and paying for telehealth services unless they are provided at an eligible site, which is generally a hospital or other healthcare setting, and in a rural area. Which means that before the public health emergency, the vast majority of Medicare beneficiaries could not access telehealth services.

In response to the COVID-19 public health emergency, however, Congress provided CMS the authority to waive these restrictions for the duration of the public health emergency, which CMS subsequently did. So pursuant to this waiver, CMS now, at least for the duration of the public health emergency, is allowing for physicians to provide telehealth to Medicare patients nationwide, not just those in rural locations. They're permitting patients to receive telehealth services in their homes or wherever they are located. And they've also added some other flexibilities such as adding interim coverage for more than 150 services for the duration of the COVID-19 public health emergency that weren't available prior to the public health emergency. They've also increased payment for telehealth services to be equivalent to in-office rates, and provided flexibility to allow for a patient-physician relationship to be established via telehealth platforms in many circumstances, even when that might not have been the case prior to the public health emergency.

Dr. Turck:
Turning to you now, Ms. Marks, what's the Medicare claims data showing us about how different types of services have been provided via telehealth during the pandemic?

Ms. Marks:
Sure, well, you know, pre COVID, telehealth only represented less than one-tenth of 1 percent of total Medicare spending on physician services. So a very, very small percentage. Just about five weeks into COVID, by mid-April of 2020, it had grown to 16 percent of total Medicare physician service spending. So that was just a huge increase in a very short period of time.

About half of the Medicare telehealth spending went to established patient office visits. Another 18 percent was for telephone visits that could either be people who only had landlines or people who had smartphones but didn't have enough connectivity or technology to use audio/video services. Another 17 percent went for mental health services. And then 4 percent each was for nursing facility visits and new patient office visits that were provided via telehealth. So all together just those five categories of services -- established and new-patient office visits, telephone visits, mental health services, and nursing facility visits -- accounted for 84 percent of the Medicare physician services that were provided via telehealth in 2020.

There are other important services also provided via telehealth during COVID. Those included established patient home visits, emergency department visits, critical care services, and the monthly services for taking care of patients with end-stage renal disease. All of those services are going to continue to be available via telehealth through at least the end of 2023.

And finally, there are some other codes that were provided pretty frequently via telehealth during this public health emergency, but which will not remain on Medicare's telehealth list when the public health emergency ends. There were 50,000 hospital admissions via telehealth, 142,000 new patient nursing facility visits, and about 153,000 visits for physical, occupational, or speech therapy services.

Dr. Turck:
And, Ms. Horvath, if we keep our focus on the available data, what's it showing in terms of physician sentiment around licensure in telehealth?

Ms. Horvath:
Sure. So thanks so much for the question. The COVID-19 Telehealth Coalition did a survey of physicians last year. And one of the questions they asked was identifying barriers to access to telehealth post COVID-19. And the number one barrier identified was, actually not surprisingly, it was low or no reimbursement. But what was a little bit surprising was licensure, which was identified as kind of all the way at the bottom. Only 18 percent of physicians surveyed identified licensure as the barrier. I guess it becomes a little less surprising now when we look back and realize that the vast majority of patients that used telehealth over the past 20 plus months have done so with a physician with whom they have an existing patient-physician relationship. And most physicians, likewise have mostly seen patients with whom they have an existing patient-physician relationship, as well.

I think this really speaks to the transformational shift in the hybridization of physician practices and using telehealth for either in-person care for their patients or telehealth based on what is clinically appropriate for the care sought at that moment.

Dr. Turck:
As a follow-up to that, Ms. Horvath, how can physicians quickly gain licensure in other states? And what are some policy options state lawmakers should consider to assist those who are interested in practicing telehealth in multiple states?

Ms. Horvath:
Yeah, so the AMA supports state-based licensure, and believes that physicians need to be licensed in the state where the patient is located, including for services provided via telehealth. The easiest way for physicians who are interested in practicing in multiple states and to obtain licensure in multiple states is through the Interstate Medical Licensure Compact. And 33 states plus DC and Guam have adopted that Compact. So it's likely that the state that you're in has adopted the Compact.

To answer the second part of your questions around policy options, we would encourage states to join the Interstate Medical Licensure Compact if they have not already done so. And in addition, we would encourage state lawmakers to consider narrow exceptions to licensures for telehealth. So for things like physician-to-physician consultations, or in the event of an urgent or emergent circumstance.  We would also encourage states to consider a narrow exception to licensure in those cases when a patient might seek care while out of state, but from their physician back home with whom they have an existing relationship, and for care that is incident to an existing care plan or one that is being modified. And really, I think the purpose there is recognizing that in those instances and in those circumstances, it's really that physician back home that knows the patient best and it's really about supporting and promoting the continuity of care in those cases. 

Dr. Turck:
For those just tuning in, you're listening to Perspectives with the AMA on ReachMD, MD. I'm Dr. Charles Turck. And today I'm speaking with Ms. Sandy Marks, Ms. Kim Horvath, and Mr. Kyle Thomson, about policies around Medicare coverage of telehealth.

So the three of you have given us some really great insights so far into where we're currently at, but now I'd like to take some time to look ahead to the future. Mr. Thomson, what are the biggest challenges for federal telehealth policy beyond the COVID-19 pandemic?

Mr. Thomson: 
So interestingly, I think the biggest challenges facing telehealth policy in general are maintaining some of the gains and services that have been made during the public health emergency. At the federal level, as we discussed, the biggest concern is the possibility for Medicare coverage of telehealth services to revert back to the same restrictions that existed prior to the pandemic, once the public health emergency declaration ends. Without intervention from Congress, in fact, the vast majority of Americans that have come to rely on telehealth services during the public health emergency will abruptly lose access to these services almost completely with very few exceptions.

At the AMA, we strongly believe that Congress must act now, as soon as possible really, to remove any arbitrary restrictions on who may receive telehealth services and where they may receive them. Continued access the telehealth services beyond the public health emergency is critical for patient populations that have come to rely on its availability.

Dr. Turck:
And, Ms. Marks, if we zero in on the Centers for Medicare and Medicaid Services, what does the AMA see as the most important areas for CMS to focus on moving forward?

Ms. Marks:
Thank you for that question. The early COVID experience in the spring of 2020 was having telehealth as the only option. Patients had to stay home. Many physicians and practice staff were also working from their homes. But in the future, the issue for CMS to deal with is what are the optimal approaches to supporting digitally-enabled hybrid care that’s going to blend virtual, in-person, and remote monitoring services.

For people who have functional limitations, getting themselves to regular in-person appointments to manage their chronic conditions can be a struggle. For many patients, they just like doing telehealth or telephone visits. Their increased satisfaction can lead to more patient engagement in their treatment plan, more focus on the way they manage their condition at home, and lead to better outcomes. So CMS has a lot of opportunities here to facilitate improvements in care. And we think it's going to be an exciting time.

Dr. Turck:
Now we're almost out of time for today. So I'll turn to you, Ms. Horvath, for the final word. As we look ahead to the start of the 2022 state legislative sessions, what are the top telehealth issues you would like lawmakers to focus on?

Ms. Horvath:
So, four things. First, we would encourage lawmakers to support coverage and payment, removing any remaining barriers to coverage of telehealth, whether it's geographic restrictions, or originating site restrictions. Coverage of services provided via telehealth really need to be on the same basis as comparable services provided in person.

Second, we would support fair payment of telehealth. What we've learned over the past 18 plus months is that when barriers to coverage are lifted, and lawmakers support fair payment for telehealth, telehealth can be fully integrated into physician practices, and patients are more likely to go to their own physician for care via telehealth. This supports continuity of care and the patient-physician relationship. And it's critically important for continued access to high-quality telehealth.

Third, we believe that care policy should support the ability of physicians to provide telehealth to their patients. And because we know that not all care can be provided via telehealth, we need to ensure that patients have access to care in person when needed, whether it's clinically appropriate for the care staff, or simply because the patient wants to be seen in person. Either way, patients should not face additional hurdles or burdens or cost to do so.

And finally, equity. Telehealth, we believe, has the power and potential to address some inequities in healthcare. But to get there, we need to adjust some inequities in access to telehealth. So we would encourage state lawmakers to support expanding broadband access, increasing affordable internet connectivity, supporting fair and equitable payment, supporting digital literacy programs, and supporting programs that ensure interpreter services are available for telehealth for those who may be hard of hearing or who may have limited English proficiency.

Those are just a few but really important moving forward. And the AMA is ready to work with lawmakers on all of these at the state level.

Dr. Turck:
Well, with those forward-looking thoughts in mind, I want to thank my guests Ms. Sandy Marks, Ms. Kim Horvath, and Mr. Kyle Thomson, for sharing their insights and Medicare coverage for telehealth services. It was great speaking with you all today.

Ms. Marks:
Thanks again for having us.

Ms. Horvath:
Thank you.

Mr. Thomson:
Thank you.

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This was Perspectives with the AMA on ReachMD, produced in partnership with the American Medical Association. To access other episodes in this series, visit reachmd.com/AMA where you can Be Part of the Knowledge. Thanks for listening!