Telemedicine Dynamics: Payer Perspective

Before the pandemic, telemedicine was slow to catch on. But as COVID-19 persists, it’s become a more viable way of getting much-needed health care without having to visit a doctor’s office or hospital. Many insurers, reluctant to pay for a wide range of telemedicine services pre-pandemic, waived their restrictions and paid the full cost of teleservices. But as the COVID-19 outbreak subsides, the question is will they continue to pay for these services? Or, is telemedicine just another part of the new normal for patients, doctors, and insurers? To learn more, GLG talked to Elizabeth Bierbower, former Segment President of Employer Group and COO of Specialty Benefits, Humana. Below are a few select excerpts from our broader discussion.

Can you share your thoughts on the growth in telemedicine we’ve seen to date and what you see as the tailwinds from the payer perspective?

Obviously, because of the pandemic, telehealth has exploded seemingly overnight. In the past we’ve seen approximately three barriers to telehealth growth. The first barrier has been coverage. Coverage is really varied. Medicare — as you probably know — has significant restrictions on coverage.

The second has been awareness. Typically, when people have an issue, they want to call their doctor. If their doctor doesn’t have that service, then their next thought is to go to the urgent care. Their natural impulse isn’t to call a telehealth provider. Up to now we’ve needed more awareness around this, and now the pandemic is bringing telehealth into the mainstream.

The third barrier has been provider adoption. When people have an issue, they really want to go to their provider. But if the provider doesn’t offer that service, they may really be hesitant to go to a provider that they don’t know, even if it is convenient.

The tailwinds going forward? Telehealth has proved very effective during a major pandemic; we’ve seen exponential growth. That’s what’s captured people’s attention, whether it’s Congress or whether it’s in the administration saying, “Wait a minute, we need to do something to make sure that people can continue to have access.”

Let’s dig deeper into reimbursement. What business lines have had access to telemedicine, and how does that differ between commercial risk, administrative services only (ASO), Medicare, Medicaid, etc. Are there examples of some using the per member per month (PMPM) model whereas others might use visit fee only?

Most payers covered telehealth. Even many Medicaid payers covered it. Medicare’s coverage — as I said — came with restrictions. Health plans in general really wanted people to have access to these services. When used appropriately, telehealth can be effective and have positive outcomes while reducing cost. As a result, we saw many health plans embedding telehealth services into their benefit plan design for their fully insured members. If they had clients that were self-funded, it would be up to the client whether or not that client wanted to embed the telehealth services into their benefits plan. Many of those ASO clients did embed telehealth services into their plans.

In terms of the actual reimbursement between the health plans and the telehealth companies, they varied significantly. Many of them continue to operate on a fee-for-service basis and the telehealth provider would just submit a claim as any other provider would. Some of them considered PMPM pricing. Early on, health plans gravitated more toward fee for service because uptake wasn’t where it needed to be, and fee for service felt like the right approach to take when they were still testing to see what the uptake would be.

Should telehealth lose reimbursement parity within office face-to-face visits, what kind of impact do you expect that shift back to have on telemedicine adoption post-pandemic?

Number one, it depends on what the ultimate reimbursement is. Number two, what types of services that a provider bills for. Now that providers have had access to telehealth and have started to use it, they may find even if parity doesn’t exist, it is really effective in remote monitoring. Why not use remote monitoring for certain patients who are eligible and would benefit by it? Now that providers have really had a taste of it, I think you will see them stepping back and saying, “Well, okay, what other services could I be providing and feel like I’m getting fair reimbursements warrant using telehealth?” I would expect that people are going to continue to look for ways to leverage this technology.

For what services or modalities does it make sense to reimburse telehealth at parity?

There are many that make sense — including many primary care services, especially as you can have connected devices. My primary care physician, for example, teases me and says, “I listen to your heartbeat because I know that’s what people expect.” Instead, there is a lot of information that physicians can get by looking at patients and by collecting data from them, in terms of changes. Physical therapy is another example. We can be almost or just as effective when the physical therapist shows you what to do via telehealth. There are many opportunities.

The provider community will likely recognize that they can extend their reach and get to hard-to-access places if they really think about how to use it. Some hospitals put telehealth in with the EMT. They’re in the ambulance and very, very effective, so that they can have real-time connectivity with physicians. There are many potential use cases. You will likely be seeing and hearing more about those going forward.

As we look to the spectrum of health care services from urgent care, ER, primary care to even specialties like dermatology, where do you see the greatest use and growth of telemedicine?

I’ve seen areas where there’s a real access barrier. Practices where there are long wait times: behavioral health, psychiatry, cardiology. In some areas, it is very difficult to get in to see a cardiologist. If you are not seeing that cardiologist within 14 days, you’re likely going to the ER.

Dermatology — another practice that sometimes has long wait times — is also a good example. But think of a telehealth visit for a patient with suspected skin cancer. You could have a consult with the primary physician in the room, something that would pay off if you need to get the person into the right kind of treatment.

How should payers evaluate the competitive landscape between consumer-focused telemedicine providers and those that are more provider-focused?

Many payers now also have provider practices that they’re closely affiliated with. A payer will need to consider the experience for its members. Is it going to be easy? That is really going to be the driving thing for them. Number one, is it a simplified experience?

They need to consider the kind of data they’re going to be able to get back from the telehealth platform. Besides the claim, is there going be other data that they’re going to get? They need to look for a partner. One vendor may be just more provider-focused versus consumer-focused and they have to decide which might give them more benefit. If I were a telehealth platform vendor, I’d be having lots of conversations with my health plan partners and saying, “What are your additional use cases?”

That’s how I think about it, not just what can I get now, but who will be able to partner with me over the long term, as I determined that there are more opportunities to deploy this to have better access to my members.

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About Elizabeth Bierbower

Elizabeth Bierbower is a strategic leader with more than 30 years of proven executive-level experience in the health insurance industry with experience in all product lines, including commercial and Medicare Advantage. She most recently served as Segment President and a member of Humana’s Executive Management Team, overseeing the Group and Specialty Segment generating over $7 billion in revenue and covering 11 million individual, employer group, and military health members. Prior, Beth held the position of Chief Operating Officer of Humana’s Specialty Benefits division and was an Enterprise Vice President leading Humana’s Product Development and Innovation teams.

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This article is adapted from the July 9, 2020, webcast “Telemedicine Dynamics: Payer Perspective.” If you would like access to this teleconference or would like to speak with Elizabeth Bierbower, or any of our more than 700,000 experts, contact us.