WHAT IS TELEMEDICINE?

“Using interactive telecommunication technology—audio and/or video—to deliver health care services”.

That is the simplest definition of telemedicine. The technology allows patients the convenience / safety of consulting with their doctor from their home.

WHY IS TELEMEDICINE?

While used infrequently prior to the COVID-19 pandemic, reports released since March 2020 have shared a dramatic spike in telemedicine delivery. A little over 43% of Medicare visits for primary care were delivered remotely using telehealth in April 2020. In February 2020, just before the pandemic touched down in the U.S. it was a negligible 0.1% of visits. A survey conducted among the general population found an increase in telemedicine use from 6% to 25% pre- and post–COVID-19, respectively.

IS TELEMEDICINE TRULY ACCESSIBLE?

In response to the pandemic, Congress allocated additional resources to the Telehealth Network Grant Program for the next 5 years. It is important to bear in mind, however, that not all clinics and health systems are equipped with the infrastructure needed to deliver telehealth, and it could be an added cost for these clinics.

And what about the cost for patients? Here is some information on how health plans cover telemedicine services:

Medicare Coverage of Telemedicine

Telehealth services are reimbursed by Medicare under Part B coverage. However, the enrollee may be responsible for 20% of the charges, in addition to the deductible being applied. General telehealth services covered by Medicare include:

•       Office visits
•       Consultations
•       Psychotherapy
•       Certain other medical or health services

In 2019, Medicare made the following changes to telehealth coverage:

•       Included telehealth services at home and at renal dialysis centers
•       For patients with acute stroke, they can get telehealth services for faster diagnosis, evaluation, or treatment of symptoms, independent of their location
•       Substance use or co-occurring mental health disorder patients can get telehealth from home

During the pandemic, the program eased certain restrictions on telemedicine delivery such as:

•       Allowing enrollees from any location to access care from their home—not just enrollees living in rural areas
•       Allow telemedicine to be delivered via a smartphone with real-time audio/video capability
•       The need for the provider to have treated the beneficiary in the last three years
•       Waiving HIPAA (patient privacy) enforcement for telemedicine
•       E-prescribing of controlled medicines

Additionally, individuals suspected of having a coronavirus infection or those exposed to someone with the virus are asked to call their doctor first (if they have mild symptoms), prior to visiting an emergency room or urgent care facility. This helps streamline the process and keep everyone safe.

Medicare Advantage members may have additional service coverage and should check with their specific plan on the benefits offered.

Medicaid Coverage of Telemedicine

Each state has the flexibility to determine telemedicine coverage for Medicaid enrollees, including the specific type of care or service. In the face of the COVID-19 pandemic, the Centers for Medicare & Medicaid Services released a new set of guidelines on how Medicaid agencies and other stakeholders associated with providing care to Medicaid beneficiaries can do so by expanding telehealth. Restrictions that existed on ‘distant’ (where the provider is located) and ‘originating’ (where the patient is located) sites, the mode of telehealth used (telephone vs two-way audio/video technology) and establishment of a patient-physician relationship have been eased.

All 50 states and Washington, D.C., have some telehealth policy for Medicaid. Most updated information on specific coverage can be found on the website of the Center for Connected Health Policy. These updated policies may include access to telemedicine services for:

•       Behavioral health
•       Pediatric care
•       Reproductive and maternal health
•       COVID-19 care
•       Dental health
•       Speech therapy
•       Physical and occupational therapy

Private Insurer Coverage of Telemedicine

Telehealth coverage laws for private insurers vary by state—50% of U.S. states mandate that medically necessary services that meet the standards of in-person services must be covered under telemedicine by state-regulated private plans (fully insured health plans such as group and individual plans). However, reimbursement for telemedicine services may not be the same as in-person services—again, a state-based difference—clinics may be reimbursed at a lower rate than equivalent in-person care. However, the scenario has changed during COVID-19. According to the Kaiser Family Foundation, 16 states have mandated equal reimbursement for the same service delivered in-person or via telemedicine.

In states that do not mandate telehealth, coverage decisions are made by the health insurance companies, which is why changes to telehealth during the pandemic have varied based on the insurer. Some have eliminated or reduced beneficiary cost-sharing for some time for COVID-19–related visits or other health conditions. Others are widening their in-network telehealth providers and expanding the covered services for plan enrollees.

However, a recent report indicated that several private health insurance companies will be reverting to pre-pandemic policies, or have done so already. UnitedHealthcare members, for example,

•    Enrolled in Medicare Advantage plans, will have to start cost-sharing (co-pay, coinsurance, or deductible) for COVID-19–related or other kinds of virtual visits, for in-network as well as out-of-network service providers
•   Enrolled in Individual and Fully Insured Group Market Health Plans:
  • Will have expanded telehealth access through December 31, 2020 for in-network providers and October 22, 2020 for out-of-network providers for COVID-19 visits
  • Will have expanded telehealth access through December 31, 2020 for in-network providers for other health conditions. Expanded telehealth access to out-of-network providers for other health conditions ended on July 24, 2020.
  • Cost-sharing for both in-network and out-of-network providers for COVID-19 visits will be waived till October 22, 2020. For other health conditions, cost-share waiver for in-network providers ended September 30, 2020. The waiver did not apply for out-of-network providers.

We have a good resource on health insurance terms.

Patients should contact their health plans to confirm specific policy changes for telehealth coverage.

Interest in Telehealth

Both patients and health care practitioners seem interested in seeking advantage of telehealth coverage. Medicare patients, a majority of whom may be at a higher risk of developing COVID-19, continue to use telehealth for their primary care visits. The question is, will patient attitudes change after learning they would have to pay a higher amount for their telehealth visit? Will they still go ahead with their telemedicine appointment, prefer to go to the clinic, or just cancel their visit and neglect any symptoms they may have?

Hopefully, we can include our survey results here.

Additional Resources

1.     Details on telehealth from the Mayo Clinic: https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/telehealth/art-20044878#:~:text=Telehealth%20is%20the%20use%20of,or%20support%20health%20care%20services.
2.     Information on telehealth utility from the Centers for Disease Control & Prevention: https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html.

The information in this article was researched and summarized by Surabhi Dangi-Garimella, Ph.D., Principal, SDG AdvoHealth, LLC. Improving patient access is our mission and we are happy to utilize a variety of experts to carry that out.