Will health systems sustain telehealth if pandemic pay rates, coverage drop?

Health systems across the nation drastically expanded telehealth services during the pandemic so patients could receive care while social distancing and minimizing the virus spread.

Pensacola, Fla.-based Baptist Health Care CFO of the Healthcare Division and Vice President of Finance Rob Tonkinson said the system saw rapid telehealth service expansion during the pandemic and have found it as an effective tool for addressing patient concerns. "We are hopeful that reimbursement rates will be maintained at current levels. We will be monitoring the situation with all payers and will need to address accordingly if reimbursement decreases are implemented," he said.

CMS and commercial payers rolled back regulations that previously prohibited widespread coverage and adoption of telehealth and virtual care, but the changes were temporary; when the pandemic ends, some of the benefits could as well. A few commercial payers have announced their initial policy changes will be extended through the end of the year, or become permanent, but CMS has not yet announced benefits will be permanent. Prior to the pandemic, telehealth was covered in only certain circumstances and reimbursed less than in-person visits.

Given the current financial strain health systems are under due to the pandemic, if telehealth pay rates drop, will systems continue to offer services at the same level?

Hospital Sisters Health System in Springfield, Ill., had a strategic plan to grow telemedicine before the pandemic, which was accelerated in the past few months to continue serving patients. The system plans to continue down that path going forward regardless of reimbursement rates.

"We have built reports to monitor payments," said Nikki Harper, vice president of revenue cycle at Hospital Sisters Health System. "We have worked with our contracted payers to talk through reimbursement and coverage for these services. We are hopeful the expanded reimbursement will continue. If the coverage and reimbursement returns to pre-COVID, we will continue to provide what we do now since it's the right thing to do for our patients. We have already secured the technology and have the resources to adequately perform these services."

Hospital Sisters Health System sees telehealth as an extension of in-person services and Ms. Harper is hopeful that the work of HSHS' Chief Medical Officer Gurpreet Mander, MD, on various committees will influence CMS and commercial payers to maintain current reimbursement rates for telehealth. "After reviewing the data, we know it’s by far less expensive to provide care in this setting so it's a winning situation for the providers, payers and patients," she said.

Martin Doerfler, MD, senior vice president of clinical strategy and development and associate chief medical officer of New Hyde Park, N.Y.-based Northwell Health, said he doesn't think the state is at risk of losing telehealth coverage except the CMS waiver regarding the geographic limitations to coverage. That is a big risk, he said, due to a "dysfunctional federal government."

"If that coverage waiver is not made permanent telehealth to fee-for-service Medicare patients will become a non-covered service. We will have no choice but to notify FFS Medicare patients and offer telehealth services as self-pay," he said. Otherwise, New York has coverage parity for Medicaid and commercial coverage excluding ERISA covered plans, for office-based services and said since the latter part of 2019 the health system was paid at negotiated rates that are similar to office-based and telehealth services.

"Were this to change, we will make this part of our rate negotiations with our major carriers," he said.

During the pandemic, Atlanta-based Emory Healthcare transitioned around 30 percent of its usual in-person visits to telehealth, reaching about 3,000 visits per day, up from a few dozen per day before the pandemic. CEO Jonathan Lewin, MD, reports that telehealth visits have seen tremendous adoption and clinician as well as patient satisfaction.

"Clearly, this model has many benefits for all involved, and our great hope is that we will be able to continue to see reimbursements from both governmental and commercial payers commensurate with the value this brings to patients and society," he said. "However, understanding that reimbursement may drop to the point at which many of the services we currently are providing will become cost-prohibitive to continue, we see several areas that will likely remain across many of our service lines. One area that predated the COVID-19 related acceleration of our telehealth activities that will undoubtedly continue is our work providing consultation to assist physicians managing their patients in distant or rural hospitals."

He said the system's nephrology program allows for dialysis in rural Georgia hospitals without local nephrology coverage and prevents urgent transfer for renal failure. The health system also anticipates continuing preoperative evaluations and postoperative visits for patients who live significant distances away over telehealth regardless of reimbursement. He also mentioned psychiatry consultation via virtual visits will be an ongoing effort.

"While excited about the prospects, it is too early in telehealth adoption and experience to fully understand what long-term rates should be," Dr. Lewin said. "Additionally, the same professional clinical expertise is being provided under most circumstances regardless of care setting. We therefore encourage CMS and other payers to extend waivers as currently authorized with extension of equivalent reimbursement between in-person and telehealth visits."

Tom Brazelton, MD, MPH, FAAP, medical director of the UW Health Telehealth Program and professor of pediatrics at the University of Wisconsin-Madison School of Medicine and Public Health, said telehealth will be a critical aspect of his system's strategic plan moving forward even if reimbursement rates and coverage are cut.

"Healthcare needs to move away from a 'stimulus-response' level of functioning," he said. "The reflexive 'no payment therefore no care' is antiquated and fails to tackle the social and economic determinants, and inequities, of health and healthcare in our country. Our new normal must include the lessons learned from this pandemic. We'd be foolish not to adopt the principles we've successfully put in place, tested, and adapted to over the last three months: physical (not 'social') distancing, web-based meetings, shared workspaces, work-from-home solutions, etc., and that's just on the health system side. From the patient's perspective, the telehealth adoption rates have exceeded expectations without a change in the standard of care for those conditions that can be managed using remote technology. Our delivery model is safer for everyone without an observable difference in quality."

Dr. Brazelton said the health system is seeing its highest member satisfaction and net promoter score ever since implementing widespread video visits. "With such widespread adoption, we anticipate coverage will actually go up even though reimbursement will likely go down, at least initially, as we recalculate the actual costs associated with telehealth," he said. "Telehealth requires a different calculus than brick-and-mortar clinics. The cost for telehealth will be up to health systems to establish fair recompense with payers, but we do see telehealth as an opportunity to bring down the costs of healthcare."

Despite many executives' optimism about continuing telehealth efforts despite any reimbursement or coverage changes, some physicians have a different view. Alexa Kimball, MD, president and CEO of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center in Boston and president of Physician Performance LLC, attributes the widespread telehealth adoption to regulatory rollbacks and sees that contracting if those regulations return.

"Uncertainty surrounding insurance reimbursement remains one of the biggest determining factors for ongoing success in telehealth," she said. "We no doubt will be living in a world of both in-person and telecare for some time since the need for social distancing will obligate us to see fewer patients in our clinical settings. Telehealth will help providers to balance these challenges and enable better patient access. But maintaining and expanding telehealth reimbursement is absolutely imperative. Insurers must understand that telehealth visits are often longer, not shorter, than in person visits, and require a significant amount of technical and administrative support. Yes, telemedicine can be less expensive – but that's because it requires fewer buildings, not less effort. If reimbursements drop, it's likely that clinicians will offer virtual care under only limited circumstances – and that would undo all the critical progress we’ve made over the past few months."

More articles on telehealth: 
FCC awards $20.18M more in telehealth funding, surpasses $100M in total program funding
Intermountain rolls out virtual program to deliver hospital care to patients at home 
Permanently higher telehealth pay rates under review, CMS says 


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