Article In Brief
The AAN call for greater parity in telehealth reimbursement comes at a time when payment practices for virtual visits are varied and unpredictable around the country. More research to support the utility of virtual visits is needed to learn more about what that parity means.
The AAN's newly published Telehealth Position Statement calls for payment parity so that virtual care can become a sustainable complement to in-person neurologic care.
While the exact definition of parity will need to be worked out over time, the concept—that neurologists and other health care providers will be reimbursed fairly for virtual encounters—appears to have widespread support.
Or at least that's what AAN members heard when they participated in the annual AAN advocacy event, Neurology on the Hill (NOH), held virtually on May 19.
“The response from Congress was overwhelmingly positive, including [support for] pay parity,” Jaime M. Hatcher-Martin, MD, PhD, lead author of the AAN position statement, said in an email. “Many shared stories about themselves or family members who accessed telehealth during the pandemic.”
The expansion of telehealth, driven by a series of waivers issued by the Centers for Medicare & Medicaid Services (CMS) in early 2020, will continue throughout this year, courtesy of the 2021 Medicare Physician Fee Schedule.
Telehealth advocates believe that Congress will support the widespread use of telehealth beyond that, but AAN leaders are concerned about the unpredictable payments for virtual visits.
At Akron Children's Hospital, a review of claims made to Medicaid payers in the first four months of 2021, for example, found that more than 50 percent of the highest level of codes had been “down-coded,” that is, the insurer paid for a lower level of service than [was] submitted in the claim, said Bruce H. Cohen, MD, FAAN, director of the divisions of neurology, neurosurgery, neurobehavioral health, physiatry and developmental pediatrics.
“We're seeing this with private payers too,” said Dr. Cohen, chair of the AAN Advocacy Committee. “Some payers are down-coding Level 5 visits [for more complex patients] to Level 4, saying Level 5s can only happen in person. Some insurance companies are not paying the practice-expense component of the bill.”
At the beginning of the pandemic, some insurers increased payment rates for audio-only visits to the equivalent of would be paid for in-person established-patient visits and eventually also allowed new-patient audio-only visits pay to be the same as in-person patient encounters, said Neil Busis, MD, FAAN, associate chair for technology and innovation in the neurology department at NYU Grossman School of Medicine.
“Certain payers are cutting back on some telehealth coverage and payment policies,” said Dr. Busis, chair of the AAN's Telehealth Subcommittee. “There is great variability between different payers and geographic locations.”
How widespread these changes are is difficult to assess. Because insurers have many different products, some of which vary by state, insurers' payment policies for telehealth may not be uniform.
“I have spoken with numerous neurologists, and it is really mixed,” Dr. Hatcher-Martin said.
Indeed, ever since the use of telehealth exploded at the beginning of the COVID-19 pandemic, payment for virtual visits has been uneven and unpredictable across the country. While Minnesota, Hawaii, and some other states legislated payment parity—equal pay rates for telehealth visits and face-to-face visits during the public health emergency—Pennsylvania, Missouri and others did not, according to the Center for Connected Health Policy.
Who Benefits from Telehealth?
Dr. Cohen offers an example of how telehealth saves insurers money. At the beginning of the pandemic, one of his patients who had had a prolonged hospitalization was discharged home earlier than what was expected in an attempt to avoid COVID-19 exposure.
“She was discharged on about 25 different medications, and one of our concerns was how many more hospitalizations and co-morbidities would result from the fact that we might be sending this patient home a little too early,” he said.
Initially, Dr. Cohen had three virtual visits a week with the patient, each lasting more than 40 minutes. All told, he had 35 telehealth visits and one in-person visit over a 13-month period.
“She had zero hospitalizations and seldom [had] a visit to her pediatrician or other subspecialist, and we were able to taper her off many of the medications,” he said. “I would say that's a pretty good use of telehealth services.”
Nonetheless, government and private payers have long been concerned that the convenience of telehealth might lead to overuse and increase overall spending on health care, Dr. Busis said. Gathering evidence to prove that virtual care is cost-effective for payers will take time, he said, although the financial benefits to society overall are easy to see.
“Telehealth decreases time away from work or school and time away from caregiving, and it saves travel expenses and parking expenses,” he said. “But an insurer will say, ‘That's wonderful for the patient, but how does it save money for my company?’”
Neurology had one of the greatest uptake rates for telemedicine—47.9 percent of total visits—in the two months after COVID-19 emerged in 2020, according to an analysis published in Health Affairs. Its review of insurance claims from 16.7 million people with commercial or Medicare Advantage insurance between March 18, 2020, and June 16, 2020, found that psychiatry, gastroenterology, endocrinology, and psychology were the only other ambulatory specialties with a higher percentage of telemedicine visits.
Likewise, neurology, along with psychiatry and endocrinology, had the smallest decline in total visits (virtual visits plus in-person visits) during the same period, compared to the months before the pandemic. That confirms that virtual care allowed patients to maintain access to neurology care despite the pandemic, Dr. Cohen said.
The AAN's position statement, published in Neurology online on May 13, states that the complexity of reimbursement rates and documentation standards among government and private payers presents a barrier for neurology practices to incorporate telehealth, despite its popularity with patients and providers alike. It advocates for fair and sustainable reimbursement for professional work and practice expenses.
Payment for physician services (the professional component) should be consistent, regardless of the setting. “We believe that the physician's work in terms of intensity and time is the same whether you are talking to the person on the telephone, seeing them by video, or seeing them in person, provided the standards of care are met,” Dr. Busis said.
And, too, the statement acknowledges that in terms of reimbursement—the practice component—expenses other than the physician work— might be different for virtual visits rather than in-person, but research is needed to figure that out.
Payers that are currently declining to pay for the practice-expense component of a virtual visit appear to assume that the neurology practice is incurring no such expense, Dr. Cohen said. “They are basically saying the patient is not using your exam table, you don't have to heat the office because there's no one in the room, and there's no medical assistant taking blood pressure, height, and weight,” he said.
But that view ignores the fact that some services require in-person visits, so practices must maintain offices—in addition to paying for the information technology and staffing required to support virtual visits. “You can't heat half an office or light half an office,” Dr. Cohen said.
The telehealth statement also says that appropriate reimbursement for other telehealth modalities—for example, evaluation of images sent digitally by another provider, interprofessional consultations, or remote monitoring—should also be determined after more research.
What Payers Think
The American Telemedicine Association (ATA), an advocacy organization whose members include payers and telehealth technology companies, endorses the concept of “fair pay” for telehealth services.
The “fair pay” concept acknowledges that some telehealth providers do not have brick-and-mortar facilities and, thus, do not have the expenses associated with them, said Kyle Zebley, the ATA's public policy director.
The ATA defines fair payment as payment that takes into consideration the ongoing investment necessary to ensure telehealth platforms are continuously maintained, seamlessly updated, and services can continue to expand as needed. The idea is that pay rates should be fair to payers, providers, and patients, Zebley said.
Payers are enthusiastic about telehealth, he said, and realize that if providers are not paid fairly, they will be unable to offer virtual care.
“It's a bad future for all of us if there are roadblocks to adoption of telehealth,” he said. “Whenever we think about what fair payment looks like, we need to make sure providers aren't bleeding money and resources because they are doing the right thing for their patients. That is something we feel very strongly about.”
What to Expect Next
The new AAN Telehealth Subcommittee in concert with the Medical Economics and Practice and Advocacy Committees and constituent subcommittees are planning for the next steps to achieve the goal of greater parity for telehealth services.
“The issues surrounding payment parity, site of service rules, interstate licensure and malpractice coverage based upon the site of service are being discussed by federal and state regulatory agencies and legislative bodies as well as health care systems, payers, and professional organizations,” Dr. Busis said.
“There are bills introduced in the US Congress dealing with some, but not all these issues. The concept of parity itself will be under scrutiny, as the cost to deliver care by way of telehealth may be quite different from face-to-face care, and payment policy should be driven by data, which has yet to be fully realized. In the end, telehealth services will likely be added to reimbursable care, but the individual states will likely control licensing regulations, with hopefully some loosening of the rules surrounding site of service.”
At Neurology on the Hill, AAN members asked lawmakers to cosponsor the Telehealth Modernization Act or the CONNECT for Health Act, both of which seek to maintain patient access to telehealth. Neither bill deals with the issue of payment. Rather, both bills would permanently remove the originating-site and geographic restrictions—both relaxed at the beginning of the pandemic—that have historically curtailed widespread adoption of telehealth.
Zebley said those provisions, along with other telehealth supports, might be folded into a broader bill that Congress could be motivated to pass when the public health emergency declaration is about to expire. Another possibility is that Congress will approve a one- or two-year extension of the rules currently in place for telehealth.
“Instead of permanency, in order for Congress to see how telehealth operates in non-pandemic times, there's a possibility that they will make a temporary extension,” he said. “That's clearly preferable to going over what we call the telehealth cliff, in which Medicare beneficiaries overnight lose access to virtual care.”
He encouraged neurologists—and their patients—to contact their Congressional representatives. “We've had tremendous success in terms of telehealth expansion during COVID-19 during the last 15 months, but it can all go away if Congress doesn't do the right thing and act,” he said. “Tell them, ‘don't let us go over the telehealth cliff.’”