Despite Potential Benefits, Medicare Slow to Utilize Telehealth

CHICAGO—While strides have been made in technology that could help beneficiaries gain access to better and possibly more cost-effective health care, Medicare continues to be a major hurdle, according to one industry organization.

Annually, Medicare pays only about $6 million for telehealth services, according to the Institute of Medicine. In comparison, Medicare paid over $3 billion to providers participating in the Electronic Health Record (EHR) incentive programs from 2011 to 2012.

And as of 2013, the Centers for Medicare & Medicaid Services (CMS) has a limited list of about two dozen services it will reimburse providers for using telehealth. The CMS added seven of those services this year.

Doctors and advocates of telehealth and telemedicine—the exchange of medical information from one site to another via electronic communication—say the technology is already revolutionizing the delivery of health care but that Medicare is too slow to recognize its benefits.

Original story: Despite Potential Benefits, Medicare Is Slow to Connect With Telehealth
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Related FAQ: How Does Medicare Pay for Telehealth Services?
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In addition, lawmakers have introduced legislation to expand Medicare reimbursement for certain telehealth services, such as the bipartisan Fostering Independence Through Technology (FITT) Act of 2011, but without much success, as the act died in committee. Most recently, Rep. Mike Thompson (D-Calif.) proposed the failed Telehealth Promotion Act of 2012, which sought to expand access to telehealth for people under Medicare and Medicaid.

“Telemedicine is growing by leaps and bounds despite Medicare,” said Jonathan Linkous, chief executive officer of the American Telemedicine Association (ATA). “It’s unfortunate because they’re serving a population who truly needs this.”

Telehealth and Timely Treatment

Imagine this.

A Medicare patient suffers a stroke, but the nearest hospital with a practicing neurologist is more than two hours away. Stroke victims have a greater chance of avoiding long-term brain damage if they receive clot-dissolving medication within the first hour and a half.

For the patient living in a remote or rural area, it may be difficult to get a critical and time-sensitive treatment such as intravenous tissue plasminogen activator (tPA), a clot-dissolving medication known to be beneficial in stroke care. Treatment within the first 90 minutes of an acute stroke can lead to a roughly 18-fold better chance of being helped than harmed, said Lee H. Schwamm, M.D., of the Harvard Medical School, in August 2012 at an Institute of Medicine workshop on the role of telehealth in health care.

Timely treatment is so important that the American Heart Association guidelines say “an ambulance may bypass a hospital that does not have the resources” to help patients with stroke.

According to Schwamm, a program called “TeleStroke” may be an early and sustainable application of telehealth for stroke care. Through that program, stroke specialists remotely examine and recommend treatments for patients via state-of-the-art video conferencing. The specialist can visually inspect the patient for key symptoms via high-quality videoconferencing.

An American Heart Association study found that stroke patients who were admitted to clinics taking part in the Telemedicine Pilot Project on Integrated Stroke Care between 2003 and 2005 had a 35 percent lower chance of a “poor outcome”—death or lasting disability—than those admitted to nearby hospitals without the technology.

“There’s a likelihood the patient won’t need extended rehabilitation days or nursing home days,” Linkous said, adding these benefits to patients would also save money for Medicare. “If the patient (were) covered by Medicare, then the program (would) avoid those costs.”

“There are huge savings for the patient and providers,” he said of TeleStroke and a similar service called teleradiology, which allows health care providers to send imaging studies such as X-rays, MRIs and CT scans to remotely located radiologists, many of whom are highly specialized in certain areas like neuroradiology or pediatric radiology.

Challenges With Medicare

The ATA estimates that approximately 10 million Americans were served by telemedicine in 2012, with about half through teleradiology.

Although millions are served by telehealth, in 2009, only about 14,000 Medicare beneficiaries had one or more telehealth visits, according to theInstitute of Medicine. To put this in context, rural Medicare beneficiaries represent 23 percent of all fee-for-service beneficiaries, according to theMedicare Payment Advisory Commission.

The CMS’s current list of reimbursable telehealth services includes consultations, psychiatric diagnostic interview examinations, neurobehavioral status exams and smoking cessation services. The CMS added seven new services to the list on Jan. 1, 2013, which include alcohol misuse intervention services, depression screenings and face-to-face behavioral counseling for obesity.

The widespread use of telehealth technologies in Medicare faces several barriers, experts say. These include providers’ fears of adopting of new technologies and regulations on multistate systems because providers can only provide telehealth services within their own state. Also, while some telehealth applications have been proven to work, additional evidence is needed regarding cost savings, Linkous said.

But Medicare’s biggest barrier to adoption may be its traditional reimbursement model, which is lacking incentives for providers to use the technology, experts say.

Current law only allows Medicare to reimburse certain providers, such as hospitals, rural health clinics, skilled nursing facilities and community mental health centers, in nonmetropolitan areas and for specific services. Eligible providers exclude the home care industry, which many Medicare beneficiaries use, and eligible services exclude remote monitoring technologies.

“Medicare’s definition of telehealth really needs to be updated to the 21st century,” said Richard Brennan Jr., vice president of technology policy and government affairs for the National Association for Home Care & Hospice (NAHC). “These systems can be placed in people’s homes.”

It all goes back to reimbursement, Brennan said.

“Home agencies have to find ways to pay for (telehealth),” he said. “Medicare is really hampering a role for these systems.”

Examples of various home-based telehealth technologies include:

• Teladoc: Allows people to reach a U.S. board-certified doctor or a licensed pediatrician from home. According to its website, the average doctor call-back time is 24 minutes. The doctor recommends a treatment for a medical issue and will send a pharmacy of choice a prescription if necessary.
• Blipcare Wi-Fi blood pressure monitor: Allows doctors and family members to track a person’s blood pressure readings over the Internet and to collect analytical reports.
• Blipcare Wi-Fi weight scale: Reminds people to track weight and body mass, and stores the readings with a time stamp in the user’s account. It allows caretakers to track a patient’s weight and health.

In 2010, two-thirds of Medicare beneficiaries had at least two of the 15 most common chronic conditions; 23 percent had at least four. Among the most common chronic conditions are high blood pressure, arthritis, diabetes, heart failure, high cholesterol and chronic kidney disease.

Researchers also found that the conditions accounting for most of the growth in Medicare costs and spending shifted from relatively acute conditions (e.g., heart disease) to more chronic conditions (e.g., diabetes and hypertension) during the past two decades. In 2002, beneficiaries treated for five or more chronic conditions accounted for 76 percent of Medicare spending, up from 52 percent in 1987.

“The high costs are in the chronic care management,” Brennan said. “To handle that, you need to be more sophisticated. Telehealth and remote systems are important pieces.”

Failed Legislation to Expand Telehealth

Sen. John Thune (R-SD), in 2011, reintroduced the bipartisan Fostering Independence Through Technology (FITT) Act. The bill, if it had been signed into law, would have created a pilot program to give incentives for home health agencies to use home monitoring and communication technologies.

The FITT Act was budget neutral, as home health agencies participating in the pilot program would have received annual incentive payments based on a percentage of the Medicare savings achieved as a result of telehealth services.

"Access to high-quality health care in rural areas can be costly and limited," Thune said in a 2011 statement. "Telehealth technology stands to bridge the distance gap between patients and specialized health care providers.”

In addition, he said, new and innovative measures can reduce the cost of health care in rural communities while noninvasive telehealth technology, like remote monitoring, gives seniors the ability to stay in their homes longer.

The bill was referred to the Senate Finance Committee, where it died in committee in 2012. Three previous attempts, in 2005, 2007 and 2009, also failed to reach a vote in the House of Representatives and the Senate.

On Dec. 30, 2012, Rep. Mike Thompson (D-Calif.) proposed the Telehealth Promotion Act of 2012. The proposed legislation’s goal was to increase federal support and payments for telehealth services by establishing a federal reimbursement policy under Medicare. But according toGovtrack.us, the bill was also basically dead-on-arrival, perishing in committee the same day it was introduced. If passed, the bill would have provided a federal standard for licensing, allowing providers to simply be licensed in the state of their physical location but be able to treat patients anywhere in the country.                   

Successes in Telehealth

Despite Medicare’s exclusion of home health care services in its list, the use of telehealth technologies has become the fastest growing segment in the home care industry, Brennan said. About 40 percent of the agencies in the NAHC are now using telehealth technologies.

But it’s not just the home health industry that is reaping the benefits of telehealth.

At Illinois’ state prisons, inmates in telehealth programs who have HIV and Hepatitis C seem to follow their medicine regimen and adhere to therapy more closely. Doctors say those with HIV seem to be slower to develop AIDS.

“Anecdotally, patients are getting better care,” said Dr. Jeremy Young, assistant professor of Medicine at the University of Illinois.

At any given time, there are approximately 550 inmates with HIV and another 100 with Hepatitis C in the Illinois Department of Corrections’ 29 correctional facilities scattered across the state. Having a specialist or two driving around the state seeing these patients is simply not feasible.

Using existing technologies, the Department of Corrections, in conjunction with the University of Illinois College (UIC) of Medicine at Chicago, started a program that sought to help them provide better care to the inmates.

At the UIC campus, Young said, a suite is decked with a large flat-screen television and computers to access inmates’ lab tests. Hundreds of miles away, a similar room is set up in the correctional facilities with specialized equipment such as hand-held cameras that can send clear images and video.

“We can look at the inmate’s eyes, hear their heart beats, closely observe bruises and rashes,” said Young, medical director of the UIC’s Office of Telehealth and Telemedicine. “You can do everything but touch the patient.”

At the U.S. Department of Veterans Affairs, telehealth has been a proven success story.

In 2011, more than 380,000 veterans used the department’s clinic-based telehealth services, which allows for frequent check-ups and monitoring by doctors. By 2013, the VA estimates the number of veterans that will be served by clinical telehealth services will reach 820,000, or about 15 percent of the veteran population, according Adam Darkins, M.D., of Veterans Affairs.

Another 92,000 veterans will receive home telehealth services annually for chronic care management and health promotion using mobile devices and video-conferencing. Patients are typically with a nurse or social worker when they connect with a physician at a VA hospital.

According to Darkins, assessments have shown a 53 percent reduction in bed days or hospitalizations for those under the home telehealth program and a 25 percent reduction through clinical video telehealth. The programs have saved nearly $2,000 per patient per year.

The positive results from those using telehealth, Linkous said, mean that it’s only a matter of time before Medicare catches up and expand its coverage for telehealth services.

 “Time is on our side,” he said.

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