On March 13, 2020, President Trump made an emergency declaration under the Stafford Act and the National Emergencies Act, empowering The centers for Medicare and Medicaid Services (CMS) to issue waivers to Medicare program requirements to support health care providers and patients during the initial onset of the COVID-19 Public Health Emergency (PHE) pandemic. One of the first actions CMS took under that authority was to expand Medicare telehealth, and on March 17, 2020, CMS issued an announcement allowing all Medicare beneficiaries – not just those in rural areas – to receive telehealth in any location, including their homes.
Patients weren’t the only ones who benefited from the location rule changes. CMS also issued a waiver allowing physicians and other qualified healthcare professionals to conduct telehealth services from any location (e.g., their home) and bill through their normal practice location.
In addition, CMS added 135 allowable services, more than doubling the number of services that beneficiaries could receive via telehealth. Examples include emergency department visits, initial nursing facility and discharge visits, home visits, and physical, occupational and speech therapy services.
At the same time, the Department of Health and Human services (HHS) Office of Civil Rights (OCR) announced that it would exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the emergency. These Stark law Waivers, along with additional DEA prescribing requirements and waivers, supervision requirement revisions and patient signature requirement revisions all played their part in bolstering telehealth as a vehicle for providing care to the American population.
CMS went even further from a reimbursement perspective to eliminate barriers to practitioners providing these services by paying for certain telemedicine visits (including both video and telephone only/audio), evaluation and management visits and behavioral health services at the same rate as similar in-person E&M services.
These CMS announcements not only impacted all governmental payors, but a majority of the commercial providers across the United states followed suit, ensuring their providers would be reimbursed for telemedicine visits at the same reimbursement rate that they would normally have received under their regular place of service visit as long as the PHE was still in effect.
The initial and more recent dramatic governmental cash infusions relating to funding telehealth that have taken place since March 2020 will continue to influence the patient accessibility for practitioner care. Some of the specific funding programs included the following:
- The CARES Act Reauthorizes HRSA Telehealth Resource Center grants through FY2025
- $200 million for the Federal Communications Commission to support the efforts of health care providers to address coronavirus by providing telecommunications services, information services, and devices necessary to enable the provision of telehealth services was used between April and end of July 2020.
- $1.032 billion for Indian Health Services for, among other things, increased capacity for telehealth and other teleworking capacity.
- $27 billion for the HHS Public Health and Social Services Emergency Fund for, among other things telehealth access and infrastructure.
- Department of Veteran Affairs:
- $14.4 billion to support increased demand for healthcare services at VA facilities and through telehealth.
- $2.15 billion to support increased telework, telehealth, and call center capabilities to deliver healthcare services directly related to coronavirus and mitigate the risk of virus transmission including the purchasing of devices, as well as enhanced system bandwidth and support.
All of this added up to unprecedented telehealth visit volumes in the health system. Prior to that Emergency Declaration on March 13, 2020, a total of approximately 13,000 Medicare beneficiaries had received a telemedicine visit in a week. By the last week of April 2020, this number had jumped to 1.7 million Medicare beneficiaries participating in a telehealth-based service. (Internal CMS analysis of Medicare FFS claims data for the dates of service period March 17 through June 13, 2020). Additionally, a report by HHS shows that nearly half (43.5 percent) of Medicare fee-for-service primary care visits were provided through telehealth in April, compared with far less than one percent (0.1 percent) in February before the PHE.
Even though telemedicine visit volumes have declined from the highs of April through June 2020, initial studies and data from national surveys of primary, medical and surgical specialists are expecting that, for the remainder of 2020 and at minimum through 2021, telehealth will account for at least 10% – 30% of established patient volume visits.
The spotlight on telehealth is continuing to receive national attention. On August 3, 2020, President Trump issued an additional executive order focusing on telehealth and improving access for approximately 57 million Americans living in rural communities by providing high-quality care through telehealth. The executive order included a requirement that within 30 days of the order (early September 2020), the Secretary of HHS will be required to announce a new model to test innovative payment mechanisms in order to ensure that rural healthcare providers are able to provide the necessary level and quality of care to their patients. The order also required the secretary of HHS develop and implement a strategy to improve rural health through better physical and communications-based infrastructure available to rural Americans. These orders included the following initiatives:
(a) increase rural access to healthcare by eliminating regulatory burdens that limit the availability of clinical professionals;
(b) prevent disease and mortality by developing rural-specific efforts to drive improved health outcomes;
(c) reduce maternal mortality and morbidity; and
(d) improve mental health in rural communities.
The latest proposed 2021 Physician Fee Schedule includes 9 CPT-10 codes that will become permanent as well as 13 codes that will be added to the list of telehealth services. The proposed fee schedule also clarifies that direct supervision requirements may be fulfilled while remote, removal of frequency limitations for facility inpatient-type telehealth services as well as clarifications regarding remote patient monitoring.
In addition to Federal laws, we see many states’ Medicaid programs also implementing their own specific laws for telehealth parity.
Even though Medicare’s coverage of a broad range of services is slated to end when the coronavirus no longer poses a public health emergency, and we would expect Private insurers, which followed the federal government’s lead, to revert to paying doctors for virtual visits at a fraction of the cost for traditional visits, all indications from CMS and HHS tells us that telehealth will play a part in our medical landscape in a meaningful and influential way for many years to come.
For additional information, contact Ronnen Isakov at risakov@medicmgmt.com.