Medicare Increases Telehealth Coverage...a Bit

Ken Terry

July 16, 2014

The Centers for Medicare & Medicaid Services (CMS) proposes to increase incrementally the telehealth services that Medicare will cover, including wellness visits and some behavioral health services. However, CMS continues to restrict telehealth coverage to rural areas and offers a very circumscribed definition of the telehealth technology that can serve as the basis for coverage.

In the telehealth section of a proposed rule dealing with regulatory changes affecting physician payments, CMS says it intends to pay for annual wellness visits, including initial and follow-up encounters, plus a preventive plan of care.

In the behavioral health area, CMS proposes to cover telehealth services for psychoanalysis, family psychotherapy (both with and without the patient present), and prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service.

"I think these are very good developments, and we're certainly supportive of this," Paul Summergrad, MD, president of the American Psychiatric Association, told Medscape Medical News. "Psychiatric conditions are very common illnesses, and they're highly comorbid with other kinds of conditions. They're also very costly and cause a lot of human suffering. So anything that can get better behavioral health coverage for these folks, especially in less populated areas, is great."

Dr. Summergrad added, "There are circumstances where telehealth would not work well, because the patient's visual condition may not be apparent or because you can't do a physical exam. But in many other situations, this is going to be extremely valuable."

CMS requires that telehealth consults be confined to authorized "originating sites." Effective January 1, 2014, the agency expanded these sites to include "rural census tracts" that fall inside metropolitan statistical areas. "Adopting the more precise definition of 'rural' for this purpose expands access to health care services for Medicare beneficiaries located in rural areas," the proposed rule states.

Dr. Summergrad praised CMS for broadening coverage to more areas and said he hoped Medicare would eventually cover telehealth everywhere in the country.

"A Small Step"

However, Rashid Bashshur, PhD, director of telemedicine for the University of Michigan Health System, was not impressed with CMS's responsiveness to this technology. "This is a step in the right direction, but it's a small step," he told Medscape Medical News.

Years ago, Dr. Bashshur recalled, CMS refused to cover telehealth at all, and it is still taking a very restrictive approach because it is afraid of the potential for overuse. On the basis of his own research, Dr. Bashshur has estimated that CMS paid only $12 million for telehealth last year.

"They're afraid because they've been burned before. But what they're afraid of isn't terribly realistic. Even where patients pay nothing, telehealth still has limited use," he said.

A remote consult, the CMS rule says, must use an "interactive telecommunications system" that includes audio and video, and it must be performed when the patient is present. "Store and forward" technology, which would let a physician evaluate recorded data or visual images, is not allowed, except in demonstration projects in Hawaii and Alaska.

CMS's definition of the telehealth technology it will cover resembles that of the recently issued telehealth policy of the Federation of State Medical Boards, but even the federation endorsed store and forward, and according to Dr. Bashshur, it also asked CMS to approve this technology for Medicare.

By not doing so, CMS is being overly restrictive, Dr. Bashshur said. "Store and forward is a more efficient way to deliver care, and it's suitable for certain conditions, such as dermatology conditions." CMS does allow physicians to view stored radiological images, he notes, perhaps because it does not regard those as part of remote patient consults.

If CMS were to open up and cover telehealth everywhere in the country, Dr. Bashshur said, "it would help patients in underserved areas have their needs met. It would also improve their choice of providers."

However, he does not see that happening until CMS and Congress figure out what it would cost to cover telehealth and how to deter overuse of the technology.

With regard to behavioral telehealth coverage, Dr. Summergrad said he hopes that other payers, and particularly Medicaid, will follow the example that CMS has set in its proposed rule for Medicare. Commercial payers often adopt the same coverage that Medicare has set, but that does not necessarily apply to the carve-out companies they hire to manage behavioral health, he noted.


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