New rule provides telemedicine opportunity

May 1, 2019

The federal government recently finalized a rule that will allow Medicare Advantage plans to offer telemedicine as a core benefit.

The federal government recently finalized a rule that will allow Medicare Advantage plans to offer telemedicine as a core benefit. As a result, practices of all sizes will have a greater incentive to adopt virtual visits, observers say.

Traditional fee-for-service Medicare provides very limited coverage of telemedicine. For the most part, virtual care is covered only in rural areas, and virtual consultations must be initiated in healthcare facilities.

Providers can’t bill for virtual visits with patients from their homes, with one exception: CMS last fall ruled that physicians can bill traditional Medicare for brief “virtual check-ins,” in which they determine whether a patient should come into the office. Remote evaluation of video recordings and images is also covered. 

The new rule doesn’t expand telemedicine coverage under fee-for-service Medicare. However, it gives Medicare Advantage plans carte blanche to cover any form of telemedicine, wherever it is provided or initiated. Since more than a third of Medicare patients belong to these plans, this could mean a significant change for many physicians.

Some Medicare Advantage plans already cover virtual care as a supplemental benefit for which plan members must pay extra. Now that telemedicine is a core benefit, however, “providers would be more likely to invest in the infrastructure to make this available,” says Jerry Penso, MD, MBA, president and CEO of the American Medical Group Association (AMGA).

Steven Waldren, MD, vice president and chief medical informatics officer of the American Academy of Family Physicians (AAFP), says that when Medicare Advantage plans begin to cover virtual visits with patients’ own physicians, “I think it would convince more doctors to add telemedicine to their practices.”

Modern telemedicine

The telemedicine used today represents the confluence of two forms of the technology: secure online messaging, which has been around since the early 2000s, and virtual visits based on audio-video conferencing.

Until around 2015, video visits were usually conducted between patients and doctors who worked for outside services such as American Well, Doctors on Demand, and Teladoc. But there are inherent limits to this approach, because the outside doctors don’t know the patients who consult them, and they rarely coordinate care with the patients’ regular physicians.

“The critical piece is to make sure the care is coordinated,” Penso notes.

Today, however, the telemedicine medical practices use is likely to connect patients directly to their own physician or his or her colleagues, rather than an outside doctor hired by a service. Secure texting or online messaging is often the first step. Then the patient completes an online form, providing information that may be sufficient for a doctor to diagnose and treat his or her complaint. If the doctor and the patient believe a video visit would help, that might be the next step, or the patient might be asked to come into the office.

Chronic care follow-ups

Telemedicine is most often used to diagnose and treat minor acute problems like influenza, low back pain, conjunctivitis, and urinary tract infections. Some practices are also using telemedicine for routine follow-ups on chronic conditions.

“Virtual health has been great for my diabetic patients,” says Donnie Aga, MD, medical director of healthcare innovation for Kelsey Seybold, a large multispecialty group in Houston. “I know them really well, and they can go to the lab at any time; fasting is not an issue. For routine follow-ups on diabetes, it’s very well done.”

Kelsey Seybold and Kaiser Permanente also use telemedicine routinely for post-op follow-ups, and other groups plan to follow suit. In such a virtual visit, Aga says, “Our PA will say to patients, ‘take off the bandage so I can look at the wound, let’s look at your mobility and how does it feel,’ etc. Sometimes, post-op patients are taking pain medicine, so they don’t need to be driving to the office.” 

Telemedicine is especially well suited to behavioral health, notes James Korman, Psy.D., chief of behavioral health and physician wellness for the Summit Medical Group, based in Berkeley Heights, N.J. Besides doing teletherapy and medication management with patients who have difficulty getting to the office, Korman notes, Summit has established a virtual therapy program in conjunction with its primary care offices. Primary care physicians can consult with therapists or have patients do video visits with them in the office.

Physician-to-physician virtual consults are an integral part of Kaiser Permanente’s approach, says Richard Isaacs, MD, CEO and executive director of the Permanente Medical Group. For example, a primary care doctor who is seeing a patient with a skin lesion can immediately pull a dermatologist into a virtual video conference, show him the rash and ask him what to do. 

“It’s all about care without delay,” Isaacs notes. “If you connect a primary care doctor [to a specialist] immediately via smartphone technology, that drives a lot of efficiency.”

Technology platforms

Some groups use an internal telemedicine platform that incorporates their EHR. Kelsey Seybold, for instance, uses the virtual care platform in its Epic EHR for both video visits and “e-visits” based on online messaging through the EHR’s patient portal. When a physician encounters a patient in a scheduled video visit, the doctor sees the patient on one side of the screen and views and documents in the EHR on the other side. 

The video encounters with primary care physicians can be scheduled within a day; if a patient’s doctor isn’t available, he or she can visit another physician. A dedicated team of rotating physicians handles the e-visit requests, usually within 10 minutes of a call, Aga says.

Austin (Tx.) Regional Clinic’s telemedicine service uses an outside platform from a telemedicine vendor, says Jacob Childers, MD, medical director of the service. The platform allows video, voice and text messaging.

After sending a text about his or her problem, the patient is quickly connected to a doctor. A group of 20 clinic doctors handles these requests 24/7. Some do it on their own time for extra money; others fit video visits between in-person clinic visits.

Intermountain Healthcare, based in Salt Lake City, uses a hybrid technology approach. While the group deploys its own clinicians for scheduled virtual visits, it uses American Well’s telemedicine platform, which is integrated with the scheduling module in Intermountain’s iCentra EHR (a modified form of Cerner’s software). Summit Healthcare also uses an outside platform integrated with its athenahealth EHR.

Value-based care track

An important value of telemedicine to large practices is that it supports population health management, says Richard Trembowicz, a principal with ECG Management Consulting. Groups that are taking on financial risk can use telemedicine to increase patient engagement and improve their access to care. Moreover, practices can use it to expand the number of patients their primary care providers see, he adds.

Penso of AMGA says, “If a group is taking financial risk, it’s in their interest to manage the care as effectively and as efficiently as possible-and to meet the patient’s needs, because patients have a choice of whether to stay in your network or program. For those groups, it can be very worthwhile to have telemedicine as another option.”

But most practices still receive a lot of fee-for-service income, and they may be located in areas where telemedicine is not ordinarily covered by insurance. Prevea Health in Green Bay, Wisc., for instance, uses telemedicine mainly for online messaging and video visits with its urgent care centers, says Ashok Rai, MD, president and CEO of the group.

Prevea charges patients $35 per virtual visit because their health plans don’t usually cover it. For the same reason, the group has not yet extended telemedicine to its primary care offices.

Rai hopes the new Medicare Advantage telemedicine option will help change that. “We can do a lot of care virtually if patients don’t need to come into the office and their care is covered as part of the premium. Things would be more efficient and more timely for our chronic care. In the end, it’s good for the patient, it’s good for the physician, and it’s good for reducing costs in the overall healthcare system.”

Options for smaller practices 

While fairly few small practices have used telemedicine, they should definitely start considering it, especially now that Medicare Advantage covers virtual visits, says David Zetter, CHBC, a practice management consultant in Mechanicsburg, Pa. For one thing, he says, telemedicine could help practices expand their business.

He cites a solo family physician in a rural area who is using telemedicine to provide after-hours care. For a fee that is automatically applied to their credit card, patients can have a virtual visit whenever the doctor is available. “He’s definitely filled his practice up a bit and increased revenue,” Zetter notes. Many psychiatrists in small practices,  are doing virtual mental health visits, he adds. 

Grace Terrell, MD, a North Carolina internist who founded the Cornerstone Medical Group, now part of Wake Forest Baptist Health, is a big supporter of telemedicine and believes the Medicare Advantage core benefit could prove highly important.

“Telemedicine should open up business models that aren’t based on a patient being in a facility in front of a doctor,” she says. “There are a thousand use cases out there that could redesign medicine in many ways. Over time, it could re-engineer the healthcare system so that expertise is delivered in more convenient ways through technology.”

One new business model that small practices could try, she says, involves providing care to more patients without increasing overhead costs or overburdening physicians. In a typical primary care practice, she notes, providers must see a certain number of patients each day to cover their overhead costs. But if the practice hired additional doctors or midlevel practitioners and they provided virtual visits without patients needing to come into the office, the average overhead per patient would decrease, and profitability would increase. 

“The problem with small practices now is that they want to fill their exam rooms, and that’s why they view virtual visits as one offs on top of that,” she says. “But you can imagine a situation where you have twice the number of doctors for the space you’ve got, and half the doctors are not using the space.”

Telemedicine challenges

To participate in telemedicine, Zetter says, practices first must determine which kinds of patients are likely to use the service and which of their payers cover it. If a patient’s insurance doesn’t cover telemedicine, practices must tell them that there’s an out-of-pocket cost.

It’s also important to understand each state’s regulations on telemedicine, including what kinds of services plans must cover and whether they have to cover telemedicine-provided services that are comparable to in-person services, he points out. Thirty-one states and the District of Columbia require full parity, and two other states have partial parity laws. In addition, all 50 states have some Medicaid coverage for telemedicine.

Zetter warns against simply doing video chats with patients on their smartphones because of HIPAA security and privacy considerations. Fortunately, a wide range of secure messaging and videoconferencing software is available, he notes, and some of it is not expensive. 

The AAFP offers a virtual visit platform based on software from Zipnosis. Designed for minor acute issues, the platform includes a questionnaire for patients to fill out. In most cases, a doctor can diagnose their problem and prescribe a medication based on their answers, Waldren says. Patients can also request a video visit and conduct it on the platform. 

The cost of AAFP Virtual Care is $159 per month per authorized user. Patients pay practice-determined fees for the service, but the platform can be linked to a practice’s EHR for billing purposes, he adds. 

Workflow changes

Cindy Dunn, RN, FACMPE a consultant with the Medical Group Management Association, is skeptical about the suitability of telemedicine for small practices. She notes that the practice must look at the workflow changes required to accommodate virtual visits. They also have to figure out how to document these encounters. And their billers have to learn which codes to choose for insured telemedicine services.

However, she concedes that telemedicine could work well for post-op visits, which are frequently bundled into surgical fees; as a result, surgeons earn nothing for office follow-up visits. In addition, she says, virtual visits could free up slots for doctors to see patients with more complex conditions in person. And telemedicine could help practices extend their hours.

“In the long term, telehealth will become just as much a part of care as doing routine child checks and those kinds of things,” she says. “We’ll also move from telemedicine’s current acute care focus to chronic disease management and wellness as part of value-based care. Telemedicine is going to become a big component of medicine moving forward.” 

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