Two studies: Telehealth underutilized, underbilled, even during pandemic–and accounted for only modest increases in costs, quality

April 24, 2024 | by

A newly published study in April’s Health Affairs Scholar points to telehealth’s surprisingly low reimbursable takeup among tradtional Medicare beneficiaries–even during the pandemic. This study evaluates E&M (evaluation and management) Current Procedural Terminology (CPT) billing against codes that were established during the pandemic to pay providers for telehealth (e-visits in the study), 99421-99423. It also broke down e-visits by different clinician types: primary care, medical specialties, surgical specialties, behavioral health, nurse practitioners, and physician assistants, and counted the most frequent diagnoses. E-visits constituted less than 0.1% of E&M services in the monitored period, 2020-22.

Key findings:

  • E-visit billing hit an absolute peak in April 2020 of 728 monthly encounters per 100,000 beneficiaries. It dropped off dramatically by summer 2020 and later stabilized to approximately 90 monthly encounters per 100,000 beneficiaries.
  • Only 0.8% of Medicare beneficiaries who received an E&M service were billed for at least one e-visit.
  • E-visits constituted 0.09%, 0.05%, and 0.05% of all E&M services in 2020, 2021, and 2022.
  • Primary care providers accounted for over 50% of the billing.
  • Approximately 30% were billed at the highest level of clinician time, requiring at least 21 minutes.
  • Hypertension was the most common diagnosis addressed in e-visits (21%), followed by diabetes (2.3%) and COVID-19 (2%).
  • Surprisingly, fewer beneficiaries receiving e-visits lived in rural areas.

HealthExec

Note to Readers: for those puzzled by the absence of mental health diagnoses, FAIR Health’s monthly telehealth tracker which during the pandemic showed Covid/respiratory diagnoses first, then mental health–and mental health as #1 in about 5% of claims since then –FAIR uses a different methodology. It tracks medical claims for private health plans only, not traditional Medicare, Medicare Advantage, or Medicaid. It also does a comparison on CPT 99213, comparing a specific procedure provided via telehealth to the same procedure provided in an office. 15 April methodology release

Editor’s Note, strictly anecdotal: As someone who worked as the sole marketer for a management services company with primary care ACOs during the period in early 2020 when HHS was turning out new codes nearly hourly to create telehealth flexibilities in Medicare, there was considerable confusion around codes and what they covered. Our teams, sourcing from HHS and the AMA, had our hands full to correctly specify and document the CPT codes established at that time. I know because I worked on said documentation that we condensed into a two-page fast guide and then into presentations. Many of the codes were telephonic. My conclusion about this study is that it was very narrow and tracked too few codes. Other factors: practices had difficulty using audio/video telehealth with their patient populations–if the practices had it, patients weren’t ready (tech barriers) or willing to use. Some of the practices reported that they didn’t bill for telehealth encounters during this confused time, trading off reimbursement for overall patient care and marking up quality metrics such as Annual Wellness Visits.

A second telehealth study, published this month in Health Affairs, looked at health systems to assess whether telehealth increased or decreased healthcare spending and usage by Medicare beneficiaries. The study defined by quartile health systems that had high telemedicine usage versus those with higher in-person usage, based on 2020 visits. Their conclusions tracked the changes between the 2019 baseline, 2020, and 2021-22. This study found only a modest increase after 2020 in visits and spend in the highest quartile of telemedicine usage for patient care.

  • In 2020, patients in the highest quartile of telemedicine use had 2.5 telemedicine visits per person (26.8 percent of visits) compared with 0.7 telemedicine visits per person (9.5 percent of visits) in the lowest quartile of telemedicine use.
  • Patients in the highest quartile had modest increases in office visits, care continuity, and medication adherence, as well as decreases in ED visits, relative to patients of health systems in the lowest quartile.
  • During 2021–22, relative to the lowest quartile, patients in the highest quartile had an increase of 0.21 total outpatient visits (telemedicine and in-person) per patient per year (2.2 percent relative increase)
  • That group also had a decrease of 14.4 annual non-COVID-19 emergency department visits per 1,000 patients per year (2.7 percent relative decrease)
  • Per patient per year spending increased by $248 (1.6 percent relative increase)
  • They also had increased adherence for metformin and statins.
  • There were no clear differential changes in hospitalizations or receipt of preventive care.

The researchers contend their findings confirm that the flexibilities around telehealth instituted during the pandemic for Medicare beneficiaries should continue past their scheduled expiration at the end of 2024. The moderate spending increase is also confirmed by another study through 2021 by the Medicare Payment Advisory Commission found that geographic areas with higher telemedicine uptake had a spending increase of $165 per patient and a 3 percent relative increase in total clinical encounters. Healthcare Dive

CMS clarifies telehealth policy expansion for Medicare in COVID-19 health emergency, including non-HIPAA compliant platforms (US)

March 18, 2020 | by

Today (17 March), the Center for Medicare and Medicaid Services (CMS) issued a Fact Sheet and FAQs explaining how the expanded telehealth provisions under the Coronavirus Preparedness and Response Supplemental Appropriations Act and the temporary 1135 waiver will work. The main change is to (again) temporarily expand real-time audio/video telehealth consults in all areas of the country and in all settings. The intent is to maintain routine care of beneficiaries (patients), curb community spread of the virus through travel and in offices, limit spread to healthcare providers, and to keep vulnerable beneficiaries, or those with mild symptoms, at home. Usage is not limited to those who suspect or already are ill with COVID-19.

Previously, only practices in designated rural health areas were eligible for telehealth services, in addition to designated medical facilities (physician office, skilled nursing facility, hospital) where a patient would be furnished with a virtual visit. 

The key features of the 1135 telehealth waiver are (starting 6 March):

  • Interactive, real-time audio/video consults between the provider’s location (termed a ‘distant site’) anywhere in the US and the beneficiary (patient) at home will now be reimbursed. The patient will not be required to go to a designated medical facility.
  • Providers include physicians and certain non-physician practitioners such as nurse practitioners, physician assistants and certified nurse-midwives. Other providers such as licensed clinical social workers (LCSW) and nutritionists may furnish services within their scope of practice and consistent with Medicare benefit rules.
  • Surprisingly, there is ‘enforcement discretion’ on the requirement existing in the waiver that there be a prior relationship with the provider. CMS will not audit for claims during the emergency. (FAQ #7)
  • Even more surprisingly, the requirement that the audio/visual platform be HIPAA-compliant, as enforced by the HHS Office of Civil Rights (OCR), is also being waived for the duration (enforcement discretion again), which enables providers to use Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype–but not public-facing platforms such as Facebook Live, Twitch, or TikTok. Telephones may be used as explicitly stated in the waiver in Section 1135(b) of the Social Security Act. (FAQ #8) More information on HHS’ emergency preparedness page and OCR’s Notification of Enforcement Discretion.
  • On reimbursement, “Medicare coinsurance and deductible would generally apply to these services. However, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.”

Concerns for primary care practices of course are readiness for real-time audio/video consults, largely addressed by permitting telephones to be used, as well as Skype and FaceTime, and what services (routine care and COVID-19 diagnosis) will be offered to patients.

This significant expansion will remain in place until the end of the emergency (PHE) as determined by the Secretary of HHS.

In 2019, CMS also expanded telehealth in certain areas, such as Virtual Check-Ins, which are short (5-10 minute) patient-initiated communications with a healthcare practitioner which can be by phone or video/image exchange by the patient. This could be ideal for wound care where this Editor has observed, in one of her former companies, how old phones are utilized to send wound images to practices for an accurate ongoing evaluation via special software. E-Visits use online patient portals for asynchronous, non-face-to-face communications, initiated by the patient. These both require an established physician-patient relationship. Further details on both of these are in the Fact Sheet, the FAQs, and the HHS Emergency Preparedness page with links.

The American Medical Association issued a statement today approving of the policy changes, and encouraged private payers to also cover telehealth. The American Telemedicine Association didn’t expand upon its 5 March statement praising the passage of the Act but advocated for increased cross-state permission for telehealth consults.

Additional information at HISTalk today and Becker’s Hospital Review.