The Trump administration wants Medicare for the first time to embrace telemedicine across the country by paying doctors $14 for a five-minute "check-in" phone call with their patients.
But many physicians say the proposed reimbursement will cover a service they already do for free. And the Medicare reimbursement -- intended to motivate doctors to communicate with patients outside the office -- could have a chilling effect on patients because they would be required to pay a 20 percent cost-sharing charge.
Medicare said the call would be used to help patients determine whether they need to come in for an appointment. But doctors and consultants said the virtual sessions could cover a broad array of services, including monitoring patients starting a new medicine or those trying to manage chronic illnesses, such as diabetes. The Medicare Payment Advisory Commission, which provides guidance to Congress, panned the proposal last month, saying it could lead to excess spending without benefiting patients.
"Direct-to-consumer telehealth services ... appear to expand access, but at a potentially significant cost and without evidence of improved quality," the commission's chairman, Dr. Francis Crosson, said in a letter to the Centers for Medicare & Medicaid Services (CMS). "Due to their greater convenience, these services are at risk of misuse by patients or provider."
Congress has shied away from expanding the use of telemedicine in Medicare -- even as it has become commonplace among private insurers -- because of concerns about higher spending. Budget hawks worry that rather than replace comparatively expensive in-person visits, extra telemedicine billings would add to them.
Lack of coverage -- except in rare circumstances -- means fewer than 1 percent of the 50 million Medicare beneficiaries use telemedicine services each year.
Federal law forbids Medicare from paying for telemedicine services that replace in-person office visits, except in certain rural areas. That's why CMS called the new benefit a check-in using "virtual" or "communications technology," said Jacob Harper, who specializes in health issues at the law firm Morgan, Lewis & Bockius.
In addition to the check-in call, CMS has proposed starting to pay physicians to review photos that patients text or email to them to evaluate skin and eye problems, as well as and other conditions. It also has proposed paying physicians an unspecified fee for consulting electronically or by phone with other doctors.
"Innovative technology that enables remote services can expand access to care and create more opportunities for patients to access personalized care management as well as connect with their physicians quickly," said CMS Administrator Seema Verma when announcing the proposal.
CMS said it hopes to enact the changes in 2019. Officials will announce their final rule after evaluating public comments on the plan.
Verma and other CMS officials say they believe the change would end up saving Medicare money by reducing unnecessary office visits and catching health problems early, before they become more costly to treat.
But in its detailed proposal, CMS acknowledges the telehealth service will increase Medicare costs. CMS said the telehealth will result in "fewer than 1 million visits in the first year but will eventually result in more than 19 million visits per year, ultimately increasing payments under the [Medicare physician pay schedule] by about 0.2 percent," or eventually about $180 million per year. Because the change must be budget-neutral, CMS is paying for this by decreasing some other Medicare physician payments.
CMS doesn't expect rapid adoption of the telehealth service, partly because doctors can get paid from $35 to $150 for an in-person visit. "Because of the low payment rate relative to that for an office visit, we are assuming that usage of these services will be relatively low," CMS said in its proposal.
The virtual check-in can be conducted by physicians or nurse practitioners or physician assistants working with a doctor.
Only patients who have established relationships with a doctor would be eligible for the service. Doctors also would not be allowed to bill for the check-in service if it stems directly from an in-person visit or is followed by an appointment with the doctor, according to the CMS proposal.
Dr. Michael Munger, a family physician in Overland Park, Kan., and president of the American Academy of Family Physicians, said many doctors routinely check on patients by phone. Still, he applauded the effort to increase physician pay.
"Anytime you can tie payment to what many of us are already doing is good," he said.
Mercy, a large hospital system in St. Louis, has been offering telehealth services even without reimbursement because it helps patients access care and lowers costs in the long run, said Dr. J. Gavin Helton, president of clinical integration at Mercy Virtual.
"We are already on this path, and this will help to continue to grow our programs and make them financially sustainable," he said.
Still, Helton said the "check-in" fee from Medicare won't be enough to motivate providers to start telehealth services.
He said the new reimbursement signals that Medicare wants to pay for services to keep patients well rather than just treat them while they are sick.
Other physicians were more skeptical, particularly while Medicare has also proposed reducing some fees for in-person office visits.
In a letter to CMS, Dr. Amy Messier, a family medicine doctor in Wilmington, N.C., raised concerns about the effect this could have on patients' expenses.
"I worry about implementation of this from the patient perspective now that we are charging patients for this previously free service and they have to pay their portion of the charge," she said.
"Patients will be less likely to engage their physician outside of the office visit and more likely to seek care face-to-face at more expense, when perhaps that visit could have been avoided with a phone call which they will no longer make because it comes with a charge," she said.
Dr. Todd Czartoski, chief executive of telehealth at Providence St. Joseph Health in Renton, Wash., predicts most doctors won't use the proposed telehealth service.
"It's still easier for a doctor to go room to room with patients lined up," he said. "It's a step in the right direction, but I don't think it will open the floodgates for virtual care."