CMS began broadly reimbursing for telehealth at parity with in-person visits as the pandemic stay-at-home orders began in March; many commercial insurers followed suit. HRI spoke with PwC principals Thom Bales and Jeff Jaymont about how payers view virtual care nine months into the pandemic and where it fits in their long-term planning.
Most commercial insurers are following the Centers for Medicare & Medicaid Services’ lead and paying the same rates for in-person and virtual care and have updated their policies to reflect this intent. They haven’t indicated how long that reimbursement parity will last, but they’re reluctant to make changes while the pandemic continues. There are some follow-up telephonic services that are not reimbursed which are considered services under the original payment.
Most commercial insurers continue to follow pricing parity for telehealth and in-person care. We are seeing some large commercial plans start to steer members toward preferred options, whether that be in-house or preferred providers.
Typically, the more restrictive the plan’s gatekeeping, the more it will push members toward preferred outlets. For the most part, PPOs are keeping virtual care options very open, while plans that are more focused on controlling costs and managing care are tightening venues. Employer-driven options introduce a different lens to this as some large employers contract directly with ancillary vendors.
HRI: As COVID-19 cases surge across the US, are payers starting to consider reimbursement changes for virtual care?
Jeff Jaymont: Commercial payers are waiting to see how the surge and fourth quarter continue to unfold before making any reimbursement changes. They are monitoring trends in utilization, COVID-19 care costs, deferral of non-urgent procedures, and other metrics.
Thom Bales: Virtual care hasn’t driven any particular cost trend for payers to date. The relative volume of demand compared with prior trends hasn’t been unusually high in aggregate or in complexity. Most virtual care has been primary care for basic, simple diagnosis.
Payers have seen fewer referrals for other procedures, like labs, X-rays, and other diagnostics under virtual care. Insurers are most worried about whether the surge will create more pent-up demand for services once people feel comfortable going back into facilities. On the preventive side, there is concern that some procedures are being missed, although many health plans are following up with high-risk patients.
HRI: Are payers using large, national virtual care providers; encouraging members to seek virtual care from their local providers; building their own virtual care networks and encouraging their use; or something else?
Jeff Jaymont: Most insurers have not built their own virtual care networks. Payers with large managed Medicaid populations typically are encouraging members to go to their existing providers for virtual care instead of building their own virtual networks.
Commercial plans are more likely to steer members toward preferred virtual care avenues, such as their nurse lines, as they try to keep people out of the emergency department and manage chronic conditions.
Thom Bales: Commercial plans aren’t likely to build their own virtual care networks unless they are pursuing a more integrated play already. They likely will continue to contract out virtual care or leave it to the provider networks to solve. Providers that operate their own health plans have developed, or are developing, their own virtual care networks to integrate that care into the continuum across disease states.
HRI: Have payers had difficulty with virtual care in any specific populations, regions or lines of business?
Thom Bales: Rural areas may be difficult to reach because of the lack of broadband internet access, but there are hopes that this will be mitigated when 5G is more readily available.
HRI: Are payers incorporating virtual care into their long-term strategies, and, if so, is reimbursement a concern?
Jeff Jaymont: Payers hope virtual health has staying power but not at full reimbursement rates. They want it as a lower-cost way to keep people out of the emergency department and also want routine virtual care to have a lower cost than a traditional doctor’s office visit to prevent it from being exploited. Health plans appreciate virtual care’s value as a way to engage with members and are starting to explore other automated channels, for example using chatbots powered with conversational AI to manage general member calls and handle utilization management interactions.
Thom Bales: Commercial payers will continue to use CMS coverage and reimbursement policies as a reference point for policy and negotiations. The dynamics that we see in in-person care will play out in virtual care. Providers will want payment parity to continue as long as possible, but payers will begin to migrate toward preferred, narrow networks of providers that offer high-quality care while controlling costs.
HRI: Any closing thoughts?
Jeff Jaymont: Payers need to think about how they are managing and promoting virtual care to members within their broader customer outreach strategy. People are engaging digitally more than ever before — think about how people increasingly are doing their grocery shopping on their cellphones. Payers that were behind on the digital front before the pandemic need to be thinking about their broader digital engagement strategy, not just virtual care.
Thom Bales: Consumers increasingly will expect virtual care, so payers will have to pay providers enough to give consumers access to virtual care with the providers they want to see. Health systems will provide virtual care that plays a role similar to that of a nurse line or will offer broader virtual services as part of integrated care within the health system.
The pandemic has shown that some care can be delivered virtually as effectively as in person. The next evolution will be whether care can be delivered, or at least diagnoses made, effectively by AI.