Specialty Telehealth Expands the Value of Medicare Advantage

By Jonathan Wiesen, MD

Medicare Advantage (MA), also referred to as “Medicare Part C,” a benefits plan provided to Medicare-registered patients through a private-sector health insurer, typically provides services beyond the standard Medicare benefits, including dental health, specialty pharmacy, transportation, and often telemedicine (Medicare.gov, n.d.a).

It is no surprise that enrollment in MA plans has doubled over the last decade and, to date, represents approximately 40% of all those enrolled in Medicare (Medicare.gov, n.d.b).

Post-COVID-19 societal changes for Medicare Advantage beneficiaries

The societal changes and adaptations that we have witnessed in 2020 are nothing short of astounding. Almost overnight, humanity transitioned to virtual interactions, reliant upon high-definition video conferencing software and broadband internet for business meetings, social gatherings, and family visits.

These adaptations were not limited to the young and tech-savvy. More senior citizens than ever before have been using mobile platforms for everything from social interactions to mundane tasks such as paying bills and ordering food. Healthcare for the elderly is similarly being transformed to a virtual, home-based enterprise: A recent Advisory Board Study survey demonstrated that 75% of individuals over 60 years of age used a telehealth-related monitoring device routinely (Kowalick, 2020), and a recent study indicated that a majority of MA participants have used telemedicine services during the COVID-19 pandemic, with over 90% satisfaction with the experience (King, 2020).

Global healthcare has also changed dramatically during this time. Telemedicine has become routine both for primary and specialty care, from rural hospitals to tertiary care university hospitals. Moreover, digital devices and monitoring modalities are more commonplace. Not only are individuals utilizing cloud-based telehealth patient platforms, but they are also commonly being linked to clinical remote monitoring programs, which are now reimbursable by CMS (Better Medicare Alliance, 2017).

Specialty telemedicine: Toward the next important value proposition

The value of general telemedicine for MA plans is a foregone conclusion as evidenced by its extraordinary rate of adoption and utilization during the COVID-19 pandemic.

General telemedicine—routine urgent or acute care consultations with on-call physicians—has recently been demonstrated as one of the most cost-effective benefits in MA plans (Berg, 2019).

A Government Accountability Office report from early 2019 attributed MA savings of over $500 million to telemedicine services. Given these massive cost savings, the report advocated making telemedicine services a routine benefit in MA programs and estimated that an allocation of almost $100 million to CMS’ Medicare Trust Fund will be delivered as a result (U.S. Government Accountability Office, 2019).

Cost savings attributed to telemedicine are more than $200 per episode, according to a recent study published by Anthem, which was largely the impetus for expanding and encouraging telemedicine services among their MA plans. Anthem expects that greater engagement in telemedicine services will lead to greater savings. Moreover, the study demonstrated fewer ancillary tests and unnecessary medications as compared with routine brick-and-mortar care for MA beneficiaries, without any decrease in outcomes (Morse, 2019).

Specialty telemedicine and Medicare Advantage: Post-COVID-19 safety  

There is no more compelling benefit of telemedicine than patient and provider safety, which has gained critical importance during the COVID-19 pandemic. Specialty telemedicine, in particular, has been hailed as an imperative for any and all healthcare services since it provides high-quality care while still maintaining the distancing measures necessary to prevent viral transmission.

Although caution should be expressed for all close social interactions, medical professionals must be especially cautious since they are routinely exposed to, and potential carriers of, infectious agents. With the advent of turnkey, user-friendly specialty telemedicine platforms, MA beneficiaries can access their primary care physicians or specialists routinely, frequently, and with relative ease. This is particularly relevant since MA beneficiaries’ underlying comorbid medical conditions place them at high risk for severe COVID-19 sequelae, yet simultaneously also necessitate relatively frequent medical consultations (such as with endocrinologists and cardiologists).

Safe and thoughtful care of MA beneficiaries necessitates that all telemedicine, particularly specialty services, be utilized as often as possible to protect both patients and their caregivers. What’s more, telemedicine has been demonstrated to be cost effective and highly appreciated by the MA patient population.

Case study: Inadequate usage of specialty telemedicine during COVID-19 Experts warned that fear of contracting COVID-19 would prevent individuals from seeking medical care even during medically urgent or emergent situations. A recent study published in the New England Journal of Medicine demonstrated a large and unexpected decreased incidence (approximately 40%) in ST-segment elevation myocardial infarctions (STEMI), a medically emergent diagnosis, during March. The implication of the findings was that patients were remaining at home in the face of emergent medical conditions. Fear of contracting COVID-19 prevented patients from seeking emergent medical care and likely resulted in numerous fatalities. Given many patients’ fear of in-person medical care during the pandemic, we must mobilize specialty telemedicine to care for urgently and emergently ill patients (Solomon et al., 2020).

How specialty telemedicine can address specialty provider shortages

Prior to the current pandemic, reports noted a shortage of at least 50,000 specialty providers in the United States. Reasons for the shortfall include uneven distribution of providers, a shortage of training facilities, and physicians leaving practice because of burnout and retirement. This finding is not novel, with reports on the trend going back years. The onset of COVID-19, and the subsequent closure of many primary and specialty care outpatient clinics, will likely exacerbate this deficiency.

Specialty telemedicine has been proposed as an intuitive solution for a number of reasons:

1. Telemedicine levels the playing field and streamlines physician availability. Physicians can remotely cover multiple locations at once, thereby increasing their ability to accept consultations. Moreover, inefficiencies in the system, such as delays during patient intake, do not prevent an astute telemedicine physician from seeing patients; rather, the physician can simply recalibrate and see other patients during these down times. Lastly, lifestyle considerations, which may prevent physicians from residing personally or with their family in the rural locations of the greatest physician deficiencies, would not preclude doctors from seeing patients in that region.
2. Telemedicine is cost effective and has demonstrated a great return on investment for patients, healthcare providers, and payers. For patients, telemedicine-related costs are significantly cheaper than any of the alternative modalities of treatment. The range of telemedicine costs reaches a maximum of just $79, compared to $146 for outpatient physician consults or $1,734 for an ER visit. The reasons for this are simple: In a telemedicine consult, the only two required parties are the physician and the patient, whereas the infrastructure behind an in-person patient visit includes buildings, office personnel, test equipment, nurses, and various other expense items. Vendor data from the World Health Organization also shows that telemedicine reduces the need for urgent healthcare visits by 45%, as simple conditions can be treated easily, and more complex ones can be detected and solved early on. Furthermore, 83% of conditions can be solved through telemedicine consultation instead of a scheduled doctor’s visit.

How telemedicine can be cost effective for Medicare Advantage plans

The potential benefits of telemedicine for MA patients—or, for that matter, all patients—are numerous: provider and patient safety, cost savings, improved outcomes, high satisfaction, beneficiary engagement, and chronic disease management.

1. Better convenience and better outcomes: On-demand urgent care telemedicine visits have proven to save MA beneficiaries time and money. Moreover, providing primary care via telehealth platforms will allow MA beneficiaries the convenience of continuous access to physician services, particularly related to managing their chronic medical conditions. Studies have indicated that telemedicine is also associated with improved outcomes in the MA population, particularly in rural locations where access to in-person healthcare is limited.
2. Annual primary care examination: Primary care physicians (PCP) from a telemedicine network can supplement a patient’s existing PCP services and even provide additional services as convenient for the patient. This includes the annual primary care assessment. Since MA payments are typically adjusted based on the beneficiary’s personal condition, having a comprehensive evaluation via telemedicine can ensure that patients are receiving the maximal amount provided by CMS. A thoughtful telemedicine PCP must be mindful and creative in remotely performing the physical examination components of the traditional annual primary care assessment.
3. Establishment of HMO in-network PCP and specialty coverage: In most instances (emergencies aside), MA programs cover in-network PCP and specialty services. Telemedicine allows patients to maintain a PCP and conveniently access a physician whom they trust. Additionally, specialty physicians can be accessed via telemedicine as an in-service network benefit.
4. Wellness and preventive care: MA enrollees tend to have more chronic medical conditions than the general population. Delivered through telemedicine, wellness programs can ensure that patients maintain optimal health, and chronic disease management programs can provide patients with digital tools and clinical services to manage chronic conditions (Freed et al., 2020).

The next step: Utilizing telemedicine for primary care and chronic disease management

A 2019 AAMC report estimated a physician shortage in the United States of more than 100,000 providers, distributed relatively evenly between primary and specialty doctors. Compounding this challenge is the increased burden of chronic medical conditions (Quinn, 2019).

For example, a Milken Institute report indicated that U.S. healthcare costs for chronic diseases such as heart disease, cancer, diabetes, and Alzheimer’s disease totaled $1.1 trillion in 2016. When lost economic productivity is included, the total economic impact was $3.7 trillion. This is equivalent to nearly 20% of the U.S. gross domestic product.

Current telemedicine initiatives have not targeted lowering the cost of this major driver of healthcare expenditures, and coaching and wellness programs lack crucial physician engagement and involvement necessary to manage more complex components of the diseases.

Telemedicine and telehealth have been associated with improvements in patients’ HbA1c (17%, over 50% of patients) and 70% improvement in cholesterol management. Telemedicine was also associated with significantly decreased wait times and improved visit attendance for patients with chronic conditions. This improved care led to 75% fewer hospitalizations and a cost savings of $45,000 per patient per year.

Moving forward and riding the wave: Lowering costs, improving outcomes

The remarkable clinical and cost savings data, compounded by the safety profile of telemedicine in protecting patients and providers from COVID-19, should drive MA plans to strongly consider offering not only general telemedicine, but also virtual primary care and chronic disease management.

Today’s environment is primed for the success of such a program—beneficiaries are more comfortable than ever with telemedicine and telehealth, and there is a dire need to bend the healthcare cost curve domestically and globally. Forward-thinking, progressive MA plans are encouraged to offer this type of telemedicine program and can be reassured that it will enhance healthcare safety, quality, and cost savings.

Jonathan Wiesen, MD, is founder and chief medical officer at MediOrbis. Dr. Wiesen is also a pulmonary and critical care physician passionate about clinical medicine, innovation, and medical technology.

References

Berg, J. (2019, November 21). Humana estimates $3.5B in 2018 savings from Medicare Advantage plans. MedCity News. https://medcitynews.com/2019/11/humana-estimates-3-5b-in-2018-savings-from-value-based-care/

Better Medicare Alliance. (2017, November). Telemedicine in Medicare Advantage. https://www.bettermedicarealliance.org/publication/telemedicine-in-medicare-advantage/

Freed, M., Damico, A., & Neuman, T. (2020, April 22). A dozen facts about Medicare Advantage in 2020. KFF. https://www.kff.org/medicare/issue-brief/a-dozen-facts-about-medicare-advantage-in-2020/

King, R. (2020, May 27). Poll: Medicare Advantage members are taking to telehealth. Fierce Healthcare. https://www.fiercehealthcare.com/payer/poll-shows-ma-seniors-who-use-telehealth-are-excited-to-use-service-again

Kowalick, C. (2020, April 10). Survey: Seniors embracing technology amid COVID-19 pandemic. Times Record News. https://www.timesrecordnews.com/story/news/local/2020/04/10/covid-19-moves-seniors-embrace-technology-coronavirus-survey/5122728002/

Medicare.gov. (n.d.a). Get started with Medicare. https://www.medicare.gov/sign-up-change-plans/get-started-with-medicare

Medicare.gov. (n.d.b). How do Medicare Advantage plans work? https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/medicare-advantage-plans/how-do-medicare-advantage-plans-work

Morse, S. (2019, October 16). Telehealth eliminates time and distance to save money. Healthcare Finance. https://www.healthcarefinancenews.com/news/telehealth-eliminates-time-and-distance-save-money

Quinn, W. V. (2019, August). Telehealth and Medicare: What is covered [Fact sheet]. AARP Public Policy Institute. https://www.aarp.org/content/dam/aarp/ppi/2019/08/telehealth-medicare-what-is-covered.doi.10.26419-2Fppi.00080.001.pdf

Solomon, M. D., McNulty, E. J., Rana, J. S., Leong, T. K., Lee, C., Sung, S.-H., Ambrosy, A. P., Sidney, S., & Go, A. S. (2020, August 13). The Covid-19 pandemic and the incidence of acute myocardial infarction. New England Journal of Medicine, 383, 691–693. https://doi.org/10.1056/NEJMc2015630

U.S. Government Accountability Office. (2019, April 30). Department of Health and Human Services, Centers for Medicare and Medicaid Services: Medicare and Medicaid Programs; Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Programs of All-Inclusive Care for the Elderly (PACE), Medicaid Fee-For-Service, and Medicaid Managed Care Programs for Years 2020 and 2021. (GAO Publication B-330965). https://www.gao.gov/assets/700/698923.pdf