As a result of the collaborative efforts between congressional offices and various health care stakeholders, and the feedback provided in response to the Bipartisan CHRONIC Care Working Group Policy Options Document released in December of 2015, the Senate Finance Committee recently introduced a draft of bipartisan legislation known as the Creating High-Quality Results and Outcomes necessary to Improve CHRONIC Care Act of 2016 (the CHRONIC Care Act). The CHRONIC Care Act seeks to modernize Medicare payment policies to improve the management and treatment of chronic diseases using telehealth.
Over the past several years, there has been increased attention by Congress and federal agencies on prevention, management and treatment of chronic conditions, such as cancer, heart disease, obesity and diabetes, as they are long-lasting and persistent health problems that require continuous, expensive care. Studies conducted by federal agencies have shown that patients with multiple chronic conditions can cost up to seven times as much as patients with only one chronic condition and chronic diseases are responsible for more than 75 percent of the trillions of dollars spent annually on health care. The CHRONIC Care Act aims to deliver higher quality care to Medicare beneficiaries with one or more chronic conditions and reduce the costs associated with the provision of such care through the use of telehealth.
Below is a summary of the key telehealth provisions under the CHRONIC Care Act that aim to expand access to home dialysis therapy and timely stroke care, increase convenience for Medical Advantage enrollees, and improve care coordination by accountable care organizations (ACO).
Expanding Access to Home Dialysis Therapy
Currently, Medicare covers and reimburses dialysis therapy provided to Medicare beneficiaries if certain requirements are met, including the provision of the service at an authorized originating site (including a physician office and hospital-based dialysis facility) that is located in a rural Health Professional Shortage Area (HPSA) or area outside a Metropolitan Statistical Area (MSA). The CHRONIC Care Act proposes to allow beneficiaries that receive dialysis to receive required monthly clinical assessments to monitor their condition using telehealth without geographic restriction beginning in 2018. Specifically, the CHRONIC Care Act would expand the originating sites from which the beneficiary can choose to receive an assessment via telehealth to include freestanding dialysis facilities and, importantly, the patient’s home.
Increasing Convenience for Medicare Advantage Enrollees through Telehealth
Medicare pays for a limited number of Part B services furnished by a physician or practitioner to an eligible beneficiary via a telecommunications system (i.e., interactive audio and video telecommunications system that permits real-time communication between the practitioner at the distant site and the Medicare beneficiary at the originating site). Reimbursement for these telehealth services includes payments to physicians or other professionals (at the distant site) for the telehealth consultation, and to the facility where the patient is located (the originating site). A Medicare Advantage plan may provide telehealth services to its beneficiaries, including, but not limited to, using telemonitoring and web-based and phone technologies, and providing medication therapy management via telehealth; however, any telehealth services beyond what is covered under Medicare must be paid for through the Medicare Advantage plan’s rebate dollars as a supplemental benefit.
The CHRONIC Care Act proposes to allow a Medicare Advantage plan to offer additional, clinically appropriate, telehealth services as a part of its benefits to beneficiaries in its annual bid amount. A Medicare Advantage beneficiary would have the ability to decide whether or not to receive services via telehealth. Further, including telehealth services and technologies to the package of benefits would not change the requirement that Medicare Advantage plans meet network adequacy requirements.
Providing Accountable Care Organizations (ACOs) the Ability to Expand Use of Telehealth
In recognition that telehealth may be a tool to increase access to care and drive down health care costs, the CHRONIC Care Act proposes to eliminate some of the restrictions on reimbursement for telehealth services for ACOs. Specifically, the CHRONIC Care Act would (1) allow beneficiaries assigned to an ACO under the Medicare shared Savings Program (MSSP) to receive currently allowable telehealth services in the patient’s home, (2) eliminate the geographic component of the originating site requirement, and (3) allow providers to furnish telehealth services as currently specified under Medicare’s physician fee schedule, with limited exceptions. Reimbursement under Medicare would be contingent upon the telehealth services being delivered to a beneficiary at an approved originating site, such as a hospital, or at the beneficiary’s place of residence. Not surprisingly, the CHRONIC Care Act does not propose that Medicare provide a separate payment for the originating site fee if the service is furnished in the patient’s home.
Notwithstanding, the election of President-elect Donald Trump and Republican majorities in both the House of Representatives and Senate creates uncertainty regarding the MSSP due to threats of repealing or drastically overhauling the Affordable Care Act.
Expanding Use of Telehealth for Individuals with Stroke
Currently, Medicare pays for physician services related to stroke treatment under the Physician Fee Schedule, the Hospital Outpatient Prospective Payment System and Inpatient Prospective Payment System. In addition to the physician services furnished when a beneficiary presents symptoms of stroke at the hospital emergency department, Medicare will pay a physician for consulting on a patient experiencing acute stroke symptoms via telehealth (at a distant site) if the hospital where the beneficiary presents (the originating site) is in a HPSA, or a county outside a MSA.
The CHRONIC Care Act proposes to expand the ability of patients presenting with stroke symptoms to receive a consultation via telehealth, beginning in 2018. Specifically, the CHRONIC Care Act would eliminate the geographic restriction on reimbursement for tele-stroke services to permit payment to physicians furnishing the telehealth consultation service in all areas of the country. However, the CHRONIC Care Act does not propose that the hospital at which the patient is present and the telehealth consultation is initiated receive a separate originating site payment.The CHRONIC Care Act is yet another piece of legislation aimed at expanding Medicare coverage for telehealth services for certain types of beneficiaries, signaling an increased recognition by Congress of its ability to lower the costs of health care delivery and improve patient health. Other legislation that has taken on this challenge includes the Creating Opportunities Now for Necessary and Effective Care Technologies for Health Act (S. 2484 and H.R. 4442). We anticipate the proposal of additional legislation focused on expanding coverage for telehealth services in 2017 (and beyond).