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HHS Delivers Telehealth Progress Report to Congress

August 22, 2016
by Rajiv Leventhal
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Following up on a Congressional request, the U.S. Department of Health and Human Services (HHS) has issued a report providing an update on the department’s current telehealth efforts, largely focusing on how delivery system reform initiatives may increase its use.

The report, from HHS’ Office of Health Policy, Office of the Assistant Secretary for Planning and Evaluation (ASPE), kicked off by noting that telehealth holds promise as a means of increasing access to care and improving health outcomes.  “Some analysts also see the potential for telehealth to reduce costs,” the report stated. It estimated that 61 percent of healthcare institutions currently use some form of telehealth, and between 40 and 50 percent of all hospitals in the U.S. currently employ some form of telehealth—a figure that includes rural/critical access hospitals, academic medical centers, and urban institutions. 

The report referenced a meeting earlier this year, sponsored by the Office of the National Coordinator (ONC), and inclusive of various healthcare stakeholders, that resulted in participants coming to several key conclusions regarding telehealth policy: payment reform is critical, especially more comprehensive coverage by Medicare; state licensure barriers continue to temper enthusiasm about telehealth among healthcare providers; and that high-speed broadband connections still do not reach many rural hospitals and clinics, despite significant growth in fiber-optic infrastructure nationally.

Concerning payment reform, the report discussed how the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation includes telehealth provisions. One of the provisions identifies “the use of remote monitoring or telehealth” as an example of an activity that would fall under a care coordination subcategory of the Clinical Practice Improvement Activities performance category under the Merit-Based Incentive Payment System (MIPS), a new program for assessing physicians’ and other practitioners’ performance and adjusting payments. In essence, the MACRA provision offers a possible “reward” to physicians and other practitioners who coordinate care using telehealth modalities, even when direct reimbursement for such activity may not be available.  Also under MACRA, eligible providers participating in a qualifying Alternative Payment Model (APM) will have the capacity to provide a broad array of services at a distance using many different telehealth modalities irrespective of where the patient or the clinician is physically located.

Regarding reimbursement, the report noted that, “The payment environment for telehealth services is evolving across the public and private sector with a considerable amount of variability from one payer to another. Coverage of telehealth services has been uneven across payers due in part to uncertainty regarding the value of telehealth and program integrity concerns regarding duplication of services.”

Similarly, each individual state has independent authority to regulate and oversee the practice of medicine within its boundaries. As such, the report stated, “these state licensure requirements may be inhibiting broader use of telehealth, with as many as 4 out of 5 states requiring out-of-state clinicians providing telehealth services to be licensed in the state where the patient resides.”

Further discussing challenges, the HHS report revealed that some parts of the country, particularly rural areas, still lack access to broadband speeds that may be required for advanced telehealth applications. According to the report, “Broadband access is still severely underdeveloped on many Indian reservations. At the White House Convening on Rural Telehealth, tribal leaders explained with great frustration that telecommunications companies often build broadband access right up to the border of a reservation and stop.  It may be insufficient funding or the administrative burden of obtaining right-of-way permits that keeps telecommunications companies from investing in the broadband infrastructure needed to bring telehealth to tribal lands.”

Regarding federal telehealth activity, HHS’ largest telehealth investments are in the form of payments for healthcare services through Medicare, Medicaid, and the Indian Health Service (IHS), according to the report. Over the last several years, the majority of work by the federal government on telehealth has been monitored by an interagency task force established by the Health Resources and Services Administration’s (HRSA) Federal Office of Rural Health Policy (FORHP). Indeed, the Federal Telemedicine Working Group (FedTel) was established in April 2011 to help discuss and reduce organizational silos, facilitate telehealth education and information sharing amongst members, and summarize key telehealth activities of the participants. This workgroup convenes every other month via conference call and semi-annually face-to-face. HRSA’s primary responsibility within FedTel is to internally share funding opportunities and announcements for telehealth research and planning activities throughout the federal government, according to the report.

The report also stated how ONC is “developing a first-of-its-kind inventory of federal telehealth activities.” ONC distributed a questionnaire to federal agency participants in June that seeks to ascertain ways in which telehealth activities are supported by different agencies government-wide, to eliminate duplication of effort, and to identify programmatic synergies and complementary efforts. The survey will also shed light on the ways in which different agencies and offices are planning to foster specific kinds of telehealth services, such as remote monitoring or store and forward technologies. More updates from this project are expected this fall.

The report also gave an update to telehealth efforts within the U.S. Department of Veterans Affairs (VA), since the VA is currently the largest provider of telehealth services in the country. In Fiscal Year 2014, the VA reported 2.1 million telehealth encounters, with nearly 45 percent of these “visits” involving veterans living in rural areas of the country. The VA’s telehealth programs currently provide access to 44 different clinical specialties, such as psychiatry, radiology, endocrinology, and neurology.

What’s more, HHS has sent a legislative proposal related to telehealth that illustrates its coordination as part of the President’s budget request for FY 2017. To this end, the report said, “Currently, the Medicare fee-for-service program covers telehealth services for a defined list of just under one hundred treatments, and requires services be delivered via video-link to beneficiaries living in rural areas.  The  Department’s proposal would encourage wider appropriate delivery of telehealth services by expanding the ability of Medicare Advantage organizations to deliver certain medical services, at the Secretary’s discretion, via telehealth by eliminating otherwise applicable Part B requirements that certain covered services be provided exclusively through face-to-face encounters.”

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