番茄社区

For 番茄社区's "After the Pandemic" series, we asked our to discuss what significant and lasting effects the COVID-19 pandemic will have on medicine and the delivery of healthcare.

Here, we interview Anders Gilberg, senior vice president for government affairs at the Medical Group Management Association (MGMA) in Washington, D.C.

Check out some of our other articles in the series here.

What effects will the pandemic have -- in the aftermath -- on the way medical practices are run?

Gilberg: Last year, medical practices were forced to overcome numerous challenges to cope with plunging patient volumes and increased costs while trying to stay solvent amid the COVID-19 pandemic. MGMA members reported, from an operations standpoint, that certain administrative positions such as billing, information technology, and compliance were successfully performed by employees via remote work, but it isn't clear how long this will continue.

Some practices are considering offering telework options to stay competitive in the job market, but only 15% of medical groups responding to an April 13 indicate they plan to increase their remote workforce this year. Medical groups are subject to countless privacy and security regulations, so a remote workforce is easier said than done in terms of cost and compliance considerations.

Medical practice executives in independent groups express concerns about the impact of the pandemic on industry consolidation. Medical groups have fewer financial reserves as a result of the tax code (to avoid double taxation) and are unable to sustain systemic shocks to their businesses as well as larger entities. It remains to be seen how much the events of the past year will accelerate the existing consolidation trend, but it may well prove to be a tipping point for many groups as they look to centralize administrative functions or consolidate under a larger, well-capitalized organization.

The pandemic has shown how effective virtual care can be in treating patients, and many practices are carefully evaluating new virtual service lines. How this will play out is almost entirely dependent on payer coverage and reimbursement policies. Medical practices will not be able to continue delivering telehealth services if reimbursement rates are cut after the public health emergency (PHE) ends. Some specialties, such as mental and behavioral health, which are not as dependent on physical examinations, would benefit from a telehealth model if adequately reimbursed.

Which changes that the federal government made during the pandemic -- such as loosening some reimbursement requirements -- would you like to see made permanent?

Gilberg: When the COVID-19 pandemic began, Congress and the administration acted quickly to temporarily reform traditional Medicare telehealth rules to allow patients to continue safely receiving care from their medical groups. These modifications to the existing Medicare telehealth law and regulations, including the elimination of geographic and originating site restrictions and payment parity between telehealth and in-person visits, led to a sharp uptick in telehealth utilization among medical groups. In fact, in late March 2020, 97% of MGMA members reported their practices expanded telehealth access amid the COVID-19 pandemic.

Physician practices acted quickly to incorporate telehealth visits into their workflows and have embraced telehealth visits as a means of treating vulnerable patients who might otherwise go untreated. Once the PHE is lifted, the great strides made in treating patients appropriately through telehealth will disappear with it, unless Congress acts to permanently eliminate the geographic and originating site restrictions required to bill telehealth under Medicare.

The end of the COVID-19 pandemic does not change most patients' ability to seek in-person care due to mobility or transportation issues. Virtual care is an underutilized tool in a medical practice's tool belt to treat this country's vulnerable population. However, practices cannot continue to deliver these services if reimbursement is severely reduced. Prior to the PHE, Medicare telehealth services were reimbursed at the lower facility rate.

We believe that the resources involved in furnishing visits virtually do not call for a cut in reimbursement. Group practices still must schedule visits, facilitate the visits, virtually check-in patients, document the visits, schedule follow-up appointments, and invest in HIPAA compliant platforms. As such, we would like to see telehealth visits reimbursed at the higher non-facility rate permanently.

The pandemic also highlighted the importance of audio-only visits. Telephone visits provide a lifeline to patients who are unable to attend visits in person or participate in telehealth visits due to lack of broadband access or necessary equipment to facilitate the visits. In August 2020, 82% of MGMA members reported that they billed an audio-only service during the PHE. In some cases, these visits were the only means of treating patients virtually.

A 2019 Federal Communications Commission (FCC) report estimates that over 21 million individuals do not have access to broadband. Further, researchers have estimated that 41% of Medicare patients lack access to a desktop or laptop computer with a high-speed internet connection at home. Patients should not be punished because they live in an area without access to broadband. Ironically, before the COVID-19 PHE, telehealth was only available to those in rural areas -- plenty of which did not have the infrastructure in place to conduct audio-visual visits.

Before the PHE, CMS would not cover audio-only visits, and last December, CMS finalized its proposal to discontinue reimbursement for them following the conclusion of the PHE. We think it inconceivable that patients would not have the ability to seek necessary care through telephone visits following the end of the PHE and we urge CMS to continue reimbursing for those services.

What does the future hold for telemedicine and other changes implemented during the pandemic?

Gilberg: Last year, when asked about the future of telehealth, a senior HHS official said, "The cat is out of the bag." We tend to agree, but would ask, "Who is going to feed and care for the cat?" Congress waived many of the restrictive requirements for billing a Medicare telehealth service for the duration of the COVID-19 PHE, and the subsequent uptick in Medicare telehealth visits was noticed by lawmakers.

Throughout the pandemic, lawmakers have touted the benefits of telehealth and expressed desires to make some of the waivers permanent. However, they also voiced concerns over the cost to the Medicare program, the quality of care associated with telehealth visits, and potential fraud issues. We agree that "the cat is out of the bag," but think it will be an uphill battle to convince Congress to feed and care for it.

It is likely that Congress will extend the Medicare telehealth flexibilities available under the COVID-19 PHE for a short period of time to collect data on its cost to Medicare and patient outcomes. Until these data are collected and analyzed, it is difficult to predict whether telehealth will be permanently expanded. But without the elimination of the geographic and originating site restrictions, telehealth will simply not be an option for many Americans. Without the waivers, Medicare beneficiaries were only eligible for telehealth services if they received the service from an originating site in a rural area. It is no surprise that in 2016, prior to the COVID-19 PHE, only 0.25% of beneficiaries in fee-for-service Medicare utilized telehealth services.

Even if Congress amends the law and permanently eliminates the geographic and originating site restrictions, it will be difficult for medical groups to continue delivering these services if the reimbursement drops back to the pre-COVID-19 facility rate. The difference in reimbursement between facility and non-facility rates is enough to discourage practices from continuing to offer telehealth services because they simply would not be able to sustain the costs of delivery.

The future of Medicare telehealth is dependent upon both how Congress modifies the law to reflect the waivers available during the COVID-19 PHE, and whether physician groups are adequately reimbursed for these services.

Comment