July 2020, Volume XXXIV, Number 4

Cover story two

The seeds of a revolution

Telehealth and COVID-19

he implementation and use of telehealth have undergone rapid and massive changes as a result of the COVID-19 public health emergency. In the initial month of the pandemic, the United States saw a whopping 4,300% increase in claims for telehealth encounters. The nation’s March year-over-year (2019/2020) figure jumped an astounding 8,336% in April. (See https://tinyurl.com/mp-tele-stats for statistics sorted by date or region.)

Minnesota also saw sharp increases. Stratis Health’s Virtual Health/Telehealth Sharing Group, which includes health system telehealth directors from 16 urban and rural health systems, practices, and associations, documented a 1,000-fold increase in the use of telehealth in Minnesota in the first month after the coronavirus outbreak. Prior to the outbreak, nine Minnesota health systems reported a collective 1,149 telehealth visits per day. As of April 24, the health systems reported conducting 15,480 telehealth visits per day. That total included 7,612 telephone visits and 7,868 video visits.

The United States saw a whopping 4,300% increase in claims for telehealth encounters.

To support Medicare beneficiaries receiving telehealth services, the federal government in March announced expanded coverage. The Centers for Medicare and Medicaid Services (CMS) issued Medicare 1135 waivers intended to provide regulatory flexibility for providers and enhanced utilization by patients—but those waivers may not continue after the pandemic.

Key elements of the waiver

Under its 1135 waiver—the section of the Social Security Act that enables waivers during public health emergencies—CMS chose to enact the following key components:

  • Expanded list of eligible telehealth practitioners that includes all those eligible to bill Medicare for professional services (includes physical therapy, occupational therapy, clinical social workers, etc.)
  • Originating site of telehealth visit can be patient home or residence
  • Expanded geography allowed for all telehealth visits including both rural and urban settings
  • Use of expanded list of 80+ telehealth available procedural codes
  • Payment parity for audio-only telephone visits
  • Use of Place of Service (POS) billing code where patient would have been seen
  • Provider licensure flexibility to practice in every state (subject to state licensure rules)
  • Audio-only virtual communications allowed for certain services
  • Use of non-HIPAA compliant technology platforms
  • Allowing critical access hospitals (CAH) and rural health clinics (RHC) to be originating sites

This massive, unexpected experiment in the use of technologies, processes, and role adaptations—sparked by the pandemic—removed barriers and accomplished in a few short months what otherwise would likely have taken years.

The future of waivers

In June, Stratis Health conducted a new survey of Minnesota health systems to prioritize components of the Medicare 1135 waiver that should be continued. Results in ranked order, along with benefits cited by respondents:

Maintain the expanded list of eligible telehealth practitioners that includes all those eligible to bill Medicare for professional services (includes physical therapy, occupational therapy, clinical social workers, and others). Benefit: broader set of practitioners can bill Medicare for telehealth.

Originating site of telehealth visit can be patient home or residence. Benefit: Ability to do telehealth visits in patient homes/residences.

Expanded geography allowed for all telehealth visits including rural and urban settings. Benefit: opens up urban settings for telehealth visits.

Use of expanded list of 80+ telehealth available procedural codes. Benefit: broader set of services and access allowed for telehealth visits.

Payment parity for audio-only telephone visits. Benefit: supports cases where telephone is the only option for remote visits.

Use of place of service (POS) billing code where patient would have been seen. Benefit: improves telehealth reimbursement for providers.

Provider licensure flexibility to practice in every state (subject to state licensure rules). Benefit: broader access to specialists across states.

Audio-only virtual communications allowed for certain services. Benefit: supports cases where audio is the only available method for remote visits.

Use of non-HIPAA compliant technology platforms. Benefit: allows for more options for patients/families to connect to providers.

Allowing CAHs and RHCs as originating sites. Benefit: broader access to telehealth in rural communities.

Survey respondents also suggested including pharmacies as eligible telehealth clinicians and allowing FQHCs and RHCs as eligible originating sites. These items had not been included in the Medicare 1135 waiver.

There are many lessons learned from the use of telehealth during the current pandemic.

The results of the Stratis Health survey have been shared broadly across Minnesota, including with legislators, health care associations, the Minnesota Department of Health, Minnesota Department of Human Services, and health systems. Survey results were serendipitously underscored by a 3-page letter sent to the Senate and House of Representatives minority and majority leaders supporting permanent enactment of telehealth waivers and exceptions. This national letter was signed by 340 organizations including EMR vendors, health care associations, and integrated networks, as well as to payor organizations.

Legislation

The bipartisan Enhancing Preparedness through Telehealth Act—proposed by Minnesota Sen. Tina Smith and three other senators—requires an inventory of telehealth readiness to anticipate and prepare for future needs (https://tinyurl.com/mp-legislation-01). The legislation recognizes that there are many lessons learned from the use of telehealth during the current pandemic, and seeks to put in place a five-year reporting cycle (conducted by the Department of Health and Human Services) to inform readiness steps for any future public health emergency. The recurring report will:

Conduct an inventory of telehealth initiatives in existence, including their capacity to handle increased volume during the response to a public health emergency;

Identify methods to expand and interconnect regional health information networks and state and regional broadband networks;

Evaluate ways to prepare for, monitor, respond rapidly to, or manage the events of a public health emergency through the enhanced use of telehealth technologies;

Promote greater coordination among existing federal interagency telehealth and health information technology initiatives; and

Make recommendations related to updates on the use of telehealth in public health emergencies in federal and state public health preparedness plans and any actions taken to implement such recommendations (https://tinyurl.com/mp-legislation-02).

Other lessons

In response to COVID-19, health care organizations responded quickly with adapted workflows to make the sudden shift from in-person encounters to telehealth visits. The urgency of the pandemic did not allow for typical planning cycles, budgeting, or systematic implementation steps. Rapid implementation was essential. Some organizations that had telehealth programs quickly scaled them up, while others new to telehealth had to learn and adapt to new ways of delivering patient care remotely.

Many organizations have now shifted from this hurried response to one of more deliberate planning, role redefinition, and longer-term visioning for the best use of telehealth tools. Health systems are now determining which patients are likely to benefit the most from long-term telehealth services. With provider and patient satisfaction high, telehealth options are likely to reshape health care long after the pandemic passes.

Before COVID-19 hit and the Medicare waivers were announced, Minnesota health systems identified their top challenges: educating staff and physicians on telehealth workflows; scaling up issues related to equipment availability and deployment; understanding coding/billing to obtain appropriate reimbursement; and facilitating/supporting telehealth encounters with patients.

Join the dialog

We recommend that you contact your state senator’s or representative’s offices to advocate or provide input on telehealth policy. To learn more, interested physicians can contact Sue Severson at Stratis Health.

Bill Sonterre, strategic account executive at Stratis Health, is a senior health information technology leader and business consultant.

Reid M. Haase, MHIM, is program manager and health IT consultant at Stratis Health

Suggested links

Great Plains Telehealth Resource and Assistance Center: gptrac.org/

Long-Term Care Telehealth Toolkit: tinyurl.com/mp-tele-02

National Consortium of Telehealth Resource Center Covid-19 Toolkit: tinyurl.com/mp-tele-03

Rural Telehealth Toolkit: tinyurl.com/mp-tele-04

Telehealth Toolkit for General Practitioners: tinyurl.com/mp-tele-05

Telehealth Toolkit for End-Stage Renal Disease Providers: tinyurl.com/mp-tele-06

President Trump expands telehealth benefits: tinyurl.com/mp-tele-07

Medicare—telemedicine fact sheet: tinyurl.com/mp-tele-08

Medicare telehealth FAQ’s: tinyurl.com/mp-tele-09

HRSA Telehealth Toolkit: tinyurl.com/mp-tele-10

CMS Medicare Telehealth Services: tinyurl.com/mp-tele-11

Center for Connected Health Care Policy: www.cchpca.org/

Rural Telehealth Research Center: tinyurl.com/mp-tele-12

NQF tele-behavioral health guide: tinyurl.com/mp-tele-13b

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Reid M. Haase, MHIM, is program manager and health IT consultant at Stratis Health