ACO Rules Limit Patient Telehealth Options

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In formally asking the Centers for Medicare and Medicaid Services (CMS) to modify the proposed standards for Accountable Care Organizations (ACOs), the American Telemedicine Association (ATA) essentially wants Medicare to treat telehealth services just like any other form of care.

The ATA this week sent a letter to CMS Administrator Dr. Donald M. Berwick, asking the U.S. Department of Health and Human Services, of which CMS is a part, to use its statutory authority to waive five "formidable statutory restrictions for telehealth services under Medicare Parts A and B" in the final ACO rules.

"The failure to waive these five specific Medicare requirements will effectively prohibit the ACOs from coordinating care 'such as through the use of telehealth, remote patient monitoring, and other such enabling technologies,'" the ATA letter said, quoting directly from the ACO proposal. "Given the ACOs financial limits and incentives, there is no reason for Medicare's usual utilization controls on telehealth," according to the ATA, which convenes its annual meeting in Tampa, Fla., on Sunday.

"Telehealth should be an integral part of how ACOs provide healthcare," the Washington-based organization said, citing passages from the Patient Protection and Affordable Care Act of 2010, which authorized the ACO regulations. The group also quoted President Obama, who referred to "a patient who can have face-to-face video chats with her doctor" in his 2011 State Of the Union address.

The ATA said HHS should waive five current Medicare rules that "contain major, arbitrary barriers to Accountable Care Organizations." They include:

-- The restriction on paying for videoconferencing except in rural counties. "Since many ACOs will initially be based at large urban health systems, a waiver of the prohibition on telehealth for beneficiaries in metropolitan areas is critical," the ATA argued. The group said this is critical so new technology can ease a shortage of timely stroke care in metropolitan areas. "High-quality resolution video conferencing is fast becoming common from smartphones and other small, relatively inexpensive consumer devices. ACOs should be able to use these, as appropriate, as well as other fast-evolving technologies for more efficient health care delivery," the letter said.

-- The restriction of Medicare payment for "store-and-forward" telehealth services, such as transmission of medical images to federal demonstration programs in Alaska and Hawaii. This prevents 43 million Medicare beneficiaries who live in the 48 contiguous states from receiving the same services that the federal government already covers for military personnel, veterans, Native Americans, and federal prisoners, ATA said.

-- Restrictions on what types of telehealth services Medicare covers. For example, CMS won't pay for remote consultations on smoking cessation, diabetes self-management training, hospital discharge services, medical nutrition therapy, and neuropsychological testing, according to the ATA. "The current restriction is contrary with the idea of an ACO. Under the operation of the current delivery system, CMS has reserved the right to make its own determination for each specific medical service that could be delivered by telemedicine. This highly structured approach is contrary to the philosophy and specific construction of the ACOs, where appropriate patient services and delivery approaches are delegated to the organization, which is then accountable for the patient's outcomes," the organization argued.

-- Bans on originating telehealth communication from certain locations, including a patient's home, hospices, and some dialysis facilities that stem from a decision to allow specific classes of healthcare providers to charge Medicare a facility fee. "Although not supported by statute, the specification of originating sites is now used to restrict beneficiary access to needed services that can be provided by video conferencing. We contend that a Medicare beneficiary should be covered for telehealth-provided services--even if their location is not specifically reimbursed," the letter said.

-- Restrictions on Medicare paying physical therapists, occupational therapists, and speech-language pathologists for telehealth services. The ATA contends that lifting this and the location-based prohibition would open up home-based telerehabilitation, which the group called "an important service for beneficiaries from whom going to therapy is a major barrier."

"The ACO model is an important opportunity to make Medicare health care delivery more innovative and higher performing. Telehealth is a key set of tools that has been widely acknowledged as an integral part of helping ACOs make a difference," the ATA letter concludes.

CMS is taking comments on the proposed regulations through June 6.