Ramona Midkiff

By Dawndy Mercer Plank | December 17, 2020 at 6:06 PM EST – Updated December 17 at 7:46 PM

COLUMBIA, S.C. (WIS) – In this year of firsts because of the pandemic, doctors are seeing a greater number of patients through a computer screen.

Telehealth or telemedicine is a virtual visit with your doctor that’s gaining in popularity as this two-way video communication has now become the preferred choice for some patients.

When at Lexington Medical Center’s Saluda Pointe Urgent Care, you’ll hear “I’m Dr. Crump. I’ll be taking care of you today, virtually.”

Call after call, Dr. Todd Crump spends a chunk of his day seeing his patients through a computer screen.

“We didn’t have a whole lot of telehealth within my hospital, but it’s become very popular now that COVID’s come to town because people are just afraid to go to a facility and risk catching COVID,” said Dr. Crump.

In fact, telehealth visits are becoming just as prevalent as in-person visits not just because of avoiding exposure to COVID, but because of the convenience factor.

Dr. Crump says it’s really been a game-changer, especially for working parents.

The most common virtual condition Dr. Crump sees? Sinusitis.

“Folks come into the screen and say I get a sinus infection every year when the weather changes,” said Dr. Crump.

All ages are using the telemedicine option. Dr. Crump has people in their 70s using it — though he says his nurses sometimes have to help walk the older generations through the technology.

“I’ve had a patient log in and say, ‘I’m going to be the easiest patients you’ve had today. I have a rash.’ Holds it up to the camera. And I can actually take a picture of it and put it in her chart and then send a steroid cream to her pharmacy,” said Dr. Crump.

For the Lexington Medical Center network, there are two requirements to use the urgent care visit. A patient must have an LMC MyChart account. That’s the hospital system’s electronic health record. The patient must also confirm he or she is physically located in South Carolina at the time of the virtual visit.

You do not actually schedule a virtual visit. They are on-demand visits. That means a patient puts him or herself in a queue to request the visit. Then, the healthcare provider is notified that a patient is waiting. The staff will notify the patient when the doctor is ready.

Since the onset of the COVID-19 pandemic, Congress and the Centers for Medicare & Medicaid Services (CMS) have dramatically—but temporarily—expanded coverage and reimbursement for telehealth services.

On December 1, CMS issued the final calendar year (CY) 2021 Medicare physician fee schedule (MPFS) final rule and interim final rule, including several changes to Medicare Part B telehealth payment policy. The rule makes coverage of certain services permanent, extends coverage for certain other services through the end of the calendar year in which the public health emergency (PHE) ends, and clarifies which services CMS will not be adding to the Medicare telehealth covered services list on either a permanent or temporary basis. The rule also finalizes some changes to coverage of remote physiologic monitoring services and finalizes extending the temporary flexibilities around virtual supervision through the end of 2021.

Despite these changes, the rule also illustrates the limitations that CMS has in broadly expanding coverage and reimbursement given statutory restrictions. Without further congressional action, statutory restrictions on geographic sites, originating sites, eligible technologies, eligible providers, and federally qualified health centers (FQHCs) will come back into effect at the end of the COVID-19 PHE. And with these limitations will come decreased telehealth utilization. Based on the telehealth experience gained during the pandemic, Congress may seek to make permanent—or at least extend on a longer-term basis—certain of these flexibilities.

Telehealth Flexibilities Adopted During the Pandemic

Most of the changes implemented during the pandemic are in effect only for the duration of the Department of Health and Human Services (HHS) PHE. As there are significant statutory restrictions on how telehealth services can be delivered and paid for in Medicare, to enact these flexibilities, the Administration relied on Section 1135 waiver authority, which allows HHS to waive or modify certain Medicare requirements during a federally declared emergency (among other flexibilities).

Principal changes include:

• Lifting the geographic restriction that beneficiaries must be located in a rural area;
• Permitting beneficiaries to receive telehealth services from their homes;
• Allowing a broader range of providers to deliver telehealth services (e.g., physical therapists, occupational therapists, speech-language pathologists);
• Adding coverage and payment for audio-only forms of telehealth;
• Enabling FQHCs and rural health centers to serve as eligible distant sites (i.e., where the provider is located); and
• Expanding Medicare telehealth coverage to more than 100 additional services.

Currently, the HHS PHE is set to expire on January 20, though it has been renewed several times and likely will be extended again. While CMS has taken swift and bold action to expand telehealth coverage and reimbursement, once the HHS PHE expires, so too do most of the flexibilities HHS has enabled.

In the final CY 2021 MPFS, the Administration took steps to make some of these flexibilities permanent and to extend others further, though a permanent extension of the full range of telehealth flexibilities introduced during the PHE would require congressional action.

Final CY 2021 Medicare Physician Fee Schedule Rule—Telehealth Provisions

Changes to Covered Medicare Telehealth Services

The final rule makes a number of changes to the Medicare telehealth covered services list. A range of services will be permanently added to the list, including group psychotherapy, low-intensity home visits, and psychological and neuropsychological testing. In addition, CMS will extend temporary coverage for certain services through the end of the calendar year in which the COVID-19 PHE ends, including high-intensity home visits, emergency department visits, specialized therapy visits, and nursing facility discharge day management. Finally, certain services that have been covered on a temporary basis during the PHE will not be covered on a permanent basis once the PHE ends. This includes services such as telephonic evaluation and management services, initial nursing facility visits, radiation treatment management services, and new-patient home visits. Notably, after significant public comment on the proposed rule supporting the addition of more services to the list of services covered through the calendar year in which the PHE ends, CMS extended coverage for several additional services that it had proposed ending coverage for at the end of the PHE.

Other Changes to Medicare Telehealth Services

In addition to the changes to the telehealth covered services list, CMS is finalizing a change to the frequency limit for subsequent nursing facility visits provided via telehealth—these are typically visits provided by an admitting physician to a patient in an inpatient nursing facility. Currently, CMS only reimburses for one Medicare subsequent nursing facility visit via telehealth every 30 days. In order to enable more frequent telehealth visits on a permanent basis, CMS is revising the limit and will reimburse for one subsequent nursing facility visit via telehealth every 14 days. This will allow for more frequent use of telehealth while keeping a frequency limit in place to ensure that providers are not disincentivized from providing in-person care.

The final rule also permits additional types of providers—licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech-language pathologists—to bill for brief online assessment and management services, virtual check-ins, and remote evaluations, and the rule adds new codes for these services.

Changes to Audio-Only Services

Federal law provides that Medicare telehealth services must be delivered via a “telecommunications system.” CMS has long interpreted this to preclude audio-only technology. Accordingly, prior to the PHE, the only audio-only services that CMS covered were communication technology-based services (CTBS) such as virtual check-ins, which are not considered Medicare telehealth services. However, during the PHE, recognizing that in-person visits pose a high risk of infection exposure and that not all providers and patients have access to video technology, CMS established temporary coverage for audio-only telephone evaluation and management (E/M) visits. In the MPFS, CMS is finalizing that at the end of the PHE, coverage for these audio-only telephone E/M visits will end given the statutory language regarding “telecommunications systems,” but CMS will add an additional CTBS virtual check-in code during CY 2021 for longer audio-only visits.

Changes to Remote Physiologic Monitoring Services

CMS finalized as proposed several changes to coverage of remote physiologic monitoring (RPM) services. At the conclusion of the PHE, CMS will once again require that practitioners have an established patient relationship in order to initiate RPM services and that practitioners must collect 16 days of data in each 30-day period in order to bill for those services (during the PHE, CMS is only requiring two days of collection for every 30-day period). CMS also finalized that practitioners may furnish RPM services to beneficiaries with acute conditions—previously coverage had been limited to beneficiaries with chronic conditions. In addition, CMS finalized that consent may be obtained at the time the RPM service is furnished; that auxiliary personnel (including contracted employees) may furnish certain RPM device setup and supply services; that data from the RPM device must be automatically collected and transmitted rather than self-reported; and that for the purposes of discussing RPM results, “interactive communication” includes real-time synchronous, two-way interaction such as video or telephone.

Changes to Enable Direct Supervision by Interactive Telecommunications Technology

Typically, CMS requires that “incident to” services can only be provided under the “direct supervision” of a supervising physician or practitioner. “Incident to” services permit nonphysician practitioners to bill certain services under the physician’s supervision, and “direct supervision” typically means in-person supervision. CMS finalized as proposed a policy to allow, on a temporary basis, virtual supervision using “interactive audio/visual real-time communications technology” (i.e., two-way live video), by revising the definition of “direct supervision” to include virtual presence. This will allow “incident to” services to be provided if furnished under the supervision of a virtually present physician or nonphysician practitioner in order to reduce infection exposure risk. CMS will continue allowing virtual supervision through the later of the end of the calendar year in which the PHE ends or December 31.

This year has been full of unforeseen challenges. The pandemic has forced us to adjust many aspects of our daily lives as we adapt to a new normal. While technology has played a vital role in our push towards safe and effective vaccines and treatments for COVID-19, we have also come face to face with two long-standing issues: the digital divide and federal regulations that have not kept up with the pace of technological advancements.

We know the coronavirus has led to people ignoring other medical symptoms, or not seeking treatment when they previously would have, due to fear of contracting the virus. In May, a poll showed about half of Americans delayed care because of the pandemic. In September, the Centers for Disease Control and Prevention (CDC) found that number was still more than 40 percent. It is heartbreaking to know people are jeopardizing their long-term health, and in some cases even losing their lives, because they are afraid to go to the doctor.

The digital divide has exacerbated this issue, as far too many Americans find themselves unable to access telehealth options. South Carolina has long led on telehealth policy and innovation, hosting one of just two federally-recognized Telehealth Centers of Excellence in the nation at the Medical University of South Carolina. We know how effective telehealth can be, especially for our seniors. But there is clearly more work to be done.

This year, I have worked with my colleagues on both sides of the aisle to introduce a number of proposals to address ongoing broadband challenges right here at home, such as the State Fix Act. If enacted, these bills would be game-changing for the estimated 650,000 South Carolinians who currently lack access to high-speed internet. Unfortunately, even as we continue working to improve home broadband infrastructure, outdated federal laws and regulations continue to constrain patient access to telehealth services, especially for our older and more vulnerable populations.

More than one million South Carolinians are enrolled in Medicare, where extensive restrictions on geographic location, distant and originating sites, provider-type, and services covered limit many seniors’ ability to take advantage of telehealth offerings. I have worked with my colleagues on the Senate Finance Committee to develop and advance the CHRONIC Care Act, substantially expanding access to additional telehealth benefits for most seniors enrolled in Medicare Advantage plans. But Medicare Advantage only serves about a quarter of Medicare beneficiaries, and rigid rules remain in place for traditional Medicare plans. That means 75 percent of those utilizing Medicare in our state, almost 800,000 people in total, are seeing their access to telehealth hindered by outdated and unneeded red tape.

Thankfully, early in the pandemic, Congress passed the CARES Act. One of the things the CARES Act did was create new flexibilities for telehealth coverage and payment under Medicare. However, these flexibilities are temporary. Unless Congress acts to extend some of the core Medicare coverage and reimbursement expansions beyond the end of the pandemic, whenever it may come, hundreds of thousands of seniors in South Carolina will be unable to receive covered care through virtual health technology. Nationally, that number will be in the tens of millions.

For that reason, this month I wrote a letter to Congressional leadership emphasizing how important it is that we permanently expand telehealth coverage. We have a roadmap for this, outlined in the CONNECT for Health Act, which would help to protect our seniors by modernizing Medicare payment policies. I supported this legislation before the pandemic began, and will continue pushing for its enactment as vaccines begin to help us turn the tide on COVID.

Expanding telehealth access will require a multi-pronged approach that both bridges the digital divide and secures sustainable payment and coverage policies across various programs. However, enacting the CONNECT for Health Act would help us put lessons learned from the pandemic into immediate action and improve our health care system for Americans from all walks of life, particularly with regards to our seniors and those living in rural or underserved communities.

I will continue to prioritize legislation that grants South Carolinians – and all Americans – access to telehealth services. It’s not just about learning lessons from this pandemic, but ensuring we are better prepared the next time we face a public health emergency, whenever or whatever that may be.

The CARA 2.0 bill, introduced last week, would, among other things, enable providers to prescribe medications via telehealth without an in-person visit and would allow Medicare coverage for audio-only telehealth treatment.

December 15, 2020 – A new bill before Congress aims to permanently allow healthcare providers to use telehealth in medication-assisted treatment (MAT) programs for substance abuse and provide Medicare coverage for audio-only phone calls.

The two policy changes are part of the Comprehensive Addiction and Recovery Act (CARA) 2.0 bill introduced last week by Senators Rob Portman (R-OH), Sheldon Whitehouse (D-RI) and Amy Klobuchar (D-MN). The bill increases funding authorization levels established in the original CARA legislation in 2016 and adds connected health measures to tackle the growing opioid abuse crisis.

“In recent years we have made real progress in fighting the scourge of addiction thanks to resources from the bipartisan CARA law, in addition to other bipartisan efforts in Congress,” Portman said in a press release. “However, the COVID-19 pandemic has created unprecedented challenges and we are now seeing a heartbreaking surge in overdose deaths. That is why we must redouble our efforts to combat addiction and help those who are suffering during this crisis.”

Specifically, the bill would allow providers to use telehealth to prescribe medications in MAT therapy without an in-person exam. Providers have long been hamstrung by this restriction, which was put in place by the Ryan Haight Act of 2008. That bill called for a special registration process, managed by the US Drug Enforcement Agency, for providers who want to use telehealth, but that registration process has never been created despite intense lobbying.

Recently, more than 80 organizations, ranging from telehealth health providers and health systems to the American Telemedicine Association and America’s Health Insurance Plans, signed a letter asking the DEA to establish the registration process.

“Our experience during COVID-19 has demonstrated the value of increased access to telemedicine to enable all qualified providers, including Community Mental Health Centers and addiction treatment facilities, to prescribe Medication-Assisted Treatment (MAT) to patients with Opioid Use Disorder (OUD),” the letter, penned by the Alliance for Connected Care, states.

The Ryan Haight Act laid the groundwork – reinforced by the SUPPORT Act – for a special registration that would allow providers to prescribe, deliver, distribute and dispense a controlled substance to patients without the requirement for an in-person examination. The idea behind the registration is to allow providers to use connected health platforms – including MAT therapy therapy – to treat patients living with substance abuse issue who might not have easy access to in-person treatment.

The registration would come with certain conditions:

• Providers must demonstrate a legitimate need for the special registration;
• They must be registered to deliver, distribute, dispense or prescribe controlled substances in the state where the patient is located; and
• They must maintain compliance with federal and state laws when delivering, distributing, dispensing and prescribing a controlled substance.

In addition, the CARA 2.0 bill would allow providers to use audio-only telehealth platforms in substance abuse treatment, as long as they’d first met in person with the patient.

Other policy changes included in CARA 2.0 include new research into non-opioid pan management alternatives, such as digital therapeutics; the establishment of a pilot program to study the value of mobile methadone clinics – which could include mHealth and telemedicine – in underserved parts of the country.

In addition, the bill would set aside $200 million annually to build support programs for those in recovery, including programs in rural and underserved areas that make use of telehealth to improve access.  It also would remove limits on the number of patients to whom providers can prescribe medications in MAT therapy, opening the door for providers to expand their treatment reach through telehealth.

his year has been full of unforeseen challenges.

The pandemic has forced us to adjust many aspects of our daily lives as we adapt to a new normal. While technology has played a vital role in our push toward safe and effective vaccines and treatments for COVID-19, we have also come face to face with two long-standing issues: the digital divide and federal regulations that have not kept up with the pace of technological advancements.

We know the coronavirus has led to people ignoring other medical symptoms, or not seeking treatment when they previously would have, due to fear of contracting the virus. In May, a poll showed about half of Americans delayed care because of the pandemic. In September, the Centers for Disease Control and Prevention (CDC) found that number was still more than 40%. It is heartbreaking to know people are jeopardizing their long-term health, and in some cases even losing their lives, because they are afraid to go to the doctor.

The digital divide has exacerbated this issue, as far too many Americans find themselves unable to access telehealth options. South Carolina has long led on telehealth policy and innovation, hosting one of just two federally recognized Telehealth Centers of Excellence in the nation at the Medical University of South Carolina. We know how effective telehealth can be, especially for our seniors. But there is clearly more work to be done.
How to put 2020 financial survivor’s guilt to good use

This year, I have worked with my U.S. Senate colleagues on both sides of the aisle to introduce a number of proposals to address ongoing broadband challenges right here at home, such as the State Fix Act. If enacted, these bills would be game-changing for the estimated 650,000 South Carolinians who currently lack access to high-speed internet. Unfortunately, even as we continue working to improve home broadband infrastructure, outdated federal laws and regulations continue to constrain patient access to telehealth services, especially for our older and more vulnerable populations.

More than one million South Carolinians are enrolled in Medicare, where extensive restrictions on geographic location, distant and originating sites, provider-type and services covered limit many seniors’ ability to take advantage of telehealth offerings. I have worked with my colleagues on the Senate Finance Committee to develop and advance the CHRONIC Care Act, substantially expanding access to additional telehealth benefits for most seniors enrolled in Medicare Advantage plans.

But Medicare Advantage only serves about a quarter of Medicare beneficiaries, and rigid rules remain in place for traditional Medicare plans. That means 75% of those utilizing Medicare in our state, almost 800,000 people in total, are seeing their access to telehealth hindered by outdated and unneeded red tape.

Thankfully, early in the pandemic, Congress passed the CARES Act. One of the things the CARES Act did was create new flexibilities for telehealth coverage and payment under Medicare. However, these flexibilities are temporary. Unless Congress acts to extend some of the core Medicare coverage and reimbursement expansions beyond the end of the pandemic, whenever it may come, hundreds of thousands of seniors in South Carolina will be unable to receive covered care through virtual health technology. Nationally, that number will be in the tens of millions.

For that reason, this month I wrote a letter to Congressional leadership emphasizing how important it is that we permanently expand telehealth coverage. We have a roadmap for this, outlined in the CONNECT for Health Act, which would help to protect our seniors by modernizing Medicare payment policies. I supported this legislation before the pandemic began and will continue pushing for its enactment as vaccines begin to help us turn the tide on COVID.

Expanding telehealth access will require a multi-pronged approach that both bridges the digital divide and secures sustainable payment and coverage policies across various programs. However, enacting the CONNECT for Health Act would help us put lessons learned from the pandemic into immediate action and improve our health care system for Americans from all walks of life, particularly with regard to our seniors and those living in rural or underserved communities.

I will continue to prioritize legislation that grants South Carolinians – and all Americans – access to telehealth services. It’s not just about learning lessons from this pandemic but ensuring we are better prepared the next time we face a public health emergency, whenever or whatever that may be.

By Riley Bean | December 9, 2020 at 10:18 AM EST – Updated December 9 at 1:19 PM