On July 12th, 2018 CMS took an uncharacteristically big step forward in embracing new technology with their release of the proposed fee schedule for 2019. In the proposed rule, CMS not only adds new codes for Medicare Telehealth services but also suggests reimbursement for three new types of remote provider interactions not currently included in the Medicare Telehealth Services umbrella:
• Virtual Check-Ins:
Providers would be able to bill for quick, remote consultations with patients to determine if an in-person visit is needed. The provider can still be reimbursed for the service even if there is no resulting in-person visit, and depending on the final CMS changes, may not need to have an “established” relationship with the patient (something CMS currently requires). This new type of visit would provide enormous time and cost savings for both the provider and the patient, especially if the patient has far to travel or faces a significant wait time for an in-person visit.
• Remote Evaluation of Pre-Recorded Information:
Providers could examine “store and forward” videos and images and still bill for their time – this is particularly relevant for specialists like dermatologists who may be called in for a consult. With this change, providers could send an image or video of a patient complaint to the appropriate specialist to help determine if a referral is necessary or the issue can be treated in-house.
• Interprofessional Internet Consultation:
We have heard time and again how valuable provider-to-provider consultations are in improving the quality and efficiency of care for patients. A shining example of this is one of Azara’s clients, Finger Lakes Health, where they have developed a robust dental consultation telehealth program for pediatric patients. A core component to their success is the partnership Finger Lakes established with the University of Rochester hospital. Dentists from the university are available to coach those at Finger Lakes in evaluating the center’s patients, as well as help providers build confidence in treating conditions they might typically refer for outside treatment. Allowing providers to bill for this time is a huge step forward in facilitating team-based care, a key component in PCMH recognition.
CMS would also like to add more originating sites and geographic exemptions for end-stage renal treatment, as well as create a new bundled payment model for Substance Use Disorders which would include some remote counseling.
While these changes are exciting, there is still a long way to go. The comment period for these proposed updates extends until September 10th, 2018, and while this is a hopeful development, centers interested in starting a telehealth program of their own should be prepared to wait for CMS reimbursement and coding to catch up to all the potential applications for telehealth. While attending the annual Northeast Regional Telehealth Conference in Portland, ME this year, I heard time and again how challenging it was to get buy-in from center staff to begin offering telehealth services, an attitude often due to the limited reimbursement opportunities and confusing restrictions around licensing and treatment sites. These proposed changes will alleviate some of those concerns, but centers should still be prepared to sacrifice in the beginning in favor of long-term savings and increased access for patients.
Despite CMS’s meandering pace to get on board with telemedicine, I also heard repeatedly at the conference that telehealth is coming, whether providers and insurers are ready for it or not. Consumers are demanding more convenient and cost-effective care, and patient adoption has proven to be one of the lowest barriers for centers implementing a new telehealth program. People love receiving lower bills, seeing a doctor in the comfort of their own home, and not having to take time off work or arrange transportation. The Ontario Telehealth Network recognizes these advantages and has piloted numerous telehealth programs, including telehomecare for patients with CHF and COPD, telepsychiatry for home psychiatric care, telestroke for physician-to-physician consultation across 23 hospitals in Toronto, and many more. Because Ontario has a large rural population, telemedicine has been particularly impactful for individuals and families living hours from a major hospital – this video highlights OTN’s success delivering care remotely and the positive change it can bring for patients and their families.
While the benefits of telehealth in rural communities are easy to see, there are powerful urban success stories as well. Health-E-Access in Rochester, NY is a telehealth program for inner-city day-care centers, facilitating same-day remote appointments for sick children with a provider from Golisano Children’s Hospital. A telehealth assistant at the day-care center has access to necessary examination tools and is present with the child during the telehealth visit. This assistant takes recommendations for treatment from the provider and communicates with parents by phone about the appointment. If no in-person follow up is needed, parents are saved from taking unscheduled time off work and can rest easy their child has been evaluated by a professional.
There will always be challenges to beginning a telehealth program; broadband requirements, initial start-up costs for equipment and training, establishing standard policies and procedures, and of course reimbursement concerns. However, the pay-offs are powerful. Allowing a mother to avoid an hours-long trip to the doctor for a routine check-up for her child, or video chatting weekly with an elderly couple to monitor COPD and hypertension; a telehealth solution can make a huge difference in the lives of both patients and providers. Moreover, while CMS may never move quite as fast as innovative providers and savvy consumers, it is taking significant steps to make integrating telehealth into practice easier.
If you are interested in bringing telehealth to your center, please visit HRSA’s Telehealth Programs page here where you can find funding opportunities, regional telehealth resource links, and much more.