Speaker: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today, solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at stepsforward.org.
Stacy Lloyd: Welcome to the STEPS Forward® podcast. My name is Stacy Lloyd. I'm the director of digital health and operations here at the AMA, and I will be your host for today's episode. I'm joined by guest Dr Vimal Mishra, AMA director of digital health, and Sandy Marks, AMA assistant director of federal affairs to talk about all things telehealth now that the COVID-19 public health emergency has ended.
So why don't we start by having you both tell listeners a little bit about yourself, your background, and your role, both at the AMA, and Dr Mishra outside of the AMA as well? So we will start with Sandy.
Sandy Marks: Thanks, Stacy. Yeah. I'm the senior assistant director in our federal affairs unit that's in the AMA's Washington office and is part of our larger advocacy team. And within that, I work on telehealth and some other digital health issues, a lot of Medicare payment policy issues, especially physician payment policy and value-based care policy. I also do some work on our efforts to end the drug overdose epidemic.
Lloyd: Great, thanks for joining us today. Dr Mishra.
Vimal Mishra, MD: Thank you, Stacy. And thanks for the opportunity to talk about this issue, which is very near and dear to me and my work. I serve as director of digital health at the American Medical Association, which is a part of the PS2, which is Professional Satisfaction and Practice Sustainability Group. As a clinician, I practice mostly internal medicine practice in an inpatient setting. I also serve as a vice president of digital care at the University of California, Davis Campus. As a vice president of digital care, I support UC Davis and their digital health transformation. I'm glad to be here.
Lloyd: Great to have you both. Let's get started. The use of telehealth was broadly expanded throughout the COVID-19 pandemic to really ensure uninterrupted care for patients. Many of those provisions for the use of telehealth were created as part of the government-enacted public health emergency to increase ease of adoption and use of telehealth. Now that that public health emergency has ended as of May 11 of this year, many of those COVID-19 flexibilities will end and/or some of them may remain in flux, which causes questions and uncertainty around the future of telehealth use.
I'm going to start with you, Sandy. Could you start by giving us some overview of some of the changes we'll be seeing or maybe are already seeing in the telehealth landscape now that the PHE is over? And then also some of the things that will remain consistent given the progress that we've already seen over the last few years?
Marks: It definitely has been a confusing situation because some things have been extended, some things were thought to be ending and then were extended. Things are ending at different times. Different areas of the government have different authorities over different aspects of telehealth. But I'll run through a few of the key things. The big, big change that happened for people with Medicare at the start of the COVID pandemic and the public health emergency was that telehealth became available to all Medicare patients all over the country instead of just being limited to people who lived in rural areas.
The other big, big thing was that it could become available to patients in their homes. Instead of having to leave your home and go to a clinic somewhere in order to receive telehealth services from a distant site, patients were able to get telehealth services right in their homes. They could use their personal devices to do it, like their smartphones to do it. So that was new. Later on, they added coverage for telephone visits, including smartphone calls or landline calls, other kinds of visits that were done by audio only.
Another change they made a little bit later than the very beginning was they increased the Medicare payment rates for telehealth services from what they call the facility rates, which is what a professional would receive for providing the service in a hospital or other facility versus the non-facility rates, which are what physicians are paid when they provide office-based services. And so they increased the payment rates up to the office-based rates.
So those were all a bunch of changes, and thankfully all those things are going to stay in place at least through the end of 2024. This is based on a combination of what Congress did in the Consolidated Appropriations Act 2023, where it extended the telehealth availability throughout the whole country and for patients in their homes through the end of 2024, by law. It extended the ability for Medicare to pay for audio-only visits through 2024. And then the Center for Medicare and Medicaid Services decided to continue paying for these services at the non-facility rates at least through the end of 2023. There was a lot of concern about a variety of policy changes occurring in the middle of the year. So extending through 2023 was very helpful.
Then there was a few other changes. The Drug Enforcement Administration had put in place special flexibilities for prescribing controlled substances during the public health emergency. They issued some proposed rules to change their policies on telehealth visits as a basis for prescribing controlled substances, which I think they initially hoped to finalize before the public health emergency ended. But they got more than 38,000 comments on those rules and they took a step back and said, “Well, we need to pay some more attention to this and we're going to just extend the COVID-era policies for six months,” which takes us to November 11, 2023, and they will be planning to issue more rulemaking before we get to that point.
A couple of other of less well-known changes: CMS had planned to end the policy that allows physicians to supervise medical residents at the end of the PHE to supervise them using telehealth or virtual means. But they changed their minds, and they decided to keep that in place at least through 2023, and again, deal with that in future rulemaking.
They lifted enforcement of the limits that existed on the frequency with which telehealth visits can be provided to patients in skilled nursing facilities and to inpatient hospital patients. And they decided to maintain those policies as they had been during COVID through the end of 2023 and deal with them in future rulemaking.
So future rulemaking in all these cases that involve CMS means we will be expecting to see what the policies will be in 2024 when the 2024 proposed Medicare Physician Payment rule comes out, which generally happens in July.
Lloyd: That's a lot of information, for sure. I think what I'm also hearing is while there are still some things that have proposed end dates potentially in place, it sounds like there's still some optimism and positivity around some of those things really sticking around still, given that future rulemaking is going to be part of the process.
Marks: Yeah and also future congressional action. The AMA has been working very hard to secure legislation that would permanently extend telehealth availability throughout the country for Medicare patients and not, again, limited to rural areas, and extend the ability for patients to receive telehealth services wherever they're located, whether they're home, someone else's home, wherever they happen to be. So, we're working very hard to make that happen. But the two-year extension was definitely a good first step.
Lloyd: That's great. A lot of what you were talking about is really surrounding federal policy and Medicare and CMS, but not necessarily the commercial payer side of things. This is where I'm going to toss it over to Dr Mishra. I'd love to hear from you, to talk a little bit about what you're seeing around telehealth coverage and payment changes. How are those things impacting virtual care and telehealth programs that you're seeing in your environment on what I like to call the ground floor of health care delivery?
Dr Mishra: Yeah. Thank you, Stacy. I think this is great. I just want to also put this in perspective of the impact and the changes which happened during the PHE period and how the changes and these regulations changed how we delivered care. I think it's always good to remember how it really enhanced care for our patients.
I still remember the day in March when the PHE was announced. We were doing less than 1% of telehealth visits before that because of the restrictions around it. And by April, May, we were doing 70% or more of the visit using telehealth. There were restrictions, social distancing, cancellation of elective surgeries and elective procedures, and so many different changes which were enabled. That was a complete game-changer. The telehealth implementation and the waiver was really working. We have not really assessed this in terms of how did it improve significant safety and quality and outcomes for our patients during the PHE? When we talk about the steps around now the PHE is over, how these restrictions and regulations are going to change the health care delivery one more time.
But I say that the genie is out of the bottle here, and I think we have seen lots of improved outcomes using this. And from the UC Davis perspective and from the frontline perspective overall, I think we see a lot of potential of how telehealth can continue supporting our patient-centric care, which is needed, how we can improve access as we did during COVID period, telehealth and remote patient monitoring programs and other digital health tools and technologies. So at this point of time, we are moving ahead as we are hoping to continue to see these changes be permanent.
We have some concerns certainly at the front lines, especially around residents and learner supervision using telehealth, which is going away, which is via an academic medical center. We have concerns around that because I think it had worked well and there's going to be change in the workflows around it. We, of course, have concerns around telephone calls not getting reimbursed. That's the work which we think has really supported our behavioral health patients, patients who do not have access to technologies, video technologies and broadband and others. So those are continued concerns for us. But at the same time, we believe the impact it had created, the access it had created, the outcomes it had created, has really shown that telehealth works and we need to continue in that direction.
Lloyd: That leads me actually into a next question in terms of how the PHE is affecting the use of different platforms and modalities for providing telehealth, and one thing that Dr Mishra mentioned about audio only. And I'd be interested, Sandy, if you are seeing any risk to audio only across any different specialties or services that might be provided or have been provided throughout the PHE via audio only. Is there things that are at risk versus some things that you can see sticking around because they've been proven to work very well in providing access and positive outcomes?
Marks: There was a policy adopted during the PHE that permanently allows certain kinds of services— services to treat mental health conditions, services to treat substance use disorders—to continue to be provided by audio only. But we are very committed to seeing the allowance for audio only continue to be a permanent part of the coverage. So we would really like to see the CPT codes for audio only visits continue to be covered by CMS. They raised some questions in previous rulemaking about their statutory authority along these lines, but the Consolidated Appropriations Act did extend that authority for an additional two years. And we hope that all this will be resolved before 2025 rolls around and that we'll be able to count on those services continuing to be covered because they have been a very important component of medical care during the public health emergency and afterwards, now that we're beyond the end of the PHE.
We've heard from many physicians about how they can provide care using audio only services and that it's very much equivalent to audio-video services. And for a number of patients, they're simply more comfortable talking on the phone than they are using audio-visual services. Even if they have access to them, just some of them are not comfortable with it. So we certainly hope that will continue, yes.
Lloyd: Yeah. I think that's a real positive in helping to create some equity and access there as well because we still do know that there are some challenges with broadband and Wi-Fi and people having access to even be able to do the audio-visual visits as well. So still work to be done in that area and I think the audio only really helps to support that in the meantime too. Dr Mishra, were you going to say something?
Dr Mishra: I want to highlight a few things at the frontline, especially when you talk, Stacy, around telehealth coverage and payment. How is it going to change?
We were having discussion before our conversation right now around remote patient monitoring programs. There were changes in the code and coverage starting in 2020. During the pandemic, there was change in regulation where we did not require to submit 16 days of data per month to get the reimbursement for remote patient monitoring program. There was also change in terms of the copayment where practices can waive that, and as well as, in terms of these patients do not need to be already-established patients. So, these were the three changes in the remote patient monitoring program.
Once this PHE ends, that's going to change. Now the practice will also change in terms of how patients are perceiving the coverage and payments and they will be responsible for their copay. So that might change their adoption and change in outcomes as well. Also thinking about telehealth direct to consumer or telehealth in terms of at-home services provided where they will be required to pay copay as well and how that's going to change the adoption is something to see at this point of time.
We have also seen significant change in patients, how they receive care during COVID. We know that patients now want to utilize portals to send messages. We have e-visits, which really picked up during PHE as well, and now there is a coverage and payment, which is actually permanent, which is a really great thing. And we are seeing how we can continue to leverage those codes and payments and coverage strategies to move forward. So I think these are really important topics.
Certainly, I want to also bring up some acute care at-home program. In 2020 March, CMS established Hospitals Without Walls initiative, which was expanded delivery of patient care in non-traditional settings through virtual services, which allowed hospitals and critical care access hospital to set expansion sites like other facilities, ambulatory surgical centers, hotels, dorms, community-based facilities as part of the initiative. Which was in November 2020, expanded to acute hospital care at home, which permitted hospitals to provide at-home care and services to patients with acute conditions traditionally treated in an inpatient setting. So these waivers, really, there's been a lot of research, a lot of publications, which actually shows these waivers really work. Patients get high-quality care, high-quality outcomes, and it has been extended until December 31, 2024.
So, these are the considerations when we are thinking about how we are really implementing telehealth services or digitally enabled care models into the future and how it's going to impact its adoption and payment and coverage.
Lloyd: Knowing that there's been a lot of progress, but still some work to do on the policy end of things, and I know you and that whole advocacy team has really worked so hard in this space over the last few years, what are some ways potentially our audience can continue to support these advocacy efforts? And my head goes to case studies, or showing the impact and the value of these services. Are you still interested in looking for that kind of information? What kind of data is useful? And how can physicians and health systems and practices really continue to help support the continued forward progress around telehealth?
Marks: Oh, absolutely. I think there's still a lot for us to learn. It's extremely helpful to us to have information about the effectiveness of telehealth and other digitally enabled care, how it affects the quality of care that's delivered, how it affects spending on care, including any concerns people have about problems they see in the way that care is being delivered that could potentially be addressed through changes in policies. All that kind of information is very helpful as we talk to policymakers and as policymakers run ideas by us about changes they want to make, so that we can respond accurately to what kind of impacts those changes might have, what unintended consequences they might have or how they might be helpful. So yes, very helpful to get that kind of information.
And we know there are important policymakers who are continuing to work on this, like the Medicare Payment Advisory Commission came out with their report recently on telehealth, that said as it met on this topic during the year that it was going to continue working on this issue in the future. So yeah, a lot of work still to be done. And as Congress takes up the legislation that would hopefully provide permanent extensions, they will be looking at what the impact will be on costs.
Lloyd: Dr Mishra, I am going to go to you last. I know you already provided some tips on things that are changing at the frontline, but why don't you close us out with any practical tips or pearls of wisdom for other health care leaders who are currently navigating this new telehealth landscape, or maybe even still a little bit of that uncertainty around the future of telehealth and, really, digitally enabled care?
Dr Mishra: Thank you, Stacy. I think this is really important for us to understand. There's a lot of uncertainty. There's lots of conversation going on. From our perspective, from UC Davis' perspective, at the frontline perspective, we are thinking this is going to continue. Because we want to support our patients where they are, we need to create patient-centric environment, which improves quality, decreases cost, and improves experience. And there's no other way other than telehealth digitally enabled care models to integrate already in-person services into this virtual services to move forward. We know for sure that a remote patient monitoring program gets paid for, there's coverage to it. We know that e-visit has coverage for it. The site expansion is going to be continuing until 2024, and many other hospital at-home waiver, continuing 2024. There's going to be lots and lots of outcomes which is already coming together.
So, it just feels like the genie's out of the bottle. I don't think it's going to go back. It's not going to roll back. At least from the frontline perspective, we are seeing this, we are perceiving this. And we are moving forward irrespective of fee-for-service changes. Thinking about how can we really support our patients moving forward given all the issues we are facing? We are facing issues in terms of capacity. Our patients don't have access. Our hospital runs more than 92 to 95% capacity every day for years and years. There's no other way other than supporting these patients, moving these patients quicker, improving their experiences.
I think we need to start thinking about not only in terms of what gets paid or what will happen in the future, but also thinking about return on health where we are thinking about the value streams of how is the intervention improving the access? How is it improving experience for our patients and our caregivers? How is it improving experience for our clinicians and physicians? How is it improving operational effectiveness? And there are ways to start thinking about, in the value-based care system as how it is improving the financial outcome, irrespective of one-to-one transaction, but overall how it's improving that.
From our frontline perspective, we are moving forward with that intention to improve care, to change care, to transform care, and there's no other way rather than building this digital-enabled care model for the future. I feel like the signals we are getting from our regulators is also positive. It's not all the green light yet, but I think it will be. I think there's no other way to deliver care in the future with the crisis we are facing today.
Lloyd: Thank you so much for joining us today, Sandy and Dr Mishra. The AMA is definitely focused on not only providing resources needed for the now, but also really thinking strategically ahead for the future so that we're supporting physicians, care teams and patients in realizing the full potential of digitally enabled care.
If you'd like to explore more resources on the evolving telehealth landscape, our telehealth quick guide and other resources will be linked in today's episode description. And we do also have an active asynchronous discussion on our AMA Physician Innovation Network if you'd like to connect with us, ask any questions, share your thoughts on all things telehealth post-PHE.
Thanks for listening to today's episode of the STEPS Forward® podcast.
Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, stepsforward.org.
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