Some telehealth codes are going away. How does this affect you?

In March of this year, you’ll recall that Centers for Medicare and Medicaid Services (CMS) let out the reins on telehealth services, resulting in telemedicine experiencing as much growth in three weeks as it had in the previous several years. Later, services were expanded even further to include things like physical therapy, occupational therapy, and many inpatient services.

The new proposed changes

Earlier this month, CMS released its proposed physician fee schedule for 2021, and they’ve predictably scaled back the services that are covered via telehealth. Gone are 74 codes that CMS finds have “no likelihood of clinical benefit” after the COVID-19 public health emergency ends. Some of the codes that are going away are for certain psychological testing, physical and occupational therapy, and several inpatient management codes.

In their place, though, CMS has approved nine new codes, covered through 2021 at least and ranging from care planning for patients with cognitive impairment to group psychotherapy. The mental health orientation of these new codes is exciting to us at KBGH because of our ongoing work with the Path Forward for Mental Health and Substance Abuse initiative, which includes improved access to tele-behavioral health as one of its five core areas of improvement. COVID-19 has brought an increased focus on the need for tele-behavioral health. Research released from the Wellbeing Trust reports that there could be an increase in “deaths of despair” with 75,000 more deaths due to suicide and drug misuse due to the pandemic. While more people are seeking mental health care, tele-mental health could make access easier, and also help overcome stigma still associated with mental health issues. We want to see telehealth used more extensively in mental health services! If you are interested in working with KBGH on this, please contact us.

But what’s the bottom line for the future of telehealth? It’s pretty positive overall. If your employee population is relatively healthy and unlikely to be hospitalized, and if you are located in a place with plenty of hospital beds staffed with ample physicians, then these new CMS rules aren’t likely to affect you much at all. For sicker patients, or for patients who may only have a hospital readily available that doesn’t have easy access to specialist physicians, these new rules may change their care compared to the last five months. But on the bright side, I hope that the several new telehealth services that are covered on a temporary basis are a signal that CMS has some willingness for experimentation moving forward.

Providing your feedback

If you’re interested in giving CMS feedback on these changes, please consider sending comments on the proposed rule at this link or by mail at:

Centers for Medicare & Medicaid Services, Department of Health and Human Services

Attention: CMS-1734-P

P.O. Box 8016, Baltimore, MD 21244-8016.

Comments on the proposed rule must be received by 5:00 p.m. on October 5, 2020.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

Mental Health Treatment: The Tale of Two Employees

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

You probably know someone like Juanita. Juanita feels so anxious at her job as a delivery driver that she is starting to miss work and perform poorly. She goes to her primary care doctor, who prescribes a medication to help reduce her anxiety and tells Juanita it will take two to three weeks to feel a benefit. Juanita asks if anyone like a counselor or therapist is available to see in the meantime, while she’s waiting for the medication to work. Her doc tells her that the clinic has no behavioral health providers on-site. Furthermore, unbeknownst to Juanita, her insurance policy doesn’t cover therapy sessions very well, and tele-behavioral health may not be covered at all. Juanita decides to seek out a mental health provider on her own. She calls several offices, but because of increased recent demand for mental health services, no one has an appointment available in the next three weeks. Juanita ends up on a waiting list and eventually has a good, albeit expensive, experience at her first visit and feels better. When she asks her primary care doctor and her therapist how much better she should expect to feel after her second visit, though, they can’t give a straightforward answer. They tell her this kind of improvement is hard to measure. They are, however, very careful to screen her for risk of suicide or self-harm.

Marcus works at a different company with a different philosophy toward mental health. When he begins to feel so anxious at his job as a warehouse supervisor that he worries his performance is suffering, he visits his primary care doctor, who prescribes a medication to help reduce his anxiety. His doctor tells him it will take two to three weeks to feel better, just as Juanita’s doctor did. But at his first visit, the doctor rates Marcus’s anxiety with an instrument called the Hamilton Anxiety Scale. He also schedules Marcus for a next-day visit with a licensed specialist clinical social worker (LSCSW) who the clinic contracts with to do tele-behavioral health consults, one of several options in Marcus’s network. The doctor tells Marcus that the LSCSW will work with him on “strength-based” strategies to take advantage of Marcus’s natural skills and talents as a starting point to address his anxiety. Marcus’s benefits package covers the LSCSW’s services just as it would cover any other medical treatment. After two months of visits with the LSCSW and careful medical management by his doctor, who is in frequent contact with the LSCSW, Marcus’s score on the Hamilton Anxiety Scale has declined from an initial score of 24 to a persistent score of 8, indicating likely remission of his anxiety.

The contrast between these two patients’ experiences are obvious in a high-level, qualitative sense. But they have very specific differences: Marcus was cared for in a network with an adequate number of providers, all of whom are in collaborative practice with Marcus’s primary care doctor. Telemedicine under Marcus’s employee plan is covered at the same reimbursement level as in-person visits, and behavioral health is reimbursed at the same rates as other medical care. And Marcus’s doctor and social worker objectively measured Marcus’s state of mental health in order to judge whether or not he was getting better.

These five characteristics–network adequacy, coverage of telehealth, payor parity, measurement-based care, and collaborative care between medical and mental health providers–are but a few of the marks of good access to mental health care. But they are the specific domains that the Kansas Business Group on Health is attempting to improve here in Kansas through a project with the National Alliance of Healthcare Purchaser Coalitions called the Path Forward. We’ve touched on this topic in past blog posts specifically regarding substance abuse. But since we’ve found ourselves in the teeth of a viral pandemic that is probably going to get worse before it gets better, we thought it was important to reinforce what we’re working on around mental health. The scope of this pandemic is not only physical in nature, but also impacts our mental health. There are resources available that KBGH can help you with for you or your employees.  If you have specific questions, please reach out to us. We have a number of resources available. We do not know how long the effects of this virus will last, but we know that the impact is far reaching.

COVID-19 is changing telemedicine for the better

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

I’m typing this while on voluntary quarantine at the recommendation of the Kansas Department of Health and Environment because of a recent trip to Orange County, Florida. But like many of you, I’m managing to stay busy at home. One of the things I’m doing is providing “peer-to-peer” consultation to other doctors through a platform called RubiconMD [disclaimer: they pay me for the work, but not for advertising or testimony]. Doctors who subscribe to RubiconMD can forward me labs, imaging, and chart notes for patients with tricky hormonal and metabolic problems, and I type a recommendation back to them, potentially saving the trouble and expense of an in-person visit. These so-called “store-and-forward consults,” or “e-consults,” are one form of telemedicine, and they have proven effective enough–saving ~$500 per patient per year in one study–that they are now covered by Medicare.

The more well-known form of telemedicine in which practitioners and patients interact through a screen is referred to as “real-time” telemedicine. Other than the fact that the patient connects to the practitioner through a secure internet platform, telemedicine visits look a lot like traditional in-person medical visits: someone on the patient’s end (the “originating site,” in telemedicine parlance) collects vital signs, the doctor or other practitioner conducts an interview and, with the help of the ubiquitous high-resolution cameras on modern devices and a few on-site gadgets, performs a physical examination. Then the practitioner bills for the encounter as she would any other visit, albeit with a modifier attached to the billing to indicate that the visit was done remotely.

The average patient seen in-person at a physician office spends 121 minutes on the visit: 37 minutes traveling, 64 minutes waiting, and 20 minutes with the doctor. So if you think the idea of skipping the waiting line (not to mention all the coughing and touching) at your doctor’s office is attractive, you’re not alone. Telemedicine visits have a roughly 90% patient satisfaction rate. Kaiser Permanente has seen more patients via telemedicine than in-person since 2017. Local telehealth provider Freestate Healthcare and national providers Access Physicians and Eagle Telemedicine, among others, provide remote physician services at several rural hospitals with no doctors physically on site. In our work with CDC grants around diabetes prevention, we are running a trial of Omada, a virtual diabetes prevention program, to reduce the risk of high-risk patients developing diabetes. More than half of medical schools now offer required or elective training in telehealth to improve trainees’ “webside manner.”

And telemedicine has a growing body of evidence to support its use beyond reduced wait times and patient satisfaction. The Veterans Administration has found that telemedicine use corresponds to a 59% reduction in inpatient bed days and a 31% reduction in hospital admissions.

In spite of this rosy picture, the growth of telemedicine has been slowed by a regulatory system that is not designed for rapid change. Medicare, for example, has historically enforced a “site of service” requirement for telemedicine, meaning that patients seen via telemedicine still needed to travel to a hospital or doctor’s office to get linked to the distant telemedicine practitioner. Medicare has also mandated that patients must be located in a “health professional shortage area,” meaning that patients in areas with more physicians were ineligible to receive care via telemedicine, even if it was difficult for them to travel, and even if they had a highly communicable disease. Laws have mandated that the treating physician be licensed in the state where the patient was located, meaning a doctor licensed only in Kansas couldn’t historically see a patient in Oklahoma. And federal regulators have long restricted the technology that can be used for the interface. You couldn’t simply Skype or FaceTime your doctor, since those platforms were not compliant with the Health Insurance Portability and Accountability Act (HIPAA). This is not, on its face, an unreasonable policy; health data is valuable, so it is not hard to imagine it being the target of hackers.

There has been movement on this in the last year. Medicare Advantage plans began covering telemedicine visits from home earlier this year. But the current coronavirus pandemic is forcing faster changes, probably for the better. This week Centers for Medicare and Medicaid Services (CMS) suspended site-of-service requirements and state licensure requirements for telemedicine, and the Office for Civil Rights at Health and Human Services (HHS) announced that it would waive potential penalties for using lower-security forms of video communication for telemedicine. That is, any live video chat software is acceptable for now. This means that, at least in the short term, you can Skype or FaceTime your doctor (although we still recommend a more secure platform if your doctor can offer one). And you can do it from home. This policy is extending to other insurance carriers as well. I called Aetna, who informed me that they are allowing all visits (with the usual rules on copays and deductibles) to be performed via telemedicine for the next 90 days.

...once people get a taste of life with more easy access to telemedicine, I can’t imagine them going back.

If you or your company want to seek out such secure platforms, encourage patients to talk to their doctors about starting telemedicine visits. We at the Kansas Business Group on Health believe that care continuity is important. Urgent care centers and emergency departments have an important role to play, but encouraging patients to see their own doctors, rather than unaffiliated urgent care practitioners or cash-only telemedicine companies like Teledoc, is good for patients’ care and good for your bottom line. Freestate, Zoom, Doxy, VSee, and many other HIPAA compliant platforms are available to your employees’ doctors. They should consider asking specifically about any platform’s use of business associate agreements (BAAs) to certify there are safeguards against data breaches. Even though FaceTime is now technically allowed to be used as a telemedicine platform, for example, Apple will not sign a BAA. But Skype for Business, again for example, will.

I guess if you are the type of person who tries to find the bright side of things, this blog post is for you. This is just one way that COVID-19 is going to change medicine long-term. For the next few months, telemedicine access will become what its proponents have advocated for for years: a broad-based, broadly covered service that can be provided in the patient’s home on widely available, inexpensive software platforms. This is important not only in the context of a worldwide viral pandemic. It is important because once people get a taste of life with more easy access to telemedicine, I can’t imagine them going back.

Links for Wednesday, September 5, 2018: docs are nervous about weight loss meds, risky low-carb diets, why I'm not a pediatrician, and continuity of care is good

Why don't more docs prescribe weight loss medications?

Speculation: 1) cost (and by extension, prior authorization requests); 2) residual fear from fen-phen, as one of the docs interviewed alluded to. We can surely put this to bed, since the current crop of meds has been on the market much longer than fen-phen had been when its harm was revealed; 3) nihilism. Five percent weight loss is meaningful from a medical perspective, but unless the doc is consciously, prospectively measuring outcomes like blood pressure, lipids, and fasting sugars, it won't knock her socks off. Patients won't be thanking her for getting them ready for bikini season; and 4) the old Risk Evaluation and Mitigation Strategy (REMS) for Qsymia was such a PIA that it scarred some docs to prescribing these meds.

Can we stick a fork in low-carbohydrate diets? (Ba Dum Tss)

What's a 32% increase in mortality among friends? Investigators (in a study that, to my knowledge, has not yet been published, so caveat emptor) found an association between the lowest quartiles of carbohydrate intake and death:

NHANES data. Model 1 is unadjusted for other risk factors. Model 2 is adjusted. These are ugly, ugly numbers. 

Remember: we can't draw causality from this. There is some chance that people who are sick and more likely to die from heart disease, cancer, or stroke are more likely to adopt low-carbohydrate diets. But it doesn't seem likely. The people at highest risk in this study were those over age 55 and "non-obese."

Reason # 1,001 I'm not a pediatrician:

Can. Not. Do. It.

Special shout-out to the 100 cell phone text alerts during the video. 

If lack of continuity is a mark against telemedicine, then it's a mark against the hospitalist model in general