Consequently, carrier limitations to such narrow networks of telemedicine providers have limited care to urgent or semi-urgent concerns, rather than enabling patients to utilize telemedicine as a means of augmenting chronic care management or maintaining continuity of care with their established healthcare team. Under these arrangements, patients have access to telehealth through their insurance plan (at pre-negotiated rates), but not necessarily with their own physicians. Examples include MDLive, American Well, and Teladoc, among others. Some carriers have offered coverage for telemedicine services only if care is obtained through specific telemedicine companies with which the carrier has contracted. Therefore, reimbursement was available for only a limited spectrum of virtually delivered care. For example, although coverage for follow-up evaluation and management CPT codes was available under nearly all the major commercial carriers, coverage for new patient visits, virtual check-ins, remote evaluation of digital images or video, e-visits via patient portal, and audio-only telephone care was less common.
Prior to the onset of the COVID-19 public health emergency, most carriers had restrictions on the types of services that could be delivered via telemedicine. Therefore, carriers have looked for ways to encourage patients to utilize telemedicine as a substitute for more expensive face-to-face or emergency services, rather than an addition to existing service utilization.Ĭommercial coverage restrictions have come in two flavors: limitation of services and restriction to a narrow network of providers. It is important to note that the increased healthcare utilization through telemedicine is not necessarily inappropriate, but rather a reflection of care that would otherwise not have been sought had telemedicine not been available. A RAND analysis of telehealth for acute respiratory infections estimated that net annual spending on acute respiratory illness increased by $45 per telehealth user. For-profit health insurers have paid close attention to data showing that although the cost of an individual telehealth service is significantly lower than outpatient and emergency care, the convenience of telemedicine can lead to greater use of care and consequently higher overall health expenditure. In addition to geographic restrictions imposed by Medicare, commercial payers have applied coverage restrictions on telehealth services in response to concerns over the potential for overutilization, fraud, and low-quality care. In fact, until the recent sea change in telemedicine accessibility brought about by the COVID-19 pandemic, telemedicine reimbursement had been hindered by geographic restrictions, narrow coverage policies, and a lack of payment parity. Payment models have not kept pace with the rapid expansion of telemedicine technology and scope, and a 2019 report from telemedicine provider American Well revealed that the top concern of clinicians pertaining to telemedicine adoption is uncertainty about reimbursement. Regulatory policy, in general, tends to lag behind advancements in technological capability, and telemedicine is no exception. However, as telehealth services have become more widespread in the consumer healthcare space, sustainable payment policies from public and private payers are critical to the ongoing growth and development of telemedicine. Impact of Reimbursement Limitations on Telemedicine Accessibility and AdoptionĪs telemedicine in the USA was initially envisioned as a way to increase access to healthcare for underserved and remote communities, funding for telehealth pilot programs was carved out from the budgets of government entities, such as NASA, CMS, and the Indian Health Service. Over the next two decades, telemedicine extended its reach beyond remote and underserved patients, to include after-hours care, walk-in urgent visits, remote physiologic monitoring, chronic care management, and routine evaluation and management services for the general population. The ambitions of telemedicine returned back to earth in subsequent decades, linking hospitals to airports in the 1960’s, delivering healthcare to Indian reservations in the 1970’s, providing healthcare support to Armenia in the wake of an earthquake in the 1980’s, and being introduced by Medicare as a way to deliver medical care to underserved rural populations in the 1990’s. Initially envisioned in the 1920s as a virtual alternative to a physician’s house call, the technology needed to practically implement telemedicine was not developed until mid-century, when NASA needed a way to provide medical care to astronauts in space. Telemedicine refers to the remote evaluation and treatment of patients using telecommunications technology.
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