Responding to my last blog, an astute reader asked (I paraphrase): “Where do you think telehealth comes into play with bundled payments, alternate payment models, and chronic disease management? And most importantly, who should foot the bill for the infrastructure? The payer or the providers or some creative collaboration between the two?” It’s an important question, so I’ll restate the answer in a blog of its own.
By Boris Rachev, Global Health Economist, CSC
Specifically, for the US healthcare landscape, bundled payments, alternative payment models (APMs), chronic care management (CCM) and all value-based programs outlined by MACRA, are a chance for telemedicine to shine. There are still a lot of things that need to be ironed out for that to happen though, but we are getting there. The new Centers for Medicare & Medicaid Services (CMS) rules and programs open the door to showing how these tools can help achieve the important goals of patient engagement, care coordination, expanded access to care and population health management driven by primary care providers (PCPs).
For now, there are at least three entry points for telehealth solutions into healthcare delivery:
Entry point 1: Comprehensive Primary Care (CPC+). This APM is aimed at supporting primary care practitioners in delivering “advanced” primary care. It is a multi-payer initiative that will impact 3 to 3.5 million Medicare beneficiaries, as well as millions of other Medicare Advantage, Medicaid and commercial patients.
PCPs are paid a per beneficiary, per month (PBPM) care management fee to help ensure services are “accessible, responsive to an individual’s preference, and patients can take advantage of enhanced in-person hours and 24/7 telephone or electronic access.” According to the CMS rule, “Practices must also ensure that care is ‘coordinated across the health care system,’ patients receive ‘timely’ follow-up after emergency room or hospital visits and that care is ‘patient-centered’.” Telemedicine achieves all of these goals.
Entry point 2: Medicaid and Children Health Insurance Program (CHIP). This rule allows telemedicine to be used to meet network adequacy requirements in Medicaid. Before this rule, Medicaid managed care network adequacy regulation relied heavily on attestations and certifications from states. Now, states will have to develop time and distance standards and hold managed care plans accountable. Given how difficult it can be to find medical practitioners willing to accept Medicaid, telemedicine will be important to ensuring compliance with network adequacy.
Entry point 3: MACRA and proposed rule. Telehealth figures prominently in assisting practitioners fulfill clinical practice improvement activities. It is mentioned explicitly as a way to expand practice access and manage patients. The tools can also apply in meeting practice improvement activities in the population management, patient engagement and care coordination categories. Telehealth services are categorized as “patient facing” in the legislation.
In the commercial market, telehealth is used mostly for convenience and after-hours care that can substitute for more expensive and time-consuming in-person options. In other words, the commercial sector is still waiting for the government to lead the way and gauge the risks. To date, remote patient management (RPM) has largely been used to avoid hospital readmissions and improve chronic disease management. Billing for telehealth and RPM services in Medicare and Medicaid remains difficult – there at least four bills discussed in Congress to date, however we are still waiting for legislation to update the statute governing the use of telehealth in government programs.
Regarding footing the bill, the reader is absolutely right. Going forward, a much more robust, integrated architecture and networking infrastructure will be needed so personally identifiable information (PII) can be captured and shared securely and in real time. In my opinion, the government should subsidize physicians who accept Medicare and Medicaid to build such infrastructure as an incentive. The same arrangement only seems fair for the commercial sector, where payers and providers can collaborate and negotiate their roles in investing in and building the required infrastructure – other players benefit directly (and indirectly) from telehealth as well. Digital solutions, in general, can help payers to credential providers, design networks, and improve reporting to providers, employers and brokers. I’ll be covering more of this in my next blog.