WASHINGTON -- Although much of the healthcare world's focus is on the fate of the Affordable Care Act, another area of healthcare -- telehealth -- is bubbling along on Capitol Hill.
The use of telehealth -- a term that usually encompasses physician visits via video, home monitoring of vital signs, and remote interpretation of test results using "store-and-forward" technologies -- is being promoted as a way to save time and money for patients and the healthcare system, although some critics say it can actually add costs.
To encourage greater use of telehealth, senators Brian Schatz (D-Hawaii), Roger Wicker (R-Miss.), Thad Cochran (R-Miss.), Ben Cardin (D-Md.), John Thune (R-S.D.), and Mark Warner (D-Va.) introduced the in February 2016. According to Schatz's office, the act would encourage use of telehealth by:
- Creating a program to help providers meet the goals of the Medicare Access and CHIP Reauthorization Act and the Merit-based Incentive Payment System through the use of telehealth and remote patient monitoring (RPM)
- Expanding the use of RPM for certain patients with chronic conditions
- Increasing telehealth and RPM services in community health centers and rural health clinics
- Making telehealth and RPM basic benefits in Medicare Advantage
The bill was endorsed by industry and healthcare groups. "The American Medical Association (AMA) is pleased to support legislation that would accelerate the adoption of healthcare delivery models that promote coordinated and patient-centered care," said then-AMA president Steven Stack, MD, in a . "This bill would ensure that patients and their physicians are able to use new technologies that remove barriers to timely quality care. Importantly, the bill would maintain high standards whether a patient is seeing a physician in an office or via telemedicine. We look forward to working with other supporters to advance this legislation in Congress."
Changes in This Year's Version
In May 2017, the same group of senators introduced a of their bill. The new version would permit the use of telehealth and remote patient monitoring in global and bundled payment systems, and would lift some restrictions on mental health services delivered via telemedicine, among other changes.
The bill currently has 17 Senate cosponsors. A , introduced by Rep. Diane Black (R-Tenn.), has 21 cosponsors.
Although those numbers may sound small, the law's proponents are optimistic. "We had an affirmation from many [congressional] offices that telehealth and our broadband/infrastructure requests were right on target with respect to CONNECT for Health," said Tom Leary, vice president of government relations at the Healthcare Information and Management Systems Society (HIMSS), a trade group for health information technology companies, referring to his group's recent lobbying effort on the measure.
Leary, who spoke during an interview at which a public relations person was present, noted that senators included four CONNECT for Health provisions in another piece of legislation, the , which passed the Senate last month. Those provisions allowed for use of telehealth visits for end-stage renal disease and stroke patients, and also allowed for increased telehealth use by Medicare's accountable care organizations and in the Medicare Advantage program.
One hurdle that proponents of the CONNECT for Health bill need to overcome is the perception by the Congressional Budget Office (CBO) that telehealth increases Medicare costs rather than holding them steady or decreasing them, Leary said.
"CBO's estimation to date has been that if you take down some of the geographic barriers and broaden the types of technologies accepted for Medicare reimbursement, you'll dramatically increase the cost to the Medicare program, but they're not able to take into account the long-term potential cost savings. They strictly see telehealth as a way of increasing access, therefore driving up costs," rather than substituting for in-person care, he said, adding that the four CHRONIC Care Act provisions, if the bill is eventually enacted, "would begin to help tell the story of what the impact on cost savings would be on the Medicare program."
CBO's fear hasn't been borne out so far, Thomas (TJ) Ferrante, LLM, MBA, an attorney with Foley and Lardner in Tampa, Florida, said in a phone interview. In 2016, on telehealth services, "and that might be a big number, but when it's put into perspective, the overall Medicare budget is about $600-plus billion, so that's an infinitesimal drop in the bucket ... So a lot of the concern that telehealth is going to cause costs [to skyrocket] isn't based in reality."
No Clear Definition
In addition to CONNECT for Health and the CHRONIC Care Act, there are several other bills floating around Congress that would loosen restrictions on telehealth's use, Ferrante said in a phone interview. "I think the approach this year is that they weren't sure if one bill with all these bells and whistles was going to pass, so let's have five, six, or seven different pieces of legislation" that might get attached to bigger bills.
One reason the value of telehealth is difficult for many people to pin down is that there is no universal definition of what it is, said Craig Samitt, MD, executive vice president and chief clinical officer at Anthem, a health insurer based in Indianapolis. "Telehealth is a very broad term and can be used to refer to everything from stroke follow-up to tele-ICU to urgent and convenient care," said Samitt, who spoke during an interview at which a public relations person was present. "So I think the industry struggles with a universal description of the value of telehealth, when to different people it means different things."
"Second, there is a sense that telehealth is a supplemental clinical venue as opposed to an alternative clinical venue," said Samitt, who is a member of the Medicare Payment Advisory Commission (MedPAC) but was speaking in his Anthem role. "When it is viewed as supplemental, some in the industry believe it is costly, or unnecessary, or a luxury, as opposed to an equivalent service to in-person care under certain circumstances."
"In our experience, many members and patients use telehealth as an alternative to in-person care ... If I'm a patient with a certain ailment, I don't want both a live visit and a telehealth visit -- I want one or the other."
In fact, an Anthem physician co-authored a in the Journal of Medical Internet Research comparing the costs of telehealth with in-person care. The authors examined 4,635 virtual visits and 55,310 nonvirtual visits, and found that in-person visits to retail health clinics, urgent care centers, emergency departments, and primary care offices were estimated to be $36, $153, $1735, and $162 more expensive than virtual visit episodes, respectively, including medical and pharmacy costs.
"Intuitively, one would think that technological innovation will improve efficiency and maintain quality, and we believe it's inevitable that telehealth will continue to remove costs from the healthcare system," Samitt said.
States Adding Regulations
In addition to activity on the federal level, states also are trying to sort out the rules to make telehealth work well, according to Amy Lerman, JD, MPH, an attorney with Epstein Becker Green, in Washington. Lerman and her colleagues on state laws governing telemental health, "and of all states we've looked at, only two states -- Connecticut and Massachusetts -- had material that hadn't changed. So that says something."
Lerman said she expects two areas to get more legal traction from states in the future: reimbursement issues and remote prescribing. Reimbursement is "a barrier to providers for providing these services. Many providers are trying to do it on a cash basis and charge people out-of-pocket, and certainly there's a market for that, but how sustainable is that as a business model?"
As for remote prescribing, "states are still figuring out how to put parameters in to allow physicians and others to prescribe safely and effectively via telehealth." One barrier to prescribing remotely is the Ryan Haight Act, which prohibits providers from prescribing remotely unless the patient has had a previous in-person visit. "That doesn't lend itself to the model people are trying to fit themselves into today," said Lerman.