April 30, 2020
by Connie Hwang, MD, MPH
In my recent conversations with clinical leaders across the country, telehealth has emerged as the silver lining of the COVID-19 pandemic.
Just over a month ago, the Centers for Medicare and Medicaid Services (CMS) granted emergency telehealth flexibilities, most notably waiving HIPAA privacy penalties, relaxing geographic constraints and paying for virtual office visits at in-person rates.
Members of the Alliance of Community Health Plans (ACHP) quickly operationalized these flexibilities, and, working closely with their physician groups, they are now experiencing unprecedented telehealth usage.
For instance, UPMC is handling 6,000 virtual visits per day; HAP went from an average of 1,000 telehealth claims per month, up to 18,000 in March, and is anticipating >20,000 telehealth visits for April; and Dean Health Plan, which is encouraging patients to schedule virtual appointments via Epic’s MyChart with Zoom integration, is seeing several thousand virtual visits a day.
Almost overnight, COVID-19 has rendered obsolete notions that certain physician groups would never support telehealth or that patients would be intimidated by the technology. As noted in a recent NEJM Catalyst article, “when fear of catching a potentially fatal disease strikes, telemedicine is no longer too hard.”
In speaking with ACHP clinical leaders, I have observed three early themes regarding the delivery of coverage and care via telehealth in the age of COVID-19:
1. ACHP member plans are covering a wider range of telehealth tools than CMS includes in its definition for Medicare Advantage (MA) risk adjustment.
ACHP member plan coverage includes a wide range of telehealth tools including Epic/Zoom, Skype, FaceTime, Google Duo and even the humble telephone. On April 10, CMS announced that patient data obtained from synchronous audio/visual virtual visits may be used for risk adjustment for MA, Cost, PACE, and Demonstration Organizations. While a step in the right direction, CMS is still neglecting a substantial portion of individuals who are communicating with their physicians via audio-only telephone. These telephonic visits should be included in CMS’s definition of and approach to telehealth.
According to one ACHP member, during the first four months of 2020, 18 percent of telehealth visits for its MA population are being conducted via telephone without video. Older, rural and/or lower income patients may not have easy access to internet services. Patient data from telephone visits should not be left out of CMS risk adjustment considerations, particularly for more vulnerable populations. A recent Primary Care Collaborative survey on 1,000 primary care providers supports this view; 72 percent of respondents report having patients who are unable to access video-enabled telehealth due to lack of a computer or internet access.
2. Behavioral health leaders are seeing improved patient access, visit adherence and member satisfaction after transitioning to telehealth.
ACHP Behavioral Health Leaders report that more patients are receiving care through telehealth than previously in person, coupled with fewer no-show rates and strong positive patient feedback. Since the outbreak, Geisinger’s Psychiatry and Behavioral Health Department has observed a 20 to 30 percent increase in adherence to appointments via telehealth. Clinicians recount stories of patients who are deeply appreciative of receiving mental and behavioral health services via virtual visits at home, especially at this tumultuous moment in history. That’s the good news.
The concerns, however, are numerous. Among them, COVID-19 stresses an already fragile network of behavioral health providers. These communities have been consumed in fighting the opioid epidemic, and with added pressure from COVID-19, questions remain about the best ways to leverage telehealth for substance use disorder treatment and access to specialty psychiatric care. ACHP Behavioral Leaders remain optimistic about the full potential of telehealth but warn there will be challenges in reaching the most vulnerable patients, many of whom do not have reliable telephone numbers or ready access to the internet.
3. The rapid rise in telehealth requires new and/or updated quality measures that meaningfully capture and assess the care that’s being delivered through virtual visits.
ACHP has worked closely with quality leaders across our member companies to propose recommendations for addressing COVID-19 disruptions to the MA Star Ratings program. Throughout these conversations, many quality leaders have raised concerns that existing performance measures may not be adequately capturing care that is provided in telehealth settings. Furthermore, the exponential increase in telehealth creates new urgency for standardized measures that examine the quality of care provided. The National Quality Forum’s proposed telehealth measurement framework regarding access, cost, experience and effectiveness may be helpful in building new telehealth measures that reflect the lessons learned by ACHP members during this extraordinary period of COVID-19.
As we contemplate a post-pandemic era, to what degree will those CMS telehealth flexibilities — like a rubber band that’s been stretched to its limits– snap back after the immediate COVID-19 emergency has passed?
While we can hope that the combination of consumer and provider demand for telehealth will prevent a complete rollback, ACHP members will need to continue championing policies that consider telehealth not as an adjunct to care delivery, but an integrated, evidence-based component of the standard of care. Identifying the right balance between telehealth flexibilities, privacy protections and data transparency on telehealth quality will be critical in the path forward.
At ACHP, we are committed to sharing expert insights from our members that can inform CMS and other key stakeholders on the best strategies for telehealth in the months and years ahead.
Dr. Connie Hwang is the Chief Medical Officer and Director of Clinical Innovation at the Alliance of Community Health Plans.