The Tension Between Expanding Access and Increasing Utilization

As reported in Becker’s Hospital Review, physician groups and MEDPAC have pushed back on the CMS proposal on virtual care reimbursement. According to Gooch (2018, October 10), “CMS proposed the virtual care reimbursement in its update to the 2018 Medicare Physician Fee Schedule and Quality Payment Program. Under the proposal, Medicare would pay physicians $14 per virtual check-in versus the cost of a $92 patient visit. The virtual check-in would last about five to 10 minutes. Physicians are concerned the Medicare payment would leave patients on the hook for a 20 percent cost-sharing charge.”

The article goes on to cite MEDPAC concerns regarding the convenience factor associated with direct-to-consumer telehealth solutions that on the face would appear to expand access, but have the potential to increase overall utilization. The CMS proposal, per Adminsitrator Verma is part of their Patients Over Paperwork effort and includes reimbursing providers at the rate of $14 for ‘virtual’ check-ins and these check-ins could be performed by an eligible advance practice provider (NP or PA). Administrator Verma suggests that reimbursing for virtual check-ins may reduce costs to the Medicare program by eliminating unnecessary visits. This point of view neglects to consider the evidence from prior expansions of coverage under the Physician Fee Schedule, including reimbursement above and beyond the E/M visit fee for tobacco use cessation counseling (Decision memo CAG-00241N), that demonstrates expanded access (or coverage) does not translate to direct savings. Savings from the proposed virtual visit fees may ultimately show up in less obvious and quantifiable places, like reduced ER or Urgent Care visits.