What MACRA Means for Telehealth Reimbursement

Welcome to the second half of our series on MACRA! We’re going to spend this whole post on what MACRA means for telehealth, so if you need to catch up on the basics of what the new law is and what it means for Medicare reimbursement in general, please check out part one first and then meet me back here.

If you’re already up to speed on MACRA 101, though, and you’re ready for a nitty-gritty deep-dive on what the new legislation might mean for telehealth and especially for telehealth reimbursement, then let’s get started.

Telehealth and the Quality Payment Program

The Quality Payment Program (QPP) that MACRA introduces is the linchpin of the legislation, and its payment policies will define how the new regulations as a whole will influence telehealth adoption and payment.

The QPP has two participation tracks for physicians to choose between: Advanced Alternative Payment Models (Advanced APMs) and the Merit-based Incentive Payment System (MIPS), so let’s cover how telehealth incentives will work under each of them.

Advanced APMs: Indirect Telehealth Money

As we briefly touched on in the last article, Advanced APMs are large, coordinated healthcare structures (certain Accountable Care Organizations, big dialysis programs, integrated oncology care programs, etc.) that agree to share both risk and reward with the Medicare program. If an Advanced APM can meet quality and outcome goals for a price cheaper than expected, it will be financially rewarded by the QPP. However, if its expenses outstrip its budget, then it will bear at least some of the overage alone.

There are tremendous opportunities for telehealth to be valuable for care operations that are as large and complex as Advanced APMs are. Video calls that prevent emergency department visits, lightweight online check-ins that increase the number of patient monitoring touch points between clinic appointments, HIPAA-compliant team messaging for better care coordination: the possible list is nearly endless.

For most individual physicians, however, there won’t be much autonomy within an Advanced APM to make decisions about telehealth utilization that would directly influence reimbursement outcomes for the organization. Advanced APMs are instead likely to (and, in fact, should) pick telehealth strategies for the whole operation to use in a coordinated fashion. In this way, MACRA and the QPP will reimburse physicians in Advanced APMs who make use of telehealth, but it will be indirect, occurring via increased payment for better and more efficient total care, rather than as specific new payments for telehealth services.

MIPS: Slightly-Less-Indirect Telehealth Money

Advanced APMs clearly represent the government’s vision for the future of healthcare, but a full transition to such a model will take many years. At least initially, most physicians will continue to bill Medicare Part B in a typical fee-for-service manner, and MACRA provides for this under the QPP’s Merit-based Incentive Payment System (MIPS).

As we covered in our first article on MACRA, Medicare payments under MIPS will be adjusted, positively or negatively, based on a physician’s performance across four categories of assessment:

  1. Quality
  2. Improvement Activities
  3. Advancing Care Information
  4. Cost

The Centers for Medicare and Medicaid Services (CMS) has helpfully provided a very detailed list of criteria for each of these categories on its new website for the QPP, and it appears that telehealth technologies will be useful to physicians in fulfilling a number of them. This seems especially true for the “Quality” and “Improvement Activities” measures, and we’ll share with you some of our favorite criteria from those categories, ones that should help you get reimbursed for your telehealth efforts by way of higher payments under MIPS.

MIPS “Quality” Measures

CMS lists 271 possible “Quality” measures. These metrics pertain to specific aspects of clinical practice, and they are often quite detailed and applicable only to certain medical fields (e.g., measures for “anastomotic leak intervention” or “anesthesiology smoking abstinence”).

Most practices will need to report on six of these measures to satisfy the requirements of MIPS, and telehealth will be able to help with many of them. We’ve identified a few groupings of measures to help spark your thinking:

– Clinical Outcomes Measures

Unsurprisingly, many of the Quality measures attempt to directly assess clinical outcomes. Various forms of telehealth, from home blood pressure telemonitoring to post-discharge nurse video check-ins, have been shown to improve such outcomes, and now MIPS will reward physicians for pursuing them.

There are many possible criteria in this group, but a few big examples to consider include:

  • “All-cause Hospital Readmission”
  • “Controlling High Blood Pressure”
  • “Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)”

– Patient-Reported Data Measures

A large number of Quality measures are based on patients’ assessment of their own health. For example, there are at least 12 measures that focus on “functional status” in a variety of conditions (osteoarthritis, hip or knee replacement, heart failure, etc.), and these measures generally recommend that clinicians use a “validated tool” to survey patients as a means of determining their functional status. Such surveys can be easily performed via asynchronous telehealth technologies and incorporated into in-person visits in a way that provides structured data to satisfy MIPS and that also saves time during the face-to-face visit.

Other Quality measures that center on patient reporting include inquiries on pain (“Pain Brought Under Control Within 48 Hours” for patients admitted to palliative care services), depression (“Depression Utilization of the PHQ-9 Tool”), and asthma (“Optimal Asthma Control”), among many others.

– Patient Communication Measures

There are also a number of Quality measures that relate to engaging patients in meaningful discussions for the purposes of education and shared decision-making. These will still likely require some element of an in-person visit, but a creative use of telehealth can save lots of time and provide much greater value to patients (e.g., persistent online access to educational materials and secure messaging for follow-up questions).

Examples of measures in this group include:

  • “Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options”
  • “Parkinson’s Disease: Rehabilitative Therapy Options”
  • “Patient-Centered Surgical Risk Assessment and Communication”

MIPS “Improvement Activities” Measures

“Improvement Activities” is the other category of MIPS measures that appears amenable to telehealth. Most practices will need to attest to four of these metrics to satisfy MIPS, and there are 92 possible ones to choose from.

Happily, telehealth is specifically called out as one of the measures:

Use of telehealth services that expand practice access
Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults or teleaudiology pilots that assess ability to still deliver quality care to patients.

So, right off the bat, use of telehealth technologies can get you points in the Improvement Activities category.

Other measures for which telehealth might be useful sort into a few general groups:

– Patient Experience and Satisfaction Measures

These measures all seek to elicit and prompt action on patient feedback. Telehealth technologies can help you formalize the processes necessary to do this well (e.g., adaptive, automated questionnaires), reducing the time and effort required to implement such a program and improving the robustness of the collected data.

Examples of measures in this group include:

  • “Collection and follow-up on patient experience and satisfaction data on beneficiary engagement”
  • “Collection and use of patient experience and satisfaction data on access” (access to care)
  • “Engage patients and families to guide improvement in the system of care”
  • “Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms”

– Between-Visit Patient Engagement Measures

These measures promote ongoing healthcare between visits, including increased provider-patient contact and patient self-management activities. This might seem like an invitation for lots of additional work that is not directly compensated, but with a smart use of telehealth and its powers for automation, you can hugely reduce the potential provider burden while still offering patients improved care.

Telehealth tools that incorporate care plans, scheduled coaching, and modern communication methods (e.g., secure messaging) will be especially useful with this category of MIPS criteria. Measures likely to benefit from telehealth use include:

  • “Integration of patient coaching practices between visits”
  • “Improved practices that engage patients pre-visit”
  • “Implementation of condition-specific chronic disease self-management support programs”
  • “Improved practices that disseminate appropriate self-management materials”
  • “Implementation of improvements that contribute to more timely communication of test results”

MACRA does not provide the immediate, direct reimbursement for telemedicine that many people were hoping for, but it still provides new paths to telehealth payment for those who are willing to look for them and ready to expand their view of telehealth beyond simple video visits.

MACRA’s recognition of telehealth is mostly indirect, but it is nonetheless powerful.

Modern telehealth tools now allow providers to reach out to patients in a scheduled, programmable way with coaching tips, check-ins, care routine reminders, pre-visit planning, progress checks, feedback surveys, validated clinical instruments, and all manner of other content types. If you use these options in a coordinated way with your in-person practice, many MIPS criteria become easy to fulfill, and you can set yourself up ideally for the program’s eventual +9% bonus adjustment on all of your Medicare payments while providing amazing care to your patients.

MACRA’s recognition of telehealth is mostly indirect, but it is nonetheless powerful. It’s worth your time to figure out how you can best adapt to the new law’s reimbursement opportunities and, especially, to the increasingly clear role that telehealth will play in making those opportunities realizable.

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