"We need to change the rules that keep Medicare patients in rural areas from access to quality care through telemedicine," Grassley said. "The technology exists and we should make sure seniors have access to the care they need, even if it's far from home."
Telemedicine has become an important resource for patients, especially those who live in rural areas and don't have immediate access to the medical specialists usually found in urban centers. Instead of driving a long distance they can go to a local health facility and be examined by a specialist via computer or television. A recent study from the Missouri Telehealth Network showed patients saved an average of just over $40 per visit by avoiding a trip to the tertiary hospital.
However, many telemedicine healthcare providers in rural areas say they aren't able to provide all of the services that the new technology offers because they can't afford it under the current telemedicine payment system. The Telehealth Improvement and Modernization Act of 2000 introduced today by Sen. Jim Jeffords, with Grassley as an original co-sponsor, would:
?Cover telemedicine services provided in all rural and underserved urban areas. Right now, reimbursement is limited to certain designated areas.
?Pay for a telemedicine visit the same as an in-person visit. The bill would eliminate Medicare's current requirement that a specialist who serves a patient by telemedicine split the fee for the visit with the physician who referred the patient. Since there is no such obligation for patients seen in person, telemedicine patients are less likely to receive needed specialty care.
?Remove the telepresenter requirement. Current Medicare rules mandate that a "telepresenter" doctor or nurse be with the patient while the patient is examined by the remote physician using telemedicine. However, health care providers are usually too busy to do this. Getting rid of this unnecessary requirement will save time for healthcare providers and patients, enabling more patients to be seen.
?Expand the telemedicine services covered by Medicare, including more physician services; home health care; psychological care; and physical, speech and occupational therapy.
Here are further details of the legislation:
Telemedicine has come of age. We have moved past the feasibility stage; health care can be delivered effectively using telemedicine as a tool to get the patient and the health care provider together. Significant barriers exist in the Balanced Budget Act of 1997 that need legislative remedy so that this proven method of delivering health care may be accessed by underserved Medicare beneficiaries.
1. The BBA requires "fee sharing" for reimbursement of telemedicine consultations. The site delivering the care receives the fee and is required to share a portion of the fee with the referring practitioner. The BBA did not specifically define what the fee sharing arrangement should be; the Health Care Financing Administration (HCFA) defined it as 75% for the consultant and 25% for the referring practitioner. This fee-sharing concept was designed by those who envisioned that the primary care provider would accompany the patient to the telemedicine clinic visit and should be reimbursed. In actual practice, this rarely occurs. Most primary care providers are busy in their own practices and do not attend referral appointments with their patients. This fee-sharing has also raised serious questions about the legal issues surrounding "kickbacks" and has been widely criticized by the telemedicine community, as well as the primary care providers.
This fee-sharing requirement should be eliminated and reimbursement for telemedicine should be the same as for a regular visit. Each encounter should generate customary charges. The professional fee should go to the health care provider who delivers the care. The site where the patient is presented from (e.g. rural hospital, clinic, etc.) should be able to bill HCFA for a telemedicine facility fee given that the patient must be checked into the clinic, there is customarily a nurse present, and on-site supplies are used. (See #3)
2. The requirement for a telepresenter should be eliminated. Physicians and nurse practitioners do not customarily accompany their patients to telemedicine visits. There is usually a nurse present but this should not be mandated. There are situations in which the patient would be perfectly capable of "presenting" him or herself, such as patients attending visits for psychological counseling services.
3. HCFA prohibits payment for any line charges or facility fees to cover telecommuting costs. It also prohibits the billing of beneficiaries for such charges. A recent large study from the Missouri Telehealth Network showed that patients saved an average of just over $40 per visit by avoiding the trip to the tertiary care hospital.The referring clinic should be reimbursed for the cost of their services. HCFA should generate two or three telemedicine codes for the referring clinic to use that would reflect reimbursement for the technological, clerical, nursing and supply costs. The most commonly used code should pay $20, the amount that these clinics report that they would need to sustain this service for their local patients.
This $20 facility fee will be stipulated in the law for the first 2 year period to enable the rapid implementation of its payment. Originating sites able to bill for the facility fee include physician and other practitioners offices, hospitals, critical access hospitals, rural health clinics, community mental health centers, federally qualified health centers, ambulatory surgical centers, dialysis facilities, skilled nursing facilities, Indian Health Service clinics, and comprehensive outpatient rehabilitation facilities. This would prevent someone from just putting up a shack in a parking lot and help to limit fraud and abuse.
4. Current legislation limits reimbursement for telemedicine to services provided to persons residing in Health Professional Shortage Areas (HPSAs). These HPSAs are based on availability of primary care. Telemedicine serves patients who are underserved for primary and specialty care. Medicare beneficiaries who live in an area underserved for specialty care should not arbitrarily be denied access to readily available, high quality specialty care if they do not live in a HPSA.
All programs in non-MSAs and urban HPSAs should be covered. This includes all current federal demonstration projects.
5. The Act defines telehealth as "professional consultation". An overwhelming majority of telehealth sessions involve direct patient encounters and not "professional consultations" between clinicians. Legislation is needed to recognize direct patient care in addition to professional consultations. Payment for services provided shall include payment for office visits, professional consultations, and like services of the HCPCS codes. Payment for all current procedural terminology billing codes that are covered under the Medicare program under title XVII of the Social Security Act is allowed but the secretary is given the authority to deny payment for procedure codes that are inappropriate for reimbursement if performed via telehealth technologies. She is instructed to evaluate the procedure codes and report back to Congress after two years on which are and which are not appropriate.
6. All providers eligible for HCFA reimbursement for services delivered in person should be eligible for reimbursement for services delivered via telemedicine. This should include clinical psychologists, and physical, occupational, and speech therapists. This list already includes everyone who is eligible to bill HCFA for services already.
7. Store and forward technologies should be allowed without the condition of interactivity required in federal demonstation projects conducted in Alaska or Hawaii. This limitation to two states was needed to prevent fraud and abuse and to keep the score down. These states were selected because they each have communities to which it is impossible to run T1 or ISDN lines.
8. Telehomecare should not be prohibited. Where home health providers are paid on a prospective basis, nothing prevents them from incorporating telehomecare where appropriate into their care plans. These visits do not substitute for in person visits for the billing purposes. This is not a change in the law.