Finally, a Chance for Telemedicine to Shine in Medicare and Medicaid

Posted Alliance for Connected Care Articles

This past week was big for telemedicine in public programs.  Both telehealth and remote patient monitoring (RPM) are proven tools in the commercial marketplace, but reimbursement restrictions have made adoption in Medicare and Medicaid pretty close to non-existent.  It is still essential to pass legislation to fix outdated legal barriers in these programs.  However, the Center for Medicare and Medicaid Services (CMS) created opportunities this week to demonstrate how valuable telehealth and RPM can be to the health care of millions of seniors and low-income Americans.

In the commercial market, telehealth is used for convenience and after-hours care that can substitute for more expensive and time consuming in-person options.  To date, RPM has largely been used to avoid hospital re-admissions and improve chronic disease management.  The new rules and programs released by CMS open the door to showing how these tools can help achieve the important goals of patient engagement, care coordination, expanded access to care and population health management driven by primary care providers.

Door #1: Comprehensive Primary Care + model (CPC+). This alternative payment model is aimed at supporting primary care practitioners in delivering “advanced” primary care. It is a multi-payer initiative that will impact up to 3.5 million Medicare FFS beneficiaries, as well as millions of other Medicare Advantage, Medicaid, and commercial patients.

Primary care practitioners will be paid a non-visit based, risk-adjusted per beneficiary per month (PBPM) care management fee to help ensure services are “accessible, responsive to an individual’s preference, and patients can take advantage of enhanced in-person hours and 24/7 telephone or electronic access.”

Practices must also ensure that care is “coordinated across the health care system,” patients receive “timely” follow-up after emergency room or hospital visits and that care is “patient-centered.” Telemedicine achieves all of these goals. Since primary care practices will receive a care management fee, they have flexibility on where they can make their investments. That funding won’t be subject to the legal restrictions around telehealth or the lack of payment for RPM.

Door #2: Medicaid and CHIP Managed Care Rule. The final rule allows telemedicine to be used to meet network adequacy requirements in Medicaid. Before this rule, Medicaid managed care network adequacy regulation relied heavily on attestations and certifications from states. Now, states will have to develop time and distance standards and hold managed care plans accountable. Given how difficult it can be to find medical practitioners willing to accept Medicaid, telemedicine will be important to ensuring compliance with network adequacy.

Door #3: Medicare and CHIP Access and Re-authorization Act (MACRA) proposed rule. CMS moves physicians, nurses and other practitioners into value-based care by measuring care in four categories– quality, cost (new resource use), clinical practice improvement activities, and advancing care information (new meaningful use). The alternative is moving into an “advanced alternative payment model.” Telehealth figures prominently in assisting practitioners fulfill clinical practice improvement activities.  It is mentioned explicitly as a way to expand practice access and manage patients who receive the drug warfarin. The tools can also apply in meeting practice improvement activities in the population management, patient engagement and care coordination categories. Also, telehealth services are categorized as “patient facing.”

The possibilities for more adoption in Medicare and Medicaid through these avenues is exciting.  However, billing for telehealth and RPM services in Medicare and Medicaid remains difficult.  We still need legislation to update the statute governing the these programs, but CMS’s efforts using existing authority are a step in the right direction.