Lawmakers Quibble Over Whether Telehealth Should Be Cheaper Than In-Person Visits

Congress should work to increase the use of telemedicine, home visits, remote monitoring, and other strategies to allow patients to get more care at home, lawmakers and witnesses agreed at a House hearing. But there was disagreement on whether some home services should be paid at lower rates than in-person visits.

“Telemedicine visits should be paid less than in-person visits,” said Ateev Mehrotra, MD, MPH, professor of healthcare policy and medicine at Harvard Medical School in Boston, at Tuesday’s hearing held by the House Ways & Means Committee. “Payments for care in the Medicare program are based on the time a clinician takes to provide the care, and the associated space, staff, and equipment. If something costs less, it should be paid less. While it does require some overhead, telehealth visits do not require the same practice expenses.”

“Some clinicians have objected,” continued Mehrotra, who is also a hospitalist at Beth Israel Deaconess Medical Center in Boston. “They argue that their practice expenses have remained the same because they provide both in-person visits and telehealth visits. I disagree. I do not think Medicare should cross-subsidize in-person visits with telehealth because it will create distortions in care. It will give virtual-only companies an unnecessary competitive advantage. It will also incentivize clinicians to give up their physical practice. Already we see that roughly 13% of mental health specialists have given up their physical office and gone virtual-only.”

One healthcare provider who does object to lower payments for telehealth is Rep. Drew Ferguson, DDS (R-Ga.). “Dr. Mehrotra, you’ve got an impressive resumé but you’ve never owned a solo practice in a rural area,” Ferguson said. “I think there’s a disconnect from what you say theoretically and what [happens] in practice. That overhead still exists, the building still exists, the staff still exists, the electric bill still exists … I don’t think that simply saying, ‘We’re just gonna have telehealth and we’re gonna pay less’ — I don’t think that that’s going to work. And I think it’s going to exacerbate the problem of people being willing to go into private practice and practice in rural areas.”

On another front, Ferguson also asked Nathan Starr, DO, lead hospitalist for the tele-hospitalist program at Intermountain Healthcare subsidiary Castell in Salt Lake City, Utah, about how payments for in-home visits by nurses and other healthcare providers are rolled into Intermountain’s “hospital at home” program, which mostly involves virtual care.

“I think that’s one of the big holes that exists,” Starr responded. “The billed amount for telehealth can ideally be lower because we don’t have the overhead — unless overhead exists because we need to have someone go into the home. So all of that is rolled into the payment for hospital-at-home, and we do have providers, caregivers — whether it’s community paramedics or nurses — in the home to do the physical assessment, and then we can do everything else virtually. So it is a model that can be really successful, but there is not a great answer yet to that question.”

Ferguson agreed that was a conundrum. “Having somebody drive 50 miles or 100 miles from a central location out to do something [like] an injection, in a rural community, is exponentially more than an office visit,” he said. “I don’t think bundling is the way to go because I don’t think you gain the efficiencies. I think you’re going to have to segment out those various costs.”

Rep. David Kustoff (R-Tenn.) asked Starr whether he was getting any pushback from physicians about increasing the amount of care done at home. “Not pushback, but I think it is a new way of doing things and that makes it challenging,” Starr said. “It feels weird for people to do some of this care in such a different location, and normalizing it is still part of the process we’re undergoing. It is one reason volumes still aren’t as high as they will be.”

The hearing also included testimony from patients who receive care at home, including Bell Maddux of Tobyhanna, Pennsylvania, who is managing her own in-home dialysis for chronic kidney disease. Kustoff asked her whether she saw any difference in the level of care or treatment that she gets at home compared to what used to happen when she went to a dialysis clinic several days a week.

“At the clinic, I was finding that there was a tremendous amount of non-patient-care-related pressure that the staff was under there,” said Maddux. “For example, they were required to get the patients connected in a certain timeframe because they were required to have a certain number of patients dialyzed in a specific period of time. So when they would come over [to me], they would have to rush through putting needles in. I’m trying to make small talk and they couldn’t do that because they were trying to get through their required timeframe.”

But now that Maddux is doing home dialysis, “my doctor and my dialysis nurse, I would say, are almost like friends at this point,” she added. “Not just knowing [patients’] immediate care needs, but knowing everything about their life that feeds into their care, I think it’s something that’s valuable.”

Health equity was another focus for committee members. “We have to really burrow down into health equity, and what that means,” said Rep. Terri Sewell (D-Ala.). “I believe that healthcare shouldn’t be a luxury, but it should be a right of every American. And in order to do that, we have to bring costs down,” including for drugs and biologics prescribed to outpatients. “We have to have innovative ways of making sure that we provide healthcare, and that includes care at home.”

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