Ruth Carol 2015-03-21 00:54:20
Slow progress on teledermatology reimbursement could accelerate Reimbursement is not the only challenge for telemedicine adoption, but it is one of the greatest. Whether looking at the state or federal level, payment and coverage remain patchy and sparse. All of that could change rapidly, though, as both Medicaid and Medicare policies are increasingly favoring reimbursement for a growing number of telemedicine services. Furthermore, increasing numbers of private payers are covering telemedicine, prompting what could be a reversal from the normal route by which reimbursement rates are developed through the RUC/Medicare process and leaving CMS to follow suit. Reimbursement poses the greatest challenge to the adoption of telemedicine services, according to the 2014 Telemedicine Survey conducted by Foley & Lardner LLP, a Milwaukee-based law firm. Approximately half of the 57 executives from a variety of health care organization types and sizes nationwide polled last fall identified difficulties seeking and receiving reimbursement for such services. While 90 percent of respondents reported that their organizations have already begun developing or implementing a telemedicine program, 41 percent said their organizations do not receive any reimbursement for these services. Twenty percent of executives reported receiving lower rates from managed care companies for telemedicine than in-person visits. Medicare’s thin coverage practices for telemedicine were the biggest reimbursement concern for 21 percent of respondents while 18 percent said they were most uneasy about state laws failing to mandate that commercial companies pay for such services. That is the same message Brenda Dintiman, MD, a dermatologist from Fairfax, Virginia who testified as a small practitioner on behalf of the AAD, delivered before the House Small Business Subcommittee on Health and Technology in July 2014. “Without assured reimbursement,” she said, “providers and patients are unlikely to utilize telehealth.” STATE COVERAGE RAMPS UP If the number of bills being introduced is any indication, states are definitely ramping up their telemedicine adoption efforts. During the 2014 legislative session, 36 states and the District of Columbia introduced telemedicine-related legislation. In 2015, more than a dozen states have introduced legislation. New York Governor Andrew Cuomo recently signed a bill into law that expands the availability of telehealth services and requires insurers to cover them at the same rate as in-person visits. Many of the state bills address different aspects of reimbursement for both Medicaid and private payers. Proposals in Missouri and Texas address Medicaid programs whereas legislation calls for the creation of parity laws in Colorado and North Dakota. Connecticut and New Jersey are also expected to introduce parity bills this session, noted Kelley Pagliai Redbord, MD, chair of the Academy’s State Policy Committee, which reviews the language in such bills and provides feedback on how it could be updated to align with the Academy’s position statement on teledermatology (available online at www.aad.org/Forms/Policies/ ps.aspx). Currently, 22 states and the District of Columbia mandate that private payers cover telemedicine. Despite that number doubling in the last four years, a single widely accepted standard is lacking. Reimbursement is neither consistent across payers nor across states to allow for proper patient access, Dr. Dintiman noted during her testimony. While Virginia law addresses coverage for telehealth services, this does not guarantee access with all private insurance, she said. Similarly, Missouri has a parity law, but many insurance plans, including self-insured companies, don’t fall under it, explained Rachel Mutrux, director of the Missouri Telehealth Network. When she surveyed several insurers in the state, she found that each one had its own policy for what is covered and how. Among private payers covering telemedicine services in certain states are Aetna, Blue Cross Blue Shield, Cigna, and WellPoint. The latest to join in is Highmark Commercial Insurance, a Blue Cross Blue Shield-affiliated carrier in Pittsburgh, which began covering Webbased visits — including teledermatology offered by DermatologistOnCall — for its 5.2 million members across Pennsylvania, West Virginia, and Delaware as of Jan. 1. “It’s the first opportunity where a store-and-forward teledermatology encounter is a covered benefit,” noted Mark Seraly, MD, founder of DermatologistOnCall and chief medical officer of its parent company, Iagnosis. Medicaid programs in 47 states currently offer some type of coverage for telemedicine services; however, no two states are alike. At this time, only 10 states cover store-and-forward telemedicine under Medicaid (see sidebar). But states are slowly embracing newer technology applications. Bills being introduced in Colorado, Missouri, and Texas call for coverage of store-and-forward telemedicine, Dr. Redbord noted. Twenty-three states and the District of Columbia do not specify a patient setting or patient location as a condition for payment, reports the American Telemedicine Association (ATA). While 21 states recognize the home as an originating site, 13 states recognize schools and/ or school-based health centers as an originating site. Fifteen states and the District of Columbia do not specify the type of provider allowed to provide telemedicine as a payment condition. Instead of focusing exclusively on rural areas or designating a mileage requirement, Medicaid is moving to state-wide coverage, notes the ATA in its State Telemedicine Gaps Analysis: Coverage & Reimbursement published in September 2014. MEDICARE EXPANDS COVERAGE Meanwhile, Medicare coverage is very limited. There is little latitude with regard to the originating site and practitioners who can provide telemedicine under Medicare, said Bruce A. Brod, MD, an advisor to the Academy’s State Policy Committee and member of its Congressional Policy Committee and Patient Safety and Quality Committee who offers consults through AccessDerm. It’s really designed for beneficiaries living in very rural areas and only covers live interactive telemedicine. Store-and-forward telemedicine is only covered in Alaska and Hawaii as part of a Demonstration Project. But like Medicaid, Medicare is slowly expanding its parameters for telemedicine coverage. The 2014 Medicare physician fee schedule expanded the geographic areas where telehealth services are covered. The 2015 Medicare physician fee schedule expands the services covered under telehealth. When it comes to telemedicine legislation, there is a lot more bipartisan collaboration than in the past, noted Carrie Kovarik, MD, who chaired the Academy’s Telemedicine Task Force until this March. As an example, the Medicare Telehealth Parity Act of 2014 proposed a three-phase rollout of changes to the way that telemedicine services are reimbursed by Medicare and would expand coverage for residents of both rural and urban areas. With each two-year phase, the availability and use of store-and-forward technologies would be expanded to larger populations. The bill would also introduce coverage for some telehealth services provided at home and in walk-in retail health clinics. Rep. Mike Thompson (D-Calif.) plans to reintroduce the bill with bipartisan support this spring. In January, a draft House bill started to circulate that includes a provision that would require the Centers for Medicare and Medicaid Services (CMS) to implement a methodology for Medicare’s expanded coverage of telehealth services that would either reduce costs or not result in a net increase in program spending. “It’s very broad and vague,” Dr. Brod said. “I think they’re looking for a lot of input from stakeholders, like us, to try to shape that.” In February, the public comment period ended for a proposed rulemaking published by CMS that would waive certain restrictions on the use of telemedicine by accountable care organizations (ACOs). In addition, CMS is proposing that ACOs describe how they will encourage and promote the use of enabling technologies, such as telehealth, for improving care coordination for Medicare beneficiaries. The agency reports there are now 330 ACOs in 47 states, providing care to more than 4.9 million beneficiaries. CODING FIRST, LICENSURE NEXT The primary reason that teledermatology reimbursement is lacking is because there are no current procedural terminology (CPT) codes that capture the service appropriately, according to Karen Edison, MD, deputy chair of the Academy’s Telemedicine Task Force and a member of the ATA’s Teledermatology Special Interest Group. “You can’t get paid unless you have a code for it,” she said. Private insurers can choose to use existing CPT codes for telemedicine services and reimburse services they select at rates they choose, noted Murad Alam, MD, chair of the AAD’s Telemedicine Reimbursement Advocacy Workgroup. Some private telemedicine networks, like DermatologistOnCall, routinely use CPT code 99444 to describe online evaluation and management services. CPT sometimes approves new “category III” codes, which are temporary codes for emerging technologies; if such codes were created for specific telemedicine services, private payers would have the option to cover them before they were accepted or valued by Medicare. Coding needs to be developed with the input of specialty societies to ensure that it’s fair and reflects the work and complexity of the service being provided, the same way codes do for a live visit, Dr. Brod explained. Congress and CMS shouldn’t rush this process just to get codes out there. “Codes need to be developed carefully because once they’re developed, it’s hard to go back and fix them,” he added. It’s probably not a good idea to use the same code for a teledermatology encounter as a face-to-face visit, Dr. Alam said, as it could create a perverse incentive to push the least resource-intensive method. “Codes should be developed through the normal process to keep everyone honest,” he said. They should be valued appropriately by the Relative Value Scale Update Committee to ensure that the service is reimbursed at an appropriate level and the patient has received the most appropriate service. The goal is to provide access to care for people who don’t currently have it, Dr. Alam noted, not to create strong incentives that would limit patient access to face-to-face dermatology visits. The AAD has been approached by various federal legislators for guidance as to how teledermatology services should be coded and billed through Medicare, Dr. Alam said. There have been a lot of discussions about this at meetings of the Telemedicine Task Force, State Policy Committee and Congressional Policy Committee, Dr. Edison noted. Another issue that must be resolved before reimbursement can move forward is licensure and professional accountability as it relates to cross-state practice. Most states require physicians to be licensed to practice in the state where the patient is located. The Interstate Medical Licensure Compact proposed by the Federation of State Medical Boards (FSMB) would allow for expedited multiple state licensure, but leaves the authority over patient safety and quality of care issues with individual state medical boards, which the AAD supports, Dr. Edison said. “It will help more physicians to serve more patients in multiple states,” she said. This year, legislators in nine states have formally introduced the interstate compact, according to FSMB. In January, the South Dakota Senate Committee adopted it. Getting the FSMB compact through can be challenging because each state has to go through either a legislative or regulatory process to change the law in order to join the compact, Dr. Brod said. “The more states that join the FSMB compact, the easier it is for physicians to obtain a license across state lines, the more feasible telemedicine becomes.” EXPAND TECHNOLOGY, GEOGRAPHY The store-and-forward model will have to be more widely adopted and the geographic restrictions eliminated to move telemedicine forward, Dr. Brod added. “That will take an act of Congress with a lot of input from stakeholders, physicians, technology experts, and patient advocacy groups,” he said. Des Moines, Iowa dermatologist Timothy G. Abrahamson, MD, is convinced that store-and-forward is the only viable option for teledermatology. Storeand- forward technolology allows the requesting physician to take the pictures and send the information to the dermatologist within minutes of deciding to make the consult. The dermatologist can review the photographs without coordinating with the patient or requesting physician. “It will speed access to a specialist and improve access in rural states,” he said. Dr. Abrahamson speaks from experience, having participated in a pilot program using live interactive teledermatology for inpatients at one of the five hospitals at which he has privileges. “It is very cumbersome and logistically difficult which makes its use very limited,” he said. Dr. Abrahamson is a proponent of expanding the definition of “rural areas,” as well. Iowa is just as rural as Hawaii and Alaska when looking at the percentage of the population that has to travel from one to three hours to reach a specialist, he said. Not only do hospitals in Des Moines, the largest metropolitan area in Iowa with more than 500,000 residents, lack access to dermatologists, but outside of Iowa City, 80 percent of the hospitals have little or no current access to a dermatologist, Dr. Abrahamson said. A store-and-forward system could be used to link these hospitals and clinics. Dr. Edison concurs that the geographic restrictions must go. She has patients in a nearby rehabilitation hospital who require therapy all day long. Taking these patients out of therapy for nearly three hours to go across town for an in-person appointment is neither in the patient’s best interest nor is it cost effective, she said. Dr. Edison believes that CMS is warming up to store-and-forward technology. “We need another legislative push,” she added. CLIMATE CHANGE That push may be in Health and Human Services Secretary Sylvia Burwell’s recent announcement of a transition from volume to value payments. The goal is to move 30 percent of fee-for-service Medicare payments to alternative payment models, such as ACOs or bundled payment arrangements, by the end of 2016, and 50 percent by the end of 2018. As this transition unfolds, payment for telemedicine services should accelerate. “As we move from paying for volume to paying for value, all of a sudden store-and-forward teledermatology makes a whole lot of sense,” Dr. Edison said. Telemedicine is already known to work in closed health systems such as Kaiser-Permanente and the Veterans Health Administration, Dr. Kovarik noted. Furthermore, Medicare can be more innovative through its ACOs, she said. ACOs will serve as a good working lab for telemedicine because they have a lot more flexibility in determining an appropriate originating site and who can provide the service, Dr. Brod said. “They are not bound by current laws,” he said. “It’s a way to put telemedicine out there with low risk to generate more evidence and models of best practice.” In ACOs or patient-centered medical homes, dermatologists can have an established relationship with the patient and communicate with the patient’s primary care provider, Dr. Edison said. “What’s more patient centered than taking the care to the patient?” And speaking of patients, younger ones in particular might be the ones who actually move telemedicine forward quicker than the lawmakers. “The adoption of these services is probably going to be much greater in younger people who are very used to doing everything over an electronic interface,” Dr. Alam said. “We might see Medicare slower to adopt and more private insurers taking the forefront,” Dr. Redbord added. “Younger people are better with technology, so they might serve as more of the demonstration than Alaska and Hawaii.” Dr. Seraly believes that consumers will drive the adoption of telemedicine because the timing is perfectly aligned with technology and consumer preparedness. “I believe that in 10 years, 50 percent or more of all skin care will be accessed online and will be a covered benefit,” he said. Dr. Seraly indicated that DermatologistOnCall is receiving significant interest by carriers nationwide that are looking at telemedicine as a way to provide access to patients who don’t have it and at a lower cost. In early 2014, DermatologistOnCall was in one state with 12 board-certified dermatologists; a year later, it is in 17 states with nearly 100 dermatologists, he said. “Private payers will drive it because they will see a cost benefit,” Dr. Edison said. If more private insurers develop reimbursement policies for telemedicine, that may incentivize more vendors to provide virtual office platforms, which may lead to more physicians participating, Dr. Brod added. As important as maintaining the quality of integrated care is demonstrating the value of telemedicine so that physicians are fairly compensated for their participation, he said. “The ultimate success or failure of telemedicine is finding a fair reimbursement method to make sure physicians are compensated for their skill, work, and time,” Dr. Brod concluded. “The devil is in the details and the details need to be worked out not just by Congress because they’re not the experts in this, but with a lot of input from physicians.”
Published by American Academy Of Dermatology. View All Articles.
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