How should telehealth be reimbursed?

There has been much discussion regarding reimbursement for telehealth. Classically, insurers have worried that telehealth coverage would lead to overuse. However, despite the extraordinary utility and use of telehealth during the pandemic, we have not seen providers increase the number of total visits they perform over prior patterns. Instead, telehealth appears to have been used as an essential substitute for in-person visits, and overuse appears to have been a false concern. 

We now see payers trying to decrease what they pay for telehealth on the premise that because it is remote, it should be simpler and, therefore, cheaper. There are some savings, but mostly the effort and expense to provide telehealth is more like an in-person visit than it is different.

First, let's tackle the physician portion. Guidance published recently on what physicians should charge from CMS is based on either the complexity of the visit or the time it took. Complexity is independent of whether the visit took place in person or virtually; rather, complexity may involve an assessment of the patient's symptoms, conditions, medications and laboratory tests. The physical exam can contribute to the data being evaluated, and elements of the physical exam can be assessed by video (i.e. neurology), photo (i.e. dermatology) or even via remote monitoring ⁠— and sometimes it's not necessary at all. Thus, the current system for evaluating how complex a service a physician has rendered overlaps entirely with virtual visits, which should be covered at parity with in-person visits when both involve the same level of effort.

Next is the consideration of all the other expenses that underlie a patient visit: scheduling, rooming, reconciling medications, assessing initial reason for the visit and coordinating next visit. While there is no patient room or gown for a virtual visit, the HIPAA-secure IT systems are expensive to operate, maintain and integrate, and there are costs for physician space and equipment as well. So there are some savings in the overhead cost, but the reality is that building space cost is comparable to IT overhead. 

In sum, there is a rationale for reducing telehealth costs modestly for the overhead aspects, but no rationale for reducing the physician component, which is the same. The pandemic taught us that lack of reimbursement was the major barrier to adoption of telehealth. It is a great and often essential modality, but if it isn't paid for, it won't be embraced going forward. Establishing a fair and right payment structure is critical to ensure ongoing access to virtual care beyond the pandemic. As we witnessed during COVID-19, telehealth can serve as a bridge to some of our most vulnerable patients and it must remain if we want to succeed in addressing health equity.  

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