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Capitated health-care models may be best positioned to take advantage of telehealth
Reimbursement for telehealth initiatives remains an uncertainty in the United States today, with capitated systems at the forefront in initial teleglaucoma applications.
Reviewed by Siddarth Rathi, MD, MBA
Worldwide, healthcare systems are implementing models of teleglaucoma care. Clarifying reimbursement considerations, however, is necessary for greater strides toward U.S. adoption, according to Siddarth Rathi, MD, MBA, assistant professor of ophthalmology at NYU Department of Ophthalmology. Dr. Rathi noted some examples for consideration.
The University of Alberta’s teleglaucoma program consists of a remote or in-house pathway, he noted. Patients on the remote pathway visit a local ophthalmologist or optometrist who collects standardized history, examination, and imaging findings.
The eye-care provider securely transmits the information to a remote glaucoma specialist who delivers an electronic recommendation to the referring clinician. The in-house program is a tertiary-care referral center in Edmonton.
These individuals see an ophthalmic technician who obtains the history, exam, and imaging, according to Dr. Rathi. A glaucoma specialist reviews the data and sends a report to the referring provider. The program seeks to reduce the time patients spend in the clinic, and wait to have a glaucoma evaluation. In Canada, Medicare reimburses at two-thirds of the conventional in-person fee for these consultations.
At the Lions Outback Vision Center in Australia, the patient sees a local optometrist who sends the history, exam findings, and imaging to the remote ophthalmologist. Dr. Rathi said that the specialist video conferences with the patient and the local provider to deliver the recommendations.
Australia Medicare reimburses clinicians if there is a live audio-video component to the encounter and the patient is located at least 15 kilometers away from the consulting ophthalmologist or resides in a care facility for indigenous Australians.
“Initially, there was no reimbursement for the local referring optometrist,” Dr. Rathi said, “After Medicare implemented reimbursement covering technical costs for the referring physician, the program had a 3.5-fold increase in utilization during the next 12 months.”
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Given the mix of fee-for-service and capitated care health-care delivery models in the United States, as well as the evolution of telehealth reimbursement, a combination of teleglaucoma models could be sustainable, according to Dr. Rathi.
“For example, glaucoma care could be provided via synchronized consultation with the patient who is at home or in the primary-care physician’s office,” he said. “In the future, dedicated telehealth centers could have locations across the country.”
Dr. Rathi noted that like the Canadian version, asynchronized consultations could be useful where the optometrist or general ophthalmologist routes the clinical information to an off-site specialist for collaboration.
“Remote monitoring of glaucoma patients could include home-based IOP measurements and virtual reality visual field exams,” he said.
These remote glaucoma management models have unique advantages, but adoption of telehealth services is often determined by reimbursement. In the United States, a direct-to-consumer model where patients pay for telehealth services is not well-suited to glaucoma.
“Within a capitated healthcare system on the other hand, resources can more readily be dedicated toward creating the needed infrastructure,” according to Dr. Rathi.
Reading centers with peer-to-peer consultation networks would allow high-risk patients to be prioritized for in-person glaucoma clinic visits, while low-risk patients could be followed remotely. Fee-for-service is the predominant payment model in the United States.
Medicare reimburses for telehealth if strict requirements are met. First, the patient must be physically located in a rural area-there is no coverage for patients in urban or suburban settings. Second, the patient must be located in a health-care facility (i.e., critical access hospital, rural clinic, or a physician’s office). The home setting is not included. The interaction must be over live two-way audio/video communication.
The physician must be physically located in the United States. If these requirements are met, payment is on par with in-person fees using standard remote patient monitoring codes with modifier 95 for synchronized telemedicine. Medicare covers asynchronized telemedicine only in Alaska and Hawaii, under active telemedicine demonstration programs (primarily for diabetic retinopathy screening).
RELATED: Nutrition a priority for dry eye patients“This year’s much-awaited Medicare telehealth policy updates included now covering remote consultation and pre-recorded patient information where a physician can evaluate a video or image with an established patient and offer interpretation within 24 hours,” Dr. Rathi explained.
“Now, virtual check-ins with audio and medical discussions are reimbursable without rural location requirements. Medicare provides coverage for remote physiologic monitoring for chronic disease-IOP may fall into this category. It is important to note that this is new territory for ophthalmology and is evolving, and the specialty has no prior experience with these codes.”
Coverage by commercial carriers is often dictated by state. Some states have passed telemedicine parity laws that mandate commercial insurers extend telemedicine coverage for any covered in-person service. Although a positive development, most of these laws do not mandate payment parity.
A carrier can have large differences in its reimbursement rates for services rendered in telemedicine compared with in-person services, possibly disincentivizing physicians from providing these services. Physician medical licensure requiring physicians to be licensed in the state where the patient is physically located has been a regulatory barrier to telehealth adoption. In 2017, the Interstate Medical Licensure Compact allowed expedited licensure in party states.
“Reimbursement for telehealth initiatives is far from guaranteed, with capitated systems likely leading the way in initial teleglaucoma applications,” Dr. Rathi noted. As shown in Australia, reimbursement leads to increased adoption of telemedicine and virtual consultation. Telemedicine parity laws are helping to move efforts forward as Medicare coverage of telehealth is evolving.
Siddarth Rathi, MD, MBA
This article was adapted from Dr. Rathi’s presentation at the 2019 American Glaucoma Society annual meeting. He has no financial interest in any aspect of this report.