Health and Government Operations Committee: October 15, 2020

Dr. Ateev Mehrotra, Department of Health Care Policy, Harvard Medical School

Telemedicine in the Era of Covid-19

Policymakers implemented many changes to facilitate telemedicine use.

• Telemedicine visits can be provided to patients in their homes
• All out-of-pocket costs are waived for telemedicine visits
• Payment is mandated for audio-only telephone communications
• Visits are no longer limited to rural residents
• Licensure requirements waived
• Types of providers that can deliver a telemedicine visit expanded

Challenges

• Sense of urgency given continued uncertainty about long-term plans has deterred investments by providers.
• Government and health plans leery of covering telemedicine visits permanently.
• Convenience, key strength of telemedicine, may be viewed as its Achilles heel.
• Concern that in a fee-for-service system there will be “overuse” of telemedicine.

Key Policy Considerations

• Telemedicine ≠ video/audio visits
• No single telemedicine policy
• Need for simplicity
• If providers at risk, should there be any limitations?
• How to address overuse?
  • Limitations by patient, condition, provider
• Relative cost difference – should there be parity?
• Should there be coverage of phone calls?

Q&A

Delegate Ariana Kelly: Could you expand on your point about payment parody? Could you walk me a little bit more on what that might look like?

Dr. Ateev Mehrotra: A doctor may come to you and say when I do my telemedicine visit I spent 15 minutes and my in person visit could only be 15 minutes, so why would you pay differently? When we pay a provider for an outpatient visit we are not paying just for the time. We are also paying for the rent, the overhead, the medical assistant, and the equipment. All of those costs go into that visit. Because telemedicine allows us to reduce those overhead costs, that’s why I believe in the long term it will be less costly for a provider and therefore the payment should reflect that.

Delegate Karen Lewis-Young: Can we design policies that will address the 3-5% of the population that will abuse the system? On any medical issue there are always going to be outliers, so do we address the policy to the general population or to the exceptions?

Dr. Ateev Mehrotra: One area where the exceptions come up is the issue of fraud. We have concerns and some experience already unfortunately. We may need to ensure that we make those investments to address that kind of fraud.

Delegate Susan Krebs: I’m concerned about the appropriateness of a telemedicine visit. How do we ensure that we’re not missing out on things that would have been picked up on during an in person visit?

Dr. Ateev Mehrotra: There is a variation. While there is a lot of evidence that in many clinical circumstances a telemedicine visit is an equal to an in person visit. We should not expand upon that and say all telemedicine is appropriate in all circumstances, some of that is obvious.

Delegate Susan Krebs: As we are crafting policy how in the weeds do we get with this?

Dr. Ateev Mehrotra: That would be almost impossible for you to set up policy that you would specify you can use it for this, but you can’t use it for this. In that particular case I think it should go back to the professions and our malpractice structure to enforce that we use professionalism to ensure we’re providing the right care.

Delegate Bonnie Cullison: Do you have any sense that at the federal level they are beginning to look at some guidelines around telehealth beyond Medicare, but in general or if this will really be left to the states?

Dr. Ateev Mehrotra: To date it has been very much under our federal system but the states have been given tremendous deference in terms of developing policies. On the federal level there is limitations on what they can do.

David Sharp, Director, Center for Health Information Technology and Innovative Care Delivery, Maryland Health Care Commission

Telehealth – MHCC’s Role

Telehealth is an important strategy to improve access take care and reduce health care costs, three key initiatives:

• Assess barriers to adoption and propose solutions to address barriers
• Foster technology adoption and meaningful use
• Educate providers and consumers on value and best practices

Supporting Telehealth Policy Development

The MHCC Is planning to conduct an impact evaluation of telehealth in 2021; key questions include:

• Has telehealth improved access to care, particularly for more vulnerable patients?
• Has telehealth induced new demand for services or offset in-person care?
• What is the financial impact of widespread use of Tele health on Maryland’s Total Cost of Care Model?
• Does telehealth reduce emergency department utilization?
• How can new components of telehealth, such as remote patient monitoring, be integrated into the course of care and systems of reimbursement?

PHE and Regulatory Relief Propels Telehealth

Enabled by Executive Orders from Governor Hogan and waivers from the federal government; waivers were time limited, however, many have been extended to the end of the public health emergency (PHE)

• Telehealth waivers (some variance across payors):
  • Patient location (originating site) – lessening of geographical restrictions
  • Licensing – greater flexibility is to practice across State lines
  • Patient-provider relationship – redefined what constitutes a treatment relationship
  • Eligible providers – expanded provider types that can deliver telehealth services
  • Types of services covered – increased the number of services payable when furnished via telehealth
• Cost-sharing – patient obligation eliminated or reduced
• Technology – use of popular non-public facing applications temporarily permitted to deliver telehealth services
  • The Office for Civil Rights is exercising enforcement discretion and not imposing penalties for noncompliance with the regulatory requirements under HIPPA Rules for the good faith provision of telehealth

Telehealth Adoption Pre-Covid-19

Adoption in Maryland informed by data:

• 11% – practices
• 96% – hospitals; diffusion limited to certain departments, 4% planning to implement
• 12% – nursing homes
• 27% – home health agencies; limited to remote patient monitoring
• 4% – dentists

Telehealth Adoption in Response to Covid-19

*Adoption in Maryland based partly on anecdotal information:

• 70% – practices
• 100% – acute care hospitals; expansion to most departments
• 45% – nursing homes
• 65% – home health agencies; limited to remote patient monitoring
• 6% – dentists

Telehealth Virtual Resource Center

• Featured information:
  • Payor policy changes and reimbursement
  • Web-enabled Telehealth Readiness Assessment Tool
  • Technology vendor selection guidance
  • Privacy and security considerations
  • Best practices for patient engagement and virtual care
• Resources are continuously added, reflective of stakeholder’s inquiries and requests.

Consumer Awareness Building

• Educational materials highlighting the utility of telehealth, answers to frequently asked questions about virtual care, and safety tips during the PHE.
• Podcasts highlighting the telehealth experience.
• Telehealth public service announcements

Telehealth Adoption Grant

• A technology grant awarded to three State-Designated Management Service Organizations (MSOs) to assist small practices with telehealth implementation.
  • Coaches work with practices to complete specific milestones
• Practice activity as of September 2020:
  • 150 – expressed interest in working with an MSO
  • 72 – provided with adoption support
  • 52 – attested to using telehealth in care delivery

Post Covid-19 Planning

• Momentum increasing nationally to make some telehealth policy changes permanent; a complete post COVID-19 telehealth policies are not yet clear.
• Payors have signaled that some dialing back will occur at the end of the federal/State PHE.
  • Audio only, first contact telehealth visits, telehealth from within same site.
  • Getting the prices right – Medicare will use the annual physicians fee schedule update as a vehicle for making changes to the scope and fee levels for Medicare telehealth services.
  • Medicaid federal and State collaboration on scope and payment with possible State budget impact.
• Policymakers – need to address inequities in access to telehealth.
• The MHCC is convening a Telehealth Policy Workgroup to discuss policies and potential future legislation alignment opportunities.
  • Over 60 different stakeholders consisting of payors, providers, consumers, and technology vendors, among other.
  • Virtual kick-off held September 30th, meetings are planned through the end of this year.
  • An information brief is targeted for release in 2021.

Q&A

Delegate Bonnie Cullison: Regarding expanding the accessibility and use of school based health centers. Would you be supportive of us seeing if we can find a way to make sure that can be facilitated?

David Sharp: About a year ago we were asked by the Senate Finance Chair if we would convene a work group related to school based telehealth and make some recommendations. We convened stakeholders and developed a report and identified a number of areas in which school based telehealth could be advanced in the state. Typically for the Commission to support legislation, that’s a decision made by the Commission itself. There has been a lot of support around advancing school based telehealth.

Delegate Karen Lewis-Young: Regarding students with special needs. What other things can be done to address the special needs of certain students?

David Sharp: There are school based health centers which are run by nurse practitioners or physicians and a small staff in the state. There is also school health nurses or school health services which typically include a registered nurse, that either are site specific or have several sites. With remote learning by students these health nurses have been filling the gap because they’re working with students and their families via telehealth. We’ve done some education on awareness for best practices for using telehealth.

Kathleen Birrane, Commissioner, Maryland Insurance Administration

David Cooney – Associate Commissioner – Life and Health

Carrier Response

• Expansion of telehealth systems and platforms eligible for coverage – any “non-public facing” commercial applications (e.g. FaceTime, Skype, Zoom)
• Increased scope of services eligible for telehealth coverage (conditions/services/specialties)
• Telehealth coverage of phone-only consultations
• Waiver of member cost-sharing for telehealth visits
• Provider reimbursement parity between virtual consultations and in-person consultations
• Extension of accommodations to self-funded clients

MIA Actions

• Examined and reevaluated requirements of current law in a pandemic environment
• Considered options with emergency powers
• Maintained open communication with carriers and advised them of emerging issues
• Ensured carriers were complying with existing law and encouraged carriers to accommodate reasonable provider and consumer requests
• Monitored market conditions and carrier actions – some voluntary accommodations were scaled back as pandemic subsided

Q&A

Delegate Sid Saab: Regarding cost sharing. Is there some way of communication that the insurance administration can let carries know to inform their members that if they do get a bill to call their insurance company?

David Cooney: To clarify, I think the law you’re referring to is likely referring to the coverage of Covid testing and everything like that. Telehealth specifically, the law does not require the waivers to cost sharing but companies have voluntarily done that for a significant amount of time. We’ve been tracking complaints and for the longest time we got very few on this particular issue. Recently we have received a few more, typically as soon as we’ve gotten involved the carriers have reversed themselves and it hasn’t required formal action by us to issue an order.

Delegate Sid Saab: Is there a protocol or a process that the insurance administration is doing to communicate that message out to the members or have the insurance companies communicate to their own members?

Kathleen Birrane: I can speak to our social media outreach where we have on Facebook and Twitter to address the use of telehealth. I will circle back with Associate Commissioner Joy Hatchet to look through our stock of telehealth and make sure we are addressing that particular concern.

Delegate Ariana Kelly: Related to audio only. Do we have a breakdown or rough data in terms of what the breakdown looks like? Is it low income, rural, and seniors or do we not know yet?

David Cooney: For that we don’t know yet, even getting this data from the carriers in a short period of time they said they didn’t really have the detail we were looking for.

Delegate Bonnie Cullison: Are we communicating with other states, particularly those closest to us around some policies that they may be considering in consideration of all the options and possibilities that we might be looking at when we come into Annapolis in January?

Kathleen Birrane: We are actively involved on this issue at the NAIC and we are coordinating both at the national level and we also have our zone meeting next Wednesday through Friday, which is our geographic region. Telehealth is a key component, sharing ideas and needs will be part of that.

Webster Ye, Director of Governmental Affairs, Maryland Department of Health

Kimberly Link, Liaison to the Health Occupation Boards and Commissions

Summary

• The Maryland Department of Health (MDH) is working closely with the MD Insurance Administration, the Maryland Health Care Commission, and the health occupation boards and commissions to ensure telehealth flexibilities for Marylanders during the Covid-19 declaration of emergency and catastrophic health emergency.
• Three basic efforts:
  • Ensuring alignment with federal telehealth flexibilities through the federal public health emergency (Maryland Medicaid).
  • Implementing HB448/SB402 (2020) with the boards, including the development and promulgation of regulations as appropriate.
  • Providing Covid-19 specific assistance for specific providers through Executive and Departmental orders.

Medicaid & Telehealth

• Medicaid has implemented temporary flexibilities designed to ensure safety of participants and providers during the Covid-19 pandemic.
• Most flexibilities are tied to
  • (1) Executive Orders
  • (2) Waivers from the federal government
• Federal Actions:
  • January 31, 2020: Public Health Emergency (PHE) declared (retroactive to January 27, 2020)
  • March 13, 2020: National Emergency (NE) declared
  • PHE extended for up to additional 90 days at a time; last extended Oct. 2, effective Oct. 23. The current authority expires Jan. 23, 2021.
• The federal PHE allows two principal telehealth flexibilities:
  • Using non-HIPAA compliant technology for health care providers; and
  • Audio-only services
• The combination of the federal PHE flexibilities and Governor’s Executive Orders allow Maryland to use state and federal funds to reimburse services in the home using such services. We are waiting on federal guidance on audio-only services reimbursement.

Statutes and MD Emergency Orders

• HB448/SB402 (2020) passed at the end of the 2020 session as emergency legislation, and was signed into law by the Governor as Ch. 15/16.
  • HB448/SB402 provide the new statutory basis for telehealth in Maryland, largely replacing older legislation and regulations from a year ago.
  • HB448/SB402 Does not permit telehealth services through audio-only calls, emails, or faxes.
• Exec. Order No. 20-04-01-01 (issued 4/1/2020, replaced the order of 3/20/2020) authorizes the Health Secretary to authorize health care practitioners to deliver health care services through telehealth, including realtime (or synchronous) audio-only calls or conversations, with certain conditions and suspends the HB448/SB402 prohibition of audio only calls for the duration of the Covid-19 state of emergency.

Health Occ. Board Specific Orders

• MD Department of Health Orders issued by request in consultation with the relevant health occupation Board.
• Professional Counselors & Therapists Board (4/6/2020):
  • Permits Alcohol and Drug Trainees to provide counseling services via teletherapy.
  • Permits interstate teletherapy (where professional counselor or therapist from out of state can provide services to a Maryland patient if they had a pre-Covid-19 professional relationship).
• Audiologists, Hearing Aid Dispensers & Speech Language Pathologists Board (5/8/2020)
  • Permits interstate telehealth services
• Morticians Board (7/24/2020)
  • Waives practical exam requirement for Mortician’s License.

Health Occ. Board Telehealth Updates

An informal survey of the boards revealed:

1. Numerous inquiries from licensees seeking clarification:
   1. Who can perform telehealth services;
   2. Where the client must be located, and
   3. Guidance for compliance with technological requirements, HIPPA, etc.
2. The Board of Physicians has received many complaints regarding telehealth:
   1. Out of state practitioners prescribing CDS to MD patients:
   2. Telemedicine companies and physicians prescribing high cost durable medical equipment, Rxs, CDS without a MD license;
   3. Prescriptions issued without physical examination or existing patient relationship;
   4. MD licensed physicians supervising out of state Pas, not licensed in MD, who are prescribing to MD patients, and
   5. Appropriate use and technical issues such as being required to disrobe on camera, practitioner muting relatives/power of attorney during appointment, patients being denied telehealth visits, practitioners showing up late or missing telehealth appointments.
3. Concerns that out of state providers are unregulated resulting in frustration by consumers, pharmacists, and practitioners.

Q&A

Delegate Robbyn Lewis: I was surprised to see the consumer complaints. It sounds rather disturbing and I’m trying to get context, are those types of complaints similar to ones that you might have seen pre Covid for a typical face to face clinical visit. Is this within the range of normal or is this unusual?

Kimberly Link: The question I posed to the board was complaints received regarding telehealth. I think with the increased use of telehealth services, we are getting a different strain of complaints.

Delegate Sheree Sample-Hughes: Regarding durable medical equipment. I know you raise that as being a complaint, are you referring to the fact that companies are charging more for durable medical equipment?

Kimberly Link: I’m only familiar with the information that the board of physicians provided me, so I don’t have the details of the actual complaints but I’d be happy to find that out.

Delegate Ariana Kelly: How are we getting the workers trained that we need? Have we been finding ways to alternately get more qualified workforce through virtual technology?

Webster Ye: The board of nursing has been working through it with the principle nursing home associations. It’s a question of what the appropriate level of continuing education is. As well as an associated issue with the Maryland Higher Education Commission. Whenever possible we’ve been trying to solicit clinical guidance from the board since they are regulated by their own peers. Based on their recommendations we will try to take the next steps forward.

Delegate Susan Krebs: Regarding limitations on state professional licensing and pushing for reciprocity against state lines giving more options to patients. What are we doing comprehensively to look at this issue and what are other states doing?

Kimberly Link:  I think there are 2 or 3 bills coming before you this session for interstate compacts for several of the health occupations. I think Maryland is on the advanced side in terms of being open to interstate compacts. I think that’s the best method of moving forward at this point.

Delegate Heather Bagnall: Could we get more context around complaints regarding prescribing without an in-person visit?

Kimberly Link: I will look into that and make sure that the committee gets that information.