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By Monica E. Oss

The number of consumers using telehealth is on the increase, but remains relatively small. Only 18% of consumers report that they have used telehealth services, according to an Aviza survey, White Paper: 2017 Closing The Telehealth Gap. For the other 82%, it was a matter of lack of clarity about insurance coverage and culture that primarily prevented their adoption—46% of consumers said they would find a video visit less comfortable than an in-person office visit (this was 26% for mental health visits). Another recent study, Patient Preferences For Direct-To-Consumer Telemedicine Services: A Nationwide Survey, found that a lack of familiarity is also an issue—52% of consumers are more willing to see their own clinical professionals via telehealth. And, two-thirds of consumers (60%) felt it was important for a professional practicing via telehealth to have access to their health records.

Fortunately, the reimbursement landscape for telehealth services is improving. Twenty-three states (and Washington D.C.) have full parity, meaning coverage and reimbursement is comparable from in-person to telehealth services. But only three actually have an explicit mandate for payment parity (see Telehealth Parity Laws). Forty-eight states (and Washington D.C.) provide reimbursement for some form of live video in Medicaid fee-for-service (FFS), up one state from March 2016 (Massachusetts and Rhode Island are the exceptions). Fifteen state Medicaid programs reimburse for store and forward, up three states from March 2016. And, 21 state Medicaid programs provide reimbursement for remote patient monitoring, up three states from March 2016 (see State Telehealth Laws and Medicaid Program Policies A Comprehensive Scan of the 50 States and District of Columbia).

We are seeing more movement among health plans, include Optum paying for telemental health the same as in-person visits (see For Health Plans, Technology = Improved Consumer Access) and Cigna’s expansion of its suite of telehealth behavioral and physical health services for Cigna members in 2017 (see Cigna Expands Telehealth Behavioral Health Services). And for good reason – a recent analysis of the Humana At Home care management service for its Medicare Advantage members (which is includes telephonic support) found that participants had 45% fewer hospitalizations than non-participants (see Humana At Home Service Reduces Hospital Admissions by 45%).

And there is movement among public payers. The Centers for Medicare & Medicaid Services (CMS) issued updated rules for Medicaid home health, which clarified that home health services are not limited to home settings, allowing Medicaid programs to reimburse for a physician encounter to authorize services that takes place via telehealth technologies (see CMS To Use Targeted Enforcement To Ensure Compliance With Final Rules For Medicaid Home Health Face-To-Face Visits). The Bipartisan Budget Act of 2018, signed into law on February 9, 2018, included the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017, which includes key provisions allowing Medicare to cover telemedicine services for home dialysis and stroke for all beneficiaries, as well as allowing Medicare Advantage (MA) plans to include delivery of telehealth services in a plan’s basic benefits, and providing Accountable Care Organizations (ACOs) a chance to expand the use of telehealth services (see Bipartisan Budget Act Included The CHRONIC Care Act, Expanding Medicare Telemedicine, Home Care, & Value-Based Care and Top 5 Ways Telehealth Will Change Under the New Federal Funding Bill).

Over the past several years, the U.S. Department of Veterans Affairs (VA) has also made movements in promoting telehealth. Last year, the VA released proposed rules authorizing VA-employed health care professionals to serve VA beneficiaries in any state via telehealth, with one unrestricted license from any state. This rule protects VA professionals from state licensing restrictions that require health care professionals to be licensed in the state of the consumer (see VA Proposes Removing State License Restrictions On Telehealth In Its ‘Anywhere To Anywhere’ Program). Congress has also passed legislation, the Veterans E-Health and Telemedicine Support Act of 2017, which includes similar requirements (see Senate Passes VETS Act, Enhancing Telehealth Access for Veterans and House Passes Bill Expanding VA Telehealth Across State Lines). In line with this rule from the VA, the Department of Defense (DoD) also released updates to TRICARE coverage, requiring telehealth to be covered in the same way it covers in-person visits (see Major Changes Coming To DoD’s TRICARE System Jan. 1). And on March 6, 2018, the VA announced it launched a pilot telehealth program to provide rural veterans with post-traumatic stress disorder (PTSD) remote access to psychotherapy and related services (see VA Launches Pilot Telemedicine Program For Rural Veterans With PTSD).

But with more reimbursement and rising consumer adoption, provider organization investment in telehealth remains relatively small. About 44% of provider organizations over $25 million in revenue are using telehealth technologies, and about 33% of organizations under $25 million are using telehealth technologies (see The Tech-Enabled Provider Organization: The 2017 OPEN MINDS Health & Human Services Technology Survey). A survey by Sage Growth Partners (SGP) (with 36% respondents representing integrated delivery networks, 36% in specialty hospitals, 24% in academic medical centers, and 4% win community hospitals) found that 66% of organizations have telemedicine budgets that are $250,000 or less; 25% have budgets of $250,000 to $1 million; and 9% have budgets of more than $1 million (see Defining Telemedicine’s Role: The View From The C-Suite). Of organizations deploying telehealth, the most popular settings are emergency rooms (29%), remote patient home monitoring (21%), and non-emergency hospital services (20%), and post-acute specialty care (4%).

So why the limited investment by provider organization? From my perspective, when working with management teams of specialty provider organizations that are considering telehealth as part of a future sustainability strategy, there are a few big hurdles. First, the ability to understand and operationalize the many reimbursement rules, which translates into the “ROI” of telehealth. Second, incorporating telehealth into current clinical operations is an issue, with scheduling and EHR access being top of the list. Third is the need to change clinical culture and practice, and understanding the “new rules” of telehealth best practice. And, telehealth increases the “on demand” nature of clinical service, a negative for some clinical team members. Lastly there is a lack of understanding of how much telehealth is going to change consumer demand, and play a role in success of value-based reimbursement.

For more on the strategy and management of telehealth, be sure to check out these resources from the OPEN MINDS Industry Library:

  1. The Telehealth Market – Now, Soon & Future
  2. The Telehealth Market – The Future Has Arrived
  3. Primary Care Goes Virtual & On-Demand
  4. The Latest Telehealth Example: Pay-For-Value
  5. The Uphill Climb To Virtual Care
  6. Telehealth Legislation Everywhere
  7. Telehealth Licensure & Legislation Updates
  8. Telehealth Legislation – Filling In The Crazy Quilt
  9. The Uneven Adoption Of Telehealth – The Idaho Example
  10. Tracking The Shifting Map Of Medicaid & Medicare Reimbursement For Telehealth

For more on how telehealth can complement integrated care initiatives, join me on October 23 at The 2018 OPEN MINDS Technology & Informatics Institute for the plenary address, “Advancements In Telemedicine & The Future Of Service Delivery: Innovation Health’s Plan For Technology Integration,” by Sunil Budhrani, M.D., MPH, MBA, Chief Medical Officer, Chief Medical Informatics Officer, Innovation Health.

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