We wrote previously about how COVID-19 has shifted the Value Equation for Telehealth. Doctors previously didn’t value Telehealth since it was the same work (or slightly more) for possibly less reimbursement. Now doctors value social distancing (or at least they have no real choice but to social distance) and that revamped the value of telehealth.
The problem is that I think we all believe that we’ll eventually be able to go back to office visits. Once that happens, the reimbursement side of the value equation becomes much more important. If telehealth reimbursement isn’t on par with in person visits, you can easily see many doctors sliding back into the in person visit norm.
While it’s easy to just say “Let’s extend telehealth payment parity” and that will solve the telehealth reimbursement problem, that’s far too simplistic of a view. If telehealth just included video visits with patients, then this was probably doable. There would still be some challenging questions that have to be answered around dealing with fraudulent video visits, what types of visits should and shouldn’t be done with telehealth, and other things like that, but in many ways a video visit mirrors what’s done in an in person visit. Most payers can get their heads around this and reimburse for it on par with an in person visit.
The problem is that telehealth visits include much more than live video visits. This graphic illustrates some of the broad types of telehealth:
Source: IDTechEx report “Digital Health & Artificial Intelligence 2020: Trends, Opportunities, and Outlook“
I’d probably add a category of Chronic Care Management companies that use telehealth as a modality to this chart. Also, I’d probably remove the Mobile Health (mHealth) section, but it does highlight that basically anything that touches the patient digitally is now considered telehealth. However, the chart does show the 3 main sections of telehealth: Live Video Conferencing, Aynchronous Communication, and Remote Patient Monitoring (RPM).
How are payers going to reimburse across this wide spectrum of telehealth post COVID-19?
It’s great that Medicare announced that they’d reimburse at the same levels for a voice only telehealth visit during COVID-19. Will that last? They were reimbursing for some limited remote patient monitoring before COVID-19, but at much lower levels. There was good reason for reimbursing at those levels. If they’re not careful, it’s ripe for abuse and there’s the important question of whether things like remote patient monitoring should be reimbursed at the same level as an office visit.
As you navigate this reimbursement world, it gets complex really fast. Should the reimbursement be based on the cost to provide the service to the patient? Or should the reimbursement be based on the value that’s created for the patient, the health system, the payer, the provider, etc?
Just to complicate matters more, how are we going to start reimbursing things like at home strep tests and other at home testing that’s becoming popular during COVID-19? Who gets paid for that? And how are we going to reimburse for the follow up visit that looks at the results of the at home test? And does that follow up visit need to be a video visit or will a few text messages with your provider that says that everything is normal and you can continue the previous treatment plan be enough? Are we going to reimburse these text messages which accomplishes the same thing as an office visit the same way? What if it was an asynchronous video message or a phone call?
Let’s not even get started on the various ongoing monitoring that happens with remote patient monitoring technology. The idea has always been great, but the reimbursement model for it has been a challenge to figure out. The technology is there to provide this service. Will it finally happen thanks to COVID-19?
The obvious elephant in the room here is that I’m describing a fee for service world. It’s amazing how many of the questions above go away when you replace a fee for service approach to healthcare with a value based care reimbursement model.
Seems easy enough. Let’s just switch to a value based care model. Then, the clinician can just do what’s right for the patient and their health and they don’t have to worry about being reimbursed on a fee for service basis.
Sounds great until you get into the nitty gritty of value based care. It comes with its own questions about how much a clinician should be paid for each patient. If our understanding of humans and their health was perfect, we could do this really well. Unfortunately, we’re not there yet. So far many of the value based care efforts feel like they’re just shifting the healthcare costs around on the Titanic. It’s worth figuring it out for all the reasons mentioned above, but we’re not there yet.
Some would like to proclaim direct to consumer options as the solution. This is definitely a solution for many that can afford it and will be effective within that market. However, that’s only one segment of the healthcare market. What does that mean for the rest of the health system?
What does this all mean for telehealth reimbursement?
The future of telehealth is going to be a mix of fee for service and value based care. We’ll have to ask and answer the hard questions about how we reimburse telehealth in a fee for service world. We can’t just use the pandemic as a way to flip the value based care switch on even if many would like to do so.
As I’ve predicted a few times, watch telehealth reimbursement as an indicator of its future in healthcare. If we get it right, telehealth will become just another modality of providing care to a patient. If we do it wrong, many will slip back to the previous status quo. However, don’t underestimate the complexity of telehealth reimbursement. Also, don’t underestimate patients who will expect telehealth going forward. That should be reason enough to make sure we get telehealth reimbursement right.