At a time when congressional leaders are notoriously at odds over health care reform, one piece of health care-related legislation that has received bipartisan support is the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017 (S. 870). The bill was unanimously approved by the Senate Finance Committee on May 18 and includes several new flexibilities for Medicare Advantage plan sponsors, including the expanded use of telehealth that has been an underutilized benefit in Medicare.
Under current law, MA plans must cover the same telehealth services that are available in Medicare fee-for-service. But reimbursement for such services is contingent upon the patient’s physical presence at an approved “originating site” (e.g., a physician’s office, hospital, rural health clinic), and these sites are limited to facilities located in rural health professional shortage areas, counties not included in a metropolitan statistical area or those participating in a federal telehealth demonstration project. MA plans are free to offer additional telehealth services but only as supplemental benefits funded by rebates or premiums and not as part of their basic benefit package. Because of these and other limitations, less than 1% of Medicare and Dept. of Defense beneficiaries received care through telehealth between 2014 and 2016, despite its potential to improve or maintain quality of care, reported the Government Accountability Office.
Senate Bill Would Expand Telehealth
Originally introduced by the bipartisan Chronic Care Working Group in December 2016, the CHRONIC Care Act was reintroduced this year without two key provisions that were included in the 21st Century Cures Act, which became law in December 2016 (MAN 12/15/16, p. 1). It includes, among other things, four provisions that would expand telehealth coverage under Medicare: (1) eliminating geographic restrictions on the use of telehealth for individuals with stroke (a.k.a. “telestroke”), (2) expanding home remote patient monitoring for those on dialysis therapy, (3) enhancing telehealth coverage for accountable care organizations and (4) increasing flexibility for telehealth offered by MA plans. Specifically, Section 304 of the act would allow an MA plan to offer additional, clinically appropriate telehealth benefits in its annual bid amount beyond the services that currently receive payment under Part B beginning in 2020.
A preliminary cost estimate released May 16 from the Congressional Budget Office (CBO) concluded that the bill would neither increase nor decrease Medicare spending, and estimated that increasing convenience for MA enrollees through telehealth would lead to a potential cost savings of $80 million between 2018 and 2027. According to the American Telemedicine Association (ATA), this is the first time that CBO has scored telemedicine legislation since 2001, when legislation that is now part of the Social Security Act “created longstanding barriers for Medicare telehealth coverage.” ATA is urging its members to lobby lawmakers in support of S. 870 as well as the CONNECT for Health Act of 2017; that bill, also reintroduced this year, has similar provisions and would give providers more freedom to test telehealth.
Brodie Dychinco, general manager of convenient care for Cambia Health Solutions, says he wasn’t surprised by the CBO’s estimate, given the positive results his own company has observed in enabling these technologies for its Regence health plans and other customers. Its telehealth solutions are available primarily for commercially insured members, although they are offered on a limited basis in its MA plan in Washington state. Dychinco says there was some concern prior to rolling out the benefit about increased costs because of the sudden availability of a “new convenience.” But when tracking whether people who used telehealth were previously users of care, Cambia found that four out of every five telehealth users “were essentially replacing what would have been an in-person visit, meaning only one out of five [new visits] were essentially generated from the telehealth space,” he tells AIS Health. Moreover, the company found through survey data that patients were using telehealth in place of emergency room, urgent care and physician office visits, which resulted in the members saving roughly $80 to $120 on average per telehealth visit.
The parent company also looked into whether people who actually use telehealth end up going to the doctor anyway, but did not observe any such duplication. “When we looked at the numbers, we looked at the diagnosis during the telehealth visit, then looked at between one and six days after the visit to see whether there was another in-person visit and if there was the same diagnosis, and it was very small — under 2%,” he says. Cambia was one of 11 insurers that wrote the CBO last October requesting that “non-Medicare sources of data” be used in its analysis of the cost savings impact of telemedicine in Medicare (MAN 11/3/16, p. 8).
MAOs Welcome Opportunity to Improve Access
MVP Health Care, which signed the CBO letter, is also in support of the legislation. The insurer this year launched a telemedicine benefit allowing members in its fully insured plans that include Medicare and Medicaid to access a variety of health care professionals, including behavioral health specialists, via a mobile device or computer and webcam.
“MVP Health Care is out in front of the industry by offering direct-to-consumer telemedicine via our MyVisitNow 24/7 online doctor visits to our Medicare Advantage members,” states Cupid Gascon, M.D., vice president of clinical transformation for MVP. “We know our members always benefit from having more ways to access necessary care, which is especially true for our Medicare members who often experience barriers to access attributable to impaired mobility or limited access to transportation. Any legislation that increases access to programs such as this would be beneficial to our communities, but MVP is already committed to providing our members with the best care and greatest access possible.”
Meanwhile, Independence Blue Cross last year launched a telemedicine option with vendor MDLIVE enabling its commercial membership to connect with a network provider when needed. The plan is encouraged by the “exciting” prospect of being able to expand such services for seniors, according to Heidi Syropoulos, M.D., medical director for government markets with the Philadelphia-based insurer. “Since the ‘originating site’ for the member has to be rural, we just don’t have anybody that’s really qualified for that and as it is now, our MA plans offer essentially what [FFS] Medicare does,” explains Syropolous.
One potential use of telehealth in MA, suggests Syropoulos, could be having nurse practitioners visit a patient’s home within a week post-discharge and enabling a video conference with the patient’s primary care physician to conduct a home assessment and medication reconciliation, “which we feel and hope will decrease the likelihood that a member goes back to the hospital. And transitions of care between the Skilled Nursing Facility and the home or the Acute Care Hospital and the SNF and the home are really fraught with all kinds of problems, so expanding telehealth to the point where we’d have our eyes and ears in the home is a potential that would be really fabulous.”
View a summary of the legislation at http://tinyurl.com/kehlsml.