I needed to let everyone know that telehealth is a scam and also that it is doing more harm than good. It doesn’t help care for many of our patients and is there to make money, first for the technology companies and also to bring in revenues for the physicians during this pandemic. They are taking advantage of our patient’s fears and the physicians who are in a bind not “allowed” to see their patients and therefore not able to bill the insurance companies. But as we have found out, both in our families needing care, our friends and our patients, that not all insurers are paying for these services and if paid the rate of payment is so poor and yes, it will end soon. Then what?
This week in fact, I had to see 3 patients whose cancers were very large and should have been evaluated and treated months ago, and yes, my office was open for those cancer patients. They also had medical conditions which should have been evaluated and treated which puts me in a bind knowing that I need to do surgery on these patients and now because of many conditions, I have to remove these large cancers in my office under local anesthesia. Yes, this has been a very depressing week.
Hallie Miller further discusses this problem. CareFirst BlueCross BlueShield, Maryland’s largest health insurer, is not reimbursing some medical and mental health providers for appointments held over the phone or via audio-only platforms to the dismay of those providers.
CareFirst, which serves over 3 million members, is only reimbursing primary care physicians, obstetricians and gynecologists, and behavioral health providers under specific conditions. They are paid a flat rate of $20 regardless of the length of the call.
Other specialists such as cardiologists, ophthalmologists and neurologists are not reimbursed by CareFirst for any phone or audio-only services.
With the coronavirus pandemic prompting doctors’ offices and hospitals to restrict in-person patient visits and elective surgeries, physicians and medical professionals have been forced to rapidly adjust to telehealth methods to provide routine care. Much of the daily grind has shifted to virtual channels, with video visits and phone calls replacing face-to-face interaction between doctors and patients as public health experts caution against gathering in close proximity indoors.
Most insurers, public and private, are now paying for telemedicine. But the lack of uniformity in policy and standards among insurers has caused frustration among Maryland’s physicians and mental health professionals, who have to navigate a new mode of care with differing guidelines and rates across the board.
“If we genuinely want to meet patients where they are, we need to have multiple flexible platforms, and if the payer isn’t flexible, that’s a challenge,” said Dr. George Ruiz, the chief of cardiology at MedStar Union Memorial Hospital, MedStar Good Samaritan Hospital and MedStar Harbor Hospital. “If payment structures come into place, we can overcome one of the major barriers to care that exist in medicine.”
Ruiz said insurers should not discount phone and audio-only sessions, which can serve vulnerable patient populations that may not have the technology or the ability to set up a video visit. Phone appointments also offer patients more convenience during time-sensitive situations and keep people out of hospitals and emergency rooms.
Gene Ransom, the CEO of MedChi, the state’s medical society, said his group has lobbied CareFirst to reconsider its audio and phone-only reimbursement policy.
“By not paying for audio-only services, you’re paying for much more expensive visits to emergency rooms later,” said Ransom, adding that some CareFirst-insured patients might not seek out care in the first place if they know their insurance will not cover it. “Carving out certain specialties could lead to a really bad outcome for the patient.”
In a statement, CareFirst said it only began reimbursing for phone and audio calls as a result of the coronavirus pandemic and then only for some doctors to allow check-ins to maintain continuity of care. It will continue such coverage after July 24 when a member cost share waiver put in place during the outbreak expires.
It also will continue to cover telemedicine, which it defines as a combination of interactive audio and video, as it did before the pandemic, CareFirst said.
“Visits that include both audio and visual components allow for provision of quality care for our members,” according to the statement.
CareFirst, in its statement, also noted that many doctors’ offices have reopened to provide on-site care.
Dr. Michael Silverman, managing physician at Cardiovascular Specialists of Central Maryland, a Johns Hopkins affiliate, believes video adds little to the substance of a telehealth visit. A phone call, he said, can deliver urgent care to patients with physical or technological limitations.
Silverman said a patient called him on June 10 for a 22-minute consultation about his spinal surgery the next day, which precipitated another 20 minutes of medical record review and note writing. CareFirst did not reimburse him for this effort, he said.
“There are physicians right now who are really suffering, financially,” said Silverman, adding that he came close to having to close his practice when the coronavirus pandemic reached Maryland in March.” A call to a cardiologist goes a long way, but if they can’t call, so be it.”
Ransom said insurers should follow the federal government’s lead, which has issued guidelines for Medicare and Medicaid — the services that cover older adults and people with low incomes — to cover audio and phone appointments and waive member cost shares until further notice. Other providers such as Aetna, Cigna and UnitedHealthcare also cover audio-only visits, though the guidelines differ from company to company.
Some providers said insurers should standardize telehealth so it can be utilized beyond the fall, as such services offer a number of benefits for both patients and doctors.
Paul Berman, a Towson-based psychologist and director of professional affairs for the Maryland Psychological Association, said telemedicine has proven especially effective for people with depression and severe phobias who struggle with leaving the home or driving. It also serves as a vital lifeline for people with substance use disorders or those suffering from acute crises.
Berman said CareFirst’s $20 flat fee for “phone consultations” for behavioral health providers covers only specific sessions that are initiated by the patient and are not related to matters discussed within seven days prior or 24 hours after the call. As a result, it does not provide for continuity of care.
“You have people who benefit from, and even need, ongoing treatment in order to stabilize their emotional state and physical health, and if they don’t have access to services, their functioning deteriorates,” Berman said. “Many psychologists … are not able to make paid contact with patients because of this exclusion.”
Berman said psychologists and counselors, in particular, will be put at risk if they are forced to return to their offices during the ongoing pandemic, as therapy requires face-to-face interaction for up to an hour. Public health experts have warned that such interaction, especially indoors, can lead to transmission of COVID-19 through aerosols.
To mitigate out-of-pocket costs for patients, Berman said some psychologists have decided to provide low-fee services, or have patients to scale back the number of sessions scheduled per month. But this can create gaps in care for patients that lead to regression in their mental health, he said.
“People have been locked out of the ability to make use of mental health services if insurance has not waived the telephone exclusion,” he said. “It makes no sense.”
U.S. COVID-19 deaths rise for second week in a row and it continues to rise
Reporter Lisa Shumaker noted that the U.S. deaths from COVID-19 rose for a second week in a row to more than 5,200 people in the week ended July 19, up 5% from the previous seven days, a Reuters analysis found.
The country reported over 460,000 new coronavirus cases last week, up nearly 15% from the prior week, according to the analysis of data from The COVID Tracking Project, a volunteer-run effort to track the outbreak.
Nineteen states have reported increases in deaths for at least two straight weeks, including, Arizona, Florida and Texas.
Testing for COVID-19 rose by 9% in the United States last week and set a new record high on Friday, with over 850,000 tests performed, the Reuters analysis found.
Nationally, 8.5% of tests came back positive for the novel coronavirus, down from 8.8% the prior week but still higher than the 5% level that the World Health Organization considers concerning because it suggests there are more cases in the community that have not yet been uncovered.
Thirty-one states had positivity test rates above 5%, according to the analysis, including Arizona at 24%, Florida and Nevada at 19%, and Idaho and Alabama at 18%.
Nationally, new COVID-19 cases have risen for seven straight weeks. Forty-three states reported more new cases of COVID-19 last week compared to the previous week, the analysis found.
For the first time since April, cases rose in New York State week over week, breaking a 13-week streak of declines. New Jersey now leads the nation with cases falling for two weeks in a row. The other six states have only seen cases decline for one week.
U.S. Coronavirus Deaths Could Be Cut 67 Percent With ‘Universal Mask Usage,’ Study Finds
Almost everyone is arguing about the use of masks and part of the problem is the changing opinions on mask wearing as well as the exhaustion of lockdowns and quarantines. Soo Kim reports that with novel coronavirus cases in the U.S. approaching nearly 3.9 million, several local authorities have issued orders requiring face coverings in public in a bid to reduce the spread of infection.
While many people have been opposed to mask mandates, the widespread use of masks could potentially help significantly reduce the country’s daily case count and daily death toll, according to data from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington.
The U.S. daily death toll is currently projected to be around 815 by November 1, according to projections from the IHME. . This daily death toll projected for November 1 could be reduced by over 66.4 percent if “universal masks” were applied across the country, the institute noted.
Universal mask usage refers to a 95 percent usage of masks in public in every location, with “mandates re-imposed for six weeks if daily deaths reach eight per million (0.8 per 100,000),” the institute explained.
Universal masks could also reduce the country’s projected daily case count for November 1 by more than half, according to the research. The daily case count in the U.S. is currently projected to reach around 124,929 by November 1, the IHME noted.
If universal masks were applied across the country, the projected daily case count could be reduced to about 46,495 by November 1, over 62.7 percent less than the current daily case count projected by the institute for the same date.
The daily case count and daily death toll in Arizona, which was found to be the most “anti-mask” state by a survey of over 150,000 Twitter posts using anti-mask-related hashtags, could also be reduced by around 70 percent if universal masks were applied across the state.
The state’s daily case count is projected to hit around 3,176 by November 1, which could be reduced to around 899 with universal mask usage, according to the IHME projection, a more than 71.6 percent reduction in daily new cases.
Arizona’s daily death toll is expected to reach nearly 20 by November 1. But the projected daily death toll could be reduced by over 68 percent if universal masks were applied, the IHME noted.
Statewide mask mandates have been issued in several parts of the country, including most recently in Texas, Kansas, Pennsylvania and Oregon.
Masks are currently not required in Iowa, Montana, South Dakota, and Wisconsin.
Face coverings are required in certain counties and cities within Alaska, Arizona, Florida, Georgia, Idaho, Kentucky, Minnesota, Mississippi, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, South Carolina, Tennessee, West Virginia, and Wyoming.
This week, President Donald Trump appeared to have shifted from a reluctance to wearing face masks to suggesting they are patriotic, while sharing a photo of himself wearing one in a post Monday on his official Twitter account.
Telehealth could grow to a $250B revenue opportunity post-COVID-19: analysis
Heather Landi pointed out that during the COVID-19 pandemic, consumer adoption of telehealth has skyrocketed, from 11% of U.S. consumers using telehealth in 2019 to 46% of consumers now using telehealth to replace canceled healthcare visit, according to consulting firm McKinsey & Company’s COVID-19 consumer survey conducted in April.
McKinsey’s survey also found that about 76% of consumers say they are highly or moderately likely to use telehealth in the future. Seventy-four percent of people who had used telehealth reported high satisfaction.
Health systems, independent practices, behavioral health providers, and other healthcare organizations rapidly scaled telehealth offerings to fill the gap between need and canceled in-person care. Providers are ready for the shift to virtual care: 57% view telehealth more favorably than they did before COVID-19 and 64% are more comfortable using it, according to McKinsey’s recent provider surveys.
Pre-COVID-19, the total annual revenues of U.S. telehealth players were an estimated $3 billion, with the largest vendors focused on virtual urgent care.
Telehealth is now poised to take a bigger share of the healthcare market as McKinsey estimates that up to $250 billion, or 20% of all Medicare, Medicaid, and commercial outpatient, office, and home health spend could be done virtually.
The consulting firm looked at anonymized claims data representative of commercial, Medicare, and Medicaid utilization.
The company’s claims-based analysis suggests that approximately 20% of all emergency room visits could potentially be avoided via virtual urgent care offerings, 24% of healthcare office visits and outpatient volume could be delivered virtually, and an additional 9% “near-virtually.”
Up to 35% of regular home health attendant services could be virtualized, and 2% of all outpatient volume could be shifted to the home setting, with tech-enabled medication administration.
Many of the dynamics that have helped to expand telehealth adoption are likely to be in place for at least the next 12 to 18 months, as concerns about COVID-19 remain until a vaccine is widely available.
Going forward, telehealth can increase access to necessary care in areas with shortages, such as behavioral health, improve the patient experience, and improve health outcomes, McKinsey reported.
Providers and patients are concerned that recent federal and state policies expanding access to telehealth will be rolled back once the emergency period ends.
Industry groups, including the College of Healthcare Information Management Executives (CHIME), are calling on lawmakers to ensure the changes enacted by Congress and the administration become permanent.
McKinsey’s research indicates providers’ concerns about telehealth include security, workflow integration, effectiveness compared with in-person visits, and the future for reimbursement.
“We call on Medicare and all other insurers to continue to fund telehealth programs and work collaboratively on coverage and coding to lessen provider burden. We cannot go back to pre-COVID telehealth; instead, we must go forward. Patients will demand it and providers will expect it,” CHIME CEO and President Russell Branzell said in a recent statement.
Telehealth also is drawing bipartisan support. Senator Marsha Blackburn, R-Tenn., urged Congress to “continue to support this expansion and codify the administration’s changes to support the health needs of the American people,” in a recent news release.
Rep. Robin Kelly, D-Illinois, is introducing a bill directing HHS Secretary Alex Azar to oversee a telehealth study looking at the technology’s impact on health and costs, Politico reported in its newsletter today.
Taking advantage of the telehealth opportunity
Healthcare providers and payers will need to take action to ensure the full potential of telehealth is realized after the crisis has passed, according to McKinsey.
There continue to be challenges as providers cite concerns about telehealth include security, workflow integration, effectiveness compared with in-person visits, and the future for reimbursement. There also is a gap between consumers’ interest in telehealth (76%) and actual usage (46%). Factors such as lack of awareness of telehealth offerings and understanding of insurance coverage are some of the drivers of this gap.
“The current crisis has demonstrated the relevance of telehealth and created an opening to modernize the care delivery system,” McKinsey consultants wrote. “Healthcare systems that come out ahead will be those who act decisively, invest to build capabilities at scale, work hard to rewire the care delivery model, and deliver distinctive high-quality care to consumers.”
McKinsey outlined steps industry stakeholders should take to drive the growth of telehealth.
Payers: Health plans should look to optimize provider networks and accelerate value-based contracting to incentivize telehealth. Align incentives for using telehealth, particularly for chronic patients, with the shift to risk-based payment models.
Payers also should build virtual health into new product designs to meet changing consumer preferences, This new design may include virtual-first networks, digital front-door features (for example, e-triage), seamless “plug-and-play” capabilities to offer innovative digital solutions, and benefit coverage for at-home diagnostic kits.
Health systems: Hospitals and health systems should accelerate the development of an overall consumer-integrated “front door.” Consider what the integrated product will initially cover beyond what currently exists and integrate with what may have been put in place in response to COVID-19, for example, e-triage, scheduling, clinic visits, record access.
Providers also should build the capabilities and incentives of the provider workforce to support virtual care, including, workflow design, centralized scheduling, and continuing education. And, health systems need to take steps to measure the value of virtual care by quantifying clinical outcomes, access improvement, and patient/provider satisfaction. Include the potential value from telehealth when contracting with payers for risk models to manage chronic patients, McKinsey said.
Investors and health technology firms: These players also can support the new reality of expanded telehealth services. Technology firms should consider developing scenarios on how virtual health will evolve and when, including how usage evolved post-COVID-19, based on expected consumer preferences, reimbursement, CMS and other regulations.
Investors also should develop potential options and define investment strategies based on the expected virtual health future. For example, combinations of existing players/platforms, linkages between in-person and virtual care offerings and create sustainable value. Investors and technology companies also can identify the assets and capabilities to implement these options, including specific assets or capabilities to best enable the play, and business models that will deliver attractive returns.
And Now Payment Problems as Patients Lose Coverage due to COVID Leigh Page reviewed what many practices are seeing happen as the lockdowns ease up. Percy Erachshaw, DO, a general surgeon, was happy and encouraged when New York City started to open up a bit during the COVID outbreak and patients began coming back into doctors’ offices and having online visits. But Erachshaw, like many physicians nationwide, is quickly learning that the insurer payments he’s expecting may be a thing of the past.”The patient volume is back,” said Erachshaw, who manages four practice sites in Brooklyn and Queens, New York. Two of the sites that had been closed for 2 or 3 months recently reopened. However, “I have patients who don’t have insurance coverage anymore. They lost their jobs, but they are my long-term patients, so I can’t turn them away”. Many of these patients need help getting on Medicaid, but Erachshaw doesn’t have enough staff to help them. Much of his former staff left the practice and are not returning. With unemployment benefits temporarily enhanced by federal dollars, “They discovered they were making more money staying at home than working,” he said. Many Patients Lost Healthcare Coverage Because of layoffs during the COVID-19 crisis, an estimated 12.7 million Americans lost employer coverage from early March to May 1. Even some workers who have not been laid off may lose coverage. Although the Affordable Care Act requires large employers to provide health insurance, small businesses can cancel coverage.
“Depending on how long the high unemployment lasts, practices could have many more uninsured patients,” said Lori Foley, managing principal in Atlanta, Georgia, for PYA, a national healthcare consulting and accounting firm.
Patients who lose coverage have the option of buying their own insurance, but in many cases, Foley says, they can’t afford to do so. “Premiums for individual health insurance can be expensive, and laid-off workers may not have been saving for that, because they did not expect to be laid off,” she said.
Indeed, many people simply don’t have the funds to take out a new insurance policy. According to one analysis, 40% of Americans do not have $400 to cover unexpected expenses.
Don’t expect patients who have been laid off to turn up at your office with a new form of coverage, says Kathryn I. Moghadas, a healthcare consultant in Winter Springs, Florida. “They’re not going to run out and get new coverage,” she said. “If they come in, they’ll want to use their credit cards and negotiate a cheaper rate with the office.”
Many people who are still working are concerned about their finances or about getting the virus, so they’re limiting their medical care. Health insurers Humana and Aetna recently noted that use of medical services has plummeted by at least 30%.
High deductibles, which have become increasingly common, also incentivize people to cut back on care, particularly at the beginning of the year, before they have met their deductible. Among workers who have a health insurance deductible, the average deductible is $1655 this year.
Many patients are selecting health services on the basis of price. More hospitals are providing their prices online and even offer tools to calculate payment estimates. Patients also have begun to expect price quotes from practices.
“When these patients call a practice, they may not want to simply book an appointment,” Foley said. “They will want to hear about your prices. Many practices are still not used to this. They often don’t have the self-pay prices and payment plan information available.”
Payers Are Making It Tougher Some health insurers are taking longer to pay because, like many other businesses in the COVID-19 era, they have fewer staff, says Michael La Penna, a practice management consultant in Grand Rapids, Michigan. “Due to the lower staffing, it can take an insurer longer than the usual 30 to 45 days to process a payment,” he said. Low staffing has also made it hard to get prior authorizations, such as for primary care physicians’ (PCPs’) referrals to specialists in health maintenance organizations (HMOs). “We will call the HMO and we would be put on hold forever,” Erachshaw said. “It has been a mess and a half. If you don’t have an approval for a referral, you can’t refer the patient.” Some payers have temporarily waived the prior authorization process for certain services during the COVID-19 crisis, but they may not implement those changes. “Many payers claim to have relaxed authorizations for ‘most’ or ‘many’ services,” the report said, “but what ‘most’ or ‘many’ means is anyone’s guess.” Another area of confusion is the new or enhanced telehealth payments that Medicare and many private payers are temporarily allowing during the COVID crisis. “The typical PCP has six, seven, eight different payers, each with a different telehealth policy,” said Robert L. Phillips, MD, executive director Center for Professionalism and Value In Healthcare, a think tank in Washington, DC. “As a working clinician, I can’t manage all of those policy differences in my head.” “Each insurer has slightly different rules on telehealth, and they keep changing,” said Rebecca Etz, PhD, co-director of the Larry A. Green Center, another think tank in Washington, DC, which promotes primary care. “For example, some won’t pay for telephone-based care if the call lasts less than 10 minutes.” Insurance companies themselves may be confused about their own telehealth policies and thus underpay or deny payment to providers. Telehealth organizations say insurers have been slow to update their software and policies. Spotty payments for telemedicine and many other services mean many doctors are reimbursed only a fraction of what they are entitled. In an April survey of physicians and other clinicians in primary care, 57% said that fewer than half of their visits in the past week were reimbursable. Here are some ways practices can deal with patients who lose insurance and the insurance plans that represent them. Keep the bill low. Look for ways to keep costs in check. For example, “physicians could find less expensive form of meds for patients who are concerned about high costs,” Moghadas said. Know your prices. “Practices should be able to tell self-pay patients what they basically can expect to pay,” Foley said. At the least, a practice could state that a new visit would cost $150 for the visit, plus additional costs for labs and x-rays, and a visit for an established patient would cost $75, she says. Bring your patients back in. Many of your patients are not going to return to you without a little nudge. “You can’t sit back and wait. You need to remind them,” said Phil Boucher, MD, a pediatrician in Lincoln, Nebraska, who has been a speaker on the online Back to Busy Summit for physicians who want to revive their practices in the era of COVID-19. “Reach out to your patients by sending them an email, if not a text or a message on social media,” he advised. “Better yet, go on local news and talk about your practice opening. Give them a reason to come in, such as annual checkups and routine care.” For example, Moghadas notes that diabetes patients generally need to come in every 3 months, and women need to see their gynecologist more often than once a year. “You can set up your EHR system to determine when each patient needs to come in,” she said. Update insurance coverage information. “Asking every year about insurance coverage is not frequent enough right now because there are so many changes going on,” Foley said. “Ask about coverage on each visit.” adds that when employees are laid off, coverage often lasts for the rest of the month. If patients inform you of the change immediately, you might be able to get them in to see you before coverage ends, he says. Help patients get coverage. “Help to get patients signed up with Medicaid or COBRA,” Boucher said. “Your billing people can do this through a phone call.”
Small practices, however, may not have extra staff to do this work, Foley says. Also, many practices have staff shortages, such as Erachshaw’s practice. “I still have to find and train enough staff to get vital signs,” Erachshaw said. “I don’t have enough people to sign patients up for Medicaid.”
Effective Tactics to Collect from Patients Having many uninsured patients means you have to shift to getting more payments from patients, which is harder to do than getting paid by insurers, Moghadas says. “It really takes a lot of effort to collect this money,” she said. “Most practices are already experienced with patient collections, due to high deductibles,” Foley said. “Practices need to identify who is self-pay and what their discount approach is. “You have to collect at the time of service,” Foley adds. “If you wait until after the appointment, the chances of payment drop considerably.” If the bill is past due, “tell them about it when they come in for their next appointment,” she said. “It’s easier to collect a bill face to face.” When patients say they can’t pay the bill, ask about their financial hardship. “Find out their household income,” Foley said. “Set up a sliding scale in which payments are reduced depending on the patient’s income. Health systems do this all the time.” After sending a few bills, Foley says, the next letter to the patient ― the pre-collect letter ― should state that the bill will now go to a collection agency unless it is paid in full. “People worried about their credit rating, such as those buying a house, will pay, but others are willing to let their debt go to a collection agency,” she said. Creating payment plans requires setting a reasonable monthly amount to be paid. “If you set the amount too low, it could take years to pay off,” she said. If the amount owed is $500 or less, she recommends setting up three monthly payments, and if it’s over $1000, then six monthly payments. The Future The road ahead for doctors still seems very bumpy. The reopening of public places is coming in fits and starts, and when the number of COVID-19 cases rises again, patients stay away for a while, Phillips says. “Each temporary spike in COVID cases has a lasting effect on practices,” he said. “Patients will disappear for a while afterward. Philips predicts that because of the epidemic, primary care practices will lose almost $20 billion by the end of the year. If temporary telemedicine payments were removed, the losses could be double that, he says. When Medicare and other payers drop the current higher payments for telemedicine, as planned, many doctors will be forced to give up telemedicine, predicts La Penna. “At lower or nonexistent reimbursement rates for telemedicine, it would not be worth their while to use it,” he said. Some doctors, however, are doing surprisingly well now that the virus is abating and some restrictions have been lifted in some areas. When surgeries were temporarily banned because of COVID-19, George Waring IV, MD, an ophthalmologist in Mt. Pleasant, South Carolina, lost almost all his patients. When he reopened in May, he was not sure whether his previous volume of patients would return. Many of his patients undergo Lasik surgery to replace glasses or contact lenses, or they receive advanced lens implants after cataract surgery, both of which are usually not covered by health insurance. But as it turned out, he’s had more visits than at this time last year. Was this the result of pent-up demand for services, as many observers expected after bans on elective surgery are lifted? “No,” he said, “it’s much more than that.” He has several explanations for the high demand. “Having to wear masks against COVID makes people less comfortable wearing glasses, because they steam up,” he said. “Also, people need to avoid putting their hand on their face, which you have to do to insert contact lenses. So, they want Lasik. “Furthermore,” he added, “sheltering in place has made some people more contemplative, and they may get a new perspective on life and consider visual self-improvement.”
The question is what does the future look like and how do we prepare, which is what a paper that I wrote with two co-authors and was just accepted for publication considered (Science and Data Driven Choice: Shaping Empowerment During COVID-19 and Beyond)… Yeah!