Federal Government Authorizes Telehealth Waiver Pilots for Medicare Value-Based Care

Recent policy changes by the U.S. Department of Health and Human Services Center for Medicare and Medicaid Services (CMS) have been designed to make telehealth services more broadly available to Medicare beneficiaries. The changes follow a Congressionally-mandated report highlighting how reimbursement restrictions limit telehealth use, and so requirements have been relaxed for the Medicare Fee-For-Service effective January 1, 2019. Policy changes are pending for Medicare Advantage (MA) plans, effective for the 2020 plan year.

Even before the recent rulemaking, key reimbursement restrictions related to geography and originating sites were changed under several CMS waiver pilots. In addition, the Center for Medicare and Medicaid Innovation (CMMI) has awarded grants for pilot programs that include telehealth.

Value-based programs that waive telehealth restrictions include: Next-Generation Medicare Accountable Care Organizations (NGACOs); Bundled Payments for Care Improvement (BPCI); and, Comprehensive Care for Joint Replacement (CJR). They are briefly described in the November 2018 CMS Report mentioned.

Medicare Next Generation ACOs (NGACO)

Under the updated NGACO model for telehealth, the goal is to test whether combining the right financial incentives and tools to better support patient engagement and care management will improve patient outcomes and lower expenditures for Medicare FFS beneficiaries. Those organizations participating in the program were allowed as early as 2016 to provide telehealth services to Medicare beneficiaries residing outside rural areas while in their homes.

Also waived for NGACO organizations is the limit on the use of asynchronous or “store-and-forward” technologies, previously limited to a federal telemedicine demonstration program in Alaska and Hawaii. After several NGACOs let CMS know their providers were providing quality, cost effective care using the technology, CMS broadened the scope of the waiver. Effective January 1, 2018, NGACO’s may now bill Medicare for services using this technology only for teledermatology and teleophthalmology services. NGAACOs must submit specific information to CMS to qualify including an Implementation Plan that details how the waiver will be used, in what settings and more.

Bundled Payments for Care Improvement (BPCI) Initiative

The BPCI Initiative includes four broadly defined models of care that link payments for the multiple services a beneficiary receives during an episode in care. As with other value-based models, under BCPI, organizations accept greater risk for care with the goal of better quality, improved care coordination at a lower cost to Medicare. CMS has waived telehealth geographic requirements during a Model 2 or Model 3 episode as long as all other Medicare criteria for coverage and payment are met. In Model 2, the episode includes the inpatient stay in an acute care hospital plus the post-acute care and all related services up to 90 days after hospital discharge. In Model 3, the episode of care is triggered by an acute care hospital inpatient stay but begins at initiation of post-acute care services with a skilled nursing facility, inpatient rehabilitation facility, long-term care hospital, or home health agency.

Comprehensive Care for Joint Replacement (CJR) Model

The CJR program is a value-based care model for hip and knee replacements – the most common inpatient surgeries for Medicare beneficiaries. Here, bundled payment and quality measurement applies to physicians, hospitals and post-acute providers for better care coordination and patient outcomes. As with the NGACOs model, a waiver of telehealth requirements allows patients to receive telehealth services while at home, no matter where they live. Further, a payment requirement waiver allows distant site payments to apply to certain HCPCS codes that are specific to the CJR Model.

Telehealth in CMS Innovation Center Models

Under the Health Care Innovation Awards (HCIA) program grants are awarded for a diverse set of models to test new delivery approaches to achieve better quality at lowers costs for those enrolled in Medicare, Medicaid and the Children’s Health Insurance Program (CYHIP). Under grants awarded in 2012 and 2014, several included “elements” of telehealth but not involve waivers of telehealth requirements.

One example of an HCIA using telehealth was cited in the CMS report: The University of New Mexico Health Science Center tested expansion of existing telehealth infrastructure to form a statewide 30-hospital telehealth system to provide neurological consultation through software and audiovisual equipment.

Telehealth Expansion

One thing is certain: between testing new Medicare value-based care models and relaxation of various Medicare telehealth requirements, there will be ample opportunity to learn about how telehealth is improving Medicare beneficiary care, population health and transforming care delivery for better quality, satisfaction and cost efficiency.  And what often is tested in Medicare often creates an echo effect that benefits the rest of the health insurance industry.

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