Telehealth extensions signed into US law with Federal FY 2023 omnibus bill

January 4, 2023 | by

Jammed into the final moments of the now-ended 117th Congress before Christmas was the passage of the FY2023 ‘omnibus’ $1.7 trillion Federal budget bill. This bill did at least several good things for those of us concerned with US telehealth, as it extended provisions for Medicare reimbursement that become guidelines for commercial health plans and help to cement telehealth as a permanent part of health care delivery. There is also a tax provision that affects high-deductible health plans. 

Their passage is important as the Covid-19 Public Health Emergency (PHE) is set to expire on 11 January and no movement has been publicly discerned for its renewal. In the fall, the Department of Health and Human Services (HHS) notified US state governors that there would be at least a 60-day notice before the PHE ends. It is unknown whether this notice has been given.

To summarize the two-year extensions that go to the end of 2024:

  • Expanding originating and geographic site to include anywhere the patient is located, including the patient’s home
  • Expanding eligible practitioners qualified to furnish telehealth services, including occupational therapists, physical therapists, speech-language pathologists, and audiologists
  • Extending the ability for federally qualified health centers (FQHCs) and rural health clinics (RHCs) to furnish telehealth services
  • Delaying the in-person requirement for mental health services furnished through telehealth, including the in-person requirements for FQHCs and RHCs
  • Extending coverage and payment for audio-only telehealth services
  • Extending the Acute Hospital Care at Home (AHCAH) initiative, pioneered by Johns Hopkins two decades ago. It also requires the HHS Secretary to publish a report comparing AHCAH programs with traditional inpatient care delivery. 
  • Extending the ability to use telehealth services to meet the face-to-face recertification requirement for hospice care
  • Extending high deductible health plan (HDHP) safe harbor exceptions for telehealth services in high-deductible health plans.

The final bill did not extend the Ryan Haight in-person waiver for the remote prescription of controlled substances. As mentioned in our earlier article, this is a wise move in this Editor’s view given the abuse of this waiver by certain telehealth organizations. ATA/ATA ACTION release.

The HHS Secretary will be required to submit a report to Congress on the utilization of the above services. The interim report is due in October 2024 and the final report in April 2026, according to the American Hospital Association. Affecting hospitals and practices in the bill:

  • It delayed the statutory Pay-As-You-Go (PAYGO) Medicare 4% sequester for two years, preventing the $38 billion in Medicare cuts that otherwise would have taken effect in January.
  • Partial relief from a 4.5% reduction in physician reimbursement rates starting on 1 January. The legislation reduced the cut to 2% for 2023 and around 3% for 2024.

HealthcareFinance

Other features of this bill having an effect on healthcare and telehealth (from Infrastructure Report Card):

  • $455 million for the expansion of broadband service, including $348 million for the ReConnect program, a series of grants administered by the US Department of Agriculture for the construction, improvement, or acquisition of facilities and equipment needed to provide broadband service in eligible rural areas. This could help rural areas and hospitals in provider-patient and provider-to-provider consults.
  • $1.65 billion for the National Institute of Standards and Technology (NIST), an increase of $424 million, or 34%, above the FY 2022 enacted level. Specific funding is allocated for the measurement labs and research at $953 million, a $103 million or 12% increase above the FY 2022 enacted level. The goal is to spur research advances in cutting-edge fields like carbon dioxide removal, artificial intelligence, quantum information science, and cybersecurity.

The bill was signed into law by the president on vacation in St. Croix, USVI. Given the bumpy start of the 118th Congress today, these are at least not up for grabs.

CMS telehealth pandemic waivers boosted usage among disadvantaged, urban patients

May 11, 2022 | by

Broadening telehealth usage areas when in-person visits are restricted boosts–telehealth usage. Beyond the tautology, the surprising finding here is that it benefited two groups that telehealth hasn’t done well with prior to the pandemic: those living in the most disadvantaged neighborhoods and in metropolitan areas. It also increased usage among women and those of Asian and Hispanic heritage.

The Johns Hopkins study, published in Health Affairs (abstract only, restricted access), reviewed 30 million Medicare fee-for-service claims to quantify outpatient telemedicine use before and after the Medicare telemedicine coverage waiver that took effect on 6 March 2020. Prior to the waiver, Medicare beneficiaries were covered very narrowly for telehealth, in designated rural areas and specific designated facilities, using synchronous audio/video only–a total of 0.42% with one outpatient visit. After the waiver, this grew to 9.97% of patients with at least one outpatient telemedicine visit. Medicare had previously reported that Medicare beneficiary telehealth usage had grown to over 40% during the pandemic.

According to the study abstract, “After adjustment [for demographic variables], our data suggest that the coverage waiver increased access to telemedicine for all Medicare populations, including people residing in the most disadvantaged neighborhoods, although the odds of use were persistently lower with increasing age.” Other studies had found disparities based on demographics such as race, income, and residential location, with higher status pointing to greater telehealth usage, but this study indicates that the loosening of restrictions did not contribute further to these disparities. Thus the logic points to more availability (access) powering increased usage, or at least the odds of use, in this disadvantaged/minority population. 

It is certainly an argument for retaining most of the telehealth waivers–which will require Federal legislation for Medicare after the 90-day Public Health Emergency renewal expires in mid-July, if not renewed. Healthcare Finance, FierceHealthcare

Congress may extend emergency telehealth flexibilities for Medicare, high-deductible plans for five months in spending bill

March 10, 2022 | by

The quaintly titled 2,741 page $1.5 trillion omnibus bill to fund the US government for the remainder of fiscal 2022, rolled out in the wee hours of Wednesday, includes an extension of telehealth flexibilities established under the COVID-19 public health emergency (PHE). The flexibilities extend full geographic coverage (versus rural only), location (home and medical facilities), and full payment for beneficiaries and providers, including some audio-only visits. This will apply, however, only to Medicare beneficiaries and providers, members of high deductible health plans (HDHP), and patients of rural health clinics (RHCs), and Federally Qualified Health Clinics (FQHCs). This is a five-month stopgap into 14 September. (The Federal fiscal year 2023 starts 1 October.)

The telehealth rule extension includes:

  • Practitioners such as physical therapists, occupational therapists, special therapists, and audiologists 
  • Originating sites can be anywhere in the US including the home and medical facilities
  • 1,400 Federally Qualified Health Centers (FQHCs) and 4,300 Rural Health Clinics (RHCs) can continue providing telehealth services including mental health visits
  • Waiving in-person initial visit requirement for mental health as well as postponing the in-person visit six months after receiving a telehealth visit
  • Audio-only allowed for Medicare
  • HDHPs have a continued ‘safe harbor’ to offer members telehealth services pre-deductible for the remainder of the 2022 plan year 

The vote is scheduled for the House today (9 March–still not finalized as of this writing), and to the Senate 11 March, with a concurrent short-term funding extension to give the Senate the usual time through 15 March. As of this time of writing, the floor wrangling continues with COVID-19 funding dropped and $13.6 billion in emergency non-defense aid to Ukraine added. The inclusion was cheered by ATA and ATA Action in their release; also Becker’s Hospital Review and Roll Call.  Update: the House passed the domestic portion of the bill 260-171 late Wednesday 9 March evening, and it moves on to the Senate.

CMS expands telehealth, RPM in 2021 Physician Fee Schedule, creates post-pandemic temporary category (updated)

December 3, 2020 | by

On 1 December, the Center for Medicare & Medicaid Services (CMS) announced its all-important 2021 Physician Fee Schedule (PFS), which sets out the fees and rules for physicians providing services to Medicare fee-for-service beneficiaries and generally serves as a guideline to commercial payers. If one only reads the release headline, one would assume that the national telehealth payment expansion that was approved when the public health emergency (PHE) was declared in March would be largely retained permanently in the 2021 PFS after the earnestly desired end of the PHE, extended to 20 January 2021,

Interpreting CMS-speak is always a task, and so it is here. Your Editor will do her best to unpack it. 

Paragraph 5 is the sobering note for the telehealth ‘bulls’. Telehealth expansion, on a permanent basis, applies to Rural Health, Federally Qualified Health Centers (FQHC), and certain Medicare program models (e.g. two-sided Medicare Shared Savings Program ACOs, ESRD, Episode Payment models, and Medicare Advantage), and with a limited number of new codes. From the release:

“This final rule delivers on the President’s recent Executive Order on Improving Rural Health and Telehealth Access by adding more than 60 services to the Medicare telehealth list that will continue to be covered beyond the end of the PHE….These additions allow beneficiaries in rural areas who are in a medical facility (like a nursing home) to continue to have access to telehealth services such as certain types of emergency department visits, therapy services, and critical care services.”

The release then goes on to explain the kicker: “Medicare does not have the statutory authority to pay for telehealth to beneficiaries outside of rural areas or, with certain exceptions, allow beneficiaries to receive telehealth in their home.” (Editor’s emphases) 

What seems like a pullback in the PFS is a reversion to status quo ante in geographic and model restrictions, which can’t be changed except by Congress. What CMS can do is expand, and create, new Categories for covered codes.

  • CMS expanded Category 1 which is the basic list of telehealth covered codes (CPTs and HCPCS). If you are in a rural area or a covered model, the expansion is real but limited: the number of new codes in Category 1 is nine codes of the 60 stated in the release. 60 is also far less than the 144 service codes added since the start of the PHE.
  • The remaining telehealth codes of the 60 quoted are in a new, temporary Category 3, which will extend through the calendar year the PHE ends–which is, as of today, 31 December 2021. (If the PHE goes into 2022, unless the rule is changed, 31 December 2022.)
    • Category 3 includes over 50 telehealth service codes for the PHE that are not in Category 1–thus the count of 60 the CMS press release trumpeted. 
    • What is not spelled out in CMS’ press release or public Fact Sheet is if statutory geographic (rural) and model restrictions will apply to this category after the PHE ends. Given the above, this Editor’s interpretation is that statutory restrictions will apply unless there’s a Federal change.
  • The Fact Sheet also clarifies certain frequency limitations, who can deliver telehealth services in a practice, telephone-only interactions with a new HCPCS code, and direct practitioner supervision.  Fact Sheet–Final Policy, Payment, and Quality Provisions Changes

For remote patient monitoring (remote physiologic monitoring) services which were modified during the PHE, there are important clarifications and two finalizations of modifications to RPM services made during the PHE, also in the Fact Sheet. 

The exception to the above is apparently the Medicare Diabetes Prevention Program (MDPP). Virtual delivery of certain services, such as educational classes which shifted from in-person to virtual and weight measurement, will not continue past the end of the PHE. CMS MDPP release. Also mHealth Intelligence.

What this all really means. CMS has Kicked The Telehealth Can Down The Road for 2021. They have retained many of the changes that the pandemic forced, but the geographic and model restrictions remain. But practices have made serious procedural modifications to incorporate remote and telephonic visits. Many patients in the Medicare age group are still self-isolating to a significant degree, and depending on the path of COVID-19 (and the flu) have good reason to limit in-office visits. This year’s use of telehealth in this group, according to CMS, was astounding: between mid-March and mid-October 2020, over 24.5 million out of 63 million beneficiaries received at least one of those 144 Medicare telemedicine services. What remains unclear is if Category 3, after the PHS, could continue to apply nationally through Congressional action, as there are several bills before this soon-to-close Congress.

Certainly this, plus post-COVID usage, will influence the 2022 PFS and perhaps stimulate Congress to allow CMS to permit payment for telehealth services nationally.

Editor’s note: References in addition to above are Center for Connected Health Policy’s Telehealth and Medicare page, the proposed CY 21 PFS Fact Sheet (PDF), and COVID-19 Telehealth Coverage Policies. Hat tip to former colleague Madeline Short, COO of Wilems Resource Group.

Update 3 December: The American Telemedicine Association published its comments on 2 December, agreeing with CMS Administrator Seema Verma’s comments on making telehealth permanent outside of geography, itemizing the present bills languishing in Congress, and also lamenting the short shrift that the final rule gave to remote patient monitoring. Also, Healthcare IT News includes additional comments from ATA chief Ann Mond Johnson. Some states like Texas and Wisconsin are pushing for updated parity rules applying to state-regulated plans, which would include commercial plans and Medicaid. Hat tip to reader Paul Costello for the heads-up.

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.

$8bn COVID-19 supplemental funding House bill waives telehealth restrictions for Medicare beneficiaries (US)

March 6, 2020 | by

The House of Representatives, which controls appropriations, has passed H.R. 6074, the Coronavirus Preparedness and Response Supplemental Appropriations Act. The bill provides $8.3 billion in new funding that includes a significant telehealth waiver for Medicare. From the bill summary on Congress.gov:

Within the Department of Health and Human Services (HHS), the bill provides FY2020 supplemental appropriations for

the Food and Drug Administration,
the Centers for Diseases Control and Prevention,
the National Institutes of Health, and
the Public Health and Social Services Emergency Fund.

In addition, the bill provides supplemental appropriations for

the Small Business Administration,
the Department of State, and
the U.S. Agency for International Development

The supplemental appropriations are designated as emergency spending, which is exempt from discretionary spending limits.

The programs funded by the bill address issues such as

developing, manufacturing, and procuring vaccines and other medical supplies;
grants for state, local, and tribal public health agencies and organizations;
loans for affected small businesses;
evacuations and emergency preparedness activities at U.S. embassies and other State Department facilities; and
humanitarian assistance and support for health systems in the affected countries.

The bill also allows HHS to temporarily waive certain Medicare restrictions and requirements regarding telehealth services during the coronavirus public health emergency.

Sponsored by retiring Rep. Nita Lowey (D-NY), it was introduced and passed in the House 415-2.

In the text of the bill, the telehealth-pertinent portion permitting CMS to waive restrictions on telehealth for Medicare beneficiaries during this emergency is Division B, Sections 101-102. This cost is estimated at $500 million by The Hill.

The bill went to the Senate yesterday (4 Mar) for final approval. There is already an amendment proposed by Senator Rand Paul (R-KY) to offset the $8 bn of the bill with unobligated, non-health related foreign aid funds (FreedomWorks). Whether this is the ‘offset’ for telehealth that is mentioned in The Hill as under negotiation is not revealed.

The American Telemedicine Association (ATA) approved of the waiver. Ann Mond Johnson, the ATA’s CEO, urged “CMS to implement its waiver authority as soon as possible to ensure health care providers understand any requirements and help speed the deployment of virtual services” and pledged “The ATA and its members will continue to work with federal and state authorities, including HHS and the CDC, to address the COVID-19 outbreak and ensure resources are appropriately deployed for those individuals in need of care and help keep health care workers safe.” ATA press release, Hat tip to Gina Cella for the ATA heads-up

CMS’ three new proposed telehealth codes, changes on inclusions, in 2020 Medicare Physician Fee Schedule (US)

August 21, 2019 | by

A little-noticed part of the Center for Medicare & Medicaid Services’ (CMS) annual proposed Physician Fee Schedule rule (Federal Register) for Medicare payments is that CMS on its own, without any provider requests (surprisingly), has proffered three new reimbursement codes, all centered on opioid use treatment:

HCPCS code GYYY1: Office-based treatment for opioid use disorder, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month.

HCPCS code GYYY2: Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; at least 60 minutes in a subsequent calendar month.

HCPCS code GYYY3: Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes (List separately in addition to code for primary procedure).

These are classified as Category 1 as they are similar to services already offered under telehealth, so are likely to go into effect on 1 January.

This adds to telehealth services under the SUPPORT Act that removed the geographic limitations for telehealth services furnished to individuals diagnosed with a substance use disorder (SUD). effective 1 July.

Most telehealth services to beneficiaries (Medicare-speak for patients) eligible for reimbursement are limited to qualifying rural areas or one of eight types of qualifying sites and the practitioners are included in one of ten categories of distant site practitioners eligible to furnish and receive Medicare payment for telehealth services. Services also have to be through real-time audio/video and the code (Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCs) are included under Medicare.

Comments on the Rule are accepted through 5pm on 27 September. National Law Review has the details for filing comments here.

CMS urged to further reimburse telehealth remote patient monitoring with three new CPT codes

June 14, 2018 | by

The Centers for Medicare & Medicaid Services (CMS), which controls payments to doctors for the Medicare and state Medicaid programs, has been urged by 49 healthcare organizations and technology vendors to further unbundle the controlling CPT code for remote patient monitoring (RPM), 99091. The 2018 Physician Fee Schedule (PFS) Final Rule finally separated RPM from telemedicine remote visits by permitting separate payment for remote physiological data monitoring by unbundling CPT 99091 to reimburse for patient-generated health data (PGHD)–a new term. The letter to Administrator Seema Verma proposes 2019 adoption of three additional American Medical Association CPT Editorial Panel-developed codes which further break down various aspects of RPM, while maintaining 99091. 

CPT codes for Medicare and Medicaid are important because they also influence private insurers’ reimbursement policies. Practices which get paid for RPM are more likely to adopt enabling technologies if they are affordable within how they are paid. 

CMS started to include telehealth RPM in 2015 in a chronic care management code, 99490, but specifically prohibited the use of CPT 99091 in conjunction with CCM. This created a lot of confusion after some brief moments of hope by tying technology to a complex CCM model.

It’s possibly a ‘light at end of the tunnel’ development for hungry tech companies, but one which won’t be determined till end of year when PFS rules are released. Also Healthcare Dive.

Soapbox: JPM’s Dimon takes the 50,000 foot view on the JP Morgan Chase-Berkshire Hathaway-Amazon health joint venture

April 10, 2018 | by

Mr. Jamie Dimon, the chairman and CEO of JP Morgan Chase, had a few thoughts about the JPM-Berkshire Hathaway-Amazon healthcare JV for all three companies. You’ll have to fill up the tea or coffee mug (make it a small pot) for it’s an exceedingly prolix Annual Shareholder Letter you’ll have to sled through to find those comments. Your Editor has taken her punishment to find them, towards the end of the letter in ‘Public Policy’. 

They demonstrate what this Editor suspected–an headache-inducing mix of generalities and overreach, versus starting modestly and over-delivering.

  • Point #1 sets up what has gone wrong. Among several, “Our nation’s healthcare costs are twice the amount per person compared with most developed nations.” Under point 2 on how poor public policy happened, an admission that Obamacare fixed little:

Here’s another example: We all know that the U.S. healthcare system needs to be reformed. Many have advocated getting on the path to universal healthcare for all Americans. The creation of Obamacare, while a step in the right moral direction, was not well done. America has 290 million people who have insurance — 180 million through private enterprise and 110 million through Medicare and Medicaid. Obamacare slightly expanded both and created exchanges that insure 10 million people. But it did very little to fix our broken healthcare system and has, in fact, torn up the body politic over 10 years — and this tumult may go on for another 10 years.

  • Point #7 is about fixing the deficit and the ill effects if we don’t. In Mr. Dimon’s view, healthcare is a major part of this through the uncontrolled growth of entitlements, with Medicare, Medicaid and Social Security leading the pack–skipping over the fact that nearly all Americans pay into Medicare and SSI well in advance of any entitlement collection. Healthcare is also an offender through unnecessary costs such as administrative and fraud (25-40 percent),  and six mainly chronic conditions accounting for 75 percent of spending.
  • The experts–specifically, their experts–will fix it! “While we don’t know the exact fix to this problem, we do know the process that will help us fix it. We need to form a bipartisan group of experts whose direct charge is to fix our healthcare system. I am convinced that this can be done, and if done properly, it will actually improve the outcomes and satisfaction of all American citizens.”
  • The generalities continue with
    • The JV “will help improve the satisfaction of our healthcare services for our employees (that could be in terms of costs and outcomes) and possibly help inform public policy for the country.” 
    • Aligning incentives systemwide ‘because we’re getting what we incentivize’
    • “Studying the extraordinary amount of money spent on waste, administration and fraud costs.”
    • “Empowering employees to make better choices and have the best options available by owning their own healthcare data with access to excellent telemedicine options, where more consumer-driven health initiatives can help.”
    • “Developing better wellness programs, particularly around obesity and smoking — they account for approximately 25% of chronic diseases (e.g., cancer, stroke, heart disease and depression).”
    • “Determining why costly and specialized medicine and pharmaceuticals are frequently over- and under-utilized.”
    • “Examining the extraordinary amount of money spent on end-of-life care, often unwanted.”
    • “To attack these issues, we will be using top management, big data, virtual technology, better customer engagement and the improved creation of customer choice (high deductibles have barely worked”).

This Editor has observed from the vantage of the health tech, analytics, payer, and care model businesses that nearly every company has addressed or is addressing all these concerns. So what’s new here? Perhaps the scale, but will they tap into the knowledge base those businesses represent or reinvent the wheel? 

A bad sign is Mr. Dimon’s inclusion of ‘end of life care’. This last point is a prime example of overreach–how many of the JV’s employees are in this situation? The ‘attack’ tactics? We’ve seen, heard, and many of us have been part of similar efforts.

Prediction: This JV may be stuck at the 50,000 foot view. It will take a long time, if ever, to descend and produce the concrete, broadly applicable results that it eagerly promises to its million-plus employees, much less the polity. 

Telehealth policy and reimbursement changes summarized by Center for Connected Health Policy (US)

February 23, 2018 | by

A significant barrier to the adoption of telehealth (defined here as video consults, store and forward imaging, and remote patient monitoring) is the issue of reimbursement gaps. Basic Medicare (the Federal program for those over 65) pays for video and store and forward only under certain conditions (primarily under rural telehealth programs) but does pay for RPM as part of chronic care management (albeit under a maze of codes and procedures). Medicaid (the state low-income insurance program) is far more lenient, and private pay in states varies widely, with 36 states having some form of parity payment legislation. However, Medicare is planning expansion beyond what is covered in private plans (Medicare Advantage) by 2020. Some Federal programs such as the advanced Next Generation ACO program and the bundled payment Comprehensive Care for Joint Replacement model have telehealth waivers.

The always-helpful Center for Connected Health Policy (CCHP) has published a five-page guide to where these programs stand. Becker’s Hospital Review. CCHP PDF.  

Rounding up what’s news: LindaCare, TytoCare funding; Medicare telehealth parity, Norway’s big cyberhack, Virta reversing diabetes, DARPA’s 60th birthday

February 9, 2018 | by
[grow_thumb image=”https://telecareaware.com/wp-content/uploads/2017/12/Lasso.jpg” thumb_width=”100″ /]Your Editor’s been away and then largely out of pocket over the past two weeks. Here’s our roundup/catchup beyond the bombshells:

In remote patient monitoring for chronic disease, Philips, PMV, and other investors invested €7 million ($8.6 million) in Belgium’s/Hartford CT’s LindaCare. The Series B funding will accelerate its US expansion of OnePulse for remote monitoring of chronic heart failure and cardiac arrhythmia patients with Cardiac Implanted Electronic Devices (CIED). It is in use in major European hospitals and in US trials, though there is no mention in the release or on their website on CE Marking or FDA clearance/clinical trials. Previously from its 2013 founding, it had €1.6 million in funding. Also Mobihealthnews.

TytoCare, a remote monitoring telehealth/video consult platform which integrates peripherals for a virtual physical exam, raised $25 million in a Series C round led by large Chinese insurer Ping An via their Global Voyager Fund plus Walgreens, Fosun Group, OrbiMed, LionBird, and Cambia Health Solutions. Release. Their total raise is $45.6 million since 2012 (Crunchbase). Their most current partnership is with Long Island-based Allied Physicians Group which is featuring at-home telehealth visits at its pediatric practice in Plainview.

More favorable Medicare reimbursement for telehealth is the subject of four US Congressional bills. The one furthest along is the ‘Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act of 2017’ (S.870), which aims to improve at-home care, increases Medicare Advantage flexibility, gives ACOs more options and expands telehealth capabilities for stroke and dialysis patients. It passed the Senate in September and now goes to the House Subcommittee on Health of the Committee on Energy and Commerce. The effect of all four is on Medicare payment parity with in-office visits, which does not currently exist and is not affected by the various state parity bills on insurance for those below 65. American Well touts a 10-fold growth in revenue, but the likelihood of any of these four bills being signed into law is small, particularly with a pending report from the Medicare Payment Advisory Commission. Becker’s Hospital Review

Norway released at end of January news on an “advanced and persistent” 8 January cyberattack on Health South East RHF. This has both a health breach and military twist.

(more…)

Humana-Omada Health diabetes prevention program could cut $3 bn in Medicare expense: study

February 8, 2017 | by

A study performed by insurer Humana using the Omada Health program for diabetes prevention effectively lowered weight, improved cholesterol, blood glucose and mood. 500 volunteer subjects from Humana’s Medicare Advantage program, enrolled during 2015, lost an average of 13 to 14 pounds over a year (7.5 to 8 percent). They also saw improvements in cholesterol levels, blood glucose levels and subjective measures of moods and self-care. Individuals were chosen from administrative medical claims based on metabolic syndrome diagnosis or a combination of three of four of the following diagnoses: prediabetes, hypertension, dyslipidemia, and obesity. Based on the researchers’ calculations, this type of prevention program among this group if widely implemented among overweight adults could reduce Medicare costs by $3 bn over 10 years, not only for diabetes but also heart disease and high blood pressure.

Omada Health’s program included an online small group support, personalized health coaching, digital tracking tools, and a weekly behavior change curriculum. These one-hour lessons focused on a single topic were delivered via laptop, tablet, or smartphone, and included interactive games or exercises, written reflections, and goal-setting activities. The content was approved by the CDC Diabetes Prevention Recognition Program. Data was gathered via wireless scale, pedometer for physical activity, online food intake logging and standard lab results. “In conclusion, this study demonstrated that older adults who agreed to participate in this program were able to engage meaningfully and gain important health and wellness benefits during a relatively short time frame.”

While the cost reduction estimate is exactly that, other studies directionally confirm health improvement and savings: the National Diabetes Prevention Program (NDPP) which is the model for the Omada program, the BMJ/Noom Health study, and the Fruit Street/VSee telehealth program being used by St. Jude Children’s Research Hospital, University of South Florida and University of Michigan. mHealth Intelligence, study (full text in Journal of Aging and Health/Sage Journals)

Action This Day in US healthcare, coming to pharma, insurance, home care and innovation

February 1, 2017 | by

Action This Day, in Churchill’s words. Today’s news of President Trump meeting with the CEOs of US pharmaceutical companies– Novartis, Merck, Johnson & Johnson, Lilly, Celgene, and Amgen–along with the PhRMA association head, indicates the speed of change that this two-week old Administration intends in healthcare. Trump’s points to the Pharma Giants: drug prices need to be brought down, especially for Medicare and Medicaid patients, through competitive bidding not price-fixing; bringing home production to the US; and that there is ‘global freeloading’ on US drugs. This last is a bit vague, and the pricing part may stir some Standard Republican Resistance, but what Trump also came down firmly for is speeding up the drug approval process. In return, the execs asked for tax reform.

Notable here is this quote:  “I’ll oppose anything that makes it harder for smaller, younger companies to take the risk of bringing their product to a vibrantly competitive market,” Trump said. “That includes price-fixing by the biggest dog in the market, Medicare, which is what’s happening.” The Hill, Business Insider

Does this mean an open door and encouragement for healthcare technology?

Certainly many startups, early-stage companies, and Grizzled Pioneers are eagerly anticipating a more open healthcare business environment than the many dictates, restrictions and the constant changing of goalposts they have faced for the past eight years. The hope is an openness of the Powers That Be on the Federal side (CMS, HHS, FDA) to innovation, patient-centered care and a change away from hammering constantly on lowering cost through a multitude of controls and top-down diktats on what Healthcare Should Be.

This Editor has seen companies straining to hang in there, playing the niches, moderating their equity raises, merging, projecting profitability sometime in the future. Some have not made it. One is the pioneer telehealth company Viterion Corporation, which was quietly dissolved by its parent company in Japan for various reasons at end of last year. (Editor’s disclaimer: I was marketing director for the company.)

Already innovation is reaching long-neglected areas like home care. Home support for the aging population isn’t buzzy, analytic or sexy, but it’s ready for change. The Financial Times takes a look at this $40 bn US market, focusing on the Hometeam caregiving service presently in New York, New Jersey and Pennsylvania, which has over $43 million in investment after only three years (Crunchbase); Honor, which has over $65 million in funding, operating California and Texas. Their points of difference from traditional home care agencies involve models and technology. Hometeam employs carers who are full employees with benefits and an average of $15/hour pay, double that of the usual minimum wage paid to independent contractors. They equip carers with iPads to track what happens in the home, and to report daily to families. Honor has an algorithm to help it scale up from the 100 or so carers who are the ‘break point’ in matching carers with patient needs. In contrast, the UK is far behind in development. The article looks at Vida which uses a mix of carers and technology for its private pay clients. Now approved by the Care Quality Commission, Vida is already in talks with local councils across London and Brighton. But funding is thin: £400,000 of start-up funding and planning to raise £1 million. Tech start-ups try to fix ailing US elderly care sector. If paywalled, search on the title. Hat tip to Susanne Woodman

Action Next Days? Predictions have been all over the place since the election. Many have been overheated (and highly political), but others explain the complexities of undoing the past six years. A reminder: the PPACA did not go into effect until 2010 and most of the provisions kicked in during 2011. Health tech law firm Epstein Becker Green trotted out its crystal ball (more…)

The global ‘state of telehealth’ according to Dr Topol: work in progress

July 20, 2016 | by

Are we approaching a ‘tipping point’ in telehealth and telemedicine within 5 to 10 years? While telemedicine (doctor-patient, hospital-hospital video consults) and even telehealth (patient monitoring generally at home) are becoming more common, Drs Eric Topol and E. Ray Dorsey see the tip coming within the decade in their New England Journal of Medicine (NEJM July, subscription required) article, moving from the early adopters to the majority. But there are still substantial barriers: interstate licensing, fragmented care, spotty state and Federal reimbursement including Medicare, wireless coverage enabling mobile monitoring, the future of the doctor-patient relationship, even the potential for narcotic abuse. They also need to move into the private sector. Somewhat misleading are the 2 million telehealth visits counted by the Veterans Health Administration; it includes the larger programs in store-and-forward information transfer and clinical video consults versus in-home telehealth.

Three trends they see paving the way to ubiquity:

  1. Moving beyond providing access to being driven by convenience and reducing cost
  2. Not just for acute conditions, but for monitoring chronic and episodic conditions (although vital signs monitoring, which is the core meaning of telehealth, has been doing so since the early 2000s)
  3. Migration from hospitals and satellite clinics to in-home and mobile applications

While the two doctors caution on risks, including breaches, they see telemedicine and telehealth increasing the delivery of care in the next ten years and spreading globally. Healthcare Informatics, Qmed

AHRQ ‘evidence map’ pinpoints chronic condition telehealth, telemental health (US)

July 6, 2016 | by

The US Government’s Agency for Healthcare Research and Quality (AHRQ) released a final and fairly positive report analyzing telehealth effectiveness. It was a meta-review of 58 systematic research reviews on telehealth. Criteria were that the studies could examine real time or asynchronous telehealth, onsite or at distance, and that the patient interacted with healthcare providers for the purposes of treatment, management, or prevention of disease.

The abstract’s conclusions are positive for remote patient monitoring (RPM) for chronic conditions and for telemental health:

  • Positive outcomes came from the use of telehealth for several chronic conditions and for psychotherapy as part of behavioral health
  • The most consistent benefits were when telehealth was used for communication and counseling, plus remote monitoring in chronic conditions such as cardiovascular and respiratory disease
  • The improvements were in outcomes such as mortality, quality of life and reductions in hospital admissions

POLITICO’s Morning eHealth has additional and most interesting background. The AHRQ was tasked by two Senators, John Thune (R-SD) and Bill Nelson (D-FL) to analyze telehealth for effectiveness through a literature review and “to give a government’s view – not an industry-funded study or a poorly-conducted academic study – on what the technology could do if, for instance, Medicare paid for more of it.” The December draft seemed to be ambiguous on telehealth studies to date, citing uneven quality and the poor definition of telehealth. (more…)

The widening gyre of insurers covering telehealth (telemedicine?) (US)

February 20, 2016 | by

Is a tipping point nearing? Soon? An article in Modern Healthcare that contains a heavy dollop of promotion headlines ‘telehealth’s’ adoption by insurers such as Blue Cross Blue Shield of Alabama, Anthem and Highmark. When read through, it’s mainly about telemedicine (video consults) but does touch on the vital signs monitoring that’s the basis of telehealth. Video consults through Teladoc and other services such as Doctor on Demand and American Well are gradually being reimbursed by private insurers, despite the concern that it would actually drive up cost by being an ‘add-on’ to an in-person visits. Medicaid increasingly covers it, and states are enacting ‘parity’ regulations equalizing in-office and virtual visits including, in many cases, telehealth. Yet the move for coverage is hampered by lack of reimbursement to doctors, or the perception of limited or no payment. Even Medicare, a big advocate for alternative models of care, currently pays little out for telehealth–$17.6 million on a $630 million+ program. The Congressional Budget Office is skeptical, despite the savings claimed by CONNECT for Health Act in both the Senate and House [TTA 12 Feb]. Virtual reality: More insurers are embracing telehealth