In the spring of 2020, Mike Meehan spent a month unconscious and intubated for severe COVID-19 at New York-Presbyterian Hospital. When he returned home, he started meeting with a therapist to help him recover mentally from his serious illness.
He worries a policy change by his insurer will disrupt his progress with his telemedicine provider.
Related: Aetna to cut some virtual care coverage
Meehan’s insurer, CVS Health subsidiary Aetna, will cut commercial telehealth coverage for dozens of services Dec. 1, including some behavioral health services. The coverage had been extended past the end of the public health emergency.
“It's upsetting to see and it's upsetting not to get clarification on it,” said Meehan, who works as a commercial insurance account manager at Willis Towers Watson, an employee benefits consultancy.
As hospitals and clinicians’ in-person capacity has increased and consumer demand for most telehealth visits wanes, many commercial carriers are reevaluating their virtual health coverage. Providers, payers and patients’ inevitable fight over virtual care access and pay has come to fruition.
Congress mandated insurers pay providers equal rates for virtual and in-person care for Medicare enrollees during the COVID-19 pandemic, and many commercial carriers followed suit, leading more patients to schedule telehealth visits. Regulatory flexibilities also contributed to an explosion of venture capital investment in new digital health companies.
But many health systems have had trouble maintaining mental health services amid a lack of practitioners and inconsistent reimbursement by commercial insurers.
Dr. Joseph Betancourt, president of the research institute the Commonwealth Fund and a practicing primary care physician, said it makes sense for insurers to roll back commercial coverage for services better suited for in-person visits, like ophthalmology services.
But he said he worries that changes in commercial reimbursement will limit the services health systems can offer. Virtual care is often necessary for patients who live in rural areas and must drive long distances for care, those who don’t have transportation and patients who don’t speak English as their first language, he said. It is also a good fit for mental healthcare, for which there is a lack of practitioners and a major stigma, Betancourt said.
“Virtual care plays an important role in behavioral healthcare, especially as it relates to health equity,” he said.
Aetna's commercial telemedicine coverage is more extensive than its pre-pandemic offerings and "the modifications are in-line with the industry,” a spokesperson wrote in an email.
Insurance lobbying group AHIP declined to comment.
Limiting commercial reimbursement for mental health services could exacerbate other problems, said Vasanta Pundarika, head of the healthcare investment banking group at Matrix Capital Markets Group.
It has been increasingly hard for patients with severe mental health conditions to find available beds among post-acute providers. As a result, patients are being treated in hospital emergency departments for increasingly long stints, sometimes waiting for weeks, months or years for placements.
“If a lot of those [downstream referral] partners were using telehealth services for mental health and substance use services, it might result in patients staying in the ER longer, or getting discharged and ending up back in the ER,” said Pundarika, who described Aetna’s coverage changes as “shortsighted.”
Insurers have been lobbying for more regulatory flexibility when it comes to virtual care services.
Companies support a House bill that would allow employers to exempt telehealth services from the Affordable Care Act’s consumer protection requirements. Insurers also support the continuation of some COVID-19 flexibilities, such as allowing telehealth providers to practice across state lines.
“We’re trying to encourage the right kind of care in the right settings,” said Jennifer Jones, executive director of legislative and regulatory policy at the Blue Cross Blue Shield Association. “There's been some right-sizing as people have had more options, and we've learned more about what is effective in telehealth and what is less effective.”
Some insurers are increasing copays and cost-sharing requirements that were relaxed during the pandemic, she said. Carriers are also reevaluating their payment to providers. Because telehealth does not require the same overhead resources from providers, it should not be paid at the same rate as in-person visits, Jones said. Telehealth also could potentially increase healthcare costs by promoting easy access to unnecessary care.
“I would expect that the way that we're administering these things to be responsive to changes in the environment," Jones said. "Otherwise, we're not being good stewards of our resources, and we're not moving with the dynamics of the healthcare system.”
The dispute has made its way to state legislatures. All but seven states and Puerto Rico have regulatory language requiring insurers to pay for virtual doctors' appointments, according to the National Consortium of Telehealth Resource Center’s Center for Connected Health Policy. But these policies do not mandate carriers cover every virtual care service. Twenty-two states require carriers to pay providers the same rate as in-person visits, according to the consortium.
Even in those areas, many of the state laws lack specificity so the reality looks very different than the intent of the statutes, said Mei Kwong, executive director of the Center for Connected Health Policy.
“If we can spot an off-ramp, we're pretty sure the health plan can too,” Kwong said.
