While it may be imperfect, the CONNECT for Health is a critical step in telemedicine adoption. On a recent trip to DC I got to discuss the bill with key legislators, and a few critical issues rose to the surface.
by Judd Hollander, MD
The CONNECT for Health Act is major step toward allowing people to receive the care they need and deserve in a more efficient patient-centered manner. The Act would create a bridge program to help eliminate or reduce some of the restrictions Medicare now applies to telehealth, especially with alternative payment models (APM) and metric based incentive payment systems (MIPS); promote the use of remote patient monitoring for certain chronic conditions, expand allowing originating sites to include telestroke evaluation and management sites, and dialysis facilities; and further permit telehealth in community health and rural health clinics. The proposed Act is not perfect; but it is an important step forward.
My colleague, Roger Band, and I thought members of Congress and federal agencies might like to hear from providers who utilize video visits to care for patients. We met with 8 members of the House and Senate or their legislative aides. These included bill sponsors Senator Roger Wicker [R-MS], Senator Brian Schatz [D-HI], and Diane Black [R-TN]; PA Senators Bob Casey [D] and Pat Toomey [R]; and PA Congressmen Robert Brady [D], Pat Meehan [R] and Charlie Dent [R]). Additionally, we spent time with representatives from the Food and Drug Administration Center for Devices and Radiological Health (Digital Health Division); White House Office of Science and Technology Policy (OSTP); Office of the Assistant Secretary for Planning and Evaluation (ASPE) in Health of Human Services; Veterans Administration (VA), and the Office of the National Coordinator (ONC).
Rather than go to Congress asking for money, we chose to discuss broader issues of the Act. We chose not to discuss reimbursement.
We emphasized that access is more important than geography. Timely and appropriate medical care can be very difficult in rural environments; however, rurality is not the only item that impacts access. Greater numbers of people in urban communities might have access difficulties than much larger areas of rural counties.
Although most medical expenses occur in people with chronic diseases, hospitalizations, which are the main drivers of expenses, occur in people with acute exacerbations of chronic diseases. It is imperative to be able to utilize telemedicine to treat acute exacerbations of chronic conditions.
The requirement in the Act that people have two or more chronic conditions and be hospitalized or seen in the emergency room twice in the past year is not practical for the average provider to know. It may result in the unintended consequence of having providers send more people to the emergency room just so they meet criteria to be better managed at home with telemedicine. This could drive up expenses.
We are deeply concerned about the way care coordination gets emphasized by many people. Restricting telemedicine use to an “established relationship” or“primary care provider” may not help achieve the goal of care coordination. In the ideal world, a patient would speak with their provider who can access their medical record. In reality, the “on call” physician is usually someone they don’t know who does not have access to their medical record, yet that provider is considered to have an established relationship. We would proffer that the ability to perform care coordination is more important than whether or not the provider meets the definition of an established relationship. For example, an emergency physician, with access to the medical record, can better coordinate care with the primary physician than their partner who is in a restaurant when fielding the call.
Additionally, let’s not limit telemedicine use to primary care providers such as family or internal medicine. If a woman with breast cancer has her medical oncologist effectively delivering all her care, her telehealth option should not be limited to care provided by her family physician.
We should not limit provider-to-provider critical care consultations to stroke. Stroke has served as a model for these types of consultations, but we would recommend using the infrastructure that exists to treat other life threatening conditions.
After our day in Washington DC, there is clarity about how we can get over the Hill. It is a four-letter word – DATA. Although everyone supported telemedicine conceptually, everyone expressed concern about the paucity of data. The government will not support higher expenses in the absence of higher value care. Does telemedicine reduce expensive care or result in more visits without improved outcomes? Which subsets of patients benefit? Does it reduce caregiver time commitment for visits? Does it improve or worsen antibiotic resistance.
The telehealth industry can help by reducing barriers to research. Large telemedicine providers need to partner with researchers who can analyze and publish their data. Industry should not keep their data private. Health systems must make sure they do not sign vendor contracts that enable information blocking (creating hurdles regarding sharing of data). Researchers must begin to address these questions. Academic Medical Centers (AMCs) need to brainstorm about how they can work together. A meeting of AMCs this June 21 and 22 will address the ways they can form clinical and educational partnerships, as well as develop the research infrastructure required to facilitate creation of the evidence base that can be used to inform policy makers. Already 70 representatives from AMCs, Congress, government agencies, and the FDA are attending (contact firstname.lastname@example.org for further information)
Finally, want to make a difference? Speak with your federal representatives and ask them to support the Act. It is not perfect, but it is one step we must take to get telemedicine over the Hill.