What it means for patients and your provider customers
Editor’s note: COVID-19 might not be ending, but the Public Health Emergency is. And the impact on your physician office customers may be far-reaching. In Part 1, we look at potential implications on telehealth/digital health and the distribution and provision of COVID-19 vaccines. Next month we’ll look at the implications of potential Medicaid cuts and changes in enforcement of the physician-self-referral Stark Law.
The federal Public Health Emergency (PHE) for COVID-19 has expired. “We are in a better place in our response than we were three years ago, and we can transition away from the emergency phase,” declared the Department of Health and Human Services in February.
Two of the changes likely to affect physician practices are:
- Telehealth/digital health: Although many telehealth flexibilities will be extended through December 31, 2024, some changes will become effective May 11. For example, clinicians once again will be required to have an established relationship with a patient prior to providing remote-patient-monitoring services. In addition, the ability of healthcare providers to dispense controlled substances via telemedicine without an in-person interaction will be affected.
- COVID-19 vaccines: Distribution and provision of the vaccine will be taken out of the hands of the federal government and moved to traditional healthcare coverage.
Telemedicine
“Telehealth has caused the most angst among our members,” says Claire Ernst, director of government affairs, Medical Group Management Association.
During the PHE, individuals with Medicare had broad access to telehealth services, including in their homes, without the geographic or location limits that usually apply. The good news for the medical community is that Congress extended many PHE-related telehealth flexibilities through December 31, 2024, including:
- People with Medicare can access telehealth services in any geographic area in the United States, not just rural areas.
- People with Medicare can stay in their homes for telehealth visits rather than traveling to a healthcare facility.
- Audio-only visits will be offered to those who are unable to use both audio and video (e.g. smartphone or computer).
“Telehealth services became a game changer in both rural and urban areas throughout the country,” says Kelly Ladd, CEO, Piedmont Internal Medicine, Atlanta. Prior to the PHE, only rural areas could provide and receive payment for these services. But that has changed, she says.
“Many of our senior citizens – including those in urban settings – do not feel comfortable going out in bad weather to go to the doctor. Telehealth allows them to engage with their provider for chronic care and even acute illnesses. It is especially helpful because it allows us to see the patient through video so we can make certain assessments. If the patient does not have video capabilities, we can still hear their voice, assess background noises, and have the personal engagement.”
Many practices have taken the time and expense to incorporate telehealth into their workflow, and they are hoping their investment won’t be cancelled with the expiration of COVID-era telehealth flexibilities, she says. “What CMS fails to realize is that providers must pay for the technology to provide these services and follow the same workflow as traditional office visits. We still must complete patient registration, review the patient chart, generate claims for payment and process those payments.” In addition, practices have had to adjust their IT networks to add additional cybersecurity and adhere to HIPAA policies and procedures to ensure patient health information laws are followed.
An Illinois State Medical Society survey found that of the 81% of its physician members who reported using telemedicine, three-quarters had not done so prior to the start of the pandemic, says the Society’s president-elect, Rodney S. Alford, M.D. “The flexibilities that were instituted at the federal and state level created a pathway for physicians to incorporate telemedicine into their practices.”
Reimbursement an issue
Prior to the pandemic, among the most significant barriers to telemedicine was the fact that many payers, including Medicare, had restrictive reimbursement policies, says Dr. Alford. Illinois has already taken action to permanently retain many of the emergency flexibilities that applied to state-regulated health plans. Further, in-network healthcare professionals or facilities in the state must be reimbursed for telemedicine encounters at the same reimbursement rate that would apply to services delivered via an in-person encounter, at least through 2027.
Claire Ernst believes that eliminating payment parity for telemedicine and in-person visits, as CMS plans to do January 2024, could present challenges for MGMA’sphysician-practice members. “There’s a large differential – as much as 30% – between tele visits and in-person visits, given the technology needed and workflow accommodations that must be made,” she says. “We’ll be looking at CMS’s proposed Physician Fee Schedule, probably in July, to see if they address that.”
Compliance with HIPAA rules presents another telemedicine challenge for practices. During the pandemic, HHS’s Office for Civil Rights relaxed enforcement of some HIPAA-related requirements, including the use of HIPAA-compliant telemedicine platforms, she says. That will probably change in May. Smaller practices may be more adversely affected than big ones, as they conduct fewer telehealth visits and are less likely to use HIPAA-compliant platforms, she says.
Another telehealth-related issue to watch is interstate licensure for Medicare patients, says Ernst. During the pandemic, qualified clinicians were allowed to provide telemedicine services to patients in states other than their own, provided the other state did not object. That could change.
In addition, questions have been raised about reimbursement for audio-only telemedicine services. The American College of Physicians is pleased that CMS is extending coverage of audio-only E/M services until at least December 2024, says Shari Erickson, chief advocacy officer and senior vice president of governmental affairs and public policy. Researchers have begun to identify the positive impact on health equity of audio-only E/M services, she says.
But regardless of what Medicare does, not all private payers will necessarily follow suit. “Many have stopped payment for these services altogether over the past year, if they covered them at all during the worst of the pandemic,” says Erickson. “And those that cover them may or may not be paying at the same rate as CMS. From a practice perspective, this makes for a very inconsistent experience and creates uncertainty as to if or how much physicians will be paid for offering audio-only services to their patients.”
Remote patient monitoring
The end of the PHE also means changes for remote physiologic monitoring, or RPM. During the PHE, CMS permitted clinicians to bill for remote physiologic monitoring services furnished to both new and established patients, and to patients with both acute and chronic conditions. When the PHE ends, clinicians must once again have an established relationship with the patient prior to providing RPM services.
Piedmont Internal Medicine implemented remote patient monitoring and chronic care management services three years ago, says Kelly Ladd. “They have had a significant and positive impact on patient care” and have kept patients out of the Emergency Room, hospital admissions and readmissions. Blood pressure monitoring, pulse oximeter readings and glucometer-reading devices transmit information directly to software, which is monitored on a daily basis by nurses, she says. RPM facilitates patients’ engagement between the patient and the physician’s care RN/team on a regular basis, she adds.
COVID-19 vaccines
The end of the Public Health Emergency coincides with the U.S. government’s plan to transition the provision of COVID-19 vaccines and treatments to the traditional healthcare marketplace. In a statement, the Department of Health and Human Services said the transition is not tied to the ending of the COVID-19 PHE, but rather reflects the fact that the federal government has not received additional funds from Congress to continue to purchase more vaccines and treatments.
When this transition occurs, many Americans will continue to get free COVID-19 vaccines, according to HHS. Vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) are a preventive health service for most private insurance plans and will be fully covered without a co-pay. Currently, COVID-19 vaccinations are covered under Medicare Part B without cost sharing, and this will continue. Medicaid will continue to cover all COVID-19 vaccinations without a co-pay or cost-sharing through September 30, 2024, and will cover ACIP-recommended vaccines for most beneficiaries thereafter.
“A top priority for family physicians and the AAFP [American Academy of Family Physicians] is to ensure patients have continuous healthcare coverage and ongoing access to comprehensive care once the PHE ends,” says Tochi Iroku-Malize, M.D., president of AAFP. “Transitioning COVID-19 vaccines to the commercial market may create financial and operational challenges for physician practices and could negatively impact access to and utilization of COVID-19 vaccines for patients.
“If the price of the vaccines is too high, physician practices may struggle to make the upfront investment in COVID-19 vaccines,” she says. “Additionally, patients often prefer to receive vaccine counseling and administration from their usual source of primary care, such as their family physician. As the PHE unwinds, the administration and Congress must work to ensure appropriate COVID-19 vaccine prices and payment rates to enable trusted physicians to offer vaccines, promote vaccine confidence, and bolster vaccination rates.”
Says Kelly Ladd, “Insurance carriers have not set their reimbursement fees, so we don’t know how much we are going to be paid yet for the vaccine.” And that amount will probably differ depending on the payer. What’s more, payers tend to update their fee schedule quarterly, she says. “The problem is, we typically don’t receive this information until the quarter is more than halfway through. We are not able to make an informed decision on which vaccine brand to choose.”
Next month: Impact of the end of the Public Health Emergency on the Medicaid population and on enforcement of the physician-self-referral Stark Law.