Considerations for Policy Makers Wanting to Optimize Telemedicine, Virtual Care

Through a collaborative effort by Catalyst for Payment Reform, the American Benefits Council, and Mercer, 4 key telemedicine considerations were issued for policymakers seeking to capitalize on the substantial growth in telemedicine and virtual care.

Through a collaborative effort by Catalyst for Payment Reform (CPR), the American Benefits Council, and Mercer, 4 key telemedicine considerations were issued for policymakers seeking to capitalize on the substantial growth in telemedicine and virtual care use, said Andréa Caballero, MPA, program director for CPR.


AJMC®: Hello, I'm Matthew Gavidia. Today on the MJH Life Sciences’ Medical World News, The American Journal of Managed Care® is pleased to welcome Andréa Caballero, program director for CPR.

Andréa, great to have you on. Can you just introduce yourself and tell us a little bit more about your work?

Caballero: Sure. Thank you, Matthew! Thanks for having me. My name is Andréa Caballero, and I am the program director for Catalyst for Payment Reform. In my role, I do a variety of things. Measuring payment reform at the state and national level is sort of my primary role. I also follow health policy issues, state and federally. About CPR, we're a national nonprofit 501(c)(3) independent organization that represents public purchasers [and] private purchasers, about 32 organizations that represent about 16 million plus covered lives and about $84 billion in health care spending.

AJMC®: Amid the COVID-19 pandemic, use of telemedicine and virtual health care have risen substantially as more patients seek care without the threat of infection. Can you speak on the current state of telehealth in the health care ecosystem?

Caballero: Sure, I guess it might be the understatement of the year if I were to say that the use of telemedicine has increased substantially. It's not just because this is the first time telehealth is being offered to employees. I think the most current statistic is from FAIR Health; t has a monthly health regional tracker on telehealth, and it's said that telehealth visits have increased 8336% year-over-year since April. So, that is a tremendous growth.

With that growth comes some challenges, so changes in the ecosystem. On the provider side, they're having to adjust to new technology, to relating to patients in a virtual way and not in a physical way. Payers are adjusting to new payment methods for telemedicine and they're having to adjust their benefit adjudication because they have rules now where they might have to waive copays or coinsurance. Regulators are responding very rapidly or trying to respond rapidly and implementing emergency rules. And of course, purchasers are looking just to make sure that their employees are getting the care that they need.

In the background, you have vendors who are offering telehealth services that are rapidly changing their business models and trying to keep up with the demand. And so you have all of these moving parts that really require fast adjustment during the pandemic, and it's within a system that historically just does not move very rapidly.

AJMC®: Beyond the social distancing attributes present during the pandemic, what are some other notable benefits of telehealth and ways it can surpass even that of normal in-patient care?

Caballero: I think if you talk to a normal patient—I myself have had a telehealth visit—I think people would probably say a benefit is convenience. Last year, about 77% of people said they would try telemedicine, but only 9% were actually using it–this was in 2019. But now you have massive use, as I stated before, of telemedicine. So, the convenience, people are working from home; the travel they don't have to account for. So there's convenience. But I also think that access is a tremendous benefit for this. You've got access to perhaps primary care specialists or mental health specialists or things that you might not have been able to get in a timely way before, so you got the benefit of access.

You also have, I guess I would say, benefits related to short-term cost savings. As I mentioned, health plans and self-funded employers are waiving copayments for telehealth visits, and they're doing this temporarily, but that's a benefit to employees because that lowers their out-of-pocket spending. You also have new rules. The CARES Act enacted by Congress allows for telehealth visits to be covered on a predeductable basis. So, this means that patients don't have to meet their deductible before they can get a telehealth visit. So, that too, provides a cost savings.

I think just the access to care in underserved communities. You have these underserved communities, rural communities, [that] may not have a lot of providers with timely access. It's all just kind of being accommodated, and it's a benefit to telemedicine. I also think we've all probably been talking about mental health these days, and there were challenges to access to mental health services prior to the pandemic. But at least during the pandemic, if there's a sort of a bright spot here, it's that people who are needing mental health services now more than ever, with the anxiety of the economy or losing a job or having children at home and teaching them at home—we have unprecedented reports of anxiety and depression, and so people who might otherwise not get that care might need to travel and have an hour in-person visit with someone–they might not have done that, but now they're able to do that. So, that's another added benefit.

AJMC®: To build on that, what are some current challenges that employers and health care purchasers face when seeking to better leverage telemedicine and virtual health services?

Caballero: Well, there are some really well-intended, temporary policy decisions that were made in the early days of the pandemic. Things like waiving the copays or relaxing the rules on who can deliver care to patients, who didn't have to have had a preexisting relationship. Even the technology platform. They're allowing it to be Zoom or it could be FaceTime. Those are all things that weren't allowed before. So, those were really well-intended, necessary things. But there are a few things. So, traditional telemedicine was offered through vendors like Teladoc, Doctor on Demand—things we understood and you had them on your smartphone or something like that. Utilization was low, but it was really for urgent care, episodic care. zit was not intended to have a long term relationship with your doctor. And those visits cost about $40 to $50. But now we're transitioning from traditional telemedicine to virtual care and that's really different.

Virtual care is where you have an established relationship with your provider, not someone you might just see on an urgent basis. And they're offering more complex care, because they have an established patient–provider relationship. So, vendors are now changing their business models, and they're marketing themselves as virtual care, virtual primary care, and what used to be $40 to $50 per visit, they're now increasing their prices.

So, you have the challenge of rising costs just on your traditional telemedicine. But then you also have the issue of how do purchasers pay for care and how are their benefits changing. And we're CPR so we care deeply about how care is paid and want to make sure that it's value-based. We want to make sure that any rules that go into place permanently aren't restrictive in the way employers can design their benefits. So, I'll just give you an example of that. Payment parity, meaning that payers, including self-funded purchasers, have to pay a virtual visit the same as they would an in-person visit, these are temporary rules. But if you look long term, virtual care just doesn't require the same brick and mortar, doesn't require the same time. And so virtual doesn't always justify equal payment.

It also could result in purchasers find challenges in the possibility of upcoding. So, our current coding system under fee-for-service doesn't really allow for the adjustment in time or intensity that is required for in-person visits. In other words, the payments might not match the level of intensity and you end up paying more for something then you might for an in-person visit. I guess if you think about this, and purchasers think about this a little bit more long term, virtual visits are not ultimately going to replace in-person visits on a 1-to-1 basis. So you're not offsetting one with the other.

Eventually, there's going to be the combination of both virtual care and in-person care. And so since you're not going to have an offset here, you're going to have a combination, you actually increase utilization and then total cost of care will increase. So, purchasers are concerned about total cost of care, and if you can't adjust the payment to accommodate what kind of care virtual care is really delivering and paying it not on a fee-for-service basis, but paying for it in a way that makes sense, then purchasers can really see challenges to being able to deliver those value-added benefits.

AJMC®: In looking at a post–COVID-19 world, the American Benefits Council, Catalyst for Payment Reform, and Mercer provided 4 considerations for policymakers to capitalize on the current momentum behind telemedicine and virtual health care. Can you speak further on each of these considerations?

Caballero: Sure. So, there are 4 recommendations that all 3 of our organizations are educating people about and advocating for, which is, first we’d like Congress to make permanent the provision in the CARES Act that allows telehealth visits to be paid for on a predeductible basis. So, for HSA [health spending account]-eligible plans, we'd like them to make that provision permanent where telehealth visits can be made before the deductible is met. So, that's the first one, and it's in the CARES Act and to make that permanent is perhaps not that challenging.

The second is that purchasers and purchasers that we work with would like to offer telehealth and telemedicine benefits as a stand-alone benefit, but right now, they have to be part of the medical benefits and they have to be equal. So, it's a little bit of a wonky situation, but we would like to continue to be able to offer telehealth benefits on a stand-alone basis. And if we do that, we would like it to be what's called an accepted benefit under the Affordable Care Act (ACA) and therefore that standalone benefit is not in violation of the ACA.

The third is one that involves states, but if Congress was able to send the signal to states to remove the barriers to telemedicine, I think that would be very beneficial. States have already tried to do this on an individual basis, but Congress sending that message could be very helpful. So, some of these barriers are requirements that providers and patients have preexisting relationships. So, removing that barrier. Allowing patients and providers to be in different states and not having to reside in the same state or having the same state licensure, that's another barrier that we would like to have removed.

Then, finally, the fourth thing that we are advocating, or educating I should say at least as a 501(c)(3) educating on, is that we really urge anyone to oppose mandates that will limit an employer or a purchaser’s ability to create value-based benefit designs and value-based payment. These mandates are things, as I mentioned, like payment parity, paying for virtual care at the same level as in-person visit, that's a mandate. And so we would urge people to not have that mandate. It also includes covering telemedicine services at the same level of medical services or in-person service, any in person service, and that just really isn't feasible. So, opposing those types of mandates is the fourth item that we're recommending.

AJMC®: Lastly, do you have any other concluding thoughts?

Caballero: Well, I guess I would say that if there was a bright spot in the pandemic, it's that there has been such a tremendous use of telehealth. Patients are embracing it, and providers are embracing it. And so that's a real bright spot. I think the last thing is that we're Catalyst for Payment Reform, and we've been measuring payment reform over the past 10 years. We've been trying, the industry has made progress, but we've been building off an old fee-for-service system. And we have an opportunity here to take a look at telemedicine and how we pay for telehealth services versus in-person visits and really create a new payment model that works under the system. One that doesn't try to fit a square peg into a round hole, and putting fee-for-service and applying it to telehealth when it wasn't intended to.

So, we really think there's an opportunity to address payment and ensure that access is preserved and people can continue to use these services, which there's no question that people will continue to want to. So, I think those are the bright spots and opportunities.

AJMC®: To learn more, visit our website at I’m Matthew Gavidia, thanks for joining us!

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