Originating site and expansion of CMS reimbursement receive greatest support; parity pay may face an uphill battle.
Telehealth has not only been embraced by consumers and physicians during the pandemic, it appears to have won bipartisan support from key U.S. senators based on comments and the line of questioning that occurred in a U.S. Senate Committee on Health, Education, Labor & Pensions hearing yesterday. Legislative support will be necessary to make permanent policy changes that were temporarily lifted earlier this year to provide Americans access to healthcare via telehealth.
Coupled with state-led initiatives that allow physicians to practice across state lines, these dynamics have ignited virtual care initiatives around the country, catapulting telehealth into a new era of usage and acceptance.
"We've crammed at least 10 years of experience into [the last] three months," said U.S. Senator Lamar Alexander, R-Tenn., yesterday. While senators and four witnesses discussed many aspects of telehealth, Committee Chairman Alexander focused on permanently changing two key policies: originating site and expansion of telehealth to more providers.
"My recommendation, based on the testimony we've heard today, is of the 31 federal policy changes that we've had—which have helped cause this explosion of telehealth—that at least two be made permanent, which all the witnesses agreed with," he said at the conclusion of the hearing. "One was the originating site rule, and two was [expansion of] Medicaid-Medicare reimbursement."
According to CMS, the originating site refers to the location of the patient at the time service is rendered. The temporary policy change lifted restrictions, enabling care to be delivered anywhere, including a patient's home. Prior to this waiver, Medicare only paid for telehealth services when the person receiving the care was located in a designated rural area or at a clinic, hospital, or other approved medical facilities for the service. The second policy expands the types of providers who could be reimbursed for telehealth services to include any healthcare professional who is eligible to bill Medicare for their professional services.
Beyond support for those changes, the questions and testimony covered a broad range of topics. Among those generating the greatest interest were the digital divide, leading to lack of access for some populations, and parity reimbursement.
The Digital Divide
Senator Tina Smith, D-Minn., said, "The move to telehealth has also revealed some significant weaknesses in our system. While telehealth has been a lifeline to some, the lack of technology, digital literacy, and access to high speed internet is a digital divide that exacerbates health disparities for people of color, rural communities, and poor communities. She cited U.S. Census Bureau statistics indicating that 37% of Black American households and 31% of Hispanic American households have no broadband services or computer access in their homes, and 2018 Federal Communications Commission estimates that 35% of Americans living on tribal lands lack access to broadband services.
"So the disparities in access to technology reflect the underlying inequity that exists throughout our society in urban and in rural areas," Smith said. "So this moment presents us with a unique opportunity to learn from the last three months to assess how telehealth has worked and to make changes we need to make to close these disparities and to improve telehealth delivery."
Witnesses explained the benefit of being able to offer audio-only care through the telephone to reach these patients.
Joseph C. Kvedar, MD, president of the telemedicine association, ATA, said that "Reimbursement for telephone encounters was really helpful in helping cross the digital divide. We should continue that level of reimbursement if, for no other reason, than to address this underserved population problem." Kvedar is also vice president of Connected Health at Partners HealthCare, and professor of dermatology at Harvard Medical School.
Another witness, Sanjeev Arora, MD, MACP, FACG, the founder and director, Project ECHO/ECHO Institute and distinguished and regents’ professor, University of New Mexico Health Sciences Center, pointed out that "the bigger problem is these people never had access to specialty care, so in addition to really overcoming overcomin the geography divide, there is a massive capacity shortage in this country for providing specialty care." Telehealth can help address this issue as well, he said.
Also discussed during the hearing was whether providers should receive parity reimbursement for telehealth services, equal to what they would receive for an in-person visit. Based on comments from a couple of Republican senators, the quest for parity pay for telehealth services may meet with some resistance. Senator Bill Cassidy, M.D. (R-La.) who is a physician pointed out that overhead costs might be reduced for physicians providing telehealth services.
"There's been discussion [about] telemedicine being reimbursed the same as in-person visit," Cassidy said. "Frankly, I'm a physician. If I had one day of my life in which I was only doing telemedicine, I would have sent everybody home, gone into my closet, sat in front of my computer with my EHR [electronic medical record] on this screen and my Zoom on that screen and I would have just typed away answering phone calls, speaking through the internet, and really my overhead would have been markedly diminished in terms of personnel. On the other hand there is the fixed cost in terms of the initial investment."
He asked witness Andrea D. Willis, MD, MPH, FAAP, senior vice president and chief medical officer of BlueCross BlueShield of Tennessee, how their organization was addressing parity pay. The carrier may be the only payor in the commercial sector to have permanently extended reimbursement for telehealth.
"We did pay parity going into this," Willis said. "We didn't feel like we could have that kind of conversation in a crisis situation, and we're not in rush to abandon that. But we are going to be looking to the data to make sure that we see the efficiencies we think that we think we are going to see. What we don’t want to do is to inject additional healthcare costs into the system."
Senator Mike Braun, R-Ind., also commented about parity reimbursement. He urged a need for cost transparency and said "… since I think [telehealth lowers the] cost to deliver service—not to raise [reimbursement] to a parity—but to start the process of lowering costs. If that's not done across the industry, there's going to be a rude awakening for it with a much different paradigm down the road."
“We've crammed at least 10 years of experience into [the last] three months.”
U.S. Senator Lamar Alexander, R-Tenn.
Mandy Roth is the innovations editor at HealthLeaders.
Senators at Health Committee hearing expressed support for continuing certain telehealth policies.
Of the 31 temporary federal policy changes, there seems to be the greatest interest in permanently changing the originating site rule and expansion of reimbursement to a greater number of providers.
Concerns about broadband access inequities led to discussions about the benefits of audio-only service through phone calls.
The quest for parity pay for telehealth services may meet with some resistance.