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Source/Disclosures
Source:

CMS. Final policy, payment, and quality provisions changes to the Medicare physician fee schedule for calendar year 2021. https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-1. Accessed December 7, 2020.

Disclosures: Clear reports being employed by Bicycle Health, Inc, a management organization affiliated with his medical group, Bicycle Health Medical Group, which cares for patients with opioid use disorder. Khan reports being a shareholder in Anthem Inc., Iora Health and Oak Street Health.
December 10, 2020
6 min read
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CMS makes some telehealth services permanent after COVID-19

Source/Disclosures
Source:

CMS. Final policy, payment, and quality provisions changes to the Medicare physician fee schedule for calendar year 2021. https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-1. Accessed December 7, 2020.

Disclosures: Clear reports being employed by Bicycle Health, Inc, a management organization affiliated with his medical group, Bicycle Health Medical Group, which cares for patients with opioid use disorder. Khan reports being a shareholder in Anthem Inc., Iora Health and Oak Street Health.
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CMS recently announced that many of the expanded telehealth services it is covering due to COVID-19 will be permanently covered after the pandemic.

“During the COVID-19 pandemic, actions by the Trump administration have unleashed an explosion in telehealth innovation, and we’re now moving to make many of these changes permanent,” Alex Azar, HHS secretary, said in a press release. “Medicare beneficiaries will now be able to receive dozens of new services via telehealth, and we’ll keep exploring ways to deliver Americans access to healthcare in the setting that they and their doctor decide makes sense for them.”

Khan on CMS telehealth

CMS said that 60 of the 144 telehealth services newly offered during the COVID-19 pandemic will become permanent, including services for group psychotherapy, cognitive assessment and care planning, psychological and neuropsychological testing, and domiciliary, rest home or custodial care services for established patients.

Additionally, it finalized a list of services that will be included under Category 3, which consists of services added during the pandemic that will remain covered until December 21, 2021, or until the end of the calendar year when the COVID-19 public health emergency is declared over. These telehealth services include home visits to established patients, certain ED visits, nursing facilities discharge day management, critical care services, inpatient neonatal and pediatric critical care, and physical and occupational therapy services.

CMS also finalized the decision that direct supervision in telehealth visits can be provided with interactive audio and video technology through the end of the year the pandemic ends or December 2021.

The organization also announced that it commissioned a study of its telehealth changes during the pandemic to evaluate the possibility of new ways telehealth, virtual care supervision and remote monitoring can be used to provide more efficient care to patients.

Healio Primary Care spoke with experts to find out how changes to telehealth have affected their practices amid COVID-19 and whether CMS made enough services permanent.

Benefits of CMS changes to telehealth

Ali Khan, MD, MPP, FACP, executive medical director at Oak Street Health and faculty member in the department of medicine at the University of Chicago’s Pritzker School of Medicine, told Healio Primary Care that the changes CMS has made to telehealth restrictions have “absolutely” improved patient care.

“These have been the only lifeline for many patients and many practices alike,” he said. “Whether it’s primary care focused on less-than-optimal diabetes management, infertility consultations that are all too often time sensitive, skin checks via video for tele-dermatology or mental health visits exploring the impact of social isolation, loneliness and burnout during this pandemic, CMS’ support of telehealth has undoubtedly kept patients healthier — and it’s stabilized many practices financially at the same time.”

Khan also said that the CMS changes to allow telehealth for services for remote patient monitoring and hospital-at-home type services have been “fantastic.”

“As patients, we're always at risk of worrying alone,” Khan said. “Having the ability to, at the touch of a button, talk to a trusted physician or care team member means a great deal.”

Telehealth in opioid use disorder care

Brian Clear, MD, medical director of Bicycle Health, a virtual clinic for the treatment of opioid use disorder, told Healio Primary Care that certain telehealth changes have allowed physicians to provide virtual psychological and behavioral services to patients with opioid use disorder “and be compensated for it.”

Photo of Brian Clear
Brian Clear

Clear noted that these changes are a sign that telehealth has been “accepted and valued” by the medical system and is beginning to be considered equivalent to in-person care.

He added that the expanded acceptance of telehealth amid the pandemic “gives medical programs and systems the assurance that they need to begin investing in and promoting telemedicine technology,” and provides “programs like Bicycle Health confidence to say that improving access to OUD [treatment] through telemedicine care is a sustainable model that has a future beyond the tiny self-pay corner of medical practice in the U.S.”

Among the changes that CMS implemented during the COVID-19 pandemic, Clear said that the most impactful has been the temporary waiver of the Ryan Haight Online Pharmacy Consumer Protection Act.

“Ryan Haight attempts to restrict unscrupulous medical providers from prescribing dangerous substances without performing an adequate assessment of a patient,” Clear said. “When written, it didn't consider a future in which telemedicine technology is advanced enough to provide high quality assessments, and it arbitrarily and incorrectly assumes that an adequate assessment for a new patient must always be done in the same room with that patient.”

He added that the waiver has temporarily corrected this and allows health care workers to establish care relations and begin treating patients with OUD through telehealth.

According to Clear, Bicycle Health has been able to provide treatment for hundreds of new patients who had previously not been diagnosed because they were unable to access in-person care. Before the pandemic, more than 75% of new patients had previously received treatment, and now, more than 50% of new patients have not previously received an OUD diagnoses or care.

“The waiver has been tremendously beneficial for public health and not just in a way that’s confined to reducing COVID-19-exposure risk,” Clear said.

Are the permanent additions enough?

Khan said that the decision to make some telehealth services permanent after the pandemic is “game changing,” and shows CMS’s commitment to moving forward with care that prioritizes patient preferences using technology that is familiar to them.

“There’s no reason, from the vantage point of the natural pace of innovation, to go backward into a predominantly face-to-face mode of care delivery,” Khan said. “We should meet people where they are, and we should pay for that equally to ensure that there’s no undue motive in helping patients choose which modality makes the most sense for everyone involved — especially them.”

Khan added that some services like home physical and occupational therapy, discharge day management, home visits to established patients and end-stage renal disease capitation visits that were given Category 3 coverage “make more sense as permanent services covered by telehealth.”

This is because, he said, patients often claim that times of home services are not convenient for them or that they are too tired on the day of discharge to go to other office visits.

“When that pushback happens, we lose the opportunity to engage people meaningfully — and we all lose in the process when adverse consequences then occur, such as rehospitalizations or ineffective rehabilitation,” Khan said.

Therefore, he said that “for those who can make it work from a technological perspective, we should open up the gates to more robust telehealth services — particularly ones such as these that help people heal at home and stay in place.”

Moving forward, Clear said that CMS should consider shifting reimbursement for services to be more outcome-based.

“Ideally in a medical system that values patient outcomes and holds providers accountable to those outcomes, we drop the ‘telemedicine’ modifier entirely and instead reimburse for addressing a problem and achieving an expected or better-than-expected outcome,” Clear said, adding that this system does not currently exist in the U.S.

“CMS feels a need to dictate what tools are and aren’t appropriate for a given service,” he said.

For instance, Clear said CMS determined that telehealth cannot be used for ED services after the pandemic.

“Their logic, presumably, is that they don’t want to encourage emergency departments to use an inadequate tool to deliver a service that generally needs to be in-person,” Clear said. “That reasoning is fair for most cases in the present time, but it also discourages innovative practice to address unique needs and further improve telemedicine technology.”

According to Clear, having an outcome-based reimbursement system would mean that CMS would not have to dictate how and when telehealth services are implemented because there would already be a disincentive for using the wrong tool with patients.

“I would like to see CMS move toward a system that doesn’t consider where or how a medical service is delivered at all, but instead is based on what problem is being treated and how well it’s treated,” he said.

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