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Medicare Advantage Telehealth Rule Could Be Big for Health Systems


David Harlow says the move could benefit providers, patients and more.

Photo has been altered. Licensed from Halfpoint - stock.adobe.com.

Up until now, Medicare Advantage plans have been able to offer telemedicine services beyond those covered by traditional Medicare only as supplemental benefits. But a recently finalized federal regulation lays out the roadmap for a significant telemedicine expansion for Medicare Advantage plans.

Enabled by the Bipartisan Budget Act of 2018, the latest expansion eliminates for Medicare Advantage plans the general Medicare requirement that the patient be in a healthcare facility to receive telemedicine services. (With minor exceptions, this has meant that telemedicine has been covered by Medicare only where the patient is in a healthcare facility — usually a rural healthcare facility — and a physician — usually a specialist at a larger facility — consults via live video link.)

In addition, Medicare Advantage plans are being given broad discretion in implementing this expansion.

The effect that this change is likely to have on the prevalence of real-time video-linked telemedicine (so-called “synchronous telemedicine visits”), as well as on broader telehealth services, should not be underestimated.

Medicare Advantage plan members represent a growing percentage of Medicare beneficiaries. The most recent figures show that, of the 64 million Medicare beneficiaries today, 22 million are Medicare Advantage members. This represents the culmination of a steady increase both on a percentage basis and on an absolute basis over the past 20 years. Within the Medicare population, telemedicine has slowly but surely gained traction over the years, with rural telehealth visits increasing over 25% per year in the decade ending in 2013. As the ranks of Medicare Advantage members come to include more and more folks comfortable with transacting everything in their lives via their smartphones, tablets and laptops, the opportunity for the healthcare delivery system to provide more interaction via telemedicine continues to grow.

David Harlow, J.D., MPH

David Harlow, J.D., MPH

As the federales say, “We believe MA (Medicare Advantage) additional telehealth benefits will increase access to patient-centered care by giving enrollees more control to determine when, where and how they access benefits.” The feds also estimate that moving telehealth from supplemental to basic benefits will save beneficiaries $80 million over 10 years, and that the expansion will save beneficiaries more than $500 million over 10 years by reducing travel time to providers. Officials say that covering the services as part of the basic benefits will increase utilization. In the zero-sum game of federal budgets, this means that there is a baseline assumption that increased telehealth utilization will generate savings in other line items; otherwise, other line items will have to be cut to accommodate the new kid on the block.

It is also important to note that the rule has a broad definition of telehealth services provided via electronic exchange: “Secure messaging, store and forward technologies, telephone, videoconferencing, other internet-enabled technologies and other evolving technologies as appropriate for non-face-to-face communication.” The federales deliberately do not define the technology in a limiting way, and do not even define the type or scope of care that is clinically appropriate to be delivered in this manner, leaving it up to the Medicare Advantage plans to work out both the scope and the appropriateness issues.

So, what can a forward-thinking health system do to take advantage of the opportunity that this new Medicare Advantage regulation represents? It is an opportunity for the provider organization, for the MA plan and, of course, for the beneficiaries as well (and not just in terms of saved coinsurance dollars and travel time).

There will be time to grow telehealth offerings over time, but behavioral health services might be one of the areas in which a healthcare provider organization could begin to offer services under the expanded telehealth benefit. Provider organizations would do well to continue to grow their capacity to deliver behavioral health services via telehealth platforms. This mode of service delivery addresses the reluctance of some patients to be seen entering a mental or behavioral health professional’s office, and it also addresses the severe shortage of mental health professionals and maldistribution of resources — making behavioral health services available to patients with opioid abuse conditions who live in rural areas, for example.

It is worth noting that venture-backed digital health and digital therapeutics companies have already recognized the potential value of this market; companies including Omada and Livongo, which began by addressing pre-diabetes and diabetes, respectively, have recently expanded into behavioral health services. More traditional healthcare provider organizations would do well to observe this trend and consider how they may emulate companies that sometimes seem nimbler. In addition, easier access to mental health services will likely reduce the burden on primary care providers, who end up shouldering much of the caseload that should be directed to behavioral health team members.

The Medicare Advantage coverage expansion for telehealth services should be leveraged to streamline administrative and data collection functions and to improve care coordination, care management and direct patient care. This opportunity is magnified because it comes together with the expansion in coverage over time on the commercial side, and other recent incremental changes to Medicare rules on telehealth (for example, see the 2019 Medicare Physician Fee Schedule, section Modernizing Medicare Physician Payment by Recognizing Communication Technology-Based Services, adding coverage for virtual check-ins, review of store-and-forward still or video images sent by patients, remote monitoring and consults).

In order to reap the benefits, provider organizations will need to continue to invest in the deployment of telehealth tools, and patients and clinicians must be educated about the range of tools available and the benefits that they will enjoy as a result of their use. (While it should go without saying, deployment of telehealth tools must also be grounded in foundational data privacy and security policies and procedures, infrastructure and staff and patient education.)

More broadly, as we continue the drive from volume to value across all payers, cost-effective deployment of telehealth tools in support of patient care will help move closer to achieving the Quadruple Aim, benefiting all participants in the healthcare delivery marketplace.

David Harlow, J.D., MPH, is a healthcare attorney with deep experience in business, strategy, policy, compliance and proactive counseling in the healthcare industry, working with provider organizations and technology companies of all shapes and sizes. He is recognized as a thought leader in digital health, data privacy and the broader healthcare sphere. David has a deep passion for innovation, a preference for simplicity where feasible and a practical approach to crafting actionable solutions. Read David’s award-winning blog, HealthBlawg, and listen to his healthcare innovation podcast, Harlow On Healthcare. You should follow him on Twitter: @healthblawg.

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