Telehealth’s Missing Link: In the Rush to Implement Virtual Care, What Did CMS Leave Out?


Imagine three months from now when the predicted ‘second wave’ of COVID-19 is expected to resurge and we’re still without a vaccine. Telehealth has become the entry-point to care, widely adopted by patients both young and old. Now, when an elderly diabetic patient wakes up in the middle of the night with a dull ache on her left side and back, she doesn’t ignore the symptom, like she may have during the first COVID outbreak. Instead, she logs online to her local hospital’s website from a cell phone and accesses a simple questionnaire to report her health history and presenting symptoms. The whole process takes just a couple of minutes and she immediately hears back from her health provider with the suggestion to schedule an in-person appointment for further testing to rule out any kidney issues. 

This patient doesn’t become one of the nearly 50% of Americans who delayed care during the initial COVID pandemic. She was able to access care without having to download an application or wait to schedule a virtual appointment during normal business hours. She receives virtual asynchronous care on-demand, coordinated to sync with her electronic health record. The next day, she receives a follow-up call from her primary care doctor to ensure her symptoms were alleviated with the over-the-counter pain medication she was prescribed. 

I applaud the article written by Paul Grundy, MD, and Ken Terry, “Primary Care Practices Need Help to Survive the COVID-19 Pandemic,” in which they called on Congress to make health policy decisions that will provide immediate financial relief for primary care practices. We must mitigate the real risk we face: the highly possible shutdown of our healthcare system. Amid the coronavirus pandemic, the U.S. healthcare system has taken an enormous financial hit and primary care practices have been especially affected and are struggling to survive. As the authors point out, telehealth has taken the spotlight to fill the acute need for an influx of patients needing to access care under social distancing practices. Telehealth can increase access to care, relieve provider burden, reduce costs to systems, and improve patient outcomes. However, this is only possible with on-demand telehealth, or asynchronous care. 

If COVID-19 has a silver lining, it is that forced social distancing has accelerated telehealth adoption by as much as 20 years, according to Deloitte. And while no one is certain when or how the crisis will end, one thing is abundantly clear: widespread use of telehealth is here to stay. Or, as CMS administrator Seema Verma said, “The genie’s out of the bottle on this one.”

That said, in the rush to implement telehealth solutions, CMS and many providers—failed to include asynchronous virtual care as a viable alternative to in-person care. Now though, we have the opportunity to develop a more thoughtful strategy going forward––one that can brace our system at a time when it needs the support.

First, we must establish a broader definition of “telehealth” that includes modalities other than video visits. Non-video forms of virtual care also deliver value for both patients and providers. In some cases, they may go further than video can to increase access and affordability and to protect a patient’s continuum of care. 

Take asynchronous virtual care delivery, for example. 

According to the FCC, approximately 21 million people lack broadband access, which makes video-based telehealth unavailable to large portions of the U.S. Asynchronous telehealth solutions don’t require high-speed internet or even a 4G mobile connection to deliver care. The store-and-forward nature of these platforms means very little data is required to exchange the crucial information needed to provide a complete episode of care.

Asynchronous telehealth platforms that fully integrate into clinical workflows ensure a patient’s electronic health record is intact. This is especially important during times of crisis when a patient seeks care remotely to avoid possible infection. If he or she receives care that isn’t reflected in their record, important information is lost and can impact the quality of care they receive in the future.

Because store-and-forward telehealth platforms boost clinical efficiency by saving provider time over in-person or video visits, they provide cost savings for all involved—healthcare systems, payers, and patients. When some of those savings are passed on to patients, reducing their overall out-of-pocket costs, those patients are less likely to avoid care due to financial concerns that include the threat of surprise bills.  

It is likely, if not inevitable, that how patients access care has been changed forever by COVID-19. Telehealth will continue to play a major part in how patients get care, but virtual care has much more to offer than video visits. Regardless of the modality, if a provider is able to deliver an episode of care that is held to the same standard and quality of in-person care, that visit should be reimbursed at a level that is fair to all parties involved. 

CMS has a real opportunity to help strengthen our injured healthcare system. In addition to patients who have access challenges, providers and systems are struggling financially. If patients put off visits because securing a video or in-person appointment is a challenge, we are going to see fewer ambulatory and non-acute patients, which has an immediate financial impact on systems and could lead to more chronic and emergent conditions that could have been avoided. 

Now is the time for Congress to take action and adjust the CARES Act to include ALL types of telehealth solutions, including virtual care like asynchronous telehealth, and to compensate providers for using it accordingly. These telehealth policy changes should be permanent – our new normal. Perhaps then we will look back at the COVID era as a pivotal time in our nation’s history when healthcare changed for the better. When we considered new entry points to care that are effective, reduce burden on clinicians, and offer more immediate care beginning with triage for patients. It’s the silver lining in this cloudy mess. 

Ray Constantini, MD is the CEO and Co-Founder of Bright.md.

3 replies »

  1. CMS does pay for async store and forward under G2010… They just don’t pay very much

    The good news is that CMS does not consider async telehealth actual telehealth. That means that Medicare can expand coverage and reimbursement via regulation instead of needing an act of Congress.

  2. Hear, hear. I keep drawing the parallel with my lawyer. I have received thousands of dollars of cognitive services with a few in person, an occasional Zoom and lots of phone conferences. Cognitive work is cognitive work. As a physician, I help run a Suboxone group 200 miles away from my iPhone on a tripod.

  3. Ray is dead right here. Yes he runs an asynchronous telehealth company but the point is that we should have a payment system (preferably a global budget) that prioritizes the best tool for the job. Clearly asynchronous communication has a very valuable place and is in many cases much more efficient than a live video visit. So lets get it paid for by CMS and lets get CMS and other payors paying providers in a way that they get to make the choice to use the most efficient tools.