Healthcare providers who were only passingly familiar with telehealth before the COVID-19 pandemic are certainly acquainted with it now – either due to its high-profile rise in popularity or because waivers from the Centers for Medicare and Medicaid Services have allowed them to start implementing it themselves. These waivers are temporary, of course. But long-term change will likely be permanent.
For lasting change in areas such as reimbursement and the ability to offer telehealth across state lines, an act of Congress will be required, and on the surface this seems like a tall order. Partisan gridlock has become a staple in American governance, and healthcare has been a particularly contentious topic. The Affordable Care Act has been strained by a legislative tug-of-war, and intraparty squabbles have erupted over the best method for healthcare reform.
Telehealth, though, may be one of the few areas in healthcare primed for bipartisan support. It has proven popular with providers and patients alike, and, as the coronavirus has essentially shut down elective surgeries and other service lines, it has been a much-needed lifeline for hospitals looking to breathe life into their ailing margins.
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While traditionally, telehealth services have been reimbursed at a lower level than in-person visits, in March, CMS allowed for more than 80 additional services to be furnished via telehealth and for providers to bill for telehealth visits at the same rate as in-person visits.
This is to apply for the duration of the emergency declaration.
"We're billing out and getting paid. It has kept our cash flow moving, as we had to significantly reduce our inpatient and in-person visits," said Sarah Kier, Emory Healthcare's vice president of patient access, physician group practices.
Consider the financial benefits. Jason Popp, a partner at Alston and Bird's healthcare litigation group, pointed out that, historically, telehealth was only available to people living in rural areas. And even in those cases, it had to be performed at a sanctioned clinic or facility in the area.
Now, with the waivers in place, almost anybody with broadband internet can access telehealth, and can do so from their homes. This has allowed healthcare organizations to continue offering certain basic services that otherwise would be lost to them.
"To me, that's the most significant waiver," said Popp. "My hope is that post-COVID Congress will essentially adapt to that. I don't think telemedicine should be limited to rural settings, and from a logistical standpoint, doing it from your home is a great thing.
"When the pandemic started, physicians in practices were seeing big changes because they couldn't see patients anymore," he said. "Now they're quickly adapting to the change. Otherwise, they've got limited revenue because patients aren't coming to clinics or certain facilities. It's been a bit of a wake-up call to practitioners who were previously kind of opposed to telehealth. Now they're seeing there are immense benefits. After the pandemic, many will continue to provide telehealth."
And then there's the reimbursement picture. In 1997, Congress said telehealth could only be reimbursed in limited scenarios, and not much changed until CMS gave Medicare Advantage plans more leeway last year. But the technology itself has changed quite a bit. The regulatory framework has lagged behind the actual technological advances in the field.
While CMS' waivers will evaporate once the public emergency ends, elected officials will likely have reason to consider more permanent regulatory changes given telehealth's ongoing effectiveness in everything from primary care visits to behavioral health.
Popp expects that a post-COVID Congress will likely first address the geographic expansion of telehealth access, with reimbursement soon to follow. After all, the model has proven especially effective in the realm of preventative care, which leads to a decrease in hospital care, and has opened up new revenue streams for healthcare facilities during a critical time.
Dr. Erin Jospe of Kyruus has seen providers latch onto the technology quickly, and has marveled at the speed with which some organizations have implemented services – some of them having started with nothing.
"There's a widespread belief that this is the way to meet a lot of need in a safe way that still feels good," said Jospe. "It's meeting people's needs in a way that is both satisfying and effective. This is really hitting both notes very well. .... It's a huge advance in convenience, but it's not coming at the sacrifice of excellence."
As the industry begins to look forward to a world beyond (or alongside) the coronavirus, Jospe envisions a gradual, "hybrid" reopening of services. Certain health ailments will obviously require hands-on management, and their services will open back up in time, but other things that can be effectively managed remotely will probably continue to be for a while. That will require hospitals and health systems to be nimble and react quickly to change on the regulatory front.
In particular, Jospe singled out Atlanta-based Emory Healthcare as a provider that has rapidly adjusted to the new landscape.
"Emory has been remarkable," said Jospe. "I was stunned by the velocity with which they made this change. … They went from zero telemedicine appointments to over 4,000 a day."
Sarah Kier, Emory's vice president of patient access for physician group practices, said the ramping-up of telehealth services was extremely rapid – so much so that 91% of its providers have been trained in telehealth, or are practicing it actively. In total, 39 subspecialties have been onboarded for telehealth over the past seven weeks or so.
The healthcare system has facilitated two weekly meetings with physicians to go over clinical questions and standard operating procedures, and phone calls with nurses and administrators have taken place every other week – an intense process that has enabled rapid adoption.
"This is how we're getting consent, this is how we're accessing medical records – all the little things people have to know to make the wheels on the bus go 'round," said Kier. "It's exhausting. I'm so impressed with the provider uptake. Our providers care about the continuity with our patients."
A week before COVID-19 hit the U.S., Emory signed a contract with American Well to provide telehealth services, but the system isn't using their technology yet; there simply hasn't been enough time. To make up for it, the health system has been conducting telehealth visits over Zoom, which luckily is HIPAA compliant under the waivers.
"Even when and if regulations go back into place, the platforms will be HIPAA compliant and tick all the boxes," said Kier. "This is all reimbursable activity. We're running almost a 96% yield rate – actual payments vs. expected payments. That's fantastic, better than the usual yield rate. We're billing out and getting paid. It has kept our cash flow moving, as we had to significantly reduce our inpatient and in-person visits."
Because so much of the industry is rapidly trending in this direction, Spier said it would be difficult to go back to pre-COVID telehealth reimbursement levels. Some service lines, such as telepsychiatry, would still be reimbursed at their current levels, but things like imaging and labs would see reimbursement cut by 60% to 70%.
"Those service lines would love to see a scenario where these levels are sustained," said Kier. "Some things won't work for telemedicine, but for the things that do work, our patients and providers would love to see it continue post-COVID."
Switching to the American Well platform will likely take months. But however Emory offers telehealth in the future, it's here to stay at the health system.
"We want telemedicine to remain a way that we care for our patients," said Kier. "We think it's the right thing to do. It saves time and overhead dollars. It would allow us to remain nimble once COVID has come and gone."
If a reversion to pre-pandemic reimbursement levels creates a kind of limbo for providers, Jospe envisions a scenario in which remote monitoring becomes a bigger part of hospital care. A combination of home health aides, visiting nurses and straightforward video interactions could provide an interim way forward, at least until Congress acts on something more lasting.
"I hope and pray these changes are permanent," said Jospe. "This is a valid care mechanism and you should not be penalized for embracing it. I can't imagine going back. From an effectiveness standpoint, from a convenience standpoint, it is truly a valuable way to deliver care."