Healthcare lawyer Andrew Selesnick said one key will be to establish a stable, user-friendly platform that can make documentation seamless.
The future potential of telehealth hinges on how it’s reimbursed. Virtual care may be popular among patients, but if providers can’t get paid for their services, it’s unlikely they’ll be able to continue to provide them.
The government has signaled its support for reimbursing some telehealth services, at least in the short term. The Centers for Medicare and Medicaid Services announced earlier this month, for example, that it would add 11 virtual services to its reimbursement list during the COVID-19 public health emergency – following in the footsteps of its earlier flexibilities for virtual care.
This could act as a signal for other payers to do the same, said Andrew Selesnick, a shareholder in Buchalter’s Los Angeles office, in a Healthcare IT News interview. “The government can play a very positive role in telehealth by establishing clear standards and clear reimbursement guidelines,” said Selesnick. If the government, for example, requires documentation for certain services and certain rules around telehealth, “then the payers will be hard pressed to ignore them for a lengthy period of time.”
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“If Medicare says you have to cover something – that’s going to be harder” for private payers not to cover it, Selesnick said.
Indeed, private payers have slowly begun to reinstate out-of-pocket costs for telemedicine. UnitedHealth Group and Anthem are saying that some members will be responsible for copays, coinsurance and deductibles for non-COVID-19 virtual visits.
The COVID-19 pandemic has “been a time of tremendous change” with regard to virtual care, said Selesnick.
Given the dozens of changes to policy at the federal level, including allowing providers to practice across state lines and to regard a patient’s home as an originating site, “we’ve probably had more regulatory reform in the last six months than we’ve had in the last six years when it comes to telehealth,” he said. “Many of my clients who weren’t even telehealth providers before have jumped into the fray.”
The providers most focused on the future of reimbursement and telehealth tend to be primary care clinicians, Selesnick said, as well as a “goodly number” of emergency physicians.
“They can do a lot of things, and they’re used to dealing with limited information and making decisions with people they don’t know,” said Selesnick, making them particularly nimble when it comes to virtual care.
“Hospitals and health systems were very active as well, because they had such a huge drop in volume at the early stage of the pandemic,” Selesnick continued, with many of them pivoting to ramp up existing telehealth technology and accommodate patients. “A lot of places saw drops of 30 to 50% in volume, and they have fixed costs – and people still need care.”
When it comes to the future of reimbursement, Selesnick predicted a continuously changing outlook over the next one to two years. “We’re going to see a lot of activity over the next 12 to 24 months, where the landscape shakes out and people have a good understanding of where they stand,” he said. “It’s going to be a struggle.”
So, given that uncertainty, how can providers best prepare?
One way, he said, is having a “stable, user-friendly platform.”
“And I don’t just mean user-friendly for the consumer; I mean for providers as well,” said Selesnick. He described clinicians who can’t easily get into their electronic health records from telehealth platforms and then just not billing for services, rather than jumping through technological hoops.
For providers, he continued, “it’s about clear guidelines” about what telehealth reimbursement requires in terms of documentation and visit length. “You put a lot of hurdles in, you’re going to have diminished use.”
Ultimately, “telehealth is here to stay,” he said. “I think there will be a scale-back in telehealth in terms of what they’re going to pay for, but it’s definitely going to stay.”
– At the onset of the COVID-19 pandemic, clinicians at Orlando Internal Medicine were faced with an impossible situation. The organization was going to have to shut down family visits for the sake of patient safety, but leadership knew this was going to tank patient satisfaction.
“We deal with some really sick patients and we had to shut everything down overnight,” Pradeep Vangala, MD, an internist at Orlando Internal Medicine, told PatientEngagementHIT. “It was a very difficult decision, both for us and our patients, as well as families who could not see the loved ones. And then we had a big problem. More of a consequence of that, which is inability or difficulty communicating with family members, which obviously is a really important aspect of the patient care, so that got severely interrupted as well.”
Vangala and his team at Orlando Internal Medicine, which treats patients across the care continuum from acute settings to long-term care to outpatient practice, were not alone in this decision. Data shows that most organizations had to make some sort of change to their family visitation policies as part of the COVID-19 lockdown in March.
Per figures in Michigan, nearly every organization made at least some type of change to family visitation policies. Some organizations limited visitors to only one family member and for only certain types of visits, while others implemented a tight family visitor lockdown.
Anecdotal evidence shows that this was the story across the country, including in Orlando. Vangala and his team began with a strict prohibition on family visitors before opening up to only one visitor per patient. Now in November, Orlando Internal Medicine allows more visitors who are subject to coronavirus screening, donning of face coverings, and restrictions within the physical space of the organization’s hospitalist groups.
But in the beginning, these family visit shutdowns were deeply upsetting for everyone, Vangala said.
“I remember family members would come and visit their families, especially the ones that are there on the first floor, and would literally come and visit the family members through the windows,” he recounted. “But all this comes from the concept of zero harm. You don’t want to do anything that in any way would harm the patient. That is of paramount importance.”
“But it was very heartbreaking and we were really hoping that we could start the family visits back as soon as we could,” Vangala added.
The boom of telehealth would prove to give Vangala and his team the respite they’d been hoping for. Just as video visits were proving essential in continuing patient access to care at the onset of the pandemic, they would also be helpful in connecting patients—and their clinicians—to family members and loved ones while the organization’s doors remained closed.
“If there is a silver lining to the whole COVID-19 pandemic, it’s the advancement in medical technology and the telemedicine platform. COVID-19 really acted as a catalyst,” Vangala said. “And that way we’re very happy because in the short run, we were able to still connect with family members, get patients to connect with family members.”
The team at Orlando Internal Medicine leveraged its telehealth platform to conduct video visits between bedridden patients and their disparately located loved ones. The organization had several iPads they would issue across the hospital, and staff members helped patients log onto the technology and visit with their family members.
This went a long way in improving the patient experience, Vangala noted, because visits with family members naturally serve as a mood-booster.
“A lot of times, if I know that my patient’s family member is going to be there on the phone, I would use that opportunity to go into the room, discuss with the family and the patient on that phone conference as to what’s going on with the patient and the care,” Vangala explained. “And that would be done on a regular basis. We would at least do it about every other day.”
This strategy has followed a similar trajectory to Orlando Internal Medicine’s work with telehealth. Prior to the pandemic, telehealth use was not quite as popular among Vangala and his colleagues, but once the virus forced clinic doors shut, it became their lifeline. Although Orlando Internal Medicine has since reopened its doors, Vangala said telehealth is still playing a significant role, thanks in large part to a streamlined digital platform from Andor Health.
“We would really want a virtual visit platform that mimics a true office visit expedience for the patient,” Vangala said. “And what do I mean by that? The patient at the time, as they get close to the visit, normally you would get in touch with the patient and say, ‘Hey, your visit is coming up.’ Then the patient gets a chance to be able to make any changes through the demographics intake forms. And when patients come in they check in with the receptionist, sit in the waiting room, go to the exam room and wait for the provider and then check out.”
Vangala’s telehealth solution enables that and mimics that entire step-by-step process. Patients receive intake forms and fill them out with the assistance of a bot, similar to working with the registration desk inside the clinic.
When it comes time for the telehealth appointment, the patient checks in with Vangala’s medical assistant over a video visit. And from there, Vangala himself meets with the patient for the physical exam. Using that same bot, Vangala can call up the patient’s medical record and share the screen to collaborate with the patient.
“So the patient is really going through the entire visit like they’re going to a regular office visit and you have the bot, which is assisting me throughout,” he pointed out. “So that is how we’re doing visits right now. And that has really transformed the way we care for our patients. Patients living far away, patients’ inability to drive—all those things, we’ve tackled them in just one go.”
It’s for that reason Vangala agrees with much of the rest of the medical industry that telehealth is here to stay, at least partially. Telehealth has been a boon for patient access to care during the pandemic and has helped Vangala overcome of the biggest access barriers he saw pre-pandemic.
“Yes, I want to see my patients,” Vangala acknowledged. “A lot of my patients I’ve known for such a long time. In the pre-COVID days, every time they’d come, I would get at least a dozen hugs a day. And so I certainly don’t want to give up on that, putting my arm around the patient’s shoulder. But having said that, there’s a lot of patients that have difficulty coming in, family takes time off. So the technology we have today is going to truly enable that level of virtual visits that we have never had before.”
He has a similar opinion about family video visits, he said.
“So COVID I’m sure with time will die down and things will get back to normal. But this new normal of being able to communicate with family members on a video conferencing chat is something that I believe is here to stay,” Vangala asserted. “There will be those visits in person, but those video-chat visits are going to be there.”
“I’m able to pull up the lab work,” he concluded. “That family member is actually able to see it. The mom may be in Florida, but the daughter is somewhere in New York or Boston, and is able to look at those lab results and X-rays along with me in real time and be able to better understand what’s going on with their loved one.”
The COVID-19 pandemic has led to a surge in demand for everything from hand sanitizer and face masks to lumber and toilet paper. It has also led to the soaring use of telehealth services: Between April 2019 and April 2020, national privately insured telehealth claims’ increased by 8,336 percent (as a proportion of total medical claims). While those ratios eventually tapered in the proceeding months as in-person visits rebounded, there’s no doubt that more patients and providers are relying on telehealth than ever before. But rural Americans are 10 times more likely to lack broadband access than their urban counterparts. In 2018, the Federal Communications Commission (FCC) estimated that one-quarter of rural Americans—and one-third of Americans living on tribal lands—did not have access to broadband (meaning download speeds of at least 25 megabits per second). By contrast, less than 2 percent of urban Americans lacked that same access.
The lack of broadband in rural areas is one of the most striking inequalities in US society. Due to the lack of broadband availability, tens of millions of rural Americans aren’t able to “see” their doctor over the internet in the same way urban Americans can.
Making matters worse, financially strapped rural hospitals are being shuttered by the dozens. An estimated 47 percent of the country’s 1,844 rural hospitals are operating in the red. Since 2005, at least 174 rural hospitals have closed, including 47 since 2018. Fifteen have closed in 2020 alone. A recent analysis found that about 25 percent of rural hospitals are at high risk of closing. More than 80 percent of these at-risk hospitals are considered highly essential to their communities and if shuttered would greatly reduce physical access to care. These closures underscore the importance of telehealth in rural areas. Rural America Is Becoming More Racially Diverse
The COVID-19 pandemic has not impacted the United States uniformly. Indeed, densely populated urban centers initially bore the brunt of the disease with certain minority populations infected at higher rates. As COVID-19 migrated from big cities to smaller towns, minority populations continued to suffer disproportionately higher infection rates. Even in predominately rural states, such as South Dakota, Asian Americans became infected at rates six times higher than their share of the population. Similarly, in New Mexico, Native Americans accounted for more than half of the COVID-19 confirmed cases but only comprised 11 percent of the population. These trends underscore an important aspect about the demographics of rural America: It is far from monolithic.
In fact, rural America is becoming increasingly diverse. In 2010, one in five rural Americans was a person of color or Indigenous individual—up from one in seven in 1990. The 2020 census will likely be even higher. Specifically, recent immigration patterns have changed the racial and ethnic composition of rural regions. In a 2018 Center for American Progress report, a sample of 2,767 rural places witnessed an average population decline of 4 percent through a 12 percent decline in native-born population but a 130 percent growth in immigrant populations. Yet, alarmingly, rural Black, Latino, Asian, and Indigenous adults are also less likely to have a personal doctor and more likely to forgo routine health care visits due to costs, just like their urban peers.
Moreover, rural Americans are statistically poorer than their urban peers across all racial and ethnic backgrounds. According to the Census Bureau’s 2013–17 five-year estimates from the American Community Survey, poverty rates for mostly rural (16.3 percent) and completely rural (17.2 percent ) counties stood higher than mostly urban counties (14.3 percent). Similarly, in the same survey, predominantly urban counties reported household incomes of $59,970 while mostly and completely rural counties disclosed figures of $47,020 and $44,020, respectively. Arguably, for rural patients, the cost of health care matters nearly as much as the access to it—with telehealth offering a cheaper and more accessible alternative during the COVID-19 pandemic. A New Deal–Inspired Solution
This rural telehealth crisis must be addressed at the federal level.
In 1930, nine out of ten rural farms and ranches in the country were not connected to the electric grid. Without electricity, rural economies were being left behind. Women and girls were forced to haul water and wash clothes by hand. Factories and big employers congregated in cities where electricity was cheap and abundant.
The New Deal changed that. With the passage of the Public Utility Holding Company Act in 1935 and the Rural Electrification Act of 1936, federal funding allowed cooperatives and other entities to string wires to rural areas. By 1950, about 9 out of 10 rural farms and ranches were connected to the electric grid. Today, that figure is close to 99 percent.
Similar federal action is needed today to solve the rural broadband problem. In 2019, the Pew Research Center found that roughly 63 percent of rural Americans have home broadband internet, still 12 and 14 percentage points lower than their urban and suburban counterparts, respectively.
How much will it cost to bridge the digital divide? Stringing fiber optic cable costs about $20,000 per mile. That’s a lot of money to spend when some rural areas may only have a few houses for every mile of cable. But that’s the very same problem that had to be overcome with rural electrification.
In 2017, Deloitte Consulting put the cost of extending rural broadband at about $40 billion. A 2018 analysis by the National Rural Electric Cooperative Association found that about 6.3 million electric co-op households “totaling 13.4 million people, lack access to adequate, high-speed broadband service.” The association’s cost estimate for addressing the problem was the same as Deloitte’s: about $40 billion.
Politicians are paying attention to the problem. Last year, FCC Chairman Ajit Pai approved $5 billion to improve rural broadband, and later this month the FCC will hold a reverse auction for some $20 billion in grants being made available through the Rural Digital Opportunity Fund. In addition, former Vice President Joe Biden has pledged to spend $20 billion on rural broadband infrastructure and plans to triple the US Department of Agriculture’s Community Connect grants partnering with rural communities across the US.
Whatever the total cost of solving the rural broadband challenge, it is clear that tens of billions of dollars in federal investment is needed.
Critics may claim that the private sector can, and should, solve this problem. But if that were true, it would have already done so. Back in the 1930s, electric companies had the ability—but not the economic incentive—to electrify rural areas. The same holds true today for rural broadband. Today’s lack of rural broadband is a market failure that can only be cured with federal dollars.
Federal investment in rural electrification helped ignite investment across the country. Manufacturers didn’t have to locate near big cities, instead, they could build factories in rural areas where land was cheaper. Electric machinery and refrigeration made farms and ranches more productive. Today, in an era where remote work is increasingly common, rural and urban Americans alike need broadband to stay connected and productive.
Federal investment in rural broadband could help reduce health care costs because it will give patients more options in how and where they seek medical care. Multiple studies have found that as hospitals close, competition declines and prices go up. If telehealth appointments provide a less costly option than in-person visits, then federal spending on rural broadband could ultimately be offset by smaller outlays for Medicare.
To be clear, federal investment in rural broadband should come with some caveats, including some influence with regard to pricing. For instance, broadband prices in a region that has benefited from federal loans should not exceed the prices paid by customers in the two closest exurban areas. Furthermore, to ensure competition, the FCC—along with the respective offices at the Federal Trade Commission and Department of Justice—should monitor and enforce antitrust measures. An Impact Beyond Telehealth
Rural broadband is not just about telehealth. The pandemic has proven that it is also essential for education and remote work. Microsoft CEO Satya Nadella recently declared that “broadband is a fundamental right.” However, just like in the 1930s with electricity, bringing broadband to rural communities will not happen easily or cheaply. Sustained political support—along with tens of billions of dollars in federal grants and loans—will be needed to bring all of rural America into the 21st century.
Now is the time for a new federal program that will energize rural broadband in the same way that the New Deal brought electricity to rural America and bring rural patients out of the digital dark. Authors’ Note
The authors are visiting fellows at the Foundation for Research on Equal Opportunity.
Columbia lawyer Byron Gipson gave telehealth a try for the first time because of the coronavirus pandemic. He needed hernia surgery. The surgeon he chose works almost two hours away at MUSC Health in Charleston, South Carolina.
Gipson would need to be in Charleston for the actual procedure, of course. But because of the pandemic, his preop meetings with his surgeon became virtual visits instead of in-person consultations. Gipson used his iPad to meet with Heather Evans, M.D., via video.
Byron Gipson
“There’s a little trepidation that you feel, that you’d like to see her face to face here or there, but she was reassuring,” Gipson said. “After meeting with her the first time, it was clear that she is obviously at the top of the profession. She knows what she’s doing. She’s just got a really good bedside manner. Well, video-side manner,” he joked. “She’d be great on Netflix.”
Telehealth was new to Evans, too. “I learned, along with everybody else in the midst of the crisis, trying to find a way to care for patients. My experience this summer was I switched to entirely video-based clinics for probably two or three months. During that time, I figured it out as we went along.”
She liked what she saw. “We really have made things work for patients in this unprecedented time. We took advantage of a crisis to be able to follow through on something that needed our attention at the time. I really think this opens us up to a whole new way of taking care of patients.”
As the South Carolina Telehealth Alliance marks telehealth awareness week, it does so at a time when more people than ever have actually used telehealth. The SCTA is a statewide initiative created by the state legislature in 2013 to expand telehealth. MUSC, which has its own Center for Telehealth, serves as the SCTA’s headquarters.
While it’s not clear yet how many people have tried telehealth in 2020, a report from the Department of Health and Human Services noted that the number of Medicare primary visits jumped from less than 1% in February to 43.5% in April as the coronavirus forced people to stay home.
Family medicine specialist Gregory Perron had never used telehealth before the coronavirus pandemic. Photo by Brennan Wesley
Doctors across the state and across a range of specialties are adjusting. Gregory Perron, M.D., a family care doctor at MUSC Health, had never used telehealth before the pandemic. “I see patients from the child-adolescent years on up but the majority of my patients are adults. During the pandemic, I’ve done video visits for patients as young as 6 and as old as 95.”
That works for a majority of the problems he treats. “We can really provide very good care via telehealth. I have some people who drive from Myrtle Beach and Florence where taking a half day off or a whole day off to drive to my office to have a brief office visit — if a physical exam isn’t needed — is not a good use of the patient’s time. I think there will definitely be a role for continuing telehealth visits after the pandemic.”
When Perron needs to see patients in person, he arranges that at the end of the video visit. “For example, if a patient brings up a rash, back pain or joint pain, I may arrange for an in-person exam.”
Dr. Eva Serber
MUSC Health psychologist Eva Serber, Ph.D., has seen advantages and drawbacks to telehealth during the pandemic. “My behavioral medicine clinic works solely with medical patients — people who are medically ill. That includes patients who come from all around South Carolina to the state’s only organ transplant center at MUSC.”
Telehealth allows them to get mental health care at home. “People sometimes have to travel anywhere from two to four hours for an appointment with us. Add sickness to it, and that makes it very difficult. Telehealth lets them stay safe in their homes and to continue to get the treatment they need.”
But there are cons, too, Serber said. “There’s a variety of barriers that are widening our health care disparities. Some patients don’t have smart phones or any device that’s capable of video. Some might have video capability but they don’t have good internet service. And some patients just don’t like the video or aren’t comfortable using technology. I have patients who are like, ‘When do I get to see you in person?’”
It’s a reminder that just having technology doesn’t ensure that it works for everyone and every situation. The pandemic has given telehealth a growth spurt with a few growing pains as well.
Gipson, the lawyer who needed hernia surgery, liked that it allowed him to see Evans without leaving Columbia. “That really made it convenient. If I’d come down, I’d have been on the road for an hour and 45 minutes both ways for an appointment that may last a half hour. It’s an important half hour, but she was able to convey all of those things through telehealth.”
Evans said telehealth made sense for her, too. “I reviewed his CT scan, which he got in Columbia, before our video visit. I was able to share my screen and go over it and explain how I was making decisions about planning his operation. We talked about the risks and benefits. He wanted to move forward even though we’d never met in person.”
The surgery was a success. And so was Gipson’s experience with telehealth. “Especially in these times when you have concerns with COVID, it’s a reassuring way to be able to do it.”
By Jason Raven | October 23, 2020 at 5:28 PM EDT – Updated October 23 at 6:23 PM
COLUMBIA, S.C. (WIS) – Gov. Henry McMaster has petitioned the Supreme Court of South Carolina to rehear a case that ruled his new grant program for private school tuition is unconstitutional.
McMaster tried to allocate $32 million of his GEER funds for the SAFE Grants program.
For background, the Coronavirus Aid, Relief, and Economic Security (CARES) Act created “Governor’s Emergency Education Relief,” or GEER funding, for each state.
The state Supreme Court ruled the grants are prohibited by the state constitution because they use public funds for the direct benefit of private educational institutions.
By Jason Raven | October 23, 2020 at 5:28 PM EDT – Updated October 23 at 6:23 PM
COLUMBIA, S.C. (WIS) – Gov. Henry McMaster has petitioned the Supreme Court of South Carolina to rehear a case that ruled his new grant program for private school tuition is unconstitutional.
McMaster tried to allocate $32 million of his GEER funds for the SAFE Grants program.
For background, the Coronavirus Aid, Relief, and Economic Security (CARES) Act created “Governor’s Emergency Education Relief,” or GEER funding, for each state.
The state Supreme Court ruled the grants are prohibited by the state constitution because they use public funds for the direct benefit of private educational institutions.
In the 33-page petition for a rehearing, the governor said the GEER funds do not qualify as state public funds.
The petition also says the ruling impacts some of the CARES Act allocations the General Assembly made earlier this year.
By Jason Raven | October 23, 2020 at 5:28 PM EDT – Updated October 23 at 6:23 PM
COLUMBIA, S.C. (WIS) – Gov. Henry McMaster has petitioned the Supreme Court of South Carolina to rehear a case that ruled his new grant program for private school tuition is unconstitutional.
McMaster tried to allocate $32 million of his GEER funds for the SAFE Grants program.
For background, the Coronavirus Aid, Relief, and Economic Security (CARES) Act created “Governor’s Emergency Education Relief,” or GEER funding, for each state.
The state Supreme Court ruled the grants are prohibited by the state constitution because they use public funds for the direct benefit of private educational institutions.
In the 33-page petition for a rehearing, the governor said the GEER funds do not qualify as state public funds.
The petition also says the ruling impacts some of the CARES Act allocations the General Assembly made earlier this year.
In September, lawmakers approved $115 million from the CARES Act to be used to reimburse local governments and independent colleges and universities in South Carolina for COVID-19 related expenses.
That money was put on hold by the Department of Administration because of the Adams v. McMaster ruling. The Department of Administration said, “Based on Admin’s internal review of the ruling and the opinion of Admin’s outside counsel, the conclusion was reached that Admin must refrain from disbursing money to private independent colleges and universities under Act 154 without further judicial direction.”
The federal government has also filed an amicus brief in support of McMaster’s petition for a rehearing in the case.
As telehealth transitions from a nice-to-have benefit to an essential form of care delivery, payers will have to make some adjustments in order to permanently integrate telehealth coverage expansions.
– Telehealth is metamorphosing and payers will have to take steps in order to permanently integrate telehealth coverage as a key form of care delivery.
When the coronavirus pandemic struck, Donna O’Shea, MD, chief medical officer of population health management for UnitedHealthcare, and other leaders at UnitedHealthcare watched as the payer’s telehealth claims shot up ten times higher than the previous year’s numbers.
It is now a familiar narrative, how the pandemic that swept the nation was a precursor to the largest surge in telehealth utilization in American healthcare’s history. Telehealth uses that might have taken years, perhaps decades, to adopt were integrated into the healthcare delivery system seemingly overnight.
“The COVID-19 pandemic may prove to be a watershed moment for the healthcare system, prompting a surge in the use of virtual care,” O’Shea told HealthPayerIntelligence in an email interview.
Donna O’Shea, MD, UnitedHealthcareSource: UnitedHealthcare
Now, payers face a new crossroads with telehealth. As telehealth waivers expire and utilization stabilizes as in-person visits return, the healthcare industry may be tempted to return to a pre-COVID mindset about telehealth.
But that may not be able to happen.
“Going into COVID, telehealth had become a nice-to-have benefit for employees who needed convenient care for minor issues and it wasn’t built with an orientation to be much more than that,” Mike Thompson, president and chief executive officer of National Alliance of Healthcare Purchaser Coalitions, told HealthPayerIntelligence. “What we have found since COVID is that, when telehealth went mainstream, the expectations went way up. As we go forward, I think it becomes more of an integrated strategy. It becomes an expectation that this is a modality that providers will use.”
A shift is coming, Thompson and O’Shea confirmed. Payers will need to support the healthcare system’s transition from viewing telehealth as an “add-on” benefit to a permanent, integrated solution.
There are a couple of questions that payers need to ask in order to develop long-lasting telehealth strategies. First, what telehealth services are the most sustainable long-term? Second, what payment strategies are appropriate for these services? The answers may vary across payers, but, overall, some themes are emerging.
What services can be provided virtually on a long-term basis?
Payers and providers have implemented telehealth for a broad range of services. However, to integrate telehealth permanently into health plan structures, payers need to assess which services are best suited to telehealth.
An early analysis of COVID-19 telehealth utilization published in May 2020 found that approximately 20 percent of all Medicare, Medicaid, and commercial outpatient, office, and home healthcare spend could transition to virtual care. This equates to around $250 billion worth of care.
Specifically, 35 percent of home healthcare, 24 percent of office visits, and 20 percent of emergency department visits could be virtualized, the report asserted.
In some areas of healthcare, payers can build on progress made before the pandemic struck.
“One of the most exciting spaces and where we’ve seen a lot of the initial growth is going to be in behavioral health,” said Thompson.
Telehealth was already being integrated as a care delivery platform for behavioral healthcare before the pandemic. With the shutdowns and the increase in behavioral and mental healthcare demand, the need to use telehealth for these conditions was inescapable.
The coronavirus pandemic took behavioral telehealth one step further.
“You don’t become a telebehavioral health provider or a regular provider. Increasingly, practices are both,” said Thompson.
The pandemic has confirmed for Thompson—and many in the payer industry at large—that many members now view telehealth as their preferred care delivery model for behavioral healthcare.
Source: McKinsey & Company
Partly, members enjoy the convenience of not having to travel to a provider’s office and still being able to connect virtually. It also diminishes the likelihood that members will experience stigma, Thompson pointed out, since they do not even have to walk outside their homes in order to see their provider.
However, other uses for telehealth have emerged due to the pandemic and the payers must identify which uses should become more permanent.
“Payers are starting to bifurcate a little bit between telehealth as a triage tool versus telehealth as a subacute or medication maintenance or check-in platform for patients to just see their providers,” Tim Epple, principal at Avalere, told HealthPayerIntelligence.
Early data indicates that using telehealth to triage is an effective way to reduce healthcare spending, he said. Ensuring that members are accessing the right level of care and not accruing unnecessary costs through avoidable trips to the emergency room is possible by simply offering a 24/7 triage telehealth platform for members to contact.
“The triage point is where you can see really clear, immediate savings,” Epple added.
In fact, in 2018, AHIP estimated that payers save over $6 billion annually by promoting remote care and telehealth options that allow members to access care from home instead of going to emergency or acute care sites.
Whereas the pandemic has tested and proved telehealth’s triage capabilities, for other telehealth uses payers may need to gather more long-term data to determine if telehealth should be permanently integrated into those care delivery processes.
“It’s going to take a little bit longer for payers to really understand, how does that potentially greater adherence to medication management hit our bottom line? Do we think doing physical therapy or other historically in-person services virtually are actually meeting the bill in terms of outcomes?” Epple said.
Thompson emphasized the ways in which telehealth could develop a more permanent, widespread role in primary care.
“We should put a lot more emphasis on primary care,” he said. “As part of putting more in some primary care, we should be building in virtual integrated care.”
O’Shea at UnitedHealthcare agreed.
“While virtual care has historically helped address minor medical issues, including allergies, pinkeye, fevers, rashes and the regular flu, we are starting to see an expansion of the types of services being offered remotely,” O’Shea noted. “The most promising developments include virtual care resources to help expand access to primary care and support chronic disease management, behavioral health, and certain types of specialty care (dental, vision and hearing).”
O’Shea emphasized that acute or follow-up virtual care can be essential for members who have complex conditions that prevent them from being able to visit the provider’s office in person.
Upon identifying forms of care that can be offered on a long-term basis, payers may find that they have to make adjustments to solidify these benefits.
For example, UnitedHealthcare has added the home as a qualified site of care to make remote patient monitoring and virtual care more accessible.
“Moving forward, we will continue to recognize the home as a qualified site of service,” said O’Shea. “This helps make it more convenient for millions of members to remotely access their own healthcare providers for certain services, including primary care physicians and specialists, outside of the provider’s office. This is an important change designed to help encourage members and care providers to continue to use virtual care, even after the pandemic wanes.”
How do we determine reimbursement for telehealth and virtual care services?
The ongoing conversation about how to properly reimburse for telehealth services will be a huge component of permanently integrating telehealth as a mode of care alongside provider offices, hospitals, and other physical sites of care.
Traditionally in this debate, providers are portrayed as universally advocating for parity between reimbursement for telehealth and in-person care while payers, by and large, resist payment parity for cost reasons.
However, Epple pointed out that there is actually more nuance to both the payer and provider views than it might appear initially. Leveraging overlapping incentives with virtual-only care providers can help payers move the conversation forward in at least one area of care.
Tim Epple, AvalereSource: Avalere
“Brick-and-mortar providers in general are probably more likely to want payment parity or relatively close to payment parity simply because they do have likely higher input costs for running their clinics and offices, but also may be seeing the patient in person as well as virtually,” Epple said.
Providers who work primarily in-person are going to be using CPT and HCPCS codes and prices that are already well-established for their in-person services. If payers try to negotiate lower rates with in-person providers, these providers are acutely aware of how much money they are losing in contrast to their in-person rates.
Strictly virtual providers, on the other hand, may be more open to novel payment arrangements.
Platforms like Teladoc and Doctor on Demand, Epple noted, might have more flexibility to adopt compensation structures that allow for a per member per month payment rate or a subscription fee model.
Nearly every payer has leveraged this type of strategy to some degree, but Epple anticipated that those novel arrangements with virtual care providers will expand.
Setting novel payment arrangements with virtual-only care providers not only has the potential to decrease healthcare spending, but it can also function as a known expense for payers at a time when future spending is uncertain.
As payers wait to see how COVID-19 affects utilization, whether a second wave will arise, and COVID-19’s impact on premiums, at least the bill for their virtual care advanced payment model will be predictable.
Ultimately, data related to long-term telehealth usage will be the main factor that settles the reimbursement debate.
“The data is still being developed to understand what the actual cost offsets or what the right payment rate looks like for telehealth. That’s something that we’ve talked to both plans and providers a lot about,” said Epple. “If there is any silver lining to 2020 in the last six months, I do think a lot of it is going to be the fact that payers are now generating a lot of data about how their chronic care patients have access to services via telehealth.”
Mike Thompson, National AllianceSource: National Alliance
Thompson agreed that now is the time for payers to lean on value-based care arrangements to incentivize telehealth as an essential care delivery platform.
“If payers prefer providers that provide the full suite of support that their members are looking for, the providers will go there,” said Thompson. “The problem often isn’t that providers aren’t willing to go there, it’s that the incentives are locked in to an old way of thinking and not what the new environment could be.”
Primary care telehealth in particular would benefit from a population-based, prepaid model, Thompson noted.
“If you don’t pay on a fee-for-service basis, you make smart decisions on how to take care of patients,” he pointed out. “That empowers providers to think in a more patient-centered way about what they actually need to see that patient for, and how they can conveniently provide the care.”
This debate will likely need to be decided by the end of the year, Thompson projected. As utilization drops back to more stable levels, payers are letting their telehealth waivers expire. When those waivers are no longer in place, the conversation about reimbursement will naturally come to a crossroads and the industry will have to make a decision.
“One of the positive things about telehealth is that it’s technology-based,” Thompson added. “Technology does allow us to integrate more systematic measurement, more systematic checks and balances into the system. We should take advantage of that. There’s no reason that virtual care couldn’t be more standardized and effective care.”
While the data is still being developed regarding the actual cost benefits of more widespread telehealth utilization, as Epple indicated, there is no doubt in O’Shea’s mind that telehealth is something UnitedHealthcare members want.
In fact, during the pandemic, the nation’s favorability towards telehealth rose, particularly among seniors who, historically, have been a difficult demographic to engage with telehealth.
Over three-quarters of seniors who used telehealth said that they would do so again in the future, according to a study on behalf of Better Medicare Alliance. More than nine in ten reported that they had a positive experience.
Thus, as UnitedHealthcare follows state and federal guidelines around virtual care reimbursement and the dust settles on that subject, O’Shea said that the payer will continue to encourage member utilization of telehealth tools.
“Continuing to drive the adoption of virtual care will be aided by multiple strategies, including the use of pro-consumer health plan designs that may make this technology more affordable, convenient and simple; consistent and customized communications that may help people identify virtual care resources and take more steps to use it; and supporting care providers so they are better able to make virtual care a key part of their practices,” said O’Shea.
As payers seek to permanently integrate telehealth into their healthcare delivery strategy, solidifying what care services most benefit from telehealth and how much they should reimburse providers will be challenging but pivotal.
By Jason Raven | September 28, 2020 at 6:47 PM EDT – Updated September 28 at 8:47 PM
COLUMBIA, S.C. (WIS) – Since the start of the COVID-19 pandemic, the Columbia VA Health Care System said call volume to the Veterans Crisis Hotline increased as much as 30%.
They said veterans calling the hotline are feeling isolated right now.
Mental health professionals said they have had to adapt how they reach struggling veterans because of the pandemic.
Andrew Selking was in the Army for more than 20 years. He said near the tail end of his military career he began to have thoughts of hurting himself.
“You need to be in a safe place,” Selking said. “It gives you that extra time. Time is what you need to get better.”
Selking reached out for mental health help. He has been receiving services from the VA for five years now. He said when the pandemic started he began getting those same services virtually through telemedicine.
“It’s actually been a lot quicker,” he said. “My doctor is able to fit in more appointments using telehealth.”
With the novel coronavirus continuing to proliferate around the world, more and more people are suffering from a different kind of pandemic: mental health and substance abuse disorders.
In response, the South Carolina Department of Mental Health teamed up with the Department of Alcohol and Other Drug Abuse Services to create 844-SC-HOPES, an anonymous 24/7 support line for those who are struggling to cope with the numerous hardships created by the COVID-19 pandemic. In addition to mental health and addictions support, the hotline was also designed specifically to help healthcare workers and those suffering financial hardships.
Deborah Blalock, deputy director of the DMH, said when people began to practice social distancing in early March, some were disconnected from their support groups, which sometimes results in a relapse.
“If people are isolated, if people can’t reach their support groups, then they’re going to perhaps drink or use other substances,” Blalock said. “We knew that for the mental health population, that being isolated may increase depression.”
Many people are facing increased anxiety over their own personal health, job security, and the wellbeing of their loved ones, Blalock said.
In a matter of weeks, the new support line was set up in collaboration with local providers and licensed mental health and substance abuse counselors. A healthcare outreach team was created to serve healthcare workers who are struggling with the stressors caused by battling the virus firsthand.
The SCDMH provides care regardless of a person’s ability to pay but people do receive a bill. Blalock said a grant covers the costs of services.
Sara Goldsby, director of the DAODAS, said in addition to the SC Hopes hotline, many of the traditional services provided by the DMH and the DAODAS have been moved online, so that people do not miss out on support, as they practice social distancing.
“People don’t need to feel disconnected and isolated,” Goldsby said. “All of the treatment services that folks would typically receive at our county alcohol and drug authorities are available by telehealth and by telephone; and this main support line that’s accessible to any South Carolinian is that connection to those services. We really want people to be reaching out to connect.”
After signing a memorandum of understanding, Palmetto Care Connections Chief Executive Officer Kathy Schwarting, left, Orangeburg County School District Superintendent Dr. Shawn Foster, center, and Regional Medical Center President and CEO Charles Williams come together for a celebratory fist bump.
The Orangeburg County School District has developed a mobile application that can link its students and their families with telehealth services.
It is something that Annesia Jackson is happy about. The Dallas native moved to Orangeburg three years ago and has two daughters who attend school in the district.
“I think it’s important. It gives ready access to a health care representative to be able to assist in situations so we don’t have to call and have a waiting time. We can get online and be able to speak to someone right then and right there to help out in a situation,” Jackson said.
She added, “This would be really good for us as parents, I believe, just to get that immediate help right then and there.”
OCSD partnered with Palmetto Care Connections, a Bamberg-based nonprofit telehealth network; the Regional Medical Center; Family Health Centers Inc. and Bamberg Family Practice for the creation of a S.M.A.R.T. (Students’ Medical Access to Resources in Telehealth) Virtual Health Collaborative.
School officials, along with those from partnering agencies, converged upon the district office in Orangeburg on Monday to announce the effort.
Under the initiative, a S.M.A.R.T. Virtual Health Collaborative app now appears on all district-issued devices and leads to a webpage of telehealth providers. Students and families can also begin accessing telehealth services through the district’s website by clicking on the app and selecting a provider of their choice.
S.M.A.R.T. can also be accessed directly through the following link: www.ocsdsc.org/telehealth. Individuals can also simply go to www.ocsdsc.org, click on Quick Links at the bottom right of the page, scroll down to Parent/Student Resources and click on OCSD – SMART Virtual Telehealth.
OCSD Superintendent Dr. Shawn Foster said it is critical to provide access to health care services to individuals who are not only without transportation, but the necessary technology to access the services remotely.
Foster recalled speaking with RMC Chief Executive Officer Charles Williams about the challenge.
“I recall Mr. Williams and his epidemiologist were talking about some of the struggles that they were having here in the community in regard to access, that he had people in this community calling in, wanting to see a doctor,” Foster said.
If the caller said they didn’t have transportation, “the hospital then followed up and would ask, ‘Well, do you have a device to use?’ They said, ‘Well, I don’t have a device. I don’t even have a smart phone.’ So they found themselves in a challenging situation, where they were trying to provide services over the phone, which is not an ideal circumstance,” he said.
Foster said it wasn’t long before the FHC came on board with the telehealth initiative.
An opportunity existed that allowed OCSD to fill a gap in providing services, he said.
“I’ve said since day one that I hope to have Orangeburg in a space where our education is no longer product-driven, that we’re solution-driven.
“When I say product-driven, I mean it’s more than about getting 24 credits and getting a high school diploma. It’s about being an educational institution that is willing to seek solutions to gaps that we have in our community,” he said.
The superintendent thanked the other community partners such as Palmetto Care Connections and its staff, including Director of Technology Matt Hiatt.
PCC is seeking to expand the list of providers in the S.M.A.R.T. Virtual Health Collaborative. There is no expense to medical entities for participation in the collaborative, but there is a request that they provide professional and patient care to those they serve.
PCC Chief Executive Officer Kathy Schwarting said, “Our whole purpose and mission in life is to make sure that rural and underserved communities have access to care. I’ve spent 25 years in rural health care, and I’ve always said that your zip code should not define the quality of service you have, the type of service, or the quality of the life that you live.”
“If you want to live in Orangeburg, Bamberg, Allendale, you should still have access to the same high-quality services. That’s what PCC is built on. … We have helped lots of rural communities in the state implement school-based telehealth, but not with the vision that Dr. Foster has had. So I’m very grateful for that,” Schwarting said.
Schwarting said children will still have access to their primary care providers.
“We have other primary clinics in the county and around the county that would like to participate. We also believe that children should have access to their primary care provider. If they already have a medical home, don’t ship them out to a health system. Let them see their health care provider if at all possible and then let the health systems, if needed, complement that service for some specialty services,” she said.
“So we’re very blessed in this community to have Mr. Williams, Dr. Foster, the Family Health Center,” she added.
Williams said, “I am so thankful to Dr. Foster. We sat down and we talked about this. The entire discussion that we had for probably a little over two hours that day, it was never about us. It was all about how we can serve.”
“Many of you that know me and you know our team, it’s all about trust, building sustainability and always focusing on the community. We do nothing for ourselves, but for the people we are blessed to serve. We are nothing but tools to be used by the master carpenter to do his work,” he said.
Williams said the mobile app will allow more people to have access to health care.
“By the grace of God and this partnership, patients that need care now, if they have a school-age child with this device in their home, they will have access. … We will be able to send them a link, they will be able to hit the link, and they will be able to be seen by their provider. Everything cannot wait.”
BAMBERG, SC—Palmetto Care Connections (PCC) Chief Executive Officer Kathy Schwarting announces that Chief Executive Officer of CareSouth Carolina, Ann Lewis and retired Director of SC Department of Mental Health John H. Magill have joined the PCC Board of Directors.
“Ann Lewis is a pioneer in her field. She has shepherded growth over the past 30 years addressing health care needs of the Pee Dee community. CareSouth Carolina now serves more than 38,000 patients and staffs over 500 employees in ten rural communities,” said Schwarting. “CareSouth Carolina has been an early provider of telehealth services in rural communities, and PCC is fortunate to have Ann’s knowledge and expertise on the board.”
Lewis has served as the Chair of the Greater Pee Dee Champion Community and on the Hartsville Rotary Club; the Coker College Board of Visitors; Darlington County Communities in Schools; Pee Dee Area Health Education Consortium; Pee Dee Alzheimer’s Association; the Children’s AIDS fund, Northeastern Rural Health Network, and many other groups.
Through CareSouth Carolina, she provides volunteer support to the American Cancer Society; American Heart Association; local chambers of commerce; downtown development associations; local agri-tourism; and was awarded the 2004 South Carolina Ambassador for Economic Development by South Carolina Commerce and the Governor, as well as numerous Volunteer of the Year awards by the organization.
On a state and national level, Lewis is the founding president of the South Carolina Rural Health Association and a former president of the South Carolina Primary Health Care Association. The National Association of Community Health Centers (NACHC) presented Ann with the 2012 John Gilbert Award, which recognizes longstanding excellence and leadership in community health. She received The Champion Award presented by the South Carolina Primary Healthcare Association in 2017 for her “extraordinary leadership, commitment and dedication to the vision and mission of community health centers.”
“PCC also welcomes John H. Magill to the board of directors,” said Schwarting. “PCC has had a long-standing partnership with SCDMH, and Mr. Magill has been an advocate of PCC’s work and a champion of telehealth for many years. After his extraordinary career in mental health, PCC is honored and privileged to have him as a board member.”
Magill retired as the SC Department of Mental Health State Director in January 2019, a position he held for 12 years. He is currently the longest serving public mental health director in the United States.
Magill began his career with the Department at the former South Carolina State Hospital in the 1960s. During his career, he served as the state of Georgia’s director for Alcohol and Drug Abuse, he was the founder and Chief Executive Officer of Fenwick Hall Hospital on Johns Island, South Carolina, and he also served as a deputy chair and Professor of Psychiatry in the Medical University of South Carolina’s Department of Psychiatry.
Magill received the Governor’s Award: The Order of the Palmetto in 2011 in recognition of his service to the citizens of South Carolina and contributions to behavioral health care. In October of 2011, the University of South Carolina’s School of Medicine honored Magill with the Dean’s Distinguished Service Award in recognition of his ongoing commitment to the School, where he remains a clinical professor of Psychiatry.
Under his leadership, SCDMH launched its nationally acclaimed Emergency Department Telepsychiatry program, which was developed to meet the critical shortage of psychiatrists in South Carolina’s underserved areas and assist hospital emergency rooms by providing appropriate treatment to persons in a psychiatric crisis. The program employs state-of-the-art telehealth technology to connect SCDMH psychiatrists to hospital emergency departments throughout the State.
Built on the success of its telepsychiatry services to emergency departments, SCDMH equipped its hospitals, mental health centers, and clinics to provide psychiatric treatment services to its patients via telepsychiatry. From 2013 – 2020, the Telepsychiatry Program has provided more than 223,000 psychiatric treatment services to SCDMH patients throughout South Carolina. SCDMH is the largest provider of telehealth services in the state.
Established in 2010, PCC is a non-profit organization that provides technology, broadband, and telehealth support services to health care providers in rural and underserved areas in S.C. PCC leads the S.C. Broadband Consortium which facilitates broadband connections for health care providers throughout the state. PCC co-chairs the South Carolina Telehealth Alliance, along with the Medical University of South Carolina, partnering with health care organizations and providers to improve health care access and delivery for all South Carolinians.
Palmetto Care Connections (PCC) is the telehealth network for South Carolina that offers telehealth support services to rural and underserved health care providers.
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