The rare bipartisan healthcare legislation has drawn some hospital concerns for its telehealth provisions, the benefits of which would not be available to the most popular type of Medicare ACOs.

May 16—The Senate Finance Committee is expected to soon advance a limited expansion of telehealth in Medicare after a bill received broad bipartisan support this week.

The Chronic Care Act aims to improve the care of Medicare beneficiaries with multiple chronic diseases through several policy changes, including expanded funding for some types of telehealth care. The need for Medicare to focus on chronic illness was highlighted by the program’s spending, 90 percent of which goes toward care of beneficiaries with two or more chronic conditions—such as heart disease and stroke—said Sen. Ron Wyden (D-Ore.).

Specifically, the legislation would expand authorization for beneficiaries on home dialysis to receive required monthly clinical assessments via telehealth, and for patients presenting with stroke symptoms at the hospital to receive remote consultations. Both provisions would begin in 2019.

Sen. Roger Wicker (R-Miss.) highlighted the expected benefits of the bill’s telehealth provisions by citing the experience of his state’s Diabetes Telehealth Network, which allows remote patient monitoring. The program monitors the vital signs of patients in Mississippi Delta and brings them in for care when indicated, and has been credited with eliminating emergency department visits among participants in its first year.

“However, Medicare is behind the curve—limiting access to millions of seniors,” Wicker said May 16 during a Finance Committee hearing on the bill. “The Chronic Care Act is a step in the right direction.” 

Stephen Rosenthal, senior vice president for population heath management for Montefiore Health System, told the panel that the bill’s expanded use of telehealth would be an excellent way to provide patients with access to services to help them better manage their chronic disease. He cited the benefits his organization has found through existing telehealth programs that expand healthcare access for rural patients and clinical education for providers.

However, Rosenthal said the bill’s telehealth provisions need to be expanded to include audio-only telehealth and communication between providers, care coordinators, and patients.

Hospital advocates have been supportive of the bill’s telehealth provisions but also urged expansion.

For instance, leaders at the American Hospital Association (AHA) wrote Finance Committee members to propose amendments that would comprehensively relax Medicare’s telehealth restrictions, such as by eliminating “originating site” requirements relating to geographic location and practice setting and by removing limitations on covered services and technologies.

Supporters of the bill note that its incremental push toward telehealth is limited by concerns that telehealth is expected to increase spending in the short term and is not proven to offer savings over the long term. For instance, the bill’s telehealth provisions were expected to comprise the bulk of its cost in the as-yet-unreleased Congressional Budget Office score, according to a member of the committee staff. 

However, analyses by UPMC Health Plan of results from several telehealth programs that it supports—including programs for telepsychiatry, stroke care, and primary care visits—have found reasons for optimism.

“Our evaluation of these to date indicate there is not an incremental cost to this, rather they replace services people would otherwise get in doctors’ offices, urgent care centers, and emergency centers,” John Lovelace, a president of the UPMC Insurance Services Division, testified to the committee.

ACO Impacts

Some types of Medicare accountable care organizations (ACOs) also would be able to expand their use of telehealth services through the legislation. For Next Generation ACOs, Medicare Shared Savings Program (MSSP) Track 2 and Track 3 ACOs, and Pioneer ACOs, the bill would eliminate the geographic component of the originating-site requirement, allow beneficiaries to receive covered telehealth services in the home, and ensure that providers furnish only telehealth services allowed through Medicare’s physician fee schedule, with limited exceptions.

However, the 95 percent of Medicare ACOs that are in MSSP Track 1 would not qualify for the expanded telehealth use, and that worries some hospital advocates.

Tom Nickels, executive vice president for AHA, said in a Nov. 22 letter that such expanded telehealth tools need to be “available to all MSSP ACOs, rather than just those in a two-sided risk track, since ACOs that do not take on downside risk still are accountable for health outcomes and costs of their attributed beneficiaries.”

Other ACO provisions in the bill allow those entities to choose prospective assignment of their beneficiaries at the beginning of a performance year and beneficiaries to choose—for the first time—to be assigned to an ACO in which the beneficiary’s main primary care provider is participating.

“In our experience, prospective attribution is one of—if not the most—critical component to success in two-sided risk models,” Rosenthal said.

The approach is key to identifying beneficiaries with a history of high costs and high service utilization and targeting cost-saving resources toward them, he said.

Other Key Provisions

Other initiatives in the bill aimed at improving the care of Medicare beneficiaries with chronic disease include:

  • Expanding the Value-Based Insurance Design pilot in Medicare Advantage (MA) from seven states to any state that wants to test whether savings are achieved without negatively impacting quality
  • Authorizing MA Special Needs Plans on a permanent basis
  • Extending the Independence at Home demonstration, which tests payment incentives and a service delivery model with home-based physician- and nurse practitioner-directed primary care teams for beneficiaries with multiple chronic illnesses

Legislative Outlook

The legislation has drawn attention across the healthcare industry because it is the product of a lengthy bipartisan process that sought consensus on its major provisions. Sen. Orrin Hatch (R-Utah) urged healthcare groups that supported the goals of the bill to help it clear Congress in what could be a contrast to the bitter legislative struggle around efforts to repeal and replace parts of the Affordable Care Act.

“We’ve got to prove the cynics wrong and get this legislation passed,” Sen. Mark Warner (D-Va.) said.

The bill was expected to pass the Senate late in the year—perhaps as part of a package of nonpartisan “extenders” of several expiring bipartisan Medicare provisions, according to a committee staff member. Although no House companion legislation has been introduced, bicameral discussions indicate the bill likely would advance in that chamber as well.

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Tuesday, May 16, 2017