Medicare Will Expand Coverage For Telehealth

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The Centers for Medicare and Medicaid Services (CMS) has proposed changing how it defines telehealth services that may be eligible for Medicare coverage. But it's unclear how far the agency will go in expanding such coverage.

In its proposed rule on changes in physician payment, CMS said that it would consider the proven clinical benefits of a telehealth service in deciding whether to cover that service. Up to now, providers have had to show that a telehealth service is "equivalent when furnished in person or through telehealth"--a criterion that CMS calls the "comparability standard."

The agency's proposed switch to a standard based on clinical benefit "would likely improve access to care by expanding the list of services eligible to be delivered via telehealth," according to a CMS fact sheet.

But, while telehealth supporters would like to see coverage of tele-stroke, tele-ICU, and some other established telehealth services, CMS specifically states that it does not believe it should cover the remote provision of critical care services.

"Because we did not find evidence that use of a telecommunications system to deliver critical care services produces similar diagnostic or therapeutic outcomes as compared with the face-to-face delivery of the services, we are not proposing to add critical care services (as described by CPT codes 99291 and 99292) to the list of approved telehealth services," CMS said. "We reiterate that our decision not to propose to add critical care services to the list of approved telehealth services does not preclude physicians from furnishing telehealth consultations to critically ill patients using the consultation codes that are on the list of Medicare telehealth services."

Until 1999, Medicare did not cover telehealth services at all. Starting that year, CMS began to pay for remote consultations for patients residing in underserved rural areas, if they were accompanied by their doctor. Later laws and regulations expanded the number of services and approved "originating sites" for telehealth. Since 2003, CMS has added 35 new services to its covered list. For example, in the proposed rule, it suggests adding smoking cessation counseling.

However, there has been a disjunction between CMS' covered services and the needs of some hospitals. For example, a recent article points out that the presence of intensivists can reduce the high mortality rate in ICUs. But there's a shortage of intensivists, and tele-ICUs--which monitor ICU patients remotely--have had relatively good outcomes, according to some studies.

For example, in a study at a large academic medical center, the risk-adjusted hospital mortality rate was 13.6% before a tele-ICU was introduced and 11.8% afterwards. A tele-ICU was also associated with shorter average length of stay and better adherence to evidence-based guidelines.

The Ochsner Health System in Louisiana recently adopted what it calls "eICU" technology to enhance critical care. The eICU program will connect Ochsner's bedside care teams with off-site critical care physicians and nurses. The organization plans to extend this service to community hospitals in rural areas. That could qualify it for CMS coverage, but only if CMS recognizes the efficacy of tele-ICUs.

Other aspects of telehealth might also benefit rural hospitals. A new study of care in critical access hospitals found that patients admitted there for heart attack, heart failure, or pneumonia had a 30% to 70% higher chance of dying within 30 days than they would in other hospitals. One solution, suggested lead author Karen Joynt, is to increase the use of telehealth.

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