CHESTERFIELD, Mo. — From a glassy four-story building in the St. Louis suburbs, doctors and nurses at Mercy Virtual Care Center give checkups and monitor vital signs for patients located miles away — even, sometimes, in other states.
Yet much of its long-distance treatment isn’t yet compensated by Medicare, the largest insurance payer in the United States.
Mercy Virtual — often referred to as the country’s first hospital without beds — is part of a new frontier in medical care. Virtual care, or telehealth, is increasingly adopted by hospitals and clinics not only to fill in shortages in rural areas but also to care for patients more proactively than many hospitals have resources for.
Mercy and other hospitals say virtual care has allowed them to achieve better patient outcomes with fewer staff. Doctors and nurses can oversee many more patients virtually than if they were to make their rounds on foot, and they’re able to simultaneously monitor blood pressure, pulse, temperature and other vital signs for dozens of patients — and intervene early if needed.
In one wing of Mercy’s virtual care center, nurses and assistants sit at six-monitor work stations where they might video into a patient’s hospital room on one screen while viewing vital signs and medical records on another. In another wing of the building, staffers hold video calls with patients in their own homes who have been equipped with iPads and medical equipment for remote monitoring.
The idea is “to meet the patients where they are, as opposed to expecting the patients to come to us,” Mercy Virtual President Gavin Helton told me during my visit last month to the hospital. “To me, that’s foundational.”
But every hospital must ultimately be paid to be sustainable, and that’s still an open question when it comes to treating patients with diabetes, congestive heart failure or other serious conditions via virtual care.
Under a long-standing restriction in federal law, the Medicare program generally only pays for telehealth services when they’re provided to patients in rural settings, where there are often doctor shortages.
From within the walls of Mercy Virtual, doctors and nurses supplement in-person care to patients in the health system’s 32 acute care hospitals. But they don’t get reimbursed by the traditional Medicare program for telemedicine in nearly half of those hospitals because of where the facilities are located.
Fourteen of the hospitals don’t qualify for telemedicine coverage for most services, under Medicare’s strict reimbursement rules.Maureen Kozlowski, director of support services for Mercy Virtual, told me they still offer virtual services throughout the hospital network because “Mercy sees providing the same level of telemedicine care in urban areas as the right thing to do for our patients.”
It’s a similar story for Providence St. Joseph Health, the nation’s third-largest hospital network, based in Washington state. Of the 110 hospitals where it provides virtual care services, at least several dozen of the facilities are ineligible for Medicare telehealth payments.
Rather than operating an entirely virtual hospital, like Mercy, Providence deploys physicians and nurses from its hospitals in Seattle and Portland to deliver virtual care to other facilities with fewer specialists present. The approach has helped rural hospitals lower their overhead costs, said Amy Compton-Phillips, Providence’s executive vice president and chief clinical officer.
“If they’re paying people to sleep in the hospital for every specialty service, that’s a lot of sunk costs,” Compton-Phillips told me. “One stroke doctor can probably cover 50 hospitals versus one hospital.”
Helton said the same. “You leverage technology to take limited clinical resources across a much larger area … as opposed to a facility having to hire that specialist, hire that physician,” he told me.
Rural hospitals are undoubtedly facing steep challenges. The rate of rural hospital closures doubled between 2013 and 2017 compared with the five years before that, the Government Accountability Office found. The closures were generally linked to financial distress and were concentrated in the South and in states that haven’t expanded Medicaid.
In light of this reality, there are some exceptions to the tight set of Medicare rules around payment for virtual care. Chief among them is a geographic provision allowing telehealth reimbursement if the patient is located within a rural area as defined by the U.S. Census Bureau or within an area designed by HHS as lacking enough health professionals.
But telehealth advocates say it’s insufficient. It’s not only rural areas that lack access to enough health providers, said Christa Natoli, deputy executive director of the Center for Telehealth and eHealth Law. Natoli pointed to low-income areas of the District where many reports have detailed a lack of medical facilities.
“You have patients literally living all over the country … and we’re not able to provide them access to good care,” Natoli said. “We have the solution that could bridge that gap but the regulations for reimbursement are not in line with what our pragmatic, modern-day need is.”
Congress has recently lifted some of the telehealth restrictions for specific illnesses, and there’s evidence the Trump administration is also on board with expanding payment opportunities as much as it’s able under current law.
As of January, providers may bill Medicare for services provided to hospital-based stroke patients and at-home patients with end-stage renal disease located in urban or suburban areas. Both changes were approved by Congress as part of a bipartisan spending agreement early last year.
The Centers for Medicare and Medicaid Services has also removed the geographic limitations on end-stage renal disease treatment if the patient is located in a renal dialysis facility where stroke patients are also being treated via telehealth.
Indeed, CMS has appeared eager to encourage use of telehealth. In the physician payment schedule the agency released in the fall, it included a new billing code allowing doctors to be paid for “check in” phone calls with patients. The agency got around the legal restrictions by declaring that these checks-ins aren’t considered telehealth services at all. (Some physicians, however, have raised concerns this could have a chilling effect on patients because they'd have to start paying a co-pay for services doctors say they're already providing free of charge.)
The agency is also seeking comments on removing the geographic restrictions for treating patients with substance abuse via telehealth and allowing reimbursement if they’re at home during a virtual appointment.
“It showed CMS — particularly this administration — they want to push the boundaries,” said Sean Cavanaugh, who directed Medicare’s payment policies at the agency during the Obama administration. “What can we do within the current rules?”
NOTE TO READERS: This is Part 1 of a two-part series about paying for virtual health care. Look for Part 2 in Monday's Health 202.
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AHH: For conservatives who failed to repeal the Affordable Care Act, rerouting veterans’ care to the private sector is the next front in the battle over U.S. health policy and will probably be a reelection theme for President Trump next year, The Post's Lisa Rein reports.
Trump’s signature policy for veterans — shifting much of their health care from the government-run system to private doctors and hospitals — is in full swing as Veterans Affairs Secretary Robert Wilkie moves quickly to roll out new rules by June that would expand access to private care. "Within two years, as many as half the seven million veterans now seen at VA could receive their care elsewhere, advocates of the change say," Lisa writes.
But Democrats in charge in the House are resisting. "They say proposed rules on when veterans could go outside VA are too lenient and would damage the government system — a long-held fear of Democrats who worry union jobs will be siphoned and the government system dismantled," Lisa reports. "While not directly opposing a veteran’s right to see a private doctor, opponents are undermining the new policy in a series of hearings, statements and letters and preparing for aggressive oversight as VA rolls out rules to put in place legislation Congress passed last year."
OOF: Mississippi Gov. Phil Bryant, a Republican, has signed a "heartbeat bill" banning women from obtaining an abortion once a fetal heartbeat is detected, a fresh effort to restrict abortion in a state with a single abortion clinic. Similar measures, which would effectively ban abortions before some women even realize their pregnant, have been advanced in Kentucky and Iowa but blocked by courts because of how early in pregnancy they would restrict the procedure. And in November a federal judge struck down another Mississippi law banning most abortions after 15 weeks.
"Right-wing and religious groups have said that they hope this rash of legislation will eventually force the Supreme Court to reconsider Roe v. Wade, the 1973 case that legalized abortion nationwide, and that they will find a sympathetic audience in recently confirmed Justice Brett M. Kavanaugh," my colleague Reis Thebault reports.
The law includes exceptions for women facing extreme health risks but also states that any physician who violates the restriction is subject to losing the license to practice medicine, Reuters notes.
Bryant tweeted this:
OUCH: Several Democrat-led states tell Politico's Alice Miranda Ollstein and Rachel Roubein that they'll refuse federal family planning dollars if the courts uphold a decision by the Trump administration to steer the money away from health providers who offer abortions or refer for them. Twenty-two states have sued the administration over the new rules, which would effectively require Planned Parenthood to drastically alter its operations, or forego an estimated $60 million in annual funding.
"Oregon and Washington already have said they would opt out of the Title X program, which steers $286.5 million for birth control and reproductive health services for low-income women, if the new rules take effect in early May," Rachel and Alice write. "Maryland could soon join them, and other states may follow. They say the new restrictions would undermine medical care for patients, and, in some cases, violate state laws."
Of the states suing over the new rules, only four told Alice and Rachel they plan to stay in the program. But that would create a major funding gap, requiring states to spend more of their own dollars or cut services to women.
"Neither Washington state nor Oregon have said how they would make up the dollars if their suits are unsuccessful," Rachel and Alice write. "Washington’s lawsuit says the state would not be able to make up the shortfall and would be forced to 'restrict the population of patients eligible for subsidized family planning services.'"
—New York City Mayor Bill de Blasio regularly praises his nearly $1 billion plan to address mental illness in the city, known as ThriveNYC, in his recent visits to early presidential primary states. But the initiative might not be going as swimmingly as the mayor makes it sound, the New York Times writes.
"But back home, the effort, now in its fourth year, has sputtered," NYT's J. David Goodman reports. "The plan, which includes dozens of discrete programs across 15 city agencies, has undergone two leadership changes in the last year; the most recent saw a top official from the Police Department, Susan Herman, taking charge last month.
"For all the talk, the initiative has been less sweeping than envisioned: A third of the budget has not been spent, according to an analysis of city data by The New York Times," David continues. "Repeatedly presented by City Hall as a four-year $850 million plan, city officials now say $560 million will have been spent in that time...The biggest challenge for Mr. de Blasio and Ms. McCray has been to identify concrete results. A spreadsheet of nearly 500 data points tracked by City Hall included almost none related to patient outcomes."
—A few more good reads from The Post and beyond:
Late Night with Seth Myers: