Telehealth May Ease Docs into ACOs, MedPAC Suggests
Providing incentives for physicians to incorporate telehealth services under the new Medicare value-based payment model may encourage fee-for-service Medicare providers to consider becoming part of an accountable care organization (ACO), the Medicare Payment Advisory Commission has noted. Telehealth may provide the risk-sharing environment that proves appealing to providers and patients alike, with the practice potentially being used to introduce providers to behavioral health and family practice modalities. The Commission defines telehealth as covering basic care and consultation for patients and doctors connecting to other physicians; patients connecting with doctors from home; doctors connecting to other physicians; remote hospital monitoring; remote home monitoring; and storing and forwarding data for remote evaluation. Under the Medicare fee-for-service system, cost-sharing is shared 20 percent with patients for telehealth, with the patient’s facility being paid a $25 flat fee, and the receiving remote facility paid 100 percent of the rate for fee-for-service. For providers at present, telehealth is either considered a cost-effective replacement for in-person consultation, or an additional supplemental service that extends costs.

WASHINGTON -- Incentivizing doctors to use telehealth services under Medicare's new value-based payment models might be a good way to get fee-for-service Medicare providers to consider joining an accountable care organization (ACO) or another new model, a member of the Medicare Payment Advisory Commission (MedPAC) said Thursday.

"We need to be building incentives to providers to want to get out of fee-for-service and get into an environment where there is more accountability and more risk-sharing," said Sue Thompson, of UnityPoint Health in Des Moines, Iowa. "So perhaps telehealth is one of those things you have an opportunity to do in a risk-sharing environment -- an [alternative payment model] that involves risk, or Medicare Advantage, or an ACO that has upside and downside risk."

"I think we'd have an easier time recruiting providers into behavioral health modalities and family practice modalities if we could talk about how this creates a lifestyle that's pretty attractive," she said. "Telehealth is a piece of the puzzle that offers all kinds of opportunity."

The commission heard a presentation on how telehealth services are being paid for under Medicare. Staff members Zach Gaumer and Amy Phillips defined telehealth as falling into six categories:

Basic care and consultations for patients and their doctors who are connecting to another doctor

Basic care and consultations for patients connecting to a doctor from their home

Basic care and consultations for doctors connecting to one another without the patient present

Remote monitoring of patients in the hospital

Remote monitoring of patients at home

Storing and forwarding data -- including images and scans -- to a remote clinician for evaluation

Currently, under Medicare's fee-for-service system, a healthcare facility that originates a telehealth visit is paid a flat fee of $25 by Medicare, while the remote site at which the consulting physician works is paid 100% of the fee-for-service facility rate. Patients have a cost-sharing responsibility of 20% for the telehealth visit. This method encourages the healthcare system to increase the volume of telehealth services provided, the presenters noted.

Substitute or Supplement?

Two schools of thought exist on telehealth, they noted: some say it can be cost-effective by substituting for in-person visits, while others say it adds costs because it is used as a supplement to in-person visits and patients still see the doctor in person anyway.

Commissioner Craig Samitt, of the Anthem health insurance company, in Indianapolis, came down on the side of cost-effectiveness. "We're currently covering and paying for a large number of low-value services, and [here] I feel we are resistant to paying for what I think is a high-value service," he said. "We seem to think telehealth is not equivalent to in-person health. But telehealth ... is in fact a substitute. It enables people to give care through an alternative modality."

"The potential value in telehealth is reduction in total cost of care," Samitt continued. "This is not a replacement or supplemental visit; this is a way to avoid multiple downstream [costs] that we would otherwise not capture in the absence of it. I would love to jump into the debate about the way telehealth is factored into the Medicare Advantage package. This should be included in the benefit package as opposed to being a supplemental benefit."

Pharmacy Services Discussed

The commission also heard a presentation on the structure of pharmacy services, including pharmacy benefit management (PBM) companies. Staff member Rachel Schmidt noted that in addition to negotiating drug prices on behalf of health plans, most large PBMs have their own specialty pharmacies -- a relationship that may present financial conflicts, since the PBMs are supposed to lower drug expenditures for their customers, but they have an incentive in their pharmacies to increase revenue as much as possible.

But commissioner Amy Bricker, RPh, of the Express Scripts PBM, in St. Louis, disagreed with that idea, adding that it is not true that PBMs will often require customers to use the PBM's pharmacy: "To suggest there's some leverage over the client isn't the case, because of the competitiveness of the industry," she said. "If you're not lowering the cost for the plan sponsor and not servicing patients appropriately, you're going to be fired."

Commissioner Jack Hoadley, PhD, of Georgetown University's Health Policy Institute, was not so sanguine. "I'm not as comforted as Amy by the notion of competition in this market," he said. "It's really unclear where the system saves money and where it adds cost. There is evidence of both, and that's what we need to try to untangle."

For example, in the Part D drug benefit world, there are cases of competing drugs -- such as etanercept (Embrel) and adlimumab (Humira), which are both prescribed for arthritis and psoriasis, "and we've seen those prices [for both] go up pretty constantly over time. We have not seen a lot of formulary competition; it's the opposite of what you'd normally expect."

Sharing the savings that come from drug rebates is a good issue for MedPAC to examine, Hoadley added. "We could think about ways to share the benefit, such as putting caps on coinsurance so beneficiaries aren't as affected by [drug price increases]."

"It's hard not to be struck by how complex this is," said commissioner Rita Redberg, MD, of the University of California San Francisco. "I feel like there are a lot of moving parts, a lot of secrecy, a lot of fees, and the whole rebate thing that's secret makes me very uncomfortable, and the whole designation of specialty drugs basically means that if you raise your prices high enough you're a specialty drug. This does not seem like a very efficient system.

"It does seem more complicated to me to have drugs covered under Part B and Part D ... I wonder if it's worth considering if there should be just one drug benefit and not to separate it like this," she said.

Rural Hospitals and Physician Supervision

On Friday morning, commissioners briefly discussed the issue of physician supervision at critical access and rural hospitals. Medicare regulations have mandated that certain procedures -- such as chemotherapy and cardiac rehabilitation -- have physicians available to supervise, even if they are not necessarily in the room. After concerns were raised by hospitals that these rules might make it more difficult for them to operate, Congress suspended enforcement of the rules from 2010 to 2016, and has proposed doing so again in 2018 and 2019.

MedPAC staff members interviewed staff from several critical access hospitals and found they were not having any trouble complying with the rules. The hospitals "are using the emergency department or family physicians in the same building or nearby to address physician supervision requirements," said MedPAC staff member Ledia Tabor. She noted that in a MedPAC report issued in 2012, the commission had said that "expectations for quality of care in rural and urban areas should be equal for nonemergency services rural providers choose to deliver."

Commissioners seemed satisfied with the idea of sticking to that wording, but possibly providing a little additional guidance as well: "It's important to take a strong position that the standard of care, whether urban or rural, must be consistent," said Thompson. "Yet we did hear from those [hospitals] leaders a plea for clarity," such as knowing how quickly a supervising physician would need to respond: "I do believe a call for clarity would be quite welcome from these organizations."

Please enable JavaScript to view the comments powered by Disqus.