Telemedicine’s uncertain future in urology

Colorado Springs, Colorado, urologist Henry Rosevear, MD, says he went from not using telemedicine before the pandemic to having it represent 15% to 20% of his practice today.

Henry Rosevear, MD

Telemedicine has become an important way to provide care for Rosevear’s Colorado Springs Urological Associates practice, which includes
11 doctors and 4 midlevel providers who not only staff the practice’s 2 main offices in Colorado Springs, but also do outreach to several mountain town clinics.

“To understand why telemedicine has worked out so well and is so important, I look at why it didn’t work out before the pandemic. Before the pandemic, good intentions aside, there were all these crazy rules and regulations about what was allowed. The combination of the bureaucratic red tape and additional costs made it a nonstarter,” Rosevear said.

There is no doubt that telemedicine has driven increased patient access and reduced patients’ expenses, including travel and time away from work,

Jonathan Rubenstein, MD

according to Jonathan Rubenstein, MD, chief compliance officer, Chesapeake Urology Associates, and chair of the American Urological Association (AUA) Coding and Reimbursement Committee.

“It has gotten to the point where telemedicine is so ingrained in my own individual practice, I almost feel guilty when I see a patient in person who could have been handled by telemedicine,” Rubenstein said.

But like other urologists, Rosevear and Rubenstein are concerned about the possibilities of a return to a regulation-laden environment for telemedicine and a decrease in reimbursement in the postpandemic era.

“As long as we’re still under the coronavirus health emergency, we will continue to have Medicare access to telemedicine,” Rubenstein said. “The concern is what happens if the public health emergency ends and there has not been a permanent telemedicine plan in place. That is why there are bills that are currently in Congress for this. It will take a lot of effort to make telemedicine access permanent for Medicare, and obviously private insurers will have the opportunity to make their own rules on telemedicine coverage.”

Ray Wezik, JD

The 2022 Omnibus Appropriations Bill locked in telehealth waivers until January 1, 2023, according to emailed responses to questions from Urology Times® by Ray Wezik, JD, AUA policy and advocacy director, and Aaron Spitz, MD, the AUA Public Policy Council’s Telehealth Task Force chair.

Aaron Spitz, MD

“Until additional legislation is passed, the waivers for telehealth cease after January 1, 2023, or at such time that the public health emergency declaration is no longer in effect. The public health emergency declaration is renewed in 3-month increments, so this may help guide telemedical scheduling of patients,” they wrote.

There is great debate on what telehealth should look like after the public health emergency ends, according to Chad Ellimoottil, MD, MS, assistant professor of urology at the University of Michigan, Ann Arbor.

Unfavorable changes could force practices to reevaluate telemedicine’s viability. Although telemedicine use fluctuates among specialties and with time, Medicare data suggest that prior to March 2020, less than 1% of health

Chad Ellimoottil, MD, MS

care providers and 1% of patients used telehealth. In March 2020, there was a big spike, but use has leveled off to 1 in 6 or 1 in 7 Medicare visits occurring by telemedicine, according to Ellimoottil, who studies telehealth use across all specialties.¹

“On the commercial [insurance] side, it’s a little higher at usually about 1 in 5 visits,” said Ellimoottil.

Current AUA data suggest telemedicine utilization in the specialty likely falls between 5% and 20% of encounters depending on the practice and setting, according to the email from Wezik and Spitz.

5 areas of concern for urologists

Ellimoottil said these 5 policy areas that are being debated could affect telehealth use at urology practices.

The concept of an “originating site.” Although this is the least worrisome because it will likely change for the better, it could have the most impact if it doesn’t, according to Ellimoottil.

Prior to the pandemic, telehealth was limited to patients in rural areas, and patients had to go to specific medical facilities to connect with providers. This part of the original law made telehealth so burdensome and restricted that it never took off, Ellimoottil said.

“Through ongoing conversations with Capitol Hill staff, we are aware of a majority of support for the elimination of originating site, and fully expect successful legislation for telehealth permanency to incorporate that policy change,” according to the AUA email.

Audio-only telehealth. “Prior to the pandemic, the Medicare program and many commercial payers said it was OK to do a video visit with patients, but it was not OK to just do a phone call and bill insurance for that phone call. What we found out during the pandemic is there are a lot of people who don’t have the ability to do video visits; they need to just use a phone,” Ellimoottil said. “The policy question is whether or not audio only should be allowed and should that be reimbursed.”

The AUA strongly supports continued availability of audio-only telehealth, according to the AUA email.

“[Although] there have been concerns about fraud, waste, and abuse of this modality, we do not believe those concerns to be special compared to overall waste in the health care system,” Wezik and Spitz wrote.

Payment parity(or, whether telehealth will be reimbursed at the same rate as in-person visits). The perception exists that the cost for practices to do telemedicine is lower than for in-person visits.

Some urologists disagree.

“Patients still need previsit and postcare coordination and nurse follow-up on orders. Clerks are still required to schedule these visits and maybe more time is required because they have to set the patient up for the visit,” Ellimoottil said.

Urologists are concerned that reimbursement for telehealth visits will go down, and, as a result, so will clinicians’ motivation for offering telemedicine.

“[Although] telehealth is terribly important to the clinic, it does not reimburse well,” Rosevear said.

Even lower reimbursement for telemedicine would be a problem that would make Colorado Springs Urological Associates consider going back to having all patients come into the clinic, he said.

Although there is not a lot of “talk” about reducing payments on the Medicare side, it is on the government’s radar, according to Ellimoottil.

“Medicare has taken the stance that it needs more data on the cost of telehealth,” Ellimoottil said. “At the state level, on 1 side, there are advocates for payment parity that are putting forward laws saying that as a commercial payer in this state you are required to pay the same amount as in person. But then there are a lot of insurers fighting back on those laws saying that we shouldn’t be forced to do that.”

The true expenses of telehealth have not been studied, according to the AUA email.

“Since the main component of a visit is the provider expertise (and malpractice risk), there really should be no difference in payment for whether the same level visit takes place in-person or by an appropriate virtual visit,” wrote Wezik and Spitz.

Interstate telehealth. The University of Michigan is in southeast Michigan, 45 minutes from Ohio, according to Ellimoottil.

“There is a large proportion of our patients who will come from Ohio for visits. Prior to the pandemic, you could never perform a telehealth visit with patients from the state of Ohio unless you were licensed in the state of Ohio,” Ellimoottil said. “During the early part of the pandemic, 50 states and Washington, DC, rolled this back, basically saying it’s a state-level decision and that people in a different state still need to be able to maintain care in this public health emergency, so if you have a license, you could perform telehealth visits with patients in any state. Slowly over time, state by state, public health emergencies have been expiring and a lot of these interstate telehealth flexibilities have also expired.”

Clinically appropriate telehealth (or, avoiding fraud and abuse in telehealth). Insurers are concerned that having fewer rules and regulations surrounding telehealth will lead to increases in telehealth fraud and abuse. For example, according to Ellimoottil, a concern is that providers will call patients with their results and bill for those calls as telehealth visits.

“Guardrails” of what constitute a telehealth visit in urology do not yet exist, Ellimoottil said. The concern among urologists is that these decisions should be made by professional societies and clinicians—not necessarily by insurers,
he said.

Urologists using telemedicine are able to determine when it is and isn’t an appropriate tool for their patients, according to the AUA email.

“There is no current evidence of widespread fraud and abuse amongst urologists providing telemedical access to their patients. The AUA has open lines of communication with CMS and has requested alerts to any such fraud and abuse should it occur so that the AUA can partner in determining solutions should they be needed. The AUA will be surveying its members through the census as to whether diagnosis specific guidelines for telehealth would be useful,” Wezik and Spitz wrote.

In the meantime, what is a urology practice to do?

During this time of telemedicine uncertainty, Ellimoottil recommends that urologists become advocates for the specialty by getting involved in organizations like the AUA.

“Tell your story about telehealth, about how it’s working and not working. Provide data to the AUA, as they are lobbying to make sure the final shape of telehealth is created in a way that is great for our patients and also sustainable for our urologists,” Ellimoottil said.

The AUA recommends that urology practices make sure their office billing systems are utilizing proper coding to ensure they are receiving appropriate payment for services provided.

“Readers can work at a grassroots level to inform their legislators about the importance of preserving telehealth access for their constituents,” wrote Wezik and Spitz.

The AUA telehealth task force offers members information through resources such as the AUA web page for telehealth and the pandemic: https://bit.ly/3FYNOJi.

Reference

1. Ellimoottil C, Zhu Z, Dunn R, et al. An evaluation of telehealth use by Medicare beneficiaries in 2020. University of Michigan Institute for Healthcare Policy and Innovation. September 8, 2021. Accessed May 17, 2022. https://bit.ly/3FZMaaI