Beginning in 2020, we have been seeing telehealth play a key role in providing care and filling access gaps for members/patients most at risk. The COVID-19 pandemic challenged the conventional health care models, as in-person office appointments became unfeasible due to strict social distancing guidelines and the need to reduce a patient’s risk of exposure. The expansion of telehealth enabled member/patients to experience continued care while reducing the risk of overburdening emergency departments and urgent care centers during the pandemic. Telehealth has presented a valuable alternative during these challenging times, with an added benefit of savings derived by reserving costly healthcare facilities and their resources for the people who need them most. According to America’s Health Insurance Plans (AHIP), telehealth could help save the United States as much as $4.28 billion 1,2 on health care spending per year, and studies have shown net cost savings totaling $100 per visit.
This upsurge in the need for telehealth has been recognized and acted upon by Centers for Medicare & Medicaid Services (CMS). Prior to COVID-19, a limited number of services were approved to be delivered via telehealth. As a result of the COVID-19 pandemic and in addition to the Public Health Emergency (PHE), CMS released “Waiver 1135,” which expanded Medicare telehealth services so members could receive care from their providers without physically traveling to a healthcare facility.
CMS announced the coverage of telehealth and introduced a number of codes to assure accurate reimbursement of those services. For example, the annual wellness visit (AWV) is a member benefit that provides key insights into health risks and care gaps, while enabling the provider to engage patients with personalized prevention plans. With the inclusion of AWV on the list of allowable CMS telehealth services, plans can ensure members receive the appropriate quality of care, minimize the risk of high-cost treatments and maintain documentation accuracy. A complete list of allowable CMS telehealth services can be found on the CMS website (CMS Telehealth Services).
Telehealth utilization is on the rise and could continue to become a mainstream channel of healthcare delivery. A survey of University of Pittsburgh Medical Center (UPMC) patients found that if they had no access to a virtual visit, 40% would have forgone care to avoid traveling.3 Looking specifically at Medicare Advantage, SS&C saw our health plans take advantage of this modified benefit for their members, with more than 36% of annual wellness visits in April 2020 delivered via telehealth.4 However, despite the rapid adoption of telehealth, the total volume of annual wellness visits in April through June was 20% lower than compared to 2019 volumes. Increasing member adoption of telehealth will help bring this number up and help ensure that appropriate care is being provided to this often high-risk population.
While the necessity of telehealth is widely recognized and accepted, there has been a definite impact on both health plans and their members. Whereas health plans adjusted to new care delivery models with few difficulties, some members have had issues when adjusting to the changes. For seniors, in particular, telehealth may have presented some early challenges in utilizing technology. Lacking the comfort of face-to-face interaction, they may have also been unsure that all care needs could be met through this virtual office visit. However, as utilization of telehealth services has become more prevalent, we have seen that there are numerous benefits to members:
The expansion of telehealth has demonstrated that it can be leveraged to efficiently and safely address care needs for members. What can plans do to be sure members are deriving the maximum benefit? We recommend continuing the infrastructure and care models that support acute telehealth and well-care visits for the chronically ill. This includes evaluating documentation and monitoring services so that preventive and chronic care are delivered at similar levels to prior periods. Further, when an annual wellness visit has been delivered by telehealth, a comprehensive review of recapture rates for risk adjustment should be performed to verify that all chronic conditions have been addressed and documented. Plans should also work closely with telehealth providers and vendors to ensure that the visits are addressing gaps in care when applicable.
Ongoing routine monitoring of coding and documentation is another area where health plans can benefit, as this allows for changes to member engagement in support of quality improvement and risk adjustment. Throughout the year, a mix of prospective and retrospective interventions can be performed to ensure that the submission of risk adjustment diagnoses represents the health risks in the plan population.
SS&C Health can support health plans in these efforts with quality and risk analytics, provider collaboration tools, encounter submissions and coding review. Contact us for more information on how we can add value to optimize your plan performance for member health goals.