There’s a big caveat in the telehealth expansion that Congress just passed Leave a comment

Congress passed its 2022 omnibus spending bill this week, expanding coverage of telehealth services under the Centers for Medicare and Medicaid Services—a big win for telehealth companies and the more than 130 million patients who rely on socialized medicine. But some experts warn that as more telehealth services become covered by insurers, the government may lose interest in healthcare initiatives that get patients the most care for their dollar.

The provision does a few things. First, it extends coverage for certain telehealth services under Medicare and Medicaid for 151 days after the pandemic-era public health emergency comes to an end in April. Second, it adds audiology, occupational therapy, physical therapy, and speech pathology to its list of reimbursable telehealth services. Third, over the next year, the Medicare Payment Advisory Commission, an independent federal body that advises Congress on Medicare policy, is charged with studying the use and impact of telehealth services on patients with an eye to whether it diminishes the quality of care.

“It’s a positive sign that Congress is starting to realize the value of telehealth service,” says Nicol Turner Lee, senior researcher and director of the Center for Technology Innovation at the Brookings Institution. “Now we have to move that temporary interest into a more permanent structure.”

Over the last two years, there have been a number of legislative efforts to ensure that telehealth services can continue to be reimbursed under Medicare and Medicaid, even after the pandemic is officially declared over. Telehealth companies like Teladoc have been funneling hundreds of thousands of dollars into lobbying efforts to get telehealth permanently covered by CMS. In general, cementing telehealth into public health infrastructure is a bipartisan issue, and politicians on both sides of the aisle seem to support it. Several bills are concerned with enabling telehealth for rural communities, where there is often less access to healthcare facilities. Turner Lee says that future legislation will have to account for the people in rural areas who don’t have internet access. “Without broadband, you can’t really use it,” she says.

But more broadband access is supposedly coming. “After we spend that $65 billion, that excuse will be gone,” says Senator Mark Warner of Virginia, referring to the money earmarked for broadband expansion within the trillion dollar infrastructure package that passed last year. A long-time proponent of telehealth, Warner worked on the 2021 CONNECT for Health Act, which seeks to widen the scope of reimbursable telehealth services. (The bill was originally introduced in 2019, failed to make it to a vote, and was reintroduced in April 2021.) The bill would include addiction care through telehealth and the ability to prescribe certain controlled substances like suboxone, which is used to treat opioid addiction, over telehealth. It would also put into place oversight mechanisms to prevent fraud and abuse, which Warner envisions as one of the only arguments against telehealth—and not a great one.

“To my knowledge, the level of fraud and abuse is quite low,” he says.

Niam Yaraghi, assistant professor of business technology at Miami Herbert Business School and a senior Brookings fellow, sees a different argument against telehealth expansion. “What I’m concerned about is that they would expand the billable services to telehealth, and they are going to kill their whole incentive for value-based care,” he says. In other words, by focusing so much of its attention on continuing telehealth access for patients, Congress could inadvertently prompt healthcare providers to abandon the value-based care model in favor of a more lucrative pay-per-service approach.

Since the 2010 passage of the Affordable Care Act, CMS has built out programs for Medicare patients that are grounded in value-based care—that is, a payment model in which the agency pays doctors for keeping patients healthy, rather than for individual services, like an ultrasound, MRI, or an annual exam. Value-based care has great promise for reducing overall healthcare spending and improving patient health, but studies evaluating value-based care programs have so far been mixed. While there has been some evidence that it can curb costs, some healthcare experts question whether or not value-based care can actually deliver better healthcare for patients than they’re already getting. Others think value-based care is integral to the future of healthcare. Yaraghi says that Congress’ push to expand reimbursable services, like telehealth, may indicate a waning affinity for value-based care.

Senator Warner, for his part, thinks the value-based-care model needs work. “I’m a big believer in value-based care, but I’m not sure I believe that the promises have met the reality yet,” he says. He’s also doubtful that reimbursing for telehealth is necessarily the demise of value-based care.

As far as fastening telehealth into law, there are still details to be worked out, he says, like which services are ultimately included and how much telehealth services should cost versus in-person care. However, the main barrier to passage, he says, will be cost. That said, he’s seen broad support for insurance-covered telehealth.

“I can’t imagine that one of the few good things to come out of COVID would be allowed to lapse,” he says. 


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