How Telehealth Became a Proven Product for Medicare Beneficiaries

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An impressive new statistic has emerged from the pandemic. Everyone knew that remote medical visits or telehealth flourished when people couldn’t or were afraid to go in person to healthcare providers. Now the Office of the Inspector General of the Department of Health and Human Services has quantified it for a large portion of the population. Some 28 million people on Medicare used telehealth in the first year of the pandemic. To learn more about what they found and why it matters, IG assistant Erin Bliss spoke with the Federal Drive with Tom Temin.

Tom Temin: Mrs. Bliss, nice to have you.

Erin Bliss: So happy to be here, Tom. Thank you.

Tom Temin: And just to set the scene here. This is one of the many studies you’ve done on the delivery of pandemic health care by Medicare and Medicaid throughout this whole thing that we’ve been through.

Erin Bliss: Yes, it’s true. This report is part of a much larger portfolio of OIG work on telehealth and is also the first in a series of three assessments specifically analyzing the use of telehealth and health insurance during the first year of the pandemic, which is March 2020 to February 2021. The first report provides a snapshot of the landscape of what this use of telehealth looks like. The second report examines which groups of Medicare beneficiaries use telehealth the most to access care and how do they access that care. And the third assessment focuses on vendor billing that may present program integrity risks.

Tom Temin: Okay, and was telehealth generally paid for or not by Medicare before the pandemic?

Erin Bliss: Before the pandemic, Medicare telehealth coverage was very limited. For example, beneficiaries in rural areas were allowed to use telehealth for certain types of services, but had to access these services from medical facilities. They couldn’t use it from home. In the year before the pandemic, less than 1% of Medicare beneficiaries received services via telehealth.

Tom Temin: Okay, so what about those 28 million who did, I think your report says that’s one in five?

Erin Bliss: Yes, actually a little over two out of five. COVID-19 has changed everything about healthcare delivery, created unprecedented challenges for how Medicare beneficiaries and others access healthcare. Thus, Congress and the Centers for Medicare and Medicaid Services (CMS) have taken a number of steps to temporarily open telehealth access to Medicare beneficiaries. Thus, CMS enabled beneficiaries to use telehealth for a wider range of services and in different locations, including from home and for beneficiaries in urban areas.

Tom Temin: And give us some of the other stats you found. I mean, 28 million, what are they usually used for, like telehealth or is that all you would usually go to the doctor for?

Erin Bliss: It was and in fact, office visits, which are essentially routine appointments with your primary or specialty care provider, accounted for the greatest amount of telehealth services. But what really stands out is how recipients are using telehealth to access behavioral health care. Thus, 43% of all behavioral health services were provided through telehealth, which was significantly more than other types of services. Thus, these office visits were only provided by telehealth about 13% of the time. So telehealth has been really crucial in meeting the growing mental health and addictions needs that have emerged during the pandemic.

Tom Temin: Yeah, so for example, psychotherapy or the kind of talk therapy where people might even have been more effective, as far as we know, under the tele-situation rather than sitting in a chair somewhere.

Erin Bliss: Exactly. There are other barriers, even beyond the pandemic, to seeking in-person care, sometimes for people with mental health issues or behavioral health issues. Thus, individual therapy, group therapy, and treatment for substance use disorders were accessed via telehealth far more frequently than other types of services.

Tom Temin: We speak with Erin Bliss, she is the Assistant Inspector General in the Department of Health and Human Services. And what can CMS get out of it? Well, let’s start with what is the status of payment for telehealth now? As you mentioned earlier, this was a temporary fix that Congress and HHS agreed to because it was an opportunity. Now we know it works. And so is it a permanent part of the Medicare system?

Erin Bliss: Not yet. Congress is therefore considering several bills that would seek to expand access to long-term telehealth and recently extended many of the current telehealth flexibilities for five months after the public health emergency ended. We therefore consider this report to provide important information to both Congress and CMS as they continue to determine in some ways the kinds of changes to be made to the permanent policy of telehealth and Medicare. They reconcile concerns about access, quality, equity and program integrity.

Tom Temin: To the right. I guess the key here is that CMS has the tools in place to assess that they are getting the quality care they are paying for when it comes to a telesituation. Is that really where the crux of this whole question lies?

Erin Bliss: This is a very important dimension, making sure that the beneficiaries receive the care they need, of the quality that they need and of the value that we pay. But yes, quality issues, access issues, and program integrity issues and making sure that providers don’t take advantage of telehealth to defraud the system are all extremely important considerations. And so CMS and Congress, where legislative authority is needed, are trying to weigh all of these different factors for this current report to provide information on what types of services were being used, how many recipients were accessing them. Interestingly, even though we had this huge increase in the use of telehealth, overall recipients were still getting most of their health care in person. Thus, telehealth accounted for only 12% of total health care services in this first year of the pandemic. Our results therefore illustrate how telehealth could fit into this larger picture of health care delivery. For behavioral health, telehealth has become an essential way for recipients to access their care. But for other services, telehealth has simply helped recipients access care when they face certain barriers, but most of their care has remained in person and with their pre-existing providers.

Tom Temin: Of course, I guess if you have a condition that requires being touched by a practitioner or an instrument, you really need to be there. So far there is no way to do this robotically. And what do you think of what CMS thinks? I mean, how do they take the report? You didn’t really have any recommendations. You found a lot of facts about all this, what happens next for the CMS?

Erin Bliss: Exactly, well, CMS is very actively evaluating its policy options and determining what it should do to move forward. We hope this information will help provide them with useful information. As I mentioned earlier, this is part of a larger series and so our upcoming reports which focus on which recipients are using telehealth and how, which has implications for access and equity, as well as program integrity risks associated with some telehealth providers. We anticipate that we will have recommendations for CMS as a result of these reports.

Tom Temin: Yes because program integrity is a big ongoing issue for CMS because it’s the biggest payer of abusive payments and some of these sensational cases come to light from time to time. And I guess you don’t want it for telehealth.

Erin Bliss: Exactly. Program integrity is a widespread issue for in-person care as well as remote care options. It is important, however, to distinguish between telehealth fraud, which is fraud involving the billing of a telehealth service itself, and what we call “telehealth fraud”, which is really the use of a telemarketing-type tactic to commit essentially traditional acts. bread and butter fraud. Thus, in recent years, the OIG has conducted several large and high-profile telefraud investigations, where perpetrators were essentially cold calls to beneficiaries making a mock visit over the phone and then ordering unnecessary medical equipment or genetic testing. The fraud in these cases was aimed at the unnecessary charging of equipment and tests. For the most part, they were actually billing for the fake telehealth phone call.

Tom Temin: Alright Alright. They sure are creative, aren’t they, scammers?

Erin Bliss: Absolutely. And this scam even preceded the pandemic but unfortunately it continued.

Tom Temin: Alright, well, this next report will bring you back for that one. Erin Bliss is an assistant inspector general in the Department of Health and Human Services. Thank you very much for joining me.

Erin Bliss: Thanks Tom. Appreciate the opportunity.

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