THE PROGNOSIS

NOTE TO READERS: This is the second installment of a two-part series on delivering virtual care. You can read Part 1 here.

CHESTERFIELD, Mo. — Major hospital networks experimenting with virtual care insist the approach is saving them loads of money. But Congress’s official scorekeeper doesn’t necessarily agree — and that makes lawmakers wary of expanding telehealth.

As we detailed in Friday’s Health 202, hospital networks including Mercy in the St. Louis area and Providence St. Joseph Health along the West Coast are leading the way with remote patient monitoring and consultations as a way to overcome physician shortages and deliver more immediate, specialized care.

But providers and telehealth experts say insurance plans are lagging on how to reimburse for virtual care, particularly the traditional Medicare program which covers 40 million mostly elderly Americans.

While a subset of seniors with privately based Medicare Advantage plans have varying degrees of telehealth coverage, the traditional Medicare program doesn’t pay providers for telehealth when it’s delivered to patients in urban or suburban areas. Except for patients with stroke and end-stage renal disease, recipients of virtual care must be in a rural area as designated by the U.S. Census for the provider to get paid by Medicare.

That means hospitals aren’t paid for many of the virtual services they provide to elderly patients, even though they say it has allowed them to improve in some key areas including shortened hospitalizations, reduced mortality rates in intensive care units and fewer incidences of sepsis.

“It’s not a sustainable model,” said Amy Compton-Phillips, Providence’s executive vice president and chief clinical officer. “The challenge is trying to do the right thing between what the need is and what you’re allowed to do from a regulatory standpoint.”

But it would be up to Congress to remove restrictions on the government paying for telehealth, because they’re embedded in the Social Security Act. And that’s difficult to do, because of cost.

When evaluating various telehealth bills, the Congressional Budget Office has generally taken the position that virtual health care would cost Medicare more, because it could drive greater use of services and can involve two separate payments — one to the provider and one to the facility where the patient is located.

To these hospitals, they’re pioneering a promising new era of medicine, one that is centered on evaluating and delivering care to the patient when they need it versus forcing patients to accommodate physicians’ often crowded schedules.

Providence, which operates 51 hospitals and more than 800 clinics across seven states, offers several virtual care programs including telepsychiatry, teleneurology and telehospitalist, focused on general care for hospitalized patients. The hospital network is expanding its virtual services for stroke patients, now that the condition is exempted from the geographical restriction on reimbursement. Compton-Phillips said the hospital network is anticipating 8,000 virtual stroke consultations this year, up from 1,400 in 2016.

At Mercy Virtual, a virtual care-only hospital in Chesterfield, Mo., doctors and nurses provide round-the-clock monitoring and consultations for patients in 32 hospitals within the Mercy network — mostly in Missouri, Oklahoma and Arkansas — and a few outside hospitals.

Mercy says its virtual ICU care program — dubbed “vICU” — has led to 35 percent lower mortality rates and 30 percent shorter hospital stays for ICU patients than predicted across its network. A spokeswoman also said the virtual care program has led to a 40 percent reduction in morality from sepsis and a nearly 90 percent reduction in patients progressing from severe sepsis to septic shock over 24 hours, because of the close monitoring of vital signs.

From stations equipped with six monitors, staff at Mercy Virtual are able to manage a massive triage system where they can alert the providers physically present in each hospital if a patient needs attention. Whereas a nurse in a traditional hospital may be assigned just a few patients to monitor, the nurses at Mercy Virtual can be monitoring 40 to 80 patients at a time using the triage information, Mercy Virtual President Gavin Helton told me during a recent visit there.

“You can tell if [a patient] is trending individually in the right direction or not based upon different parameters that we monitor behind the scenes,” Helton said. “And then we know when to intervene. We can call the site and say, ‘We think you need to go to Room 12, this patient is not doing well — or he’s about to not do well — and this how we think you should intervene.’ ”

Mercy launched its virtual hospital back in 2015, which staff proudly tout as the first hospital in the United States without beds. It now offers virtual programs including vStroke, vICU, vSepsis, vMentalWellness and vEngagement, a program where patients are given a box of medical equipment such as blood pressure cuffs and glucose monitors so they can be monitored within their homes.

Telehealth has long been viewed as a solution mainly for rural areas where there are physician shortages. But Helton stresses that it has a much broader application, allowing hospitals to revamp the patient experience by making a larger pool of specialists available to patients virtually instead of subjecting them to the limited resources of whatever hospital they’re staying in.

“Traditional health care has provided care in a provider-centric, facility-centric manner,” Helton said. “What we’re doing here is we’re providing that care in a very intentional, proactive manner to the patient either before they need it or right as they need it. You’re moving the focus from provider or facility truly to the individual patient, which is a really big deal.”

There’s strong bipartisan support in Congress for advancing telehealth. The Congressional Telehealth Caucus is headed by Democratic Reps. Mike Thompson (Calif.) and Peter Welch (Vt.). Senators including John Thune (R-N.D.) and Dianne Feinstein (D-Calif.) — are telehealth proponents.

But little has been done to advance virtual health in Medicare, partly because of the CBO’s stance. The Center for Telehealth and eHealth Law is working with Mercer University in Georgia to compile evidence that telehealth either saves money or is at least cost-neutral. The center’s deputy executive director, Christa Natoli, said the goal is to have a report ready to give the CBO sometime next year.

“If telemedicine is done right, it’s really good, quality care,” Natoli said. “It should be reimbursed, but how do we do that because there’s this big barrier in place.”

That’s not to say there aren’t legitimate concerns that paying for virtual care could prompt more waste and fraud in the health-care system. Former officials at the Centers for Medicare and Medicaid Services told me they worry some health providers might view expanded telehealth reimbursement merely as new chances to pocket cash, not as opportunities to improve care.

“Every time you create a new fee-for-service benefit like this, you will have people who say, ‘Cool, this is the way to improve care and reduce costs,’” said Sean Cavanaugh, who directed Medicare’s payment policies at the agency during the Obama administration. “But then you also have the people who are like, ‘This is a way for me to bill Medicare for more stuff.’ ”

There’s a concern that the opportunity for virtual visits — where patients don’t have to even leave their homes — might prompt a higher volume of unnecessary check-ins and tests. That’s another key issue, said Farzad Mostashari, the former national coordinator for health information technology at the Department of Health and Human Services.

“You open the door to not just replacing face-to-face visits with telehealth visits, but open the door to a massive set of services that get utilized at a high rate that would not have been utilized otherwise,” Mostashari told me.

One way to avoid that problem would be to expand telehealth payments within special experiments (called “demonstrations”) conducted by CMS where participating hospitals are paid in lump sums based on the quality, not just the quantity, of services provided. Mercy Virtual participates in some of these demonstrations, which provide a pathway for Medicare to test better ways of paying providers.

But one thing’s clear: Hospitals are forging ahead with virtual health-care, even if Medicare is not.

“People who are doing interesting things are way beyond what Medicare envisioned,” Cavanaugh said. “There’s lots of ways in which the Medicare billing rules don’t jibe with the future of medicine.”

Mercy Virtual has managed to operate in the black partly because of savings from getting patients out of the hospital more quickly and participating in CMS demonstrations. Helton acknowledged the payment challenges, but he said he’s optimistic about where things are headed.

“The changes that are being made are moving in the right direction,” Helton said. “The entire environment is moving towards supporting this.”

AHH, OOF and OUCH

AHH: House Speaker Nancy Pelosi says Democrats will roll out legislation on Tuesday focused on lowering health-care costs and protecting people with pre-existing conditions -- an effort timed to coincide with the ninth anniversary of the Affordable Care Act being signed into law. The bill would “reverse the Trump administration’s health-care sabotage, and take new measures to lower health premiums and out-of-pocket costs for families,” according to a weekend advisory from Pelosi's office.

Pelosi has repeatedly indicated her wish is to improve Obamacare over trying to pass a sweeping Medicare-for-all-type bill, which more liberal members of her caucus have been pushing for. Protect Our Care, a leading ACA-advocacy group run by top Democratic operatives, gave an early nod to the legislation, saying in a statement to Health 202 that it "strongly supports efforts by House Democrats to protect people with pre-existing conditions, lower costs, improve care, and push back on the Trump Administration’s reckless acts of sabotage."

"In November, the American people said they want aggressive action, and the legislation Democrats are unveiling on Tuesday is a giant step in that direction," said Protect Our Care Chairman Leslie Dach. "It stands in stark contrast to President Trump’s ongoing war on America’s health care and his budget that cuts Medicaid and Medicare by nearly two trillion dollars and ends protections for people with pre-existing conditions by repealing the Affordable Care Act."

OOF: Eli Lilly says the price it was paid for a key diabetes treatment actually decreased by 8.1 percent over the last five years, after accounting for rebates and discounts. That's per a report the company released amid mounting pressure over its rising insulin prices.

The company said the net price was $135 per patient per month for Humalog insulin in 2018 compared with $147 in 2014, the Wall Street Journal’s Peter Loftus reports. Meanwhile, the average list price for Humalog increased 51.9 percent to $594 per patient per month during the same period. Eli Lilly says that's because it increased the rebates and discounts it paid to middlemen in the drug-supply chain as the list price for Humalog increased. 

“Lilly said the monthly per-patient prices were based on average use of Humalog if taken as prescribed. This amounts to about two vials or more than six pen injectors, though actual utilization may vary by patient,” Peter writes.

Three major insulin manufacturers Eli Lilly, Sanofi and Novo Nordisk say they’re cooperating with a congressional investigation into their insulin prices and details about the rebates paid in the drug-supply chain, Peter adds. Earlier this month, Eli Lilly announced it would start to sell a generic version of Humalog at half the list price of the brand-name version.

OUCH: GoFundMe said it would remove campaigns raising money to promote vaccine misinformation from its platform, the latest social media company to crack down on the spread of anti-vaccine information online.

A GoFundMe spokesman said in a statement to the Daily Beast that the company is “conducting a thorough review and will remove any campaigns currently on the platform.” So far, he said the site has found fewer than 10 to take down.

The Daily Beast’s Julia Arciga reports the publication found fundraisers “benefiting or promoted by anti-vaccination or ‘vaccine choice’ groups brought in at least $170,000 in the last four years.”

“Experts say companies, especially social media platforms, are being tasked with new and challenging responsibilities as they learn to navigate the line between doing business and playing the role of censor in an age when misleading claims about health and science can have a profound impact on public health,” as our Post colleague Lindsey Bever reports. “At the same time, some anti-vaccination advocates suggest the crackdowns violate First Amendment rights, limit alternative views and give Big Pharma an upper hand.”

STATE SCAN

—There has been a wave of antiabortion bills introduced at the state level, but some have so far struggled to survive in the courts, as the Wall Street Journal’s Jacob Gershman reports.

In Kentucky and Mississippi, the Republican governors signed bills that prohibit doctors from performing abortions after fetal heartbeats are detected, but Kentucky’s heartbeat law was blocked in court the same day it was enacted. In Mississippi, abortion-rights advocates want the same to happen in the state, “where a federal judge last year struck down a less-restrictive law that would have banned most abortions 15 weeks into pregnancy,” Jacob writes.

The big question is whether the Supreme Court will take up any of these cases, with its new conservative majority. So far, the justices haven't seemed eager to revisit the court's abortion doctrine.

“Twice in recent months, Chief Justice John Roberts has sided with liberal justices in abortion cases, voting in February to suspend enforcement of a Louisiana physician-credentialing regulation, and in December turning away a petition from Republican states seeking the right to disqualify Planned Parenthood from Medicaid,” Jacob reports. Conservative advocates say the high court’s actions so far could mean it isn’t likely to make a change to the precedent set by Roe v. Wade.  

— New Jersey’s Democratic Gov. Phil Murphy said the state will run its own Obamacare marketplace in an effort to protect against the Trump administration’s moves to undermine the Affordable Care Act. New Jersey would be the 12th state to establish its own marketplace.

Murphy sent a letter to the Centers for Medicare and Medicaid Services last week about the state’s intention to start its own exchange. He said he wants to shift the federal exchange user fee to the state in order to fund the effort, as the Asbury Park Press’s Michael L. Diamond reports.

"The move by Murphy is the latest step in his attempt to shore up the Affordable Care Act, a President Barack  Obama-era law that has been under fire from President Donald Trump," Michael writes. “For example: New Jersey reinstated the individual mandate, requiring most residents have insurance or pay a penalty. It began a reinsurance program to help insurers pay for the highest-risk patients. And it prevents insurers from selling less expensive, but also less comprehensive, policies.”

"Because we are operating on the federal exchange, we are subject to the whims of the Trump administration and directly impacted by its efforts to damage and destabilize the market," said Marlene Caride, commissioner of the state’s Department of Banking and Insurance, in a statement.

— An initiative in New York City meant to address mental illness has had some challenges in the first few years. Even as Mayor Bill de Blasio and his wife Chirlane McCray traverse the country, often touting the nearly $1 billion plan, the program has failed to spend a third of its budget and has seen two recent leadership changes, as the New York Times’s J. David Goodman reports.

“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,” he writes. City officials cannot point to how many individuals have been connected to treatment after calling a new hotline, for example.

And while public health officials say the initiative has raised awareness about mental health concerns, the city is still facing challenges in addressing mental illness. “More New Yorkers dialed 911 to report a person in the midst of a mental health crisis last year — 179,000 calls — than at any point in more than a decade,” J. David writes.

— And here are a few more good reads: 

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INDUSTRY RX
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DAYBOOK

Coming Up

  • The House Budget Committee holds a hearing on the HHS budget on Tuesday. 
  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on the 21st Century Cures Act on Tuesday.
  • The Bipartisan Policy Center holds an event on federal funding to combat the opioid crisis on Tuesday. 
  • Politico hosts an event on "Opioid Misuse, Hepatitis C and HIV" on Thursday. 
SUGAR RUSH

Special counsel Robert S. Mueller III’s investigation into Russian election interference is over. Here’s what we know: