The notion of telehealth has for years loitered on the back burners of priorities with the Centers for Medicare and Medicaid (CMS). In 1993, the American Telemedicine Association was founded with the intention to promote and expand telehealth companies and access as a way of increasing patient’s access to care. As health care continued its transition to an increasing reliance on technology, CMS ruled on meaningful use for electronic health records and proposed expansions to the use of telehealth in rural areas – yet there were limitations and restrictions in place that prevented many otherwise interested patients and providers from adopting the practice.
In early 2020, as the country succumbed to the invasion of the novel coronavirus, it became quickly apparent that telehealth would need to be made readily available without the limiting restrictions previously in place. Telehealth was critical to not only benefit the patients, but to also help protect the millions of providers and staff at risk.
Once the nation’s pandemic prognosis was clear, CMS took swift and unprecedented action to expand telehealth for Medicare beneficiaries. Telemedicine – which includes telehealth and virtual services – gives patients the opportunity to visit with clinicians remotely using virtual technology. When the HHS Secretary declared a COVID-19 Public Health Emergency, CMS issued waivers to Medicare program requirements that supported health care providers and patients during the pandemic. One of the first actions was to expand the scope of Medicare telehealth services which made it easier for more types of health care providers to offer a wider range of telehealth service to beneficiaries. The results were immediate and nothing less than significant.
A nation pivots to telemedicine
Accountable care organizations (ACOs) responded quickly to the telehealth opportunities, supporting their members with best practice guides to telehealth and virtual care.
From mid-March through mid-June 2020, more than nine million Medicare beneficiaries nationwide had received a telehealth service. In rural areas, which are often limited in WiFi access, 22% of Medicare beneficiaries took advantage of telehealth, and the percentage increased to 30% in urban areas during that three-month period. The numbers of patients participating in telehealth continued to rise and despite challenges of urgent implementation plans, patients and providers reported successful results.
A Caravan Health Case Study: Alcona Citizens for Health, Inc.
Caravan Health, the nation’s leader in accountable health care, with more than 22,000 providers across the nation serving well over a half a million patients, worked closely with clients who were quickly implementing telehealth and virtual care services. Alcona Citizens for Health, Inc. (Alcona), has participated in a Caravan Health ACO since 2014. The medical group has offices in nine locations throughout Michigan. When the pandemic hit, Alcona’s staff and providers placed a priority on virtual care.
When CMS released the restrictions making it easier to bill for telehealth, Alcona relied on Caravan Health and one of their providers who had telehealth experience and stepped forward to set the stage for the entire health system. Alcona ensured that providers, staff, and patients were equipped with the tools, resources, and information required to be successful by using well-engrained population health methodologies.
When challenges inevitably presented themselves, Alcona staff successfully course-corrected. For example, many patients didn’t have access to Wi-Fi, so the responsive staff created ‘Hot Spots’ in clinic parking lots by designating parking spaces for telehealth appointments. For patients who didn’t own a smartphone or laptop, they provided tablets for them to use from the safety of their car. The tablets were donated by staff and employees and reformatted and prepared by IT teams to make them user-friendly.
Within two weeks, Alcona had converted 100% of their sites to virtual care practices and were successfully seeing 35-40% of their patients virtually. The majority of patients were seen through telehealth from their homes and each day, between 35-50 patients had appointments from the ‘Hot Spot’ zone in the designated spaces in the parking lot. The ‘drive-up telehealth’ gave patients the ability to safely see and be seen despite having no access to smart devices or technology.
"Telehealth has worked out great, we’ve served so many patients
we would not have been able to see if we hadn’t put this in place."
Caitlin Schlappi, RN
Alcona Citizens for Health, Inc.
A Caravan Health Case Study: Crouse Medical Practice & FamilyCare Medical Group
As participants in the Caravan Collaborative Pathways ACO, Crouse Medical Practice and FamilyCare Medical Group gained distinction for some of the highest rates of telehealth usage across all of Caravan Health’s ACO participants. Soon after CMS made telehealth a viable option, the providers successfully transitioned to offering virtual care to their patients – an impressive task given the multiple locations and specialties within these two medical groups. It was not without its challenges, however, as Crouse had to first overcome technological barriers with their EMR and provide additional staff and patient education, but the collective group of staff and providers committed to offering every possible option to their patients and made efforts to ensure those patients who wanted to use telehealth had the tools and resources to do so.
This dedicated group of providers have performed their Annual Wellness Visits (AWV), throughout the COVID-19 pandemic using telehealth. The virtual care implementation was so successful that their rates of AWVs were higher than their original, pre-pandemic goal. Their rates of Advance Care Planning, which is an initiative they prioritize as part of their wellness exams, also exceeded their pre-pandemic goal, increasing more than 10% from the beginning of 2020 through the third quarter. The group’s Chronic Care Management program also flourished as a result of their emphasis on virtual care. To date, data has demonstrated an improvement in enrollment rates of more than 2% during the pandemic.
Demonstrated telehealth data
Caravan Health data is indicative of national trends toward a broader acceptance of telehealth and virtual care. In Table A below, Caravan’s data demonstrates the statistically significant uptick in both virtual care and telehealth appointments from the start of the pandemic and into 2021. A large portion of Caravan clients are in rural areas which helps to explain why the telehealth numbers are larger. CMS did not require telehealth appointments to be video and given the combined likelihood of patient age, technology aptitude and rural location, a phone call (telehealth) was more convenient and possible for this patient subset.
Virtual Care & Telehealth Monthly Patients
To further explore the increase in telehealth and virtual care adoption during the COVID-19 pandemic, Table B demonstrates a flat usage of technology-driven appointments in the Caravan Health patient group. In March, however, the nearly immediate increase in telehealth and virtual care is obvious and the increase from March to April is statistically significant. The usage of technology has leveled off from the substantial growth yet continues to increase and perhaps more significantly, has not declined.
Combined Virtual and Telehealth Unique Patients
Before the COVID-19 public health emergency (PHE), only 15,000 fee-for-service Medicare beneficiaries received a Medicare telemedicine service each week. Since the pandemic, CMS added 144 telehealth services including emergency department visits, initial inpatient visits and nursing facility visits. Providers who use value-based care models were, for the first time ever, able to conduct AWVs and chronic care management visits via telemedicine. As a result, by mid-October 2020, nearly 25 million out of the nation’s 63 million beneficiaries had received a Medicare telemedicine service.
By July 2020, the proverbial writing was on the wall regarding the overwhelming acceptance of telehealth. At that time, CMS Administrator Seema Verma commented, “I think the genie’s out of the bottle on this one. I think it’s fair to say that the advent of telehealth has been just completely accelerated, that it’s taken this crisis to push us to a new frontier, but there’s absolutely no going back.”
At the end of 2020, CMS released its annual Physician Fee Schedule which included a permanent expansion of Medicare telehealth services. During the PHE, CMS had added 60 billing codes that providers can use and are currently evaluating the clinical effectiveness of these codes when delivered via telehealth and will consider adding them permanently. Meanwhile, nine codes have already been permanently added. However, CMS only has the authority to allow these codes in rural areas and under the conditions that were permitted pre-pandemic, such as when patients are in a medical setting. Use of telehealth in non-rural setting and in patient homes will require an act of Congress.
The COVID-19 pandemic has disrupted health care as we knew it and, in some cases, such as telemedicine, it is unlikely that the nation will revert to the restrictive rules that were once in place. Both rural and urban areas have benefitted from the convenience and safety factors that telehealth and virtual care offer. Providers have also noted that virtual care video appointments have given them a clearer understanding of the patient’s health by seeing the patient in their home environment.
Telehealth is health
Caravan Health CEO, Tim Gronniger, recently weighed in on this timely topic in his Healthcare Business Today article, ‘Want to Improve Health Care Quality and Access? Link Permanent Telehealth Expansion to Value’. Gronniger acknowledged that while there have been some challenges to the quick telehealth rollout, that providers and patients have praised the technology as a viral lifeline. He asserts that thoughtful, long-term legislation will be the key to continued telehealth viability. According to Gronniger, “It is critical that we take the lessons learned about patient behavior and engagement forward as we shape the future of health care in this country. We owe it to patients to get the numbers right so our providers are not forced to take a step back after taking steps forward and our patients can continue to benefit from the services that are best suited for them.”
Telemedicine will never replace the face-to-face, in office visit yet there are clear advantages to the technology-driven appointments and is likely to play a key role in boosting access to health care for future generations. A recent Modern Healthcare article touched on the subject that the health care industry should be at the forefront of bridging the digital divide by educating seniors how to use their devices, working with manufacturers to create easy-to-use tools and partnering with community agencies to expand broadband and device availability.
Notably, in January, Caravan Health published an article in Managed Healthcare Executive to address the fact that technology had entered the fray of the social determinants of health. We asserted that while technology has been a lifeline for many throughout the pandemic, certain populations – particularly those living in rural areas – were met with challenges to accessing this new form of health care delivery due to limited access and the lack of experience with or understanding how to use smart devices and virtual technology.
It will serve no one to ignore the looming crisis the lack of access represents to many and for those who have benefited from telemedicine – the trend must continue toward more efficient and effective access. Caravan Health will continue to advocate for expansions to virtual care and will support telemedicine flexibilities not only as a reliable form of health care delivery but also as an adjunct to value-based care. One thing seems clear: we are not likely to revert to the pre-pandemic telemedicine restrictions and limits, but it will take an engaged and vocal community of health care providers and thought leaders to continue the progress.