JAMESTOWN, N.D. — One of the biggest barriers to offering telehealth or virtual care service in North Dakota is unsustainable reimbursement rates to health care providers, according to Andrew Askew, vice president of public policy for Essentia Health.
Askew said former President Donald Trump directed the Centers for Medicare & Medicaid Services to add more than 80 new telehealth services to the list of services covered by Medicare and to reimburse them at the same rate as in-person services, which is referred to as payment parity. That change allowed health care providers to expand telehealth.
Prior to the pandemic, telehealth was really limited to a small set of services and usually required the patient to go to a clinic or health care facility, Askew said. He said Essentia was not able to bring virtual visits to a patient’s home until the Centers for Medicare & Medicaid Services and different states changed the regulations to allow that.
“It’s really taken off,” Askew said, referring to telehealth services. “I think today we’ve done almost 530,000 visits.”
Bill Heegaard, president of Essentia’s west market, which includes eastern North Dakota and northwestern Minnesota, said Essentia did zero telehealth visits prior to the coronavirus pandemic. During the pandemic, he said 5% to 10% of the visits at Essentia were through telehealth, but it is probably close to 5% right now.
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“I think the remarkable thing, and I will just talk about Essentia’s experience, but we went from zero to 3,000 visits per day in a matter of three weeks,” he said.
Easier access to behavioral health providers
North Dakota Insurance Commissioner Jon Godfread said telehealth visits are important in a rural state. During the pandemic, telehealth visits increased dramatically, he said, especially with people who have behavioral health issues.
He said it is easier for people in urban settings to have access to behavioral health providers.
“It’s going to be a critical piece of our health care delivery in the future because for people who live in rural settings, it gives them the opportunity to have access to specialists and have those conversations with their providers and their doctors and get that similar level of care that they may get in a more urban setting,” Godfread said.
Blue Cross Blue Shield North Dakota worked with health care provider groups and the Blue Cross Blue Shield Association and found that behavioral health is one area where its members benefit by having a telehealth visit, said Greg Glasner, chief medical officer for Blue Cross Blue Shield North Dakota.
“Right now … the only type of visit that has been shown to have similar outcomes from telehealth visits to in-office visits are the behavioral health visits,” Glasner said. “The other types of visits, there really hasn’t been any quality outcomes studies. Does it really give you the same quality outcomes with virtual visits versus in-person visits? There is really not good data out there that says one is better than the other.”
Heegaard said telehealth services are a big benefit to those with mental health issues, especially if they live in a rural community. He said people with mental health issues would normally have to drive to a provider in a larger city.
He also said those with mental health issues can avoid sharing with even a receptionist about their depression because they can set up a virtual visit on the Internet. He said it also allows the patient to see a therapist after nontraditional work hours.
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“I see it as a win-win for the patients,” he said. “I see it as a win for a state like North Dakota because we have so many challenges just because of the distance and also in certain areas, we have challenges in having those specialties available.”
Reimbursing for telehealth
Under current law in North Dakota, reimbursement for telehealth services to the health care provider can be anywhere from 20% to 40% lower than in-person services, said Askew, the public policy official from Essentia.
“That is very challenging for not only health systems or Essentia but for your smaller critical access hospitals that are interested in offering telehealth services and want to keep their patients in their communities instead of having them travel outside of the state for care or some of the state’s larger cities,” he said.
Glasner said there are rate differentials for some visits but the rates vary depending on the type of visit. He said some services, including telehealth, are reimbursed at parity.
“That has been a recent change because in order to change policy, we have to go through what is called a benefit rewrite process,” he said. “So there are a number of behavior health codes that are paid at parity, which is telehealth versus office visits. Those went into effect Jan. 1.”
Askew said health care providers such as Essentia have fixed costs that cannot be avoided such as funding its buildings, keeping the emergency room open and employing nurses for telehealth services. National providers of telehealth services do not own a hospital or offer emergency room services.
“Although it might seem like virtual care is cheaper for hospitals to provide it actually isn’t when you take into account the cost of technology and the support that needs to be there for the telehealth platform,” he said.
Godfread said he supports targeted parity over blanket parity. He said an example of targeted parity is reimbursing providers or behavioral health services. He said some insurance companies are already reimbursing health care providers with targeted parity.
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“If we pass a law in North Dakota that says behavioral health services are going to be paid at parity as in-person visits, I think we can assume to have that discussion and talk about that in the Legislature,” he said. “Last legislative session there was a bill that asked for blanket parity, so essentially any service that you received that’s done over telehealth would be paid as an in-person visit.”
He said behavioral health providers oftentimes have one to four doctors in an office together and it makes sense to reimburse them through payment parity versus doing the same for a traditional hospital.
“If you do a blanket parity, everybody is thrown into the same bucket where all the traditional services will be paid as in-person visits,” Godfread said. “It removes the incentive to actually lower the cost of health care delivery in our state, which is something we desperately need.”
Askew said North Dakota needs to follow the lead of the Centers for Medicare & Medicaid Services and 15 other states, including Minnesota, on reimbursement to providers for telehealth services.
In the last legislative session, Senate Bill 2179 looked to address the payment parity issue. The bill was approved by the Senate, but it failed to pass in the House.
“In the Senate the bill was amended to a study. Kind of a mandatory interim study to look into the benefits of telehealth,” Askew said. “In the House it was amended away from the study and actually required payment parity for a two-year period, kind of a pilot program. I think there is just a lot of debate whether or not payment parity was required at the time.”
Although it might seem like virtual care is cheaper for hospitals to provide it actually isn’t when you take into account the cost of technology and the support that needs to be there for the telehealth platform.
Glasner said Blue Cross Blue Shield North Dakota will continue to evaluate what is appropriate to be reimbursed, what level of service is appropriate to be reimbursed and where the visit took place.
He said the solutions to payment parity depend on what chair you are sitting in.
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“If you are a provider, you think they should be paid the same,” he said. “If you are a member, you think they shouldn’t be paid the same because you want to choose a cheaper option.”
He said Blue Cross continues to look at what best serves its members in the most cost-effective way to achieve good quality health outcomes.
“If we find that telehealth visits will provide that benefit then we will get to that level of reimbursement to do that,” he said. “If we think that it’s a benefit to the members to do a visit without or with the cost differential, then I think that’s the way to go because our job is to provide access of care to our members at the best cost that we can find.”
If there is an increased demand for telehealth services, Godfread said that will create an opportunity for health care providers and insurance companies to figure out how to reimburse those services.
“I don’t necessarily think the Legislature needs to legislate that because this is going to continue to evolve over time,” he said. “We are in a transition phase here for our health care delivery. So it’s really going to take some good communication between our providers and insurers on how to best serve our consumers.”
Askew said the North Dakota Hospital Association is convening a telehealth work group that will be charged with identifying and evaluating the problems and concerns that hospitals have with providing telehealth services.
“The group is also going to study how to better promote telehealth services, improve access to health care and really identify those barriers that our large and small hospitals are having of delivering that care,” he said.
