Physician groups concerned about financial shortfall for treating patients with complex health needs

The Trump administration has made sweeping changes to Medicare telehealth policies, but physician groups are concerned they will still be underpaid for treating more severely ill patients.

Federal reimbursement policies for telehealth visits have changed rapidly in the past two months amid the COVID-19 pandemic.

Medical professional groups say there remain many unanswered questions about reimbursement rates and whether doctors will get paid adequately for treating senior patients with complex health needs.

The Centers for Medicare & Medicaid Services (CMS) last month issued temporary changes and agreed to pay for virtual visits at the same rate as in-person visits while the coronavirus emergency remains in effect. As of March 30, CMS is now allowing more than 80 additional services through telehealth.

Recently, CMS said it will also boost the payment rate for telephone visits to match those for similar office and outpatient care. This change will increase payments for these services from a range of about $14 to $41 to about $46 to $110, according to CMS. The payments are retroactive to March 1.

Physician groups cheered the move as they had been aggressively lobbying CMS for pay parity for telephone visits. 

But those regulatory changes do not address audio-only visits for Medicare Advantage at-risk plans by giving physicians the ability to do hierarchical condition category coding, what's known as HCC coding, during a telephonic visit, according to Norman Chenven, M.D., vice chairman of the Council of Accountable Physician Practices.

These also don't address annual wellness visits.

"This is still a major problem for physicians who are doing audio-only visits with patients in Medicare Advantage at-risk plans. They will be penalized because this information will not be considered in setting payment for these patients," said Chenven, a family practitioner and founding CEO of Austin Regional Clinic, a multispecialty medical group in Austin, Texas.

RELATED: Trump administration opens up access to telehealth services during coronavirus outbreak

He added, "Overall we're happy with the fact that CMS has been flexible, but they have not gone far enough to the benefit of everyone."

Telephonic visits play a vital role in providing care to seniors during the health crisis. Many elderly patients lack access to technology or broadband services. More than 90% of seniors have cellphones, but less than 40% have smartphones with video capabilities, a Pew Research Center study found.

That means more than 60% of Medicare beneficiaries would be unable to communicate with their physician on video and would have to rely on telephone visits, according to the Council of Accountable Physician Practices.

At the same time, many patients in Medicare Advantage at-risk plans have complex healthcare needs.

HCC coding is a risk-adjustment model originally designed to estimate future healthcare costs for patients. Along with demographic factors, such as age and gender, insurance companies use HCC coding to assign patients a risk adjustment factor score, according to the American Academy of Family Physicians.

RELATED: CMS eases requirements for COVID-19 tests, boosts payments for telephonic visits 

Using algorithms, insurance companies can use a patient’s risk score to predict costs. For example, a patient with few serious health conditions could be expected to have average medical costs for a given time. However, a patient with multiple chronic conditions would be expected to have higher healthcare utilization and costs.

As it stands, physicians providing these telephonic visits will face a serious financial shortfall because the visits and the diagnosis of the patients will not be factored into future risk payments, Chenven said.

"This is not a sustainable situation. It compounds the financial pressures now facing health care providers. Eventually, this underpayment may impact access to care and the cost of care," he said.

Physician practices are taking a significant financial hit during the COVID-19 outbreak. Low patient volume and inconsistent reimbursement are hampering cash flow, resulting in furloughs and layoffs, according to a recent survey of 1,000 primary care clinicians in 48 states and Washington, D.C.

Most clinicians (89%) report large decreases in patient volume, and 57% say that less than half of their visits in the last week were reimbursable, according to the survey from the Larry A. Green Center in partnership with the Primary Care Collaborative.

The American Medical Group Association also is pressing CMS to clarify that audio-only visits satisfy the face-to-face requirement for the purpose of gathering diagnosis information for risk adjustment and care coordination purposes.

Diagnostic information gathered via telephone serves several important purposes beyond payment, physician groups say.

RELATED: Primary care practices struggle with inconsistent payment for telehealth, still lack testing, PPE

Coordinated care teams need accurate patient diagnoses to assess and develop care plans, deploy necessary resources at the medical group level and make informed decisions to manage patient care.

Video-based telehealth and telephonic visits will be critical components of keeping patients and physicians safe through social distancing as well as preserving access to care as physicians work to clear the backlog when restrictions ease, Chenven said.

As CMS and commercial insurers loosen telehealth rules, many medical groups would like to see those flexibilities stay in place permanently as medical practices change how they deliver care.

"We want to see a more liberalized approach to tele-medical visits and as physicians, we would like to see broader use of both audio-visual technologies," Chenven said. "The concern is that after the crisis is over, policies will go back to the status quo before COVID."