On July 15, 2020, the Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma published a blog post in Health Affairs outlining the impact telehealth has had during the COVID-19 pandemic. The post also provides a glimpse at how the agency is thinking about whether to make certain telehealth flexibilities permanent once the public health emergency (PHE) concludes.
The piece begins by outlining the actions CMS had taken on telehealth prior to COVID-19, noting recent expansions in virtual care through the addition of e-visits and virtual check-ins, as well as the flexibilities CMS gave to Medicare Advantage (MA) plans to cover any telehealth service as a part of their basic benefit packages. Administrator Verma then walks through the COVID-19 pandemic itself, restating the flexibilities offered through the CARES Act that CMS then implemented through exercising its section 1135 waiver authority.
Importantly, the piece then quantifies the rate of increase in utilization of telehealth services during the PHE, both in general and across geographies, service categories, and demographic categories. Some highlights follow:
- General rates of service: While approximately 13,000 Medicare fee-for-service beneficiaries per week accessed telehealth services prior to COVID-19, nearly 1.7 million beneficiaries utilized telehealth in the last week of April 2020 alone. Overall, around 9 million beneficiaries have received telehealth services during the pandemic. See Exhibit 1 in the blog post for a graph of the rate of increase in telehealth use.
- Utilization by geography: CMS reports that utilization is strong regardless of a beneficiary’s geographic location. It states that 22 percent of beneficiaries accessed telehealth in rural areas, while around 30 percent of beneficiaries in urban areas did so.
- Utilization by demographics: CMS data also suggests different demographic groups are accessing telehealth at similar rates. First, male and female beneficiaries have shown similar use of telehealth, with approximately 30 percent of female beneficiaries and 25 percent of male beneficiaries having leveraged the modality. CMS also states there are “no significant differences by race or ethnicity among beneficiaries who received telemedicine services (25 percent among Asians, 29 percent among Blacks, 27 percent among Hispanics, 28 percent among Whites, and 26 percent among others).”
- Utilization by service category: Administrator Verma reports that the most common services delivered via telehealth during the PHE have been evaluation and management (E/M) visits, along with mental health services. In particular, Ms. Verma states “telehealth for mental health care is showing great promise for our Medicare beneficiary population,” attributing this to a reduction of the stigma associated with seeking mental health services on an in-person basis.
- Utilization by telephone-only technologies: Ms. Verma notes that receiving care over the phone has also been important for beneficiaries, stating around one-third of beneficiaries (3 million) have received care by phone during the pandemic.
As for what this means moving forward, Administrator Verma offers a mixed story. On the one hand, she notes throughout the piece that the data “warrants consideration” of whether telehealth should become a more permanent fixture of the Medicare program, and that it would be “hard to imagine merely reverting to the way things were before.” She notes CMS is “reviewing the flexibilities” and this initial data to determine whether and which of these changes should be made permanent. Despite these positive indicators of CMS’ thinking, however, the Administrator offers some additional commentary that somewhat chills the enthusiasm around the possible extent to which the agency might these flexibilities permanent. For example:
- While offering services to both existing and new patients during the pandemic has been helpful, she states, Administrator Verma offers skeptical remarks around whether allowing providers to see new patients with “particularly acute needs” via telehealth would be helpful after the pandemic, suggesting patient safety could be at risk.
- Ms. Verma also casts doubt on whether CMS will decide to reimburse telehealth at full parity to in-person services (i.e., payments inclusive of the statutory facility-fee) once the pandemic ends. She suggests that more research may be needed to determine the level of resources involved in delivering telehealth effectively, and that decision makers should use such research to make payment decisions. She does mention, however, that there are costs associated with the new processes and technology needed to offer effective telehealth services, further indicating that CMS is not yet certain on what its decisions around payment for telehealth would be.
- Last, Administrator Verma speaks briefly to concerns around program integrity, stating that increased use of telehealth in Medicare “relies on CMS addressing the potential for fraud and abuse in telehealth.”
Of note, this blog post comes following recent congressional pressure for CMS to be more transparent with its thinking on which telehealth flexibilities, if any, it may make permanent following the public health emergency (details). While the post does not fully satisfy this request – notably, there is no mention of a timeline around when CMS plans to make key decisions on this matter, nor is there any discussion on what CMS needs from Congress to effectuate any changes it may wish to make – it does provide the clearest insight thus far into how CMS is approaching these issues.
From this, it appears likely that CMS may take some action on making certain telehealth flexibilities permanent, though there is at least some chance that certain flexibilities will be watered down (e.g., payment rates and the ability to see new patients via telehealth). CMS may also make telehealth more widely available for certain service categories too, given its observation that telehealth is most widely used for E/M and mental health services.
What is further communicated by this is that, at least in writing, CMS recognizes the value of telehealth as a covered modality under Medicare; that this value extends across patient types and locations; and, that many expect that telehealth will remain an embedded part of our health care system.