Telehealth soared in popularity after Medicare started covering claims for virtual services during the pandemic. After the pandemic emergency declaration ends (expected after the mid-term federal election), there will be a five-month period to reimburse claims. Before making telehealth reimbursement permanent, Joshua Gordon, director of health policy at the Committee for a Responsible Federal Government, says Congress should put up guardrails to prevent waste, fraud, and abuse.
Health Care News: What happened during the pandemic when Medicare began covering telehealth visits? Was there a flood of claims?
Gordon: The data are still coming in, but it is pretty clear. Before the pandemic, 1 percent or less of all health care claims involved telehealth use. At the peak of the pandemic, in April 2020, about 13 percent of all Medicare and private insurance claims were telehealth, and now it has settled down to 5 percent.
Health Care News: How did doctors like telehealth?
Gordon: There was hesitation before COVID because it required specific technology providers that tended to be expensive and tied into electronic medical records and software.
It was certainly a lifeline during the pandemic when people were afraid of in-person interaction. Doctors were financially supported and, in some cases, kept afloat by this vast expansion of telehealth. So, I do think doctors like it.
But that is one of the things we are concerned about over the long term. Providers have a lot of say in how often we interact with them because we tend to do what our doctors want us to do and if they want us to have a follow-up over telehealth, we’re not going to say no. So, doctors will have a lot of control over the utilization of telehealth and we’re worried that some of the incentives may lead to increased utilization and costs. Not in every case, but in the aggregate.
Health Care News: Because doctors have been paid the same for a telehealth visit as a physical one?
Gordon: Yes, at least in Medicare, we are reimbursing on parity with in-person. We think if telehealth is reimbursing at the same amount as in-person, that will be a perverse incentive that will increase utilization.
Health Care News: Can’t telehealth save costs by attending to medical problems before they become more complex and more expensive to treat?
Gordon: Clearly, there will be more cases where this happens. Simple interaction will replace more intense interaction with doctors, and maybe even avoid emergency situations. I do think that is why telehealth is here to stay and will be in our continuum of care going forward.
What concerns me is the incentives in our health care system. Right now, health care is often fee-for-service, where the more things your doctor does, the more they get paid.
If doctors are paid to see a specific patient over the course of the year and it’s up to the doctor to decide how to treat the patient cost-effectively without harming their care, then doctors can choose the moment to use telehealth that will be most advantageous for the patient and not cost the doctor too much. So having telehealth as part of a value-based payment system makes a lot of sense. Having it fee-for-service is what concerns me.
Health Care News: What about the argument telehealth might reduce some of the “upsell” that can take place during an in-person visit, which can add up in a fee-for-service platform?
Gordon: I have a feeling doctors will figure out ways to upsell via telehealth just as they do in person. I don’t want this to sound like I’m angry at doctors or think they don’t know what they’re doing, I’m just concerned that when you have misaligned incentives, that could be a problem.
Health Care News: Do you think if there are too many restraints on telehealth it could discourage innovation?
Gordon: There is no going back, I think, to a time when you had to travel to a specific site to use this technology, that doesn’t make sense. The key is how do you incentivize innovation without overutilization. That is a problem Medicare has across the board with all new technologies, but they can make things more expensive, not less.
Health Care News: What guardrails should Congress put in place regarding telehealth to prevent unnecessary use?
Gordon: Congress should extend these authorities for two years [not just five months] after the public health emergency ends to allow us to gather more data from a time when the COVID pandemic is not the most dominant factor in how we see our doctors. We should not rush into anything permanent because it’s always harder for Congress to change things already in law.
Also, if Medicare can, open telehealth up more in alternative payment models in Medicare Advantage and not fee-for-service.
On waste, fraud, and abuse, we will want to pay specific attention to audio-only [telehealth visits]. For example, you might have providers cold call seniors on Medicare convincing them to have a new interaction with a doctor, and that doctor then gets paid.
We are also concerned about health care apps where just interacting with the app instead of being a very patient-driven thing becomes reimbursed by Medicare at very high in-person rates.
“Fiscal Considerations for the Future of Telehealth,” health policy brief, Committee for a Responsible Federal Budget, April 21, 2022: https://www.crfb.org/papers/fiscal-considerations-future-telehealth
“Could Too Much Telehealth Drive Up Medical Costs – Joshua Gordan, The Heartland Daily Podcast, July 1, 2022.