MedPAC Recommends Limiting Post-COVID-19 Telehealth Coverage, More Study

The Medicare Payment Advisory Commission is taking a cautious approach to permanent telehealth policy, advising lawmakers to extend some emergency rules for telehealth access and coverage up to a few years after the coronavirus pandemic ends and to keep on studying how these tools and platforms affect healthcare delivery.

MedPAC’s report to Congress, released yesterday, will disappoint connected health advocates who had hoped the agency would set a clear path for long-term telehealth policy. But it also underscores the degree to which healthcare delivery has been changed by the COVID-19 Public Health Emergency.

“In the report, we present a policy option for expanded coverage for Medicare telehealth policy after the PHE is over,” MedPAC says in a press release accompanying the report. “Under the policy option, policymakers should temporarily continue some of the telehealth expansions for a limited duration of time (e.g., one or two years after the PHE) to gather more evidence about the impact of telehealth on beneficiary access to care, quality of care, and program spending to inform any permanent changes.”

The agency recommends continuing Medicare coverage for telehealth services regardless of where the beneficiary is located, as well as covering audio-only services “if there is potential for clinical benefit” and some new services. It notes that coverage for audio-only services is new, so there’s very little evidence as to whether it reduces costs or improves quality or outcomes.

It also notes that the Centers for Medicare & Medicaid Services had covered roughly 100 telehealth services prior to the pandemic, and has added more than 140 services in the past year. Nine of those new services have been made permanent through the Physician Fee Schedule, while about 60 will be covered through the end of the PHE.

“CMS should continue to temporarily cover select services that the agency determines have the potential for clinical benefit,” the agency says in its report. “We favor this approach instead of permanently covering all of the telehealth services that are temporarily covered during the PHE. After a period of time, policymakers should use information gathered during the temporary period of coverage to consider permanently covering the additional telehealth services based on the principles of access, quality, and cost.”

On other measures, MedPAC advocates the return of some polices after the PHE, as well as heightened efforts to identify fraud.

The agency recommends the CMS return to paying the PFS facility rate for telehealth services provided by providers in distant sites when the PHE ends, while collecting data on the costs that practices incur in using telehealth. This would run counter to arguments in favor of payment parity.

“We expect the rates for telehealth services to be lower than rates for in-person services because services delivered via telehealth likely do not require the same practice costs as services provided in a physical office,” MedPAC says. “Although telehealth may require upfront investments in technology and training, in the long run the marginal cost of a telehealth service should be lower than that of an in-person service. Therefore, continuing to set rates for telehealth services equal to rates for in-office services after the PHE ends could distort prices and lead clinicians to favor telehealth services over comparable in-person services, even when an in-person service may be more clinically appropriate.”

The agency also recommends discontinuing allowing providers to reduce or waive cost-sharing for telehealth services. And it recommends additional safeguards to protect Medicare and its beneficiaries from unnecessary spending and fraud. Specifically, CMS should:

• “apply additional scrutiny to outlier clinicians who bill many more telehealth services per beneficiary than other clinicians or who bill for a high number of services in a week or a month;

• require clinicians to provide an in-person, face-to-face visit with a beneficiary before they order expensive durable medical equipment (DME) or expensive clinical laboratory tests; and

• prohibit ‘incident to’ billing for telehealth services provided by any clinician who can bill Medicare directly.”

MedPAC’s report falls in line with the thinking of the American Hospital Association. In a letter to the agency last month, Ashley Thompson, the AHA’s senior vice president of public policy analysis and development, urged MedPAC to hold off on long-term policy recommendations to allow for more study.

“The increased use of telehealth since the start of the PHE is producing high-quality outcomes for patients, closing longstanding workforce gaps and those that arose as a result of a sickened and exhausted provider corps, and protecting access for patients too vulnerable to risk infection,” Thompson said. “This shift in care delivery could outlast the PHE if the appropriate statutory and regulatory framework is established. To do so, stakeholders must have time to conduct in-depth analyses of how providers have used the telehealth flexibilities available during the pandemic and the quality of patient care provided through those flexibilities. Given that the pandemic is ongoing and that the Biden administration has suggested it will maintain the PHE declaration through the end of 2021, considerably more data points on the quality and cost effectiveness of telehealth services will be developed this year.”