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Both the TREATS Act and the Telehealth Modernization Act are being re-submitted this week, as telehealth advocates look to set the agenda for post-COVID-19 connected health coverage.

February 22, 2021 – As federal and state lawmakers look to establish telehealth policy beyond the coronavirus pandemic, much of the conversation will focus on payment parity.

That’s the biggest take-away from a recent study of state telehealth commercial insurance coverage and parity laws by the Foley & Lardner law firm.

The study, the firm’s fourth, depicts a nation that had rushed to embrace telehealth roughly one year ago to better deal with the COVID-19 crisis, and was aided by federal and state emergency measures that improved access and coverage. Now lawmakers are grappling with the idea of making some or all of those emergency measures permanent to keep the momentum going.

“During the pandemic, health plans overwhelmingly changed their telehealth coverage and payment policies to encourage providers and patients to use virtual care alternatives to in-person treatment,” says Sunny Levine, an associate with the firm. “This was spurred in part by state and federal policy changes, and in part by health plan’s self-initiated decisions. Post-pandemic, health plans will continue to offer coverage of telehealth and virtual care services, although perhaps not as aggressively as currently seen.”

The path seems somewhat less rocky for some emergency measures. Nearly everyone agrees that telemental health should be permanently expanded to take on the growing issues of substance abuse, depression, stress and anxiety, while measures that expand telehealth coverage to clinics, health centers and the patient’s home are seeing widespread support. This also holds true for proposals to expand the types of providers able to use telehealth, such as therapists, social workers and home health workers, and coverage for remote patient monitoring and asynchronous telehealth.

Both Sarah Iacomini, an associate with the firm, and Alexis Bortniker, one of the firm’s partners, say state and federal actions to expand telehealth coverage will affect how private payers plot their strategies.

“Take a clinician attending to a patient with a chronic illness, for example,” says Iacomini. “They meet regularly, so it would be easier for the patient to adhere to a care plan by attending some visits via telehealth instead of only in-person. If that clinician is not guaranteed payment because the patient’s insurer doesn’t cover telehealth – or even if the private payer pays substantially less solely because the visit is virtual – then that clinician is less likely to offer telehealth to their patients.”

“A patient living in a state with coverage and reimbursement parity provisions, however, would not have their care plan compromised, as the law prevents the private payer from choosing to exert that financial pressure on the clinician,” she adds. “By enacting emergency laws, states also indirectly influence private payers because people who become used to telecommunicating with their healthcare providers will, in turn, exert demand on the insurance market to continue offering telehealth benefits even after temporary laws lapse.”

Meanwhile, the jury’s still out on how federal telehealth policy will evolve. The Centers for Medicare & Medicaid Services expanded some coverage in its 2021 Physician Fee Index, but those steps were small, and Congress hasn’t yet made its imprint on the debate with any action on bills that aimed to expand telehealth access.

“As a general matter, private payers followed Medicare’s lead on telehealth reimbursement during the pandemic, expanding access and increasing payment for providers forced to move to a telehealth model overnight,” Bortniker says. “Changes were broad. Decisions were sometimes hastily made in light of the unprecedented nature of the situation. As the months pass, and payers have more time to mine utilization data and assess the impact of the telehealth expansion, we will likely see payers to proceed in their own direction, straying from Medicare requirements where they are not applicable. Payers will develop their own policies and requirements for telehealth in order to manage costs and have better control over utilization, while still meeting network adequacy minimums.”

It could be that state actions help frame the national debate over reimbursement. Some telehealth advocates say payers should reimburse for telehealth services at the same rate as for in-person care, while others feel that payers should negotiate their own rates with providers.

The Foley & Lardner study shows that payment parity did increase during the past two years. In all, 22 states now have laws that specifically address telehealth reimbursement, up from 16 in 2019, and 14 states now mandate true payment parity, up from 10 two years ago.

Jaqueline Acosta, special counsel at the law firm, notes that 40 percent increase in states with parity laws is actually higher right now, because several states have enacted emergency measures for parity that only remain in effect for the duration of the public health emergency.

“While expansion of coverage for telehealth services is definitely positive, I believe states need to continue to shape informed and clear reimbursement policies for telehealth and digital health services,” she says. “This is a trend I hope continues.”

Nathaniel Lacktman, a partner with Foley & Lardner and chair of the firm’s Telemedicine & Digital Health Industry Team, says that issue will likely dominate state telehealth policy debate in the coming year.

“Payment parity laws were created in response to health plans paying for telehealth services at only a fraction of the rate the health plan pays for the identical service when delivered in person,” he says. “This can occur when a state enacts a broad telehealth coverage law, but fails to include any language regarding the reimbursement or payment of telehealth services. These laws are more intrusive into private contracting and opponents contend they can prevent immediate savings from telehealth by reimbursing telehealth-based services at a lower payment amount.”

But Lacktman also notes that states can design payment parity laws that give payers some leverage. In both Georgia and California, lawmakers set the base at equal coverage for both virtual and in-person services, then allowed payers and providers to negotiate alternate payment rates.

“Ideally, payment parity laws should not prevent the parties from negotiating for different reimbursement rates for telehealth vs. in-person services, so long as such negotiations are truly voluntary by the provider and not forced upon them,” he says. “Well-drafted payment parity laws can level the field for providers to enter into meaningful negotiations with health plans as to how telehealth services are covered and paid. Model payment parity laws should not eliminate opportunities for cost savings, and should allow health plans and providers to contract for alternative payment models and compensation methodologies for telehealth services, so long as those negotiations are voluntary.”

Eric Wicklund

Editor
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Obesity isn’t just a sensitive health issue — it’s dangerous and potentially deadly. Providers and payers are now using connected health tools to drive that point and enhance treatment.

America has a weight problem, with very serious consequences. And telehealth could be the answer to how people — and their care providers — come to grips with girth.

According to the Centers for Disease Control and Prevention, some 42 percent of the American population is classified as obese, up from 31 percent just two decades ago, while severe obesity has nearly doubled, from 4.7 percent to 9.2 percent. And those numbers are rising, fueled by a sedentary lifestyle, unhealthy foods, and a lack of understanding how serious it can be.

It’s more than just an issue of eating too much and exercising too little. Obesity-related conditions include heart disease, type 2 diabetes, stroke, and certain types of cancer. Extra weight can exacerbate many other chronic conditions, and it’s a gateway to reduced quality of life and preventable, premature death.

It’s also a sensitive issue: People don’t like to talk about their weight or being told to lose weight. And that’s where telehealth comes into play.

While healthcare providers can use connected health channels to have discreet, personal conversations with patients about their weight, they can also use these platforms and tools to offer education and resources, on-demand treatment, and support for everything from lifestyle choices to addiction triggers, even remote patient monitoring to keep patients on a care plan.

“Everything we do from a treatment standpoint can be done virtually,” says Angela Fitch, MD, FACP, FOMA, associate director of the Massachusetts General Hospital Weight Center and a faculty member at Harvard Medical School. “From medication [management] to counseling to treatment, we can do a lot more and have a bigger impact” via telehealth than in-person.

Using Telehealth to Tackle a Sensitive Topic

Obesity is often included in the category of health concerns that strike a sensitive chord with patients, like sexual health and diseases, gender-related concerns and issues with appearance and mental health. The emergence of direct-to-consumer telehealth platforms — think Ro, Nurx, Hims and Hers and even Planned Parenthood — has given consumers a discreet channel to address these concerns.

But for most people, the first contact is the primary care provider.

With the idea that many people aren’t comfortable talking about obesity unless they’re alone with a doctor, and they’re reluctant or embarrassed to seek help, primary care providers and specialists have taken to using telehealth to have that conversation.

Fitch says the platform offers an ideal opportunity to mix behavioral and clinical care, two critical elements of obesity treatment.

Getting patients to open up about their weight issue may be a good start, she says, “but people need more than to just talk. They need help. They need tools.”

She says many people still don’t connect weight with serious health outcomes. They’ll spend lots of money on diet aids and supplements, and talk about exercise and healthy activities, but to them it’s more about better living than living better.

“You have to live differently within the environment,” she says. “And for that you need coaching. Even Michael Phelps has a [swimming] coach, and he knows how to swim.”

That coaching works best when it’s tied into telehealth, giving both patient and provider the opportunity to connect on their own terms. And when it’s tied to clinical treatment, it carries the added weight of being prescriptive. Patients can connect with their care providers as needed, on a daily or weekly basis, and talk about both motivations and care management.

“That’s where we need to go next,” Fitch says, describing care routines that mix coaching and support with medication management, remote monitoring, and access to specialists when needed. “You need accountability for this to work, and you need structure.”

Looking ahead, Fitch would like to see clinical weight management programs that allow care providers to pull in data from wearable mHealth devices, such as fitness bands, smartwatches, and sensor-embedded garments. There are also a lot of possibilities with smart objects in the home that would allow providers to offer advice, resources, even a gentle nudge in the right direction as a patient goes through his or her daily routines.

“There’s no reason why you shouldn’t be able to get on your scale each morning and I can see that data,” she points out.

Making Obesity Treatment a Clinical Concern

While obesity is measured in terms of body mass index (BMI), starting at 30.0 (40.0 and above is termed class 3 obesity, or morbid, severe or extreme), it can also be measured in terms of cost. In 2008, the American healthcare ecosystem spent almost $150 billion on treatment of health issues caused by obesity, while someone dealing with obesity sees roughly $1,500 more per year in medical costs.

And that’s making the healthcare industry sit up and take notice.

Obesity treatment is “an emerging service,” says Louis Aronne, MD, FACP, Intellihealth’s Chief Medical Officer and medical director of the Comprehensive Weight Control Center at Weill Cornell.

Up until the past few years, he says, it was regarded as a behavioral health issue, rather than a clinical one. But with studies proving the negative health effects of weight gain — particularly in chronic conditions — care providers and some payers are now taking it seriously.

“The problem has been that providers don’t know how to treat it,” Aronne says. “It has taken a long time for obesity to be treated as a disease, and now that it is, [providers] need the resources to be able to treat it.”

Aronne, who launched the American Board of Obesity Medicine and was instrumental in getting the healthcare industry to recognize obesity as a medical issue, sees telehealth and mHealth as integral parts of a treatment program, one that also mixes in behavioral health and integrates with specialist care (cardiology, gastroenterology, endocrinology) when needed.

He says studies have shown that one-third of those in obesity treatment programs that use telehealth have lost at least 5 percent of their body weight, Over a three-year time span, that can amount to more than $700 in reduced healthcare costs, not to mention better health.

“That’s critical,” he says, adding that continued telehealth and mHealth integration can bump the percentage of people losing weight up to 70 percent as both doctors and patients become more comfortable with virtual care. “Telehealth really is the way to get more people involved in improving their health.”

Aronne is in favor of a hybrid approach that combines telehealth and in-person care. While seeing a patient virtually can help providers pick up on aspects of home life that might affect treatment, he says, providers also need to see patients in person, where they can pick up on habits and emotions that might not translate in a virtual visit.

“We need to build this into an evolving platform,” he says.

Source: Getty Images

Connected Health Tools for Obesity Treatment

While care providers can use connected health to break the ice and talk to reluctant patients about obesity, telehealth, and remote patient monitoring platforms, wearable mHealth devices and apps serve a much larger role in the treatment space. They give providers the opportunity to connect with patients on a regular basis, offering support and resources for weight control, including nutrition and exercise tips, monitoring for addictive behaviors, and on-demand access to peer support.

The Obesity Medicine Association (OMA), a national organization of healthcare providers focused on improving the lives of patients affected by obesity, has also been working to include telehealth in its practice guidelines.

In January 2021, OMA updated its OMA Obesity Algorithm to include practice guidelines for using telehealth. Called ADAPT, it creates a pathway for virtual and telephonic treatments that focuses on assessment, diagnosis, advice/education, prognosis, and treatment.

“With COVID, and even without COVID, many patients are less inclined to seek medical care (for obesity care) if it means meeting with a healthcare provider,” says Harold Bays, MD, a trustee and chief science officer of the OMA and medical director and president of the Louisville Metabolic and Atherosclerosis Research Center. “Telehealth provides a much more convenient and accessible option.”

Bays says the pandemic “has dramatically changed how providers are using telehealth to treat obesity.”

Aside from new medications and clinical measures like surgery, providers are being encouraged to use telehealth and mHealth apps that improve care management. These tools allow for more interventions and the ability to tailor a program to a patient’s specific needs, through coaching and guidance on diet, exercise, and behavioral health.

The importance of virtual guidance is that it can be accessed when the patient needs it most — at home or the office, or when grocery shopping, out to dinner, at the gym, on vacation, or any other place where a little advice or support is needed.

mHealth tools, meanwhile, can arm the care provider with even more data to influence treatment. By monitoring a patient’s weight and comparing that with other metrics, a care provider can show how weight gain affects the heart, pancreas, lungs and other organs, as well as how exercise and diet might affect those metrics in a positive way.

As Fitch mentioned, the future of obesity prevention and treatment may rest in the smart home concept, with sensors and smart devices programmed to help a consumer make informed choices on diet and exercise and alert caregivers if something is out of the ordinary.

Tackling Type 2 Diabetes Through Virtual Weight Control Programs

While obesity has a profound impact on a number of chronic diseases, it’s one of the root causes of type 2 diabetes. With that in mind, providers and payers across the country are integrating telehealth into diabetes prevention programs to help patients manage their weight and reduce the risk of developing diabetes.

This past January, Humana’s Medicaid program in Kentucky, called Healthy Horizons, launched a virtual diabetes management program with Vida Health. The program is aimed at improving access to care in a state where almost 14 percent of the adult population is living with diabetes – well above the national average of 11 percent – and where roughly two-thirds are overweight.

“Diabetes is a complex disease that requires management of current problems as well as of preventing future complications,” says Jeb Duke, executive director of Kentucky Medicaid and a regional vice president at Humana. “Interacting with the virtual team allows for reminders of both treatment of current issues and prevention care.  It also allows for positive reinforcement and praise for successes that our members achieve.”

Duke says a virtual platform allows care teams to expand their reach beyond the clinic or classroom.

“Although it does not replace the need for in-person medical visits, it is a great adjunct that decreases barriers to access for members that frequently struggle with transportation issues,” he says. “It results in increased convenience for our members in accessing the platform to connect with virtual coaches and therapists as well as learning modules to allow for a better understanding of their medical condition.”

Developed by the National Institutes of Health’s National Institute of Diabetes and Digestive and Kidney Disease (NIDDK), the diabetes prevention program (DPP) focuses on in-person classes and one-on-one coaching. Based on that model, which is administered by the Centers for Disease Control and Prevention, CMS created the National Diabetes Prevention Program for Medicare beneficiaries and launched that program in 2018.

Medicare had for a long time denied reimbursement for telehealth services in the MDPP, saying virtual channels hadn’t proven effective in affecting weight loss or reducing the diabetes risk. Some recent studies are proving that assumption wrong, and the Centers for Medicare & Medicaid Services has allowed coverage for virtual services during the public health emergency caused by COVID-19.

Telehealth advocates hope CMS will make the coverage permanent.

“It’s no secret that diabetes is a disease that has disproportionately affected minority communities across the country,” a group of Senators said when introducing a bill in September 2020 calling for permanent coverage. “To ensure that all individuals have the tools needed to combat this preventable disease, the Prevent Diabetes Act would help expand access to virtual classes under the existing Medicare Diabetes Prevention Program. This commonsense and cost-saving expansion will ensure that more Americans at risk of developing diabetes who are living in either rural or medically underserved communities, can participate in this critical program that has been proven to delay the full onset of this preventable disease.”

Should that happen, Medicare coverage will open up virtual channels for a significant population — one that shows high rates of obesity and a propensity for developing chronic diseases like type 2 diabetes. It would also throw significant support behind virtual obesity treatment programs that target any number of conditions or populations.

Getting Everyone on Board With Telehealth

While providers are seeing the clinical effects of obesity, payers and employers have been reluctant to make that connection.

“The thing that’s been stopping them is they’re worried that they’re going to be saddled with enormous costs for care,” Aronne says.

Fitch says roughly 30 percent to 40 percent of payers are now covering obesity treatment, convinced that clinical treatments can improve outcomes over the long run and reduce chronic diseases and care management costs. But like CMS, they’re still skeptical of virtual care.

“Payer support is going to be very important,” she says.

This doesn’t mean creating a few extra CPT codes, either. Fitch notes that billing and coding routines are time-consuming and, in some cases, more trouble than they’re worth, prompting providers to skip the process and forego the reimbursements. She’s hoping that obesity treatment will be incorporated into existing care pathways, so that it’s part of the standard of care instead of a new service.

Both she and Aronne see the COVID-19 crisis as helping to prove the value of telehealth delivered to the patient’s home — which, in turn, will give providers more freedom to create care management programs that include obesity prevention and treatment.

“This needs to be part of the new normal,” Aronne says. “Everyone should be using these strategies.”

A recent study by Foley & Lardner indicates telehealth reimbursement will be on top of the agenda during the coming year, but will states, private payers and the federal government find an acceptable path to true payment parity?