A host of healthcare organizations and individual healthcare providers that advocated for expanded telemedicine want federal budget and Medicare payment advisers to look outside the Medicare program for evidence of the benefits of telehealth.
Twenty-two health systems and other organizations and individuals sent a letter to Keith Hall, director of the Congressional Budget Office and Mark Miller, executive director of the Medicare Payment Advisory Commission. They asked the two officials influential in setting Medicare program reimbursement policies “to look to evidence of telemedicine's effectiveness from the commercial sector, the Department of Veterans Affairs, Medicaid, and other programs when producing future cost estimates and analyses of telemedicine utilization in the Medicare program.”
While more specialties and regions that have staffing shortages are adopting the practice of telemedicine and more insurers are paying for it, its expansion has been slowed by both medical licensing laws and overall reimbursements.
But in 2014, the Federation of State Medical Boards cautiously expanded support for using certain technologies for remote patient-physician encounters, including initial visits.
Those recommendations, though not binding on its member states' medical licensing boards, have helped serve as a catalyst for wider acceptance of telemedicine nationally by medical regulators and state legislatures.
Today, 29 states and the District of Columbia have private telehealth coverage laws. That number is expected to grow to 32 states by 2017, according to a National Conference of State Legislatures estimate.
Medicare, the 800-pound gorilla of healthcare bill payers, is moving slower. In 2014, it proposed adding a slight expansion of payment rules to include telehealth wellness and behavioral health visits, and for telehealth services in rural areas nearer big cities than previously allowed.
But in 2015, Medicare paid out just $17.6 million for telemedicine services, a miniscule amount compared against the $546 billion in total Medicare expenditures that year.
As a result, there's simply not a lot of data within the Medicare program about the cost and clinical effectiveness of telehealth, a fact the letter writers both acknowledge and propose to address.
“The lack of Medicare data is understandable given the outdated statutory restrictions on telemedicine: since federal law prevents many providers from being paid when they use telemedicine to serve Medicare beneficiaries, obviously, little data is available,” they said. “There is, however, substantial experience utilizing telemedicine outside Medicare. Combined, we have authored many studies showing its quality and cost-effectiveness in fee-for-service as well as managed care environments.
“We hope CBO and MedPAC will consider these alternative sources of evidence in producing future cost estimates and analyses of telemedicine utilization in Medicare,” they wrote.
Organizations that signed on to the missive include Ascension Health, Christus Health, the Evangelical Lutheran Good Samaritan Society, the Scripps Translational Science Institute, Stanford Health Care, the University of Virginia Medical Center and the telehealth centers at the University of Mississippi and the UMPC system.
Individual signatories include Dr. Joseph Kvedar, vice president of the Connected Health program at Partners HealthCare, Boston; and Dr. Jack Lewin, CEO of the Cardiovascular Research Foundation and chairman of the National Coalition on Health Care, a not-for-profit coalition of healthcare and other organizations attempting to rein in soaring healthcare costs.
A few years ago, recalls Kvedar, Partners conducted a year-long study using telemonitoring to stay connected in the first two months of the program with about 300 of its congestive heart failure patients. The study provides a good example of telehealth efficacy that CBO and MedPAC officials might want to know about and consider.
“We have shown that a well-run heart telemonitoring program in our hands reduces readmissions by 50% and mortality by another 40%,” Kvedar said.
“The skeptics might say, (while) you may be avoiding readmissions, you may be driving up other costs,” Kvedar said. But the Partners study team covered that base, calculating that even with increased visits and the cost of running the monitoring program, the total medical expenses of the monitored patients was 14% lower than a similarly sized cohort of CHF patients without the early monitoring.
In cardiology, “I think we're going to transform a lot of what's going on over the next decade” to bio-monitoring and other remote communication techniques, Lewin said.
Even today, follow-up care after a discharge for an angioplasty or by-pass surgery is “really important,” Lewin said. “One of the most dramatic problems we have is adherence to medications.” But 60% of heart patients prescribed antiplatelet drugs to reduce blood clotting aren't taking them two months later, Lewin said.
“At some point or another asynchronous medicine may be the way to go,” Lewin said.
As Medicare and other payers continue to move toward value-based reimbursement, where readmissions produce penalties, not added revenue, “The motivations to do these things will be very strong, but we need to have it reimbursed,” Lewin said.