Telehealth visits have been a lifeline to patients and a financial one for health care providers during COVID-19 and may become a standard practice of care in the post-pandemic world. But health plans and providers with a financial stake in risk adjustment must press for research and medical-driven policy decisions regarding effective and appropriate use of telehealth and not allow financial motives to drive policy direction.
Telehealth visits have become the essential stop gap to address the need for accessibility to clinical care when in-person visits have dropped off due to the national public health emergency. It has required rethinking about the proper place for telehealth in the array of clinical management tools. Meanwhile, stakeholders involved in risk-adjusted payment programs wonder how much telehealth care can fill in the risk adjustment and HEDIS gap left in routine care visits during the COVID crisis. From a care management perspective, they question whether telehealth can be a replacement for in-person health care services once the pandemic subsides. As far as RISE is concerned, it is important to separate these two lines of inquiry because they come from different places of concern.
Through the risk adjustment lens, the tremendous drop off in routine office visits will have a big negative impact on future payment streams unless there is a policy fix from the Centers for Medicare & Medicaid Services (CMS) to help smooth out the payment levels. The dearth of ICD-10 codes collected will severely affect the HCCs identified in the population and, hence, the ultimate risk adjustment factor (RAF) scores of the populations. Whether we are talking about Medicare Advantage plan payments or accountable care organization (ACO) performance calculations, there will be serious losses incurred, failing some regulatory solution. Also, when the annual CMS bid comes around, the fee-for-service (FFS) normalization factor will take a huge bite out of the payments for the following year.
Many health plans are eager to see CMS make a change to their policies regarding telehealth and risk adjustment. As it stands now, only telehealth visits with synchronous audio and visual features are risk adjustable. While CMS will pay for audio-only visits, those will not be risk adjustable. Presumably, there is a judgment that the ICD-10 codes captured without a visual component are more suspect and, therefore, not allowable from a risk adjustment perspective.
These payment concerns are unique to Medicare programs and do not affect Affordable Care Act (ACA) marketplace plans nearly as much. That is because the ACA payment model is a zero-sum market-level settlement, not something that is adjusted upward or downward through federal payments. The risk-adjustment mechanism is a transfer model, so the main concern is more about data integrity in capturing and applying the proper codes in the plan-to-plan transfer calculations.
There is considerable interest in broadening the Medicare policy to allow synchronous audio visits to be risk adjustable. Even from a clinical perspective, medical leaders have commented to RISE that it makes no sense to them to not allow many of the audio-only visits to be risk adjustable. They note that, if the codes from the audio visit are not going to be risk adjusted, there would be pressure to bring the patients in for a face-to-face visit in person, which may not be acceptable to the patients during the pandemic.
In the short term, telehealth visits have dramatically enhanced access to care for self-isolating patients. The technology has also boosted accessibility to those who live in rural areas and who are less able to come for in-person visits due to distances and logistics, as well. Also, for the urban populations with social determinants of health barriers, the shift to telehealth has been a positive shift. For many of these patients and elderly populations without sophisticated mobile phones, audio-only visits are practical, and they represent a dramatic improvement to their previous health care access experiences.
RISE’s point of view
RISE believes that the adoption of telehealth by CMS for Medicare will not make up the difference between the normal office visit encounters versus the 2020 pandemic levels, whether CMS sticks with allowing only synchronous audio-visual visits or if it pulls out the limitation and permit audio-only visits. The expectation so far is that the drop-off will still be very sizable in any event. The upcoming September sweeps will tell us more when those occur. Consequently, only a CMS policy intervention will head-off the financial drama we foresee ahead.
If this is the case, the industry is better off taking a two-track approach to telehealth visits for the long run. One track is to work with CMS on a policy fix. The other track is to work on the clinical side to make determinations about the appropriate use of the different technologies for continual use in the future. We should ask ourselves several questions:
- What kinds of visits should be utilized for the ongoing management of patients’ care?
- What types of adjunct technology (e.g., remote monitoring devices) can be used in the home by everyday patients to get reliable diagnostic insights?
- Are there intervals in the management of patients with chronic, co-morbid conditions where telehealth visits are appropriate if supplemented with episodic in-person clinical visits in the doctor’s office?
- What kinds of medical liabilities are incurred with the use of telehealth over time with different health conditions?
RISE believes that health plans and providers with a financial stake in risk adjustment should press for research and medical-driven policy decisions regarding effective and appropriate uses of telehealth and not allow financial motives to drive policy direction. While we understand the temptation to get the techniques and technology to support risk adjustment needs, we think the starting place must be from a clinical perspective. Risk adjustment will have to adapt to whatever makes the most clinical sense. ICertain accommodations with telehealth during the pandemic are appropriate in order to properly treat patients now. However, in the longer haul, the way forward should be navigating toward best practices rather than expediency.