Use value-based payments to resolve the telehealth payment parity debate
COVID-19 has required widespread relaxation of state and federal restrictions and a rapid expansion of telehealth. Now, as policymakers consider telehealth in the post-pandemic period, they must make decisions on parity of payments, whether to continue reimbursing clinicians equivalent amounts for in-person and telehealth visits.
Some Argue that telehealth requires less clinical effort and less overhead than face-to-face care, which minimizes the case for parity of payment. Other concerns include the lower effectiveness of telehealth compared to in-person care, the potential for abuse and fraud, and increased health care costs. Those who support payment parity believe this would help clinicians adopt and maintain telehealth as a means of supporting health care access and patient experience. The arguments on both sides would be reinforced by more high quality studies.
Since many of the tensions over parity of payments are rooted in volume-based reimbursement, another way to help resolve the debate is to test telehealth under dedicated value-based payment models.
For example, a concern about maintaining parity of payments in telehealth is that it could stimulate use that is in addition to in-person care rather than replacing it, thus increasing use and expenditure without clinical benefits. clear. These risks may be sufficient to cause some payers to move away from parity for certain telehealth modalities. Medicare offered that it will limit audio telehealth only to mental health services in specific situations after the public health emergency.
However, these concerns are more relevant in the case of volume-based fee-for-service, where spending is inherently disconnected from quality or clinical responsibility. In contrast, value-based payment models link use with responsibility for quality by design. Therefore, these models could be designed to assess the impact of telehealth use on relevant clinical, quality and expenditure outcomes.
Another example of this opportunity can be found in the argument for maintaining payment parity, as telehealth services do not necessarily cost providers less than in-person visits. In fact, costs may be similar due to equivalent malpractice expenses; complexity of patients, volume of data reviewed and risks of similar management options; and the need for staff to perform tasks such as virtual patient rooms and troubleshooting technological challenges.
Again, these points are also most relevant in fee-for-service agreements that use units of relative value to tie payment as directly and precisely as possible to things like physician effort, time staff and practice expenses. In contrast, value-based payment models encourage clinicians to provide care — whether in person or telehealth, or both — that focuses on outcomes and cost-effectiveness. Not only would this dynamic avoid the need for accurate data on spending and time, but it could also increase the likelihood of identifying creative approaches to overhaul of care involving telehealth. This may include, for example, the use of modalities or methods of care that are not currently reimbursed under fee-for-service.
Another reason to test telehealth as part of dedicated payment models is to provide formal evaluation. Unfortunately, changes implemented in fee-for-service environments may or may not be formally evaluated, creating the possibility that policymakers could invest in telehealth payment changes without understanding their positive or negative impacts. In contrast, value-based payment models must be assessed by law. Such evaluations would deepen our understanding of the impact of teleservices on relevant clinical, quality and use outcomes.
Mandatory assessments would allow decision makers to better understand other important issues such as clinical implementation and disparities. For example, formal assessments of primary care payment models included assessments of outlook, progress and areas for improvement in practice, and clinical outcomes. Assessments of bulk payment models included a specific assessment of vulnerable populations, such as those with high health care use or conditions such as dementia.
Generating similar information from telehealth policy (how it affects vulnerable populations and clinicians) is essential to inform policy. Clinicians may face significant barriers to implementing telehealth or identifying innovative approaches that merit further study. By bypassing some barriers, such as transportation, and creating others, such as internet and device access, telehealth is poised to potentially reduce some disparities for vulnerable or historically marginalized populations, while exacerbating others. Early evidence suggests that elderly, minority, non-English speaking, and rural patients are more likely to receive audio-only care compared to audio-visual care. Telehealth payment policy should be guided by data on how services affect health equity.
One way forward: use existing payment programs as the basis for new telehealth payment models. For example, the Alliance of Community Health Plans proposed a multi-year model which shares a number of similarities with Medicare’s primary care payment models. The Alliance model would start with a five-year parity-of-payment period, while plans, clinicians and patients used existing quality measures and other means to assess the best care delivered through telehealth. Subsequently, the model would shift to capitation, reimbursing clinicians on a per limb per month basis based on a high reimbursement for the most optimal services for telehealth and a lower reimbursement for lesser services. optimal.
Of course, more work would be needed to flesh out some features of the Alliance or another similar model (eg, risk adjustment; defining patient populations, not just services). Nonetheless, the idea behind a phased approach that starts with evaluating telehealth under parity of payment and switching to another payment method has merit. A similar approach could be applied to episode-based models, maintaining payment parity for telehealth services; assess how telehealth affects quality and use; and use this information to adjust telehealth reimbursement within episode spending targets.
To be fair, testing telehealth under new payment models is not a panacea. Models should take into account that telehealth benefits may vary depending on modality (eg, audio only vs. audio / video), timing (real-time vs. asynchronous), or clinical condition. Currently, evaluations of value-based payment models do not include fairness as an explicit criterion for success. Payment models for telehealth must avoid disproportionately harming safety net clinicians and the communities they serve.
Nonetheless, many of the doubts raised in the telehealth pay equity debate are based on volume-based reimbursement. One way to address these issues is to test telehealth under value-based payment models. Such an approach would avoid cost issues, facilitate the formal assessment desperately needed in our current telehealth environment, and provide a means to monitor and encourage the reduction of disparities in telehealth access. Those responsible for policy and practice should begin this work without delay. While it was COVID-19 that prompted the rapid adoption of telehealth in healthcare in the United States, it will be evidence of the pros and cons that will provide momentum for future policies and practices.
Dr Liao claims to have received honoraria from Wolters Kluwer, the Journal of clinical pathways, and the American College of Physicians; personal expenses from Kaiser Permanente Washington Health Research Institute; and Wolters Kluwer textbook royalties; everything outside of this blog post.