Today I read an interesting piece by Sean Cavanaugh, chief policy officer of ACO sponsor Aledade Inc. The piece, which appears in the Health Affairs blog, looks at the state of telehealth in the U.S. and how we got where we are. It also makes some recommendations on how to think about telehealth in the care mix going forward.
In his article, Cavanaugh asserts that it’s time we develop a rational, thoughtful policy for telehealth use, one which assumes that telehealth services will be a meaningful part of our care delivery system from now on. As things stand, we’re somewhat rudderless on the telehealth policy front. We still haven’t figured out where things should go in the wake of the telehealth explosion sparked by COVID-19. This explosion changes the boundaries of the system we had in place before which, he notes, was designed to keep telehealth far at the fringes.
As he points out, in 2016 only one-quarter of 1 percent of all Medicare beneficiaries had used the telehealth service once during the entire year. This is not so surprising, Cavanaugh notes, given that Medicare’s first-ever telehealth benefit included so many limitations on how it could be used.
Among other things, the original rules required that a beneficiary be in an “originating site,” such as a rural health professional shortage area, physician’s office, hospital or community mental health center. Not only that, Medicare only agreed to pay for care on a list of specified services provided by CMS.
Over the last 10 years, however, Medicare’s telehealth reimbursement policies have changed substantially. For example, feds began lifting some restrictions and creating exemptions allowing for telehealth reimbursement. Notably, in 2018 CMS began allowing Medicare Advantage plans to offer telehealth services as a basic benefit rather than a supplemental one and began reimbursing for telestroke, home dialysis and substance abuse telehealth visits. (It’s worth reminding ourselves, of course, that commercial payers have been moving in the same direction.)
Then, of course, the pandemic hit, and it exploded the patterns of telehealth we’d seen in the past. Between mid-March and mid-June 2020, telehealth use in Medicare shot up from near zero to more than 20 percent. More broadly, the number of US telehealth visits set up 50% during the first quarter of 2020 alone, according to the CDC.
Perhaps more importantly, it’s begun to look like high levels of telehealth use are here to stay and not just a response to the pandemic crisis. Just how big of a shift are we talking about over here? According to McKinsey & Company, 250 billion of current US healthcare spending could potentially be virtualized. In other words, telehealth is definitely part of a new normal.
The issue, Cavanaugh suggests, is how to fit telehealth services to the existing framework wisely. ”We can’t go back to a system in which virtually no one could use telehealth,” Cavanaugh writes. ”But the alternative should not be to create a new piston in the fee-for-service utilization engine either.”
The key to whether this change lasts, he says, is to embed telehealth in a payment system already designed to prevent overutilization. “In that kind of system, telehealth can be used prudently – as a substitute for in-person care – rather than as an addition to in-person care,” he suggests.
I personally have not seen any data suggesting that telehealth visits are leading to bloated spending or delivery or duplicative care, though I suppose such data might exist. In other words, I’m not entirely sold on the idea that the most important reason to consciously design telehealth into our existing health system is cost control.
However, I do share Cavanaugh’s belief that we need to rethink how the health system works now that telehealth has become a major component of care. When we encounter anything that rocks our healthcare system the way telehealth has, making specific plans for how to marshal such forces effectively is a very good idea.