NCQA Comments to PTAC on Telehealth in APMs and PFPMs

October 9, 2020

Jeffrey Bailet, MD, Chair,
Physician-Focused Payment Model Technical Advisory Committee (PTAC)
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
PTAC@hhs.gov

Dear Dr. Bailet,

Thank you for the opportunity to comment on use of telehealth to optimize care in physician-focused payment models (PFPMs) and alternative payment models (APMs). The National Committee for Quality Assurance (NCQA) strongly supports PFPMs, APMs and other value-based payment (VBP) models. We are working on several fronts to optimize telehealth to improve quality in VBPs and other arrangements:

• We co-convened the Taskforce on Telehealth Policy (TTP) that issued a report assessing telehealth’s rapid expansion during the COVID-19 pandemic and making recommendations that specifically address quality, safety and cost issues.
• We updated 40 HEDIS^® clinical quality measures to incorporate telehealth as its use rapidly expanded during COVID-19.[1]
• We promote use of telehealth and remote care to expand access in our Patient-Centered Medical Home (PCMH) and Patient-Centered Specialty Practice (PCSP)
• We and the American College of Physicians developed a “Medical Neighborhood Model” (MNM) APM proposal built on PCSPs that uses telehealth for expanded access and e-consults to improve coordination between specialists and the primary care clinicians who make referrals to them that PTAC recommended for pilot testing.
• We are developing telehealth accreditation programs and systematically reviewing how to maximize telehealth in our other programs.

Based all this work, we believe telehealth is health care’s natural evolution into the digital age and another site or modality, not type, of care. It can be as a critical tool in advancing a well-coordinated, patient-centered and value-optimized health care system. Value-based payment (VBP) models, such as PFPMs and APMs that hold clinicians and other providers accountable for costs and quality are well-suited to leverage telehealth’s potential. However, one major concern with approaches like capitation or episodic budgeting is stinting – that providers deliver less care when payments are fixed.

The pandemic related telehealth expansion to date suggests that telehealth could improve access to safe and effective care, reduce patient barriers and potentially lower cost.

Further analysis after COVID-19’s impact recede is, of course, needed, but experience to date has not confirmed concerns that telehealth expansion leads to more consumption of low-value care or fraud, waste and abuse to drive up costs.

Taken together, these facts imply strong synergies between VBP and telehealth, as providers will gain access to new modalities of care that can more easily reach patients (allowing for better population health management) while also providing strong incentives to avoid overuse.

Responses to your specific questions are below.

1.     Are there lessons learned from providing telehealth in existing APMs?

Telehealth can and should be an essential tool for maximizing care coordination, access and improved patient experience in APMs. VBP models with shared financial risk and responsibility for improving the health of a population alleviate many previous concerns about potential telehealth misuse, as they allow clinicians and patients to choose the care modalities most appropriate to their needs and preferences. Accelerating VBP adoption across public programs is the best way to expand telehealth to the level currently seen in the commercial market. That is because VBP allows flexibility based on different delivery models, markets and situations.

2.   Are there changes related to the use of telehealth technology, such as changes in scheduling, care delivery workflow, staffing, quality standards, information and supports needed by beneficiaries, etc., that may be required to optimize its use?

There are differences in workflows before, during and after telehealth encounters vs. in-person care. For example, telehealth encounters can require getting labs before a visit, ensuring that patients can use and are comfortable with the technology during the visit, and helping patients navigate needed follow-up remotely after the visit.

We should hold telehealth, as another site or modality rather than type of care, to the same quality and safety standards as other care settings. We can and should adapt, rather than reinvent, quality measures for telehealth, as NCQA did this year with 40 HEDIS measures.

We need robust education to help beneficiaries understand how to use telehealth, when it may or may not be appropriate, how to protect their privacy when using telehealth and that they have a right to obtain in-person care if that is their preference.

3.     How can stakeholders leverage telehealth to enable coordinated and integrated care delivery for Medicare beneficiaries who need frequent or complex services across a variety of providers?

Telehealth could exacerbate data silos and poor care coordination if it proliferates as electronic health records did with data blocking and interoperability challenges.

However, because of its digital nature, telehealth also has great potential to improve data sharing and coordination with the right policies in place. It is therefore essential to require accreditation for telehealth with standards that hold providers, plans and telehealth platforms accountable for clear documentation, data sharing with all members of patients’ care teams in alignment with 21^st Century Cures Act policies, privacy and security. Remote patient monitoring also has potential to facilitate better monitoring of symptoms for patients with chronic diseases than is feasible with in-person care, so allowing APMs to furnish RPM technology should be a priority so they are less likely to need more costly in-person or institutional care. Telehealth’s digital nature supports moving move to electronically shared care plans that are particularly important for patients with complex needs. Telehealth also can improve coordinated and integrated care by facilitating e-consults to ascertain in advance whether referrals to specialists are appropriate.

Stakeholders also should note telehealth’s beneficial impacts on cost and quality, particularly for patients with complex needs, from:

• Reduced missed appointments which improves care plan compliance,
• Reduced transfers from nursing homes to hospitals and emergency departments, and
• Increased use of transitional care management services that improve outcomes and reduce readmissions, mortality rates and cost.

4.       In what areas is further evidence about telehealth needed?

We need additional research on several aspects of telehealth:

• Its impact on cost and utilization outside of pandemic conditions.
• Its impact on patient safety, beyond providing expanded access that prevents care delays, preventing exposure to pathogens and minimizing travel risks and burdens. This includes assessment of best practices for safe telehealth and guidelines for when telehealth may or may not be appropriate.
• Its impact on quality and outcomes for specific types of providers, patients and conditions.
• Its impact on patient experience and how to leverage telehealth’s digital nature to provide more rapid, targeted and actionable patient experience results.
• Its impact on clinician’s and other provider’s experience, including workflows, efficiencies, best practices, financial sustainability, etc.

5.      What might be the most informative performance-related metrics and strategic approaches for monitoring and evaluating the use of telehealth as part of care delivery?

We should hold telehealth, as another site or modality rather than type of care, to the same quality and safety standards as other care settings. We can and should adapt, rather than reinvent, clinical quality measures for telehealth, as NCQA did this year with 40 HEDIS measures. And we should leverage telehealth’s digital nature to help in pilot testing better ways to measure patient experience of health that is more rapid, targeted and actionable than current, largely paper-based surveys.

6.     Are there any measures that are specific to program integrity that are important to consider as it relates to encouraging use of telehealth after the PHE? How, if at all, would these measures be different under FFS or APMs?

Fraud, waste and abuse (FWA) occur throughout health care, including in telehealth. However, arbitrary telehealth restrictions will not deter unscrupulous actors and are not a justifiable or viable program integrity strategy. The most effective approach to aggressively fighting FWA for both in-person and telehealth care is to leverage sophisticated technology tools that can enhance existing program integrity enforcement efforts, and also to drive better collaboration with health care stakeholders.

7.     What educational information would you suggest that payers and providers can provide to Medicare beneficiaries and their caregivers to maximize the use of telehealth?

We need robust education to help beneficiaries understand how to use telehealth technology, when telehealth may or may not be appropriate, how to protect their privacy when using telehealth and that they have a right to obtain in-person care if that is their preference.

Policymakers also should develop and prioritize initiatives aimed at addressing the lack of trust and digital literacy gaps that inhibit successful telehealth adoption for patients, clinicians and other providers—with particular focus on populations that have struggled in the transition to telehealth during the pandemic.

8.     How might barriers related to the use of proprietary telehealth platforms, software, and tools be overcome to enable their use in care delivery models and APMs for Medicare beneficiaries?

We should require accreditation for telehealth platforms and tools with clear standards for documentation, data sharing aligned with 21^st Century Cures Act rules, privacy and security.

9.     What are major telehealth barriers for Medicare beneficiaries related to equity such as access to broadband, technology, or familiarity with the technology, and how might they be addressed? What policies, best practices and technical approaches have providers and other stakeholders used to help mitigate these barriers?

It is critical to promptly access lack of broadband, technology and understanding of how to use it so that health care’s evolution into the digital age reduces rather than exacerbates disparities. To do this we need to:

• Expand current efforts to ensure universal broadband access.
• Identify and empower caregivers to assist in telehealth delivery
• Allow plans, APMs, clinicians and other providers to give patients technology needed for telehealth.
• Put in place the infrastructure to support the capability to overcome cultural or language barriers and work with ethnic communities and other demographic groups, on both sides of the patient-clinician relationship, to identify and address digital literacy and trust gaps that inhibit successful adoption of telehealth.

10.      What federal and/or state policy issues exist that may need to be addressed for appropriate and effective telehealth use, such as Health Insurance Portability and Accountability Act (HIPAA) privacy and security rules?

Policymakers should make permanent the following telehealth policy changes enacted during COVID-19 to improve access, patient safety and outcomes:

• Removal of strict limits on sites where telehealth visits may originate, conditions clinicians may treat and which clinicians and providers may use telehealth.
• Acknowledging that telehealth visits can establish clinician/patient relationships as long as they meet appropriate standards of care or unless careful analysis demonstrates that, in specific situations, ensuring patient safety, program integrity or appropriate high-quality care requires a previous in-person relationship.
• Allowing audio-only telehealth where evidence demonstrates it to be effective, safe and appropriate, or where it is likely to be so and offers access to care that would otherwise be unavailable to a patient.
• Allowing asynchronous telehealth (e.g., remote patient monitoring) when it is the preference or need of the patient on a limited basis as more clinical evidence is generated on best practices for ensuring quality, safety and program integrity.
• Allowing insurers to provide telehealth technology, such as smartphones and tablets, as supplemental benefits.
• Allowing telehealth across state lines by considering strategies to expedite licensure reciprocity between states, while maintaining important patient protections and disciplinary tools for bad actors.

Policymakers, however, should reinstate full enforcement of HIPAA privacy protections.

Thank you again for the opportunity to share our thoughts. If you have questions, please contact Paul Cotton, Director of Federal Affairs at (202) 955-5162 or cotton@ncqa.org.

Sincerely,
Margaret E. O’Kane
President

[1] HEDIS, the Healthcare Effectiveness Data and Information Set, is a registered trademark of NCQA.