Telehealth Reimbursement Analysis and Considerations in ...
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David A. Zablocki MPS Candidate, Biomedical and Health Informatics University of North Carolina, Chapel Hill 22 July 2020 Telehealth Reimbursement Analysis and Considerations in the Post-COVID-19 Era OVERVIEW Project Purpose & Methodology What is Telehealth Efficacy Utilization Before COVID-19 Barriers to Adoption Reimbursement Challenges Changes After COVID-19 Utilization After COVID-19 Challenges Stakeholder Considerations
Transcript of Telehealth Reimbursement Analysis and Considerations in ...
David A. ZablockiMPS Candidate, Biomedical and Health InformaticsUniversity of North Carolina, Chapel Hill 22 July 2020
Telehealth Reimbursement Analysis and Considerations in the Post-COVID-19 Era
OVERVIEWProject Purpose & Methodology
What is Telehealth Efficacy
Utilization Before COVID-19Barriers to Adoption
Reimbursement ChallengesChanges After COVID-19
Utilization After COVID-19Challenges
Stakeholder Considerations
Presenter
Presentation Notes
Project sponsored by Dr. Saif Khairat, inspired to research more after taking his informatics course and learning about his telehealth research. My background is in business and IT management; limited formal research experience – personal goal was to gain literature review experience and blend my business background with informatics. Presentation is based on project’s final deliverable which was a white paper – please contact me if you’d like that.
Literature review• PubMED, Scopus
Interviews with three health system administrators
• NC, VA, MN Supplemental research
• Reputable sources outside of databases
Purpose & Methodology
To develop a better understanding of reimbursement policy’s impact on telehealth, its future implications, and identify
gaps/research opportunities
Image Source: https://www.bioworld.com/articles/435879-senate-help-committee-considers-telehealth-after-pandemic
Presenter
Presentation Notes
Hypothesis: Significant expansion/utilization of telehealth resources driven by payer policy changes due to COVID-19
What is Telehealth?
“The remote delivery of health care to a patient through technology4”
Synchronous: Live communication (via phone or video)
Asynchronous: Exchange of information when not connected at the same time, also referred to as Store and Forward
Remote Patient Monitoring (RPM): Collection and transfer of information specifically for tracking and monitoring of patients without direct intervention required from provider
Presenter
Presentation Notes
The definition has evolved over time and does have various technical definitions as it relates to regulations, it varies significantly by state. Their variations in definitions have largely been driven by the need for clarifying reimbursement policies1
Efficacy
0
1000
2000
3000
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1990 1995 2000 2005 2010 2015 2020
PUBMED SEARCH QUERY: TELEHEALTH COUNT
Total from 2016-2020: 16,601
“There are so many patient experience studies indicating high satisfaction with telemedicine, that professionals in
the industry accept it as fact26”
- Improve access to care7
- Decrease costs8
- Satisfaction greater or equal to face-to-face visits26
The Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) also confirm consensus citing research prior to COVID-1930,32
Presenter
Presentation Notes
General consensus is telehealth has been clearly proven to improve access, costs, and satisfaction. Studies vary dramatically by specialty and telehealth technology type.
Utilization Before COVID-19
Despite growing body of evidence, utilization and adoption remained low
Graphic is from study in Minnesota that analyzed the use of telehealth users per 10,000 enrollees15, this trend was
similar across specialties and states41
As of 2013, only 50% of health systems reported having some form of telehealth4
Presenter
Presentation Notes
Despite the growing body of evidence, new technologies, and increased demand supporting telehealth, utilization was only marginally increasing prior to COVID-19. In 2013, only 50% of health systems reported having some form of telehealth4. As highlighted in Figure 1, demand has been consistently increasing though; that study analyzed the use of telehealth users per 10,000 enrollees in Minnesota15, this trend was similar across specialties and states41. As of 2018, “the global compounded annual growth rate of telemedicine (were) between 13 and 27%”26 and predictions estimated the market for telehealth would exceed $30 billion4 in 2020. Several barriers prevented increased utilization, but reimbursement practices and policies have proven to be a primary factor4. Interview of regional clinical administrator from MN: “Before COVID, we had dabbled in phone and video visits which represented less than 1% of visits overall. Within a few weeks of COVID, we rolled out a formal video/phone visit .... During the peak of COVID, video/phone visits represented 80% of overall visits.“
Barriers to Adoption
- Security13 (technical, HIPAA, and consent related) - Costs for adoption both in physical assets and training - Staff and patient cultural norms/satisfaction- Credentialing26
- Technical issues- Broadband access (health system and patient)- Available partners/providers- Regulations or policies35
- Reimbursement primary driver for lack of adoption33
Presenter
Presentation Notes
Many barriers have been researched and identified in relation to the adoption of telehealth. Those include security13 (technical, HIPAA, and consent related), costs for adoption both in physical assets and training, staff and patient cultural norms/satisfaction, credentialing26, technical issues, broadband access (health system and patient), available partners/providers, and regulations or policies35. Despite these barriers, the research conducted as part of this project clearly points to reimbursement as a primary driving factor for slow adoption prior to COVID-19. Several key developments were helpful, like parity requirements and additions to CMS’s physician fee schedules, but they were not enough to propel adoption33. Citations are applied to each line item and any bulleted items above it
Key Reimbursement Challenges
Telehealth synchronous care reimbursement rates are significantly lower in relation to face-to-face care with additional regulatory requirements41
Regulations vary by state with multiple federal organizations providing oversight and policy development1, 14, 16, 38
Cost-effectiveness and cost-structure research is limited in large part due to many newly developed technologies, unique applications based on healthcare specialty, and more complex cost structures with telehealth19, 26
A general framework for evaluating telehealth effectiveness does not appear to be widely adopted (to include recent proposal by NQF and DHHS)19, 26, 42
Presenter
Presentation Notes
CMS typically sets the baseline for reimbursement for all payers (private insurance companies) Key point: Basic telehealth reimbursement rates do not equal that of face-to-face and there is significant variation in terms of policy by state, types of technologies and their application by specialty, and lack of generally adopted frameworks to evaluate effectiveness, especially as it relates to cost. Summary developed as part of research project overall with citations referencing material that directly supports those claims
Policy Changes After COVID-19
- CMS temporarily approved telehealth for 80 new services36
- Both telephone and video to be reimbursed as if face-to-face*
- Relaxed HIPAA enforcement regarding telehealth technology services, “good faith” enforcement
- Telehealth in-home vs designated areas
- Providers can practice across state lines
- Care can be provided to new and established patients
- Increased flexibility to adjust cost-sharing for telehealth visits31
Presenter
Presentation Notes
CMS typically sets the baseline for reimbursement for all payers (private insurance companies) *not all telephone visits/codes are reimbursed the same – of the three admins I spoke with, all cited lack of reimbursement for telephone consults limiting factor Post COVID research and supplementary research points to reimbursement opportunity driving factor for new initiatives to increase utilization for telehealth
Utilization After COVID-19
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20000
30000
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50000
60000
70000
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Average Prior-to March
After March
Adoption and utilization of telehealth services
drastically increased with reimbursement cited as the
primary driver for adoption27,28,34
20% of all outpatient care ~$250 billion36
Presenter
Presentation Notes
The regional clinic manager in MN stated their utilization went to 80% of total visits, steadily at 50%, planning/targeting 30% The policy changes had a huge impact on adoption and utilization of telehealth services with increased reimbursement cited as the key driver for adoption27,28,34. Figure 3 reflects analysis done by the consulting group McKinsey & Company which highlights the massive expansion of telehealth visits and changing perceptions (infographic details directly from their report)36; they also estimate that approximately $250 billion - or 20% - of all outpatient care (via commercial or CMS) could be virtualized36. This correlates with the with the research found as part of this paper27,28,34,40,41. Figure 2 is data extrapolated from an analysis of NYC Health and Hospitals (NYC H+H) which highlights their radical shift in telehealth visits, the analysis also highlights their successes and challenges to make that happen27.
Ongoing Challenges
Policy changes are temporary and tied to national emergency status
Reimbursement challenges persist even with changes- Telephone reimbursement- Asynchronous (text messages, secure messaging
platforms)
Framework for evaluation of telehealth services especially asynchronous and RPM
Health systems are financially challenged with losses estimated at $50 billion per month37
Presenter
Presentation Notes
Despite the dramatic shift in policy and adoption, there are still major challenges with the sustainability of telehealth utilization. The first being that all the above-mentio ned policy and reimbursement changes are only temporary and are tied to the COVID-19 emergency status31. This has left many health systems calling for permanent enactment of the temporary measures or a formal review process of their effectiveness27,28,34. A recently published analysis goes as far to say that the utilization of telehealth services in the post-COVID-19 era has exposed the lack of evidence for certain face-to-face encounters27. Health systems have also been financially challenged by the COVID-19 emergency; recent estimates suggest the industry is losing $50 billion a month since March37. This problem will likely be exacerbated by the estimated 12.7 million people who lost employer provided health insurance39 only stressing the importance of continued telehealth reimbursement.
Stakeholder Considerations
Image Source: https://scottpublicrelations.com/capp-publishes-recommendations-for-telehealth/
Policy MakersState
Federal
Payers/Insurance Providers
Health Systems
HIT Companies &
Departments
Patients
Researchers
Presenter
Presentation Notes
These considerations were developed in question format as an exercise to demonstrate what future implications arose for various stakeholders as part of the research for the paper. Additionally, the goal was to provide you (the reader) with questions you could ask depending upon where and how you fit into the healthcare value stream. Policy Makers At the state level, how are we evaluating our current policies regarding telehealth and are we comparing them to the effectiveness of other states? Have we considered how telehealth utilization could increase health disparities and what could be done to alleviate them (for example broadband access)? At the federal level, will the temporary measures be permanently adopted – what is the criteria for the evaluation? The temporary measures may have addressed many concerns in relation to the adoption of synchronous telehealth, what new processes can be implemented long-term to evaluate asynchronous and RPM as their demand will likely continue to grow? How can we best coordinate the various legislative efforts to improve telehealth policies while also considering the power that non-legislative bodies have to impact policy/practice? Should we consider increasing telehealth reimbursement to foster additional research of its effectiveness (it could also provide financially struggling health systems additional funds to survive this crisis)? Payers/Insurance Providers How can we utilize value-based reimbursement models to test and foster telehealth? What initiatives do we currently have in place with health systems to address the growing demand of various telehealth services? What long term plans are in place to address the internal cost-effective evaluation of new telehealth tech, across all specialties? Health Systems Do we have the infrastructure (to include training) in place to support long term use of telehealth? Are we prepared to transition to a more secure, HIPAA compliant platform, when relaxed enforcement ends? What value streams and specialties will most likely be impacted by telehealth – how do we plan for it and maximize value? How can we partner with payers and policy makers to ensure proper reimbursement for the various forms of telehealth? How will the utilization of telehealth affect employee well-being, provider burn-out, and customer satisfaction? Healthcare Technology Companies (and Departments) How can we develop technologies to capitalize on the demand for current and future telehealth demand? Are we managing security appropriately and do we have a risk-assessment strategy to evaluate threats? Is the infrastructure in place to support easy adoption (broadband, mobile device availability, etc.)? Patients Do we have the resources to support telehealth? Are we comfortable with the privacy/consent processes and do we understand how our health system/provider manages them? What telehealth services and technologies would I derive the most value out of in my or my family’s life? Researchers What frameworks can be adopted to evaluate the dynamic field of telehealth effectively and efficiently? How can we develop and maintain relationships with stakeholders to build mutually beneficial research opportunities? Is there a specific specialty, location (state), and/or technology type that we are particularly interested in (which would help narrow research focus and new research synthesis process)?
Questions
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80d0-f7e1948d55f4_story.html34 Salamon, M. (2020, April 02). A Decade of Telemedicine Policy Has Advanced in Just 2 Weeks. Retrieved June 15, 2020, from https://www.medscape.com/viewarticle/92803835 Lin, C. C., Dievler, A., Robbins, C., Sripipatana, A., Quinn, M., & Nair, S. (2018). Telehealth in health centers: Key adoption factors, barriers, and opportunities. Health Affairs (Project Hope), 37(12), 1967-1974. doi:10.1377/hlthaff.2018.0512536 Bestsennyy, O., Gilbert, G., Harris, A., & Rost, J. (2020, May 29). Telehealth: A quarter-trillion-dollar post-COVID-19 reality? Retrieved June 7, 2020, from https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-
trillion-dollar-post-covid-19-reality37 Taylor, M. (2020, June 19). The coronavirus is devastating U.S. hospitals, which will lose $200 billion in revenue by the end of June. Retrieved June 25, 2020, from https://www.marketwatch.com/story/the-coronavirus-is-devastating-us-hospitals-which-will-lose-200-
billion-in-revenue-by-the-end-of-june-2020-06-1138 Augenstein, J., Marks, J., & Morgan, V. (2020, July 14). Executive Summary: Tracking Telehealth Changes State-by-State in Response to COVID-19 - July 2020. Retrieved July 14, 2020, from https://www.jdsupra.com/legalnews/executive-summary-tracking-
telehealth-74025/39 Page, L. (2020, July 14). Payment Problems as Patients Lose Coverage due to COVID. Retrieved July 14, 2020, from https://www.medscape.com/viewarticle/93388440 Interviews were conducted in June and July of 2020 with three health system administrators in MN, NC, and VA; all administrators oversaw operations with a mix of primary and specialty care at regionally influential health systems. For details of interviews, please
contact the author at [email protected] As part of the initial literature review process for this white paper each article was screened for references to the positive or negative impact of telehealth, if reimbursement was considered a primary limiting factor for expansion, if analysis was isolated by location or
specialty, and if it highlighted COVID-19 policy implications (among other screening criteria). For details of the synthesis process, please contact the author at [email protected] National Quality Forum. (2017, August). Creating a Framework to Support Measure Development for Telehealth . Retrieved July 1, 2020, from
https://www.qualityforum.org/Publications/2017/08/Creating_a_Framework_to_Support_Measure_Development_for_Telehealth.aspx
