January 2021

Eric Wicklund

Editor
[email protected]

Telehealth is helping businesses and schools bring people back to the workplace and campus, setting the stage for a more sustainable, long-term connected health strategy.

As the coronavirus pandemic continues to wreak havoc on the economy, businesses and schools are taking a look at telehealth to help manage “return to” strategies.

While connected health has long played a part in business health plans and school health programs, the COVID-19 crisis has turned the spotlight back onto direct-to-consumer and asynchronous platforms that allow people to connect with providers on demand. Businesses, schools, even government offices want to use those platforms to screen employees and students before they leave home and to quickly identify and treat those who show up sick.

“Ensuring a healthy and safe workforce actually starts ahead of showing up at the office,” says Kristen Valdes, founder and CEO of b.well Connected Health, one of dozens of connected health companies who have pivoted during the pandemic to launch platforms. “It’s helping employees to attest to the fact that they have not been exposed, that they are not symptomatic. Or if they were previously infected, that they are cleared to return to work.”

“Providing solutions to workers from a digital perspective also enables them to have clear instructions on how to present into the office,” she adds. “So is there a specific door that they should enter? Do they need to have their temperature screened upon entry? Are there certain markings on the floor or walls that they should follow in getting to their desk or their office environment? Are there policies around how many people can be in any one place, whether it’s getting coffee in a kitchen area or in a conference room? Is gathering appropriate?”

This also gives providers and payers an opportunity to reinforce the value of telehealth and mHealth services beyond the pandemic and back-to work and school programs, shifting the focus from identifying a potential illness to offering on-demand health and wellness services.

For Providers, A Community Service

As health systems, hospitals and medical practices look to recover from the stresses of the coronavirus pandemic, some see back-to-work and school programs as a means of re-engaging with the community. Many, if not all, were forced to shut down or severely curtail in-person care during the height of the crisis, and these programs offer a chance to reconnect with the public.

“Health systems should be poised to provide expert resources and clinical knowledge, including sophisticated infection control processes and procedures to guide employers and schools through the overwhelming amount of information and often conflicting guidelines available in a hyper dynamic landscape,” says Lori Japp, PA-C, vice president of urgent care and employer solutions for Colorado’s UCHealth.

Japp says healthcare providers can create virtual clinics in businesses and schools, allowing management to screen employees or students coming into the facility and triage anyone who might exhibit signs of infection. They can also help set up remote patient monitoring programs to treat those workers and students who are sent home.

In addition, those telehealth platforms can be used to treat other concerns as well. This is especially important as providers look to restart primary care, chronic care management and elective services that have been delayed or ignored.

“Our virtual clinics allow employers and academic administrators access to timely on-site intervention for common situations such as workplace injuries, illness, and other urgent care needs without having to send the employee or student to another facility for care,” Japp says. “In addition to being on-site, these services can be accessed remotely and virtually, synchronously and asynchronously.”

Japp says the changing nature of the pandemic makes it important for businesses and schools to partner with health systems, so as to gain access to the latest information on diagnosis and treatment.

“The landscape is continuously changing with new research, guidance, policies and procedures, making it prohibitive for a small- or medium-size business or school to keep up in the context of a possibly unknown financial future for both employers and universities,” she says. “Allocation of resources is changing in the workplace with more employees and students working remotely, which changes workplace dynamics.”

In the future, she expects health systems to expand their testing capabilities and RPM programs to not only avert another pandemic, but to help businesses and schools maintain a healthy workforce and stay ahead of seasonal problems like the flu.

Synchronous versus asynchronous telehealth

Asynchronous, or store-and-forward, telehealth enables two parties – patient and provider or provider and provider – to exchange information and images on an online platform at their convenience. It differs from synchronous telehealth in that the latter occurs in real-time, often on an audio-visual platform.

Integrating Back to Work Telehealth Into Health Plans

Payers are also gearing up to help members ease their way back into work and school.

“We see a real advantage in having the right care available at the right time,” says Diane Wolfenden, a regional vice president for Michigan-based Priority Health. “Telehealth gives us an opportunity to be more innovative, and to create access points that people prefer.”

Learning lessons from COVID-19, health plans large and small are pivoting toward healthy workplace initiatives that emphasize on-demand virtual care – not only for primary care services, but also behavioral health. Some studies have noted that access to mental health services will be even more necessary as people deal with the stress and anxiety of returning to the office, factory floor, store or school.

With telehealth and mHealth, Wolfenden says, health plans also have the opportunity to communicate more often with their members.

“You can’t just send out an e-mail or an article and say ‘That’s good,’” she says. “Accessibility is going to be important, whether we’re in a pandemic or not.”

By focusing on back-to-work and school programs, payers can increase their touch points with members, first focusing on testing and on-demand access to care. Those conversations can then evolve into health and wellness advice, appointment and medication reminders, even discussion about societal and social factors – the so-called social determinants of health – that can affect long-term health.

“During COVID we were (focusing on) messages on the need to not put off or cancel healthcare, and on offering support, especially in behavioral health,” Wolfenden says. “Now we can use those (channels) to keep the conversation going, improve those touches and boost engagement.”

Creating a New Market for Connected Care

Telehealth vendors are also pivoting to address the need for back-to-work programs. Some have fine-tuned asynchronous, orstore-and-forward, telemedicine platforms that allow employees to fill out a questionnaire at home, after which they’re directed to the appropriate care – a telehealth visit, scheduling for an in-person appointment, or resources that might include directions to the nearest COVID-19 testing center or information on vaccines, health plan benefits, even mental health services

For companies new to the idea of offering telehealth, this opens the door to a wide range of preventive health and wellness services.

“The important thing is providing choice,” says Valdes, of b.well Connected Health. “More and more employers are able to offer those choices. So if I am someone who has indicated that stress is my biggest overall health concern, I may be interested in trying out a mindfulness and meditation app to control anxieties. Or, I might want a telehealth visit with a behavioral health specialist where I can actually talk one-on-one with someone without taking time off work or sitting in a physician office. And therefore, we can use consumer likelihoods and preferences to provide that combination of in-person virtual and digital care. Everything from digital therapeutics like Headspace or Calm or Ginger for telehealth. That’s how we enable people to engage in their overall health from work or from home.”

This also addresses a trend seen in telehealth before COVID-19 surfaced: the need to tailor platforms to individual needs.

“I think a common mistake is providing a one-size-fits-all solutions,” she says. “We are individuals, each one of us, with our own preferences and our own needs. So if you said to a population, ‘We want you to use this telemedicine or this test or this location,’ there are going to be people who don’t agree with that.”

“So a lot of mistakes and incorrect assumptions are assuming that an entire population will follow one program,” Valdes adds. “And that’s why choice is so important. Employers really need to think about providing optionality. Don’t think about one solution provider and one program, think about putting together a program that offers choice that gives that one centralized launching point through a central platform so they know that it’s supported by the organization as a whole.”

Making Telehealth Work for Returning Employees

To be sure, business and schools – and everyone else, for that matter – are dealing with situations they haven’t encountered before. Few, if any, have had to implement programs that test and substantiate one’s health before they leave home.

Telehealth and mHealth tools give them that opportunity, as well as the freedom to design a plan that meets their needs now and well into the future.

“Every employer is different,” Valdes points out. “Some employers have essential personnel that must return. Others have entire populations of people who can work from home remotely for an indefinite period of time. Let’s go back to the example that I gave around when you show up to work, are you required to have a mask? Will one be provided? Are you required to sanitize and get your temperature taken or not? It’s very difficult for providers and payers to configure and customize these programs specific to an employer.”

“And each employer also has specific local and state mandates that they have to follow in addition to federal mandates,” she concludes. “So it’s important to know that whether you partner with a healthcare provider or a payer, or you build your program on your own, that you have the needs of your program defined that are specific to your own organization and that whoever develops your program has the ability to customize and very quickly also change. Because requirements are changing, as you know, sometimes day by day when it comes to COVID.”

By Kat Jercich

The COVID-19 pandemic triggered a flurry of changes to regulations around telehealth and virtual care – the vast majority of which expire once the public health emergency ends.

The current presidential administration and 116th Congress have each signaled their support for virtual care to various degrees over the past year. But neither took decisive, sweeping action that would permanently enshrine some of the major changes to telehealth policy.

So, the question on the minds of many telehealth advocates as President-elect Joe Biden prepares to take office is: What’s next?

“We are at an inflection point, and inflections bring new challenges,” said former senate majority leader Dr. William Frist, R-Tennessee, during the first day of the American Telemedicine Association’s four-part EDGE policy conference on Tuesday.

“Inflections demand changed perspectives, changed understanding, changed behaviors on our parts,” said Frist, a surgeon who is now a director at Teladoc and partner at Frist Cressey Ventures.

Frist noted that virtual care has exploded in the wake of the COVID-19 crisis. But the next steps, he said, will be safeguarding access to that care.

He noted the importance of allowing telehealth access regardless of patient and provider location, codifying a broader range of practitioners that can provide Medicare-reimbursable telehealth services, authorizing federally qualified health centers and rural health centers to continue offering telehealth, addressing cross-state licensing barriers, and treating all forms of communication equally, with regard to reimbursement, if providers can meet the same standards of care.

“There is a risk that broad telehealth deployment – if not carefully and thoughtfully designed – could replicate the barriers of the traditional bricks-and-mortar health system that produced disparities,” Frist cautioned.

Multiple panelists throughout the day raised payment parity as a particularly thorny issue. Frist noted, for example, while it was necessary to motivate physician participation during the pandemic, “since many overhead costs are totally eliminated in virtual transactions … some of these savings should flow to the patient as well as the provider.”

Similarly, Meghan O’Toole, health policy advisor for Sen. Brian Schatz, D-Hawaii, said “there’s a difference between payment during a pandemic … versus beyond.”

“Congress may not be the best suited to establishing payment rates for certain services,” O’Toole said.

“The [Congressional Budget Office] has consistently evaluated telehealth legislation as very expensive,” added Crozer Connor, senior legislative assistant for Rep. Mike Thompson, D-Calif.

In order for more lawmakers to give their full-throated support to telehealth reform Connor stressed the need for more data to support the quality of virtual patient care, saying, “What we need is payer data.”

“If we offer telehealth as an insurer, does that drive up utilization? Or is there a substitution effect?” Connor continued.

AVIA executive in residence Dr. Molly Joel Coye countered that in her panel, noting that plenty of data regarding telehealth’s effect on care exists, especially from the Veterans Administration.

“We do have data. We just don’t have it at the scale that COVID has now caused telehealth to be used,” Coye said.

Coye and her co-panelist Avalere Health senior advisor Wendy Everett forecast an overall rosy future for telehealth under President-elect Joe Biden’s administration.

“It’s mostly very good news,” Coye said.

She predicted that Biden’s administration will support the idea that broadband infrastructure alone will not be enough for parity in digital health.

It’s not just obtaining access to broadband, she said, but the ability to “pay for data charges, to have the appropriate devices and to have digital literacy” that makes a difference.

She pointed to “what I would call ‘the Geek Squad capability’ to come out and help people when it’s blowing up, and they just don’t know what to do, and they can’t make it work.”

Everett agreed with Coye that Biden’s administration “will absolutely keep the conceptual foundation that the Trump administration put in place.”

However, she noted, “there are some elements that the new administration will need to review.”

Again returning to payment for telehealth, Everett said, “We’ll likely move toward determining some level of fair payment rather than moving toward payment parity across the board.”

She also raised the importance of addressing the multi-channel delivery potential of telemedicine.

“How is [audio-only care] covered? What are we going to do about covering for text, for chatbots, for AI, for other ways of getting healthcare services to people who currently can’t get them?” she said.

One major way the next presidential term will be different, she predicted: “There’s going to be a lot of work done on expanding access to telehealth for those people who are broadly underserved.”

“Think about what they come in facing,” added Coye. “They are under the gun to show the public that they are going to do something really good for them in the next two years.”

Telehealth, she said, “is one of your key ways to make sure the public sees better access resulting from more insurance coverage.”

“We know there’s a very strong focus on equity and on access. But obviously the two are very tied together,” said Everett. If she were given the chance to pitch telehealth to senior government officials, she said she would propose, “Let’s come up with a plan for how to solve that digital divide: how to reduce the inequities and how to move telehealth across the country ubiquitously.”

By:  Scott Moody, MHA
National Telemedicine Policy Updates:

1. The Centers for Medicare and Medicaid Services (CMS) released the 2021 Medicare Physician Fee Schedule final rule on December 1, 2020. The 2,165-page final rule adds more than 60 services to the Medicare telehealth list.  These services will be covered even after the Covid-19 pandemic has ended. Early on in the Covid-19 crisis, CMS added 144 telehealth services to its coverage list through the end of the public health emergency.  Follow the link below for the list of covered telehealth services:

https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.

2. R.133 – Consolidated Appropriations Act, 2021

The President signed Bill H.R. 133 into law on December 27, 2020.  The law does provide for expansion of Medicare telemental health services; however, it does come with limitations.  The law also provides other support for telehealth growth.  Please follow the link below for further detail:  https://preview.mailerlite.com/n8x5k1

3. R.7105 – Veterans Health Care and Benefits Improvement Act of 2020

The President signed Bill H.R. 7105 into law on January 5, 2021.  The bill requires the VA to ensure that veterans participating in or receiving services under a program for homeless veterans have access to telehealth services. The VA must ensure telehealth capabilities are available to such veterans, VA case managers, and community-based service providers.

4. R.7187 – HEALTH Act of 2020

On June 11, 2020, US Reps. Glenn Thompson (R-PA) and George Butterfield (D-NC) introduced bill H.R. 7187.  The bill proposes to make permanent Medicare coverage for telehealth services provided by Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC).  The bill also has language eliminating site facility and location requirements for distant site telehealth services.  The bill is currently in the House Energy and Commerce Committee and the House Ways and Means Committee.

5. R.5201 – Telemental Health Expansion Act of 2020

Bill H.R. 5201 proposes to modify the requirements relating to coverage of mental health telehealth services under Medicare.  Specifically, the bill removes restrictions that require the originating site (i.e., the location of the beneficiary) to be in a rural area and allows the home of a beneficiary to serve as the originating site for such services.  The Bill was discharged from the Committee on Ways and Means on December 24^th to go back to the entire House.

6. R.9035 – Permanency for Audio-Only Telehealth Act

Bill H.R. 9035 was introduced on December 18, 2020 and currently resides with the House Energy and Commerce and the House Ways and Means Committees.  The bill proposes to remove geographic restrictions for certain telehealth services and to expand the use of the home as an originating site for certain telehealth services.

7. R.8755 – Expanded Telehealth Access Act

Bill H.R. 8755 was introduced on November 16, 2020 and currently resides with the House Energy and Commerce and House Ways and Means Committee.  The bill proposes to the scope of practitioners eligible for payment for telehealth services under the Medicare program, and for other purposes.

South Carolina Telehealth Policy

8. H 3230 – Medicaid Mental Health Reimbursement for Telehealth Services

H 3230 was introduced on December 9, 2020.  The bill proposes to require the Medicaid program to reimburse practitioners for mental health telehealth services.  The bill was referred to the House Committee on Ways and Means.

9. S 265 – Case of Laws of South Carolina, 1976, By Adding Section 44-7-400

Bill S 265 was introduced by Senator John Matthews on December 9, 2020.  The bill proposes to amend the Code of Laws of South Carolina to insert language to prohibit hospitals from utilizing telemedicine to deliver intensive or critical care services and to require such services be provided or supervised by a physician who is board certified in critical care medicine.  The bill has been referred to the Senate Committee on Medical Affairs.

Click Here for PDF of this report

Key regulatory flexibilities impacted by the COVID-19 public health emergency include higher Medicare payments for COVID-19 hospitalizations and telehealth reimbursement.

January 11, 2021 – HHS has renewed the COVID-19 public health emergency, extending key regulatory flexibilities such as Medicare telehealth reimbursement and higher rates for COVID-19 hospitalizations through April.

The 90-day extension of the public health emergency, effective January 21, 2021, will help hospitals and health systems battle the ongoing COVID-19 pandemic in their communities, HHS Secretary Alex Azar said on Twitter on Jan. 7.

“Our work to combat the virus will continue, as will our work to ensure a peaceful and orderly transition,” tweeted Azar, whose tenure as leader of HHS will come to a close when President-elect Joe Biden takes office later this month.

Biden has nominated Xavier Becerra, California’s Attorney General and one of the chief architects behind the Affordable Care Act’s defense in the current Supreme Court case, to be the next HHS Secretary, pending Congressional approval.

This is the fourth time HHS has renewed the COVID-19 public health emergency, with the last being in October.

The public health emergency, first enacted on Jan. 31, 2020, implemented a number of blanket waivers and regulatory flexibilities for healthcare providers to deliver fast, flexible care to infected patients while maintaining access to care for those without the novel coronavirus.

Increased telehealth coverage for Medicare beneficiaries was a key flexibility HHS has offered providers through the public health emergency. The department has added over 200 telehealth codes that are reimbursable during the public health emergency, including emergency department visits, initial inpatient and nursing facility visits, and discharge day management services.

HHS has also allowed more types of providers to bill Medicare for telehealth services given during the public health emergency and granted waivers enabling reimbursement for audio-only telehealth services.

Through the public health emergency, HHS has also paid providers 20 percent more for caring for hospitalized COVID-19 patients and waived major rules, including the long-term care hospital (LTCH) site-neutral payment policy, the LTCH “50% Rule,” and the inpatient rehabilitation facility “3-Hour Rule” for all providers.

The department has also granted providers more flexibility with where they provide care to patients and waived certain reporting requirements for the duration of the emergency.

The waivers and regulatory flexibilities have been critical to provider response efforts to COVID-19, especially since the number of new cases, hospitalizations, and deaths continue to increase across the country.

But healthcare providers are also calling on HHS to make certain flexibilities and waivers part of the permanent regulatory landscape in healthcare. For instance, providers have urged the department to keep telehealth payment parity even after COVID-19 cases go down and can be managed by providers.

“Payment parity is an important policy because it affects their financial stability; in fact, before COVID-19, finances were a significant barrier to their using telehealth at all,” the University of Kansas Medical Center recently said in a Dec. report. “Some practices would not have started using telehealth were it not for COVID-19. The nature of the disease itself (the need for less physical contact and more social distancing) certainly drove some of the increase in telehealth offering and use, but the reimbursement and other policy changes likely also played a part.”

States have started to pass legislation making telehealth payment parity or payment at all permanent, but providers are calling for HHS to set the example and make telehealth a key part of Medicare coverage.

For now, blanket waivers and other regulatory flexibilities will last until April when the HHS Secretary will have to reassess the state of COVID-19 in the country.

For a comprehensive list of waivers and flexibilities, click here.