The Trump administration has issued an executive order designed to improve access to telehealth for Medicare beneficiaries in rural America, making permanent numerous changes that had been temporarily added for the COVID-19 pandemic. The news arrives as the Centers for Medicare and Medicaid Services (CMS) posted the draft Medicare physician fee schedule (MPFS) complete with expanded use of telehealth for a number of services, and the combination of the two policies should dramatically improve the prospects for the remote monitoring systems and digital health apps needed to convert these policy aspirations into a medical reality.

The executive order (EO) cites the 57 million living in rural communities who face difficulties in obtaining medical care and thus “are more likely to die from five leading causes” than those living in urban or suburban areas. The EO states that this disparity in outcomes grew between 2010 and 2017 for several diseases and disease categories, such as cancer, cardiovascular disease, and chronic lower respiratory disease.

However, the EO further notes that nearly 130 rural hospitals have closed since passage of the Affordable Care Act in 2010, adding that the average occupancy rate for these hospitals was only 22% between 2015 and 2017. Thanks to temporary provisions for telehealth undertaken this year, telehealth visits under programs administered by the CMS skyrocketed from 14,000 per week to nearly 1.7 million, the administration said. The order makes several specific provisions, including that the Department of Health and Human Services (HHS) will have to announce a new model for payment mechanisms within 30 days of the Aug. 3 order.

HHS and the Department of Agriculture are also charged with developing a plan for communication infrastructure for these rural areas in coordination with the Federal Communication Commission. Within 60 days of the EO, HHS must devise a regulation that would make permanent the temporary easing of restrictions on telehealth undertaken in response to the pandemic.

Support for expanded telehealth for Medicare has grown drastically in recent years, particularly since the onset of the pandemic. However, some stakeholders have argued that budget scoring activities might shine a negative light on recent legislation that would expanded telehealth permanently, although a robust data collection effort might neutralize many of the related fiscal concerns. Conversely, the drastic expansion of electronic health records over the past decade should facilitate more widespread adoption of telehealth, stakeholders said.

Morgan Reed, executive director of the Connected Health Initiative (CHI), said in a statement that the EO “is a critical step in expanding telehealth coverage for some of the most vulnerable Americans during the pandemic.” Reed said the order also addresses many of the priorities emphasized by the CHI and some of its collaborators for a number of years.

Despite the order, Reed said Congress “must take further action to achieve the full benefits of all digital health tools across modalities offer, including the use of remote patient monitoring and wearables to allow patients and doctors to stay engaged in their care no matter how far they live from their provider.” He said also that efforts to expand rural access to broadband are critical to fostering more widespread and routine use of telehealth for Medicare beneficiaries.

Ann Mond Johnson, CEO of the American Telemedicine Association (ATA), said the EO “signals, loud and clear, the administration’s continued support for telehealth and virtual care.” ATA lauded the arrival of the EO along with steps taken by congressional advocates, but Johnson said, “there is more work that needs to be done, on both the federal and state levels, to cement these gains and make permanent the waivers put in place in response to COVID-19.” The ATA will continue to work with policymakers “at every level of government to create clarity around the future of virtual care services, secure necessary legislation, and ensure reimbursement for telehealth that will extend access to safe, convenient, quality health care to all individuals whenever and wherever they need it,” she said.

Draft doc fee schedule also offers telehealth provisions

The Medicare physician fee schedule (MPFS) has featured several items of interest for telehealth in the past couple of years, and the draft for calendar year 2021 goes a step farther in that direction with several provisions. The draft identifies nine new category I CPT codes services that routinely involve the use of communication technology, and more than a dozen category III CPT codes, each of which will remain in service until the end of the calendar year in which the public health emergency ends.

CPT code GPC1X, a category I code, is for primary care evaluation and management services that are deemed complex due to the probability that these encounters will incur additional needed services for the beneficiary. Several other of the category I codes deal with encounters that may involve the services of a non-primary care physician, while several the listed category III codes address home encounters or encounters in emergency departments.

The draft said that CMS will continue to require an established patient-physician relationship for claims using five CPT codes for remote patient monitoring. Four of these codes fall under the 9945X series of codes, while the fifth, 99091, was unbundled in 2018 to allow for separate payment for physician review of patient data generated by remote monitoring. The agency said it may allow non-physicians to handle the services associated with two of the other four codes, although a physician practice must file the related claim.

The draft MPFS also includes a proposal to make permanent the provision that allows non-physician practitioners to supervise the patient’s performance of diagnostic tests. Prior to the pandemic, these non-physicians could furnish the test, although only physicians could supervise the test for billing purposes. Should the CMS adopt this proposal, the change would be permanent without regard for the persistence of the pandemic.

BioWorld will cover the draft MPFS in a future issue.

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