Public health policy and public sector institutions such as CMS may be the most critical factors in the viability of telehealth. Private payers and healthcare organizations are less likely to invest in telehealth if Medicare and Medicaid do not lay the groundwork for support and regulation. Fortunately, Medicaid currently covers telehealth, to some extent, in 46 states. (4) While influential policy in favor of telehealth is slow to emerge, there are multiple motivating factors.
As previously discussed, health system reform is motivated by the Triple Aim – improve quality, improve outcomes, and decrease cost. This triple aim was most recently and notably acted on by the signing of the Affordable Care Act (ACA) in 2010. (3) The U.S. is particularly motivated by our exorbitant health care expenditure and poor health outcomes. Quality and cost control are addressed in the ACA through improvements in not only the quality, but also the efficiency, and effectiveness of the medical care we provide. (3)
Making strides in a profession notorious for resistance to change is challenging. A movement towards global payment models (where providers/healthcare organizations are rewarded based on improvements in the quality, efficiency, and outcomes of care) and away from the fee-for-service system (where rewards come from volume and quantity of services) are inspiring the needed changes. (4)
Barriers Related to Policy
- While progress has been made with Medicaid coverage, this pertains to very little of the population.
- In AZ, 25% of the population has Medicaid coverage (43% are employer covered, 14% Medicare, and 12% uninsured). (2)
- In NE, only 14% of the population is covered by Medicaid (53% are covered by their employer, 14% Medicare, and 10% are uninsured). (2)
- While CMS leads the way, policy changes are necessary to make telemedicine “attractive” to all payers not just one particular payer (Medicare, Medicaid, and Private/Commercial). (4)
- It is imperative to push private payers to reimburse at the same rate as a face-to-face visit in order for the investment of telehealth to pay off. (1)
- As the system continues to move more towards the global payment model, the fee-for-service reimbursement will become less meaningful. Providers will be more willing to utilize any tools that increase their outcomes and patient satisfaction rather than just tools they can get paid for. (4)
- Requiring special or dual licensure for cross-state telehealth services negatively impacts the likelihood of telehealth adoption due to the complexity, length of time, and added cost. (1)
- As more states relax the policy requirements on cross-state licensure, evidence on safety concerns will present itself hopefully allowing more states to comfortably follow suit. (1)
Limited Diagnoses Available for Coverage
- CMS is very slow to implement new approved billing codes that would expand the eligible services through telehealth. (5)
- Medicare generally only increases a few codes per year – even these minor expansions require significant efforts and lobbying by organizations such as the American Telemedicine Association (ATA). (5)
So, if you glazed over, let me summarize…
Take Home Points:
- Adoption of telehealth is more likely when policy change promotes private payer reimbursement in addition to CMS. (1)
- The majority of Americans have private health care insurance. Only 22 states have passed policy requiring some type of private coverage parity. (2; 4)
- CMS must be more proactive in expanding covered diagnoses for telehealth services. (5)
- State level policies that restrict telemedicine through special licensure requirements need to change in order to increase telemedicine adoption and utilization. (1; 4)
- Many of our legislators have very little knowledge regarding telehealth – we must educate and advocate to create progress in policy change (Senator Nicole Fox, personal communication, February 9, 2016).
- Without policy change, telehealth is less viable and without viable programs to provide data, policy will not change. (4)
- Adler-Milstein, J., Kvedar, J., & Bates, D.W. (2014). Telehealth among US hospitals: Several factors, including state reimbursement and licensure policies, influence adoption. Health Affairs, 33(2), 207-215.
- Kaiser Family Foundation. (2016). Health insurance coverage of the total population. Retrieved from http://kff.org/other/state-indicator/total-population/
- McDonough, J.E. (2014). Health system reform in the United States. International Journal of Health Policy and Management, 2(x), 1-4.
- Neufeld, J.D., Doarn, C.R., & Aly, R. (2016). Brief communication: State policies influence medicare telemedicine utilization. Telemedicine and e-Health, 70-74. doi: 10.1089/tmj.2015.0044
- Weinstein, R.S., Lopez, A.M., Joseph, B.A., Erps, K.A., Holcomb, M, Barker, G.P., & Krupinski, E.A. (2014). Telemedicine, telehealth, and mobile health applications that work: Opportunities and barriers. The American Journal of Medicine, 127(3), 183-187. doi: 10.1016/j.amjmed.2013.09.032.