June 18, 2020

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Virtual care and telehealth services can help your practice develop a workable strategy to deliver health care remotely. Opening a virtual front door can protect your patients and providers and when it comes to telehealth, there are more available options now than ever. New streams of revenue are within your reach and our guide can help you make a smooth and successful transition to virtual care.

Medicare’s Unprecedented Telehealth Expansions

Telehealth and virtual care services are now widely available in Medicare. This is a way to provide continuity of care while Americans are strongly encouraged to limit face-to-face interactions to prevent transmission of COVID-19. Previously, telehealth services in Medicare were only available under limited circumstances, mostly for patients located in rural areas who traveled to local medical facilities to meet with practitioners at a separate physical location. During the public health emergency, and perhaps longer, Medicare will pay for telehealth services without many of the previous restrictions.
Providers can see and evaluate patients remotely while patients are safe at home through telecommunications technology in urban and rural areas. Medicare has made several changes to ensure patients have maximum access to virtual care services, such as telehealth.

  • During the public health emergency, providers can waive or reduce cost-sharing for telehealth services under new Medicare expansions.
  • Providers and patients who use telehealth are not always required to have a previously established care relationship.
  • Medicare will pay equally for telehealth and face-to-face visits. Providers can see both new and established patients for virtual check-ins and e-visits.
  • Telehealth and virtual care have been expanded to rural health clinics and federally qualified health centers, as well as post-acute care facilities.



Primary Care and Medicare Telehealth Benefits
Caravan’s recent telehealth webinar addressed the impact of COVID-19 on primary care including planning, prevention, patient management, and virtual care options. This was one in a series of webinars to help support providers facing the crisis and those who could be facing it soon.


In this webinar, Caravan’s Medicare experts discussed the importance of keeping healthy patients out of the acute care environment through a reimagined telehealth experience. Even providers who are not overwhelmed with COVID-19 patients should develop processes and procedures to triage, test and treat/support acutely ill patients. As states and communities re-open after “shelter in place” orders, staff should reach out to their patient base to make sure they are in touch with their care providers.

Planning for the future is critically important as we don’t know when the COVID-19 pandemic will run its course. Tracking chronically ill patients can help avoid a “second tsunami” of patients who were not able to get care when the crisis first hit. One imperative is to stand up virtual care and telehealth services to reduce exposure for health care workers and elderly and vulnerable patients. As virtual medicine options are implemented, practices may consider rotating physicians and other clinical staff from in-person to telehealth.


 

Helping Medicare Beneficiaries Find Your Virtual Front Door

The COVID-19 pandemic has caused primary care service volume to a plummet, both from state and local requirements to defer services and patient reluctance to visit a doctor’s office. This means the traditional front door where patients are welcomed to a primary care practice has been unavailable. However, the long-running, firmly established relationship of trust between patient and primary care physician remains strong and may be more important than ever. Practices must capitalize on Medicare’s expanded telehealth flexibilities and make a virtual front door available to patients.
                   
For decades, primary care has been the front door to local and regional health systems. Crafted over time and shaped by human connection, these trusting relationships were forged in face-to-face interactions. Accustomed to this dynamic, many providers have believed that the integrity of this relationship relies on in-person interaction. As such, many are skeptical of telehealth’s technology solutions for care to Medicare beneficiaries.
 
COVID-19, though, is a disruptive innovator. The threat to primary care is perilous, creating serious short-term, and potentially long-term, consequences for patients and providers. Staying at home can be the best protection for those with chronic disease in the short term, yet it may prove lethal if we don’t offer a lifeline of support through a new virtual front door.
 
Primary care must adapt to social distancing for the foreseeable future. For vulnerable patients, the repercussions of going without care cannot be ignored. Left unaddressed, chronic conditions will likely worsen, resulting in hospitalizations, which could make the second and possibly third wave of COVID-19 even more deadly.
 
Teams must move swiftly, integrating innovative telehealth delivery approaches that protect and save patients and stabilize practice revenues. Primary care practices know that many Medicare patients are afraid of contracting COVID-19 at physicians’ offices, so they simply aren’t coming in for appointments. The message many have heard is “Don’t go to the doctor’s office, it’s not safe.”

For telehealth outreach to Medicare patients, a key first step is to have practice teams welcome and orient patients to virtual care, showing them the “new front door” to access care. This means proactive outreach via phone, text, or email, to introduce patients to virtual options and the technical path to finding and using the system.
 
It may be a difficult transition for patients who have known good care as seeing their doctors in person. This has been a challenge for physicians too. While Medicare’s telehealth services will never replace the art of in-person care and human touch, primary care’s origins began in patients’ homes. This is an opportunity to go back to those roots and make it easier to meet patients where they are most comfortable, and during the public health emergency, the most safe.
 
Stories abound of a palpable sense of relief on patients’ faces once they see their doctor’s familiar face on the video screen. This simple connection has the capacity to comfort and console patients during these times. It also has the capacity to give us insight into the patient as virtual care affords the provider a new lens into the patient’s life that is lost in the sterile world of office-based medicine. The words of Dr. Francis Peabody from 100 years ago still ring true, “What is spoken of as a ‘clinical picture’ is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes and fears.” One could easily argue that connecting with a patient periodically in their home is a step toward more comprehensive and patient centered care.  
 

Is it Time to Expand Behavioral Telehealth for Medicare Patients?

Many experts anticipate an uptick in behavioral health related issues as a result of the pandemic. In a recent COVID-19 educational webinar, Caravan ACO Medical Director Dr. John Findley addressed the importance of reducing the stigma of mental illness and recognized that May was National Mental Health Awareness month.

Currently, the mental health system in the U.S. is compromised, under-funded, and doesn’t have the resources it needs to meet a surge in demand. This requires primary care providers to help offset the imbalance and the webinar provided insight into how to accomplish that task. Primary care is the front door to behavioral health for the vast majority of people and typically the first place patients present with what could become a pending behavioral health concern or mental health crisis.
 
 

One common concern expressed by primary care provider teams is that behavioral health issues are difficult to manage or that they are uncomfortable providing in-between visit support. However, it is important to remember that the majority of patients with behavioral health issues suffer from anxiety and depression and have a well-established relationship with their primary care provider. Trust has already been established thus facilitating a meaningful, and oftentimes quicker, impact.

CMS encourages primary care providers to utilize telehealth and virtual care services to screen patients for depression – including substance use – and conduct brief interventions and refer to specialists and treatment when indicated. A care manager can provide a bridge between the patient’s primary care physician and a specialist and by conducting repeat assessments can effectively quantify patient improvement or need for further treatment by their provider.
 
Behavioral Health Integration, even when virtual, has proven to be successful when led by nurses operating in population health environments and can actually lower overall costs of patient care. It is important to recognize that the effects of the pandemic, and related behavioral health concerns, are not simply going to go away. CMS has recognized this by demonstrating their continued support of ACOs and the importance of BHI by placing a value on nurse-led programs that reduce costs. A new diagnosis of anxiety or depression is a relatively common scenario in primary care that is easy to follow through with telehealth, including sessions by a licensed therapist. Caravan Health studies demonstrate consistent decreases in ER utilization rates by 24% in patients who have had three or more months of BHI when compared to patients without BHI. Adding between visit nurse-led support greatly improves patient care.  



Ultimately, everyone has been impacted by COVID-19 and experienced life changes on some level. Behavioral health needs will increase, and your staff must recognize the importance of overcoming the stigma of mental illness and help patients accept care. Caravan Health provides population health nurse training that helps with this process and with the expansion of telehealth and CCM, providers are well positioned to proactively reach out to patients during periods of social isolation, which can help to identify potential concerns, particularly for those who are high-risk.
 

Advance Care Planning

In normal times, Advance Care Planning (ACP) is already part of high-quality primary care. During the COVID-19 public health emergency, it is crucial that providers add it to their planned movement to virtual care. While many areas have yet to see large numbers of COVID-19 infections, the threat of this virus spreading through any community will remain until we have a vaccine. For older Medicare patients and those with chronic conditions, this means preparing for the possibility of serious illness for the next year or more.
 
While people are sheltering in place, it is a good time to reach out and let your Medicare patients know you are available for telehealth visits, for acute problems, and to manage chronic conditions. Using these visits to check in with all older patients to review goals of care and advance care planning will provide guidance to physicians and family alike if your patient gets hospitalized with COVID-19. There is no co-insurance fee if this is done during the annual wellness visit and the fee can also be waived if provided via telehealth.
 
Patients can be assured that ACP is truly a gift to loved ones and family members who will be relieved to know this has been discussed and wishes have been documented. Otherwise, the burden is on loved ones, who will likely feel overwhelmed.

Wondering how to approach this through telehealth and where to begin? First, let the patient know you are reviewing plans with all your patients at higher risk of this virus because of age or chronic/serious conditions. Then ask if the patient is ok to talk about their wishes with you. Using open-ended questions, you will quickly get a sense of how much they have been thinking about this and if they have strong feelings about the care they would or would not want to receive. For many patients, you may be the first to ask them about how they are doing and any fears they are having during this stressful time. Be prepared for emotional responses and acknowledge that this subject may be difficult to talk about.
 

The Future of Medicare Includes Virtual Care and Telehealth Services

Practices and patients cannot wait for a return to “normal.” The fact that 20 percent or more of COVID-19 cases are asymptomatic means that although patients need care, they increase their COVID-19 risk by venturing out. There is a growing body of evidence noting a clear correlation with adverse events in those with highly prevalent conditions such as hypertension, diabetes, and obesity. Patients need primary care at home and primary care needs to survive. Virtual care and telehealth services are best practice care. Most agree that virtual care needs to be woven into the fabric of primary care delivery, becoming part of all post COVID-19 ethos.
 
Primary care providers have been reluctant to offer telehealth because barriers to entry were high—cost prohibitive platforms and high patient copays. Now, the biggest barriers have been removed by the Centers for Medicare & Medicaid Services during the COVID-19 health crisis. Although payment solutions are not yet optimal, this is an opportunity to reinvent primary care for current and long-term sustainability. The only real barrier that exists is provider willingness to widely adopt and actively endorse its value. It is time for this change.
 
The COVID-19 pandemic caught our health system by surprise and cast a light on our vulnerabilities. As business leader Jack Welch said, “If the rate of change on the outside exceeds the rate of change on the inside, the end is near.” We have a choice to approach this moment in time as an opportunity not an obstacle.
 
Primary care is still the front door to health systems in virtually every community in America. Our role as trusted advisor is of paramount importance during these unprecedented times. Although patients may be waiting for this storm to pass, it is inevitable that needs will arise. If we don’t proactively reach out, connect with, and create a clear pathway to care unlimited by geography, patients will likely be forced to seek care elsewhere or end up in high risk environments such as emergency departments or urgent care.
 
Providers have a unique opportunity to capitalize on virtual care and telehealth services – a process they weren’t trained for or have likely experienced, yet all indicators point to the future of health care now including a virtual care component. It is time to make this change for your Medicare patients and your bottom line.

Caravan has identified the five critical best practices to succeed in virtual care.

Download our Virtual Care Guide to learn more.

 

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