Key Takeaway U.S. Department of Health and Human Services Office of Inspector General Data Snapshot October 2021, OEI-02-20-00521 Most Medicare beneficiaries received telehealth services only from providers with whom they had an established relationship Background In response to the COVID-19 pandemic, both Congress and the Department of Health & Human Services (HHS) expanded access to a wide range of medical services that can be delivered via telehealth (i.e., telehealth services). This expansion enhanced the ability of health care providers to offer care to Medicare beneficiaries remotely during the COVID-19 pandemic. Prior to the pandemic, beneficiaries were only able to receive certain telehealth services from providers with whom they had an established 84% of relationship.1 However, HHS announced that it will use its discretion to not enforce beneficiaries requirements for established relationships during the pandemic.2 received all their telehealth services While the expansion of telehealth has been essential to maintaining beneficiaries' from providers with access to care, there have been concerns about the potential for fraud, waste, and whom they had an abuse associated with expanded telehealth services.3 This data snapshot provides established information to policymakers and other stakeholders about the relationship between relationship. beneficiaries and providers of telehealth services. These data are critical to informing decisions about how to structure telehealth services in Medicare on a more permanent basis. Understanding how likely beneficiaries are to receive telehealth services from a provider with whom they have had an established relationship, and the average timeframe between an in-person visit and a telehealth service, can help inform decisions on how frequently in-person care may need to be paired with telehealth services. This snapshot is part of a series of reports on telehealth; the other reports focus on telehealth utilization and program integrity. Results Eighty-four percent of beneficiaries received 84 percent of beneficiaries received telehealth services only from providers with whom telehealth services only from providers they had an established relationship. with whom they had an established In total, 26 million beneficiaries, representing 39 percent of relationship. all Medicare beneficiaries, received at least one telehealth service from March through December 2020.4 Slightly more than half of these beneficiaries were enrolled in traditional Medicare (also known as Medicare fee-for-service), while the remainder were enrolled in Medicare Advantage. Eighty-four percent of these beneficiaries received all their telehealth services from providers with whom they had an established relationship. These beneficiaries had an in- person visit or other service with each of their providers prior to their telehealth service.5 The remaining 16 percent 16 percent received telehealth services of beneficiaries received telehealth services from at least from at least one provider with whom one provider with whom they had no prior relationship. they had no prior relationship. 1 The proportion of beneficiaries receiving telehealth services from providers with whom they had an established relationship varied by type of service. Beneficiaries most commonly received e-visits, virtual check-ins, and telephone evaluation and management services via telehealth from providers with whom they had an established relationship. E-visits and virtual check-ins are brief telephone calls or online interactions via a patient portal. Telephone evaluation and management services are telephone calls to discuss a beneficiary's medical condition; these calls can last up to half an hour. In total, 84 percent of beneficiaries who had e-visits and virtual check-ins and 84 percent of beneficiaries who had telephone evaluation and management services via telehealth had an established relationship with their providers. These high proportions are not surprising because these types of services are designated for beneficiaries who have established relationships with their providers. Importantly, 83 percent of beneficiaries who received office visits via telehealth had an established relationship with their providers. These office visits are conducted via telehealth as opposed to in person and were the most common type of telehealth service. In total, beneficiaries Office visits represented 48 percent received about 45.5 million office visits delivered via of all services provided via telehealth telehealth, which accounted for nearly half of all telehealth during the pandemic. These visits services provided from March through December 2020. include services with primary care providers and specialists for the Beneficiaries who received home visits via telehealth, which purpose of evaluating or managing represented only 1 percent of all services provided via the beneficiary's medical condition. telehealth, were the least likely to have an established relationship with their providers; only 34 percent had such a relationship. Prior to the pandemic, providers typically conducted home visits to evaluate and provide care to beneficiaries in their home.6 During the pandemic, these home visits were conducted via telehealth. The proportion of beneficiaries receiving telehealth services from providers with whom they had an established relationship varied for the most common services. Source: OIG analysis of Medicare data, 2021. 2 Beneficiaries in traditional Medicare were more likely to receive telehealth services from providers with whom they had an established relationship, compared to beneficiaries in Medicare Advantage. Overall, a smaller proportion of beneficiaries enrolled in traditional Medicare received telehealth services, compared to beneficiaries enrolled in Medicare Advantage. Specifically, one-third of beneficiaries in traditional Medicare, compared to 45 percent of beneficiaries in Medicare Advantage, received telehealth services from March to December 2020. Prior to the pandemic, Medicare did not allow beneficiaries in traditional Medicare to receive telehealth services in their homes and only covered telehealth services in rural areas.7 In contrast, Medicare Advantage plans had greater flexibility to provide telehealth services to beneficiaries. For example, plans could provide services to beneficiaries in their homes and regardless of their geographic location.8 While a smaller proportion received telehealth services, beneficiaries in traditional Medicare were slightly more likely to receive telehealth services from providers with whom they had an established relationship than beneficiaries in Medicare Advantage. In total, 86 percent of beneficiaries in traditional Medicare received a telehealth service from providers with whom they had an established relationship, compared to 81 percent of beneficiaries in Medicare Advantage. This was true for nearly all of the most common services. The only exception to this was physical, occupational, and speech therapy. Beneficiaries enrolled in traditional Medicare were more likely to have an established relationship with providers for most types of services. Source: OIG analysis of Medicare data, 2021. 3 Beneficiaries had in-person visits with their providers an average of 4 months prior to their first telehealth service. In general, beneficiaries who had an established relationship with their providers had an in-person visit an average of 4 months prior to their first telehealth service. This was true for both beneficiaries in traditional Medicare and beneficiaries in Medicare Advantage. However, the average amount of time between beneficiaries' in-person visits and their first telehealth services varied by type of service. Beneficiaries who received home visits via telehealth had an in-person visit with their providers almost 9 months, on average, prior to their first telehealth service. In contrast, beneficiaries who received nursing home visits and assisted living visits via telehealth had an in-person visit more recently, an average of 2 months prior to their first telehealth service. Beneficiaries had in-person visits with their providers between an average of 2 to 9 months prior to their first telehealth service. Source: OIG analysis of Medicare data, 2021. 4 Conclusion From March through December 2020, 26 million beneficiaries accessed essential health care services via telehealth. Examining how beneficiaries used telehealth during this time can help inform policy decisions about structuring the Medicare telehealth benefit on a more permanent basis. Most beneficiaries received telehealth services from providers with whom they had an established relationship. Notably, 84 percent of beneficiaries received telehealth services only from providers with whom they had an established relationship. Those enrolled in traditional Medicare were more likely to receive services from providers with whom they had an established relationship, compared to beneficiaries in Medicare Advantage. This pattern persisted among virtually all of the most common telehealth services. Beneficiaries tended to see their providers in person about 4 months prior to their first telehealth service, on average. These data can be used to inform decisions about how to best use telehealth in Medicare and should be taken into account as policymakers continue to examine telehealth utilization and concerns about telehealth being vulnerable to fraud, waste, and abuse. This includes decisions about which services to allow to be delivered via telehealth on a more permanent basis and to what extent Medicare should require that beneficiaries have a relationship with their providers prior to receiving certain telehealth services. Methodology For our analyses, we reviewed traditional Medicare claims and Medicare Advantage encounter claims data for telehealth services provided from March through December 2020.9 First, we determined the proportion of beneficiaries who received telehealth services only from providers with whom they had an established relationship and the proportion who received at least one telehealth service from a provider with whom they had no established relationship. To determine if a beneficiary had an established relationship with each provider, we identified the date of the first telehealth service with the provider and looked back to January 2018 to determine if the beneficiary had a prior in-person visit or other service with that same provider (i.e., any provider with the same billing number, such as providers in the same practice). We then conducted this analysis for the 10 most common types of telehealth services. Using these categories, we analyzed the proportion of beneficiaries enrolled in traditional Medicare and those enrolled in Medicare Advantage who had an established relationship with their providers. In addition, for beneficiaries who had an established relationship with their providers, we determined the average amount of time between their first telehealth service and their most recent in-person visit for each of their providers. We conducted this analysis for different types of services. Standards We conducted this study in accordance with the Quality Standards for Inspection and Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. Acknowledgments Judy Kellis served as the team leader for this study. Others in the Office of Evaluation and Inspections who conducted the study include Alexis Mills. Office of Evaluation and Inspections staff who provided support include Rob Gibbons. This report was prepared under the direction of Jodi Nudelman, Regional Inspector General for Evaluation and Inspections in the New York regional office, and Nancy Harrison and Meridith Seife, Deputy Regional Inspectors General. To obtain additional information concerning this report or to obtain copies, contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov. 5 Sources 1 Certain services-such as remote patient monitoring, e-visits, virtual check-ins, and telephone evaluation and management services-are designated for beneficiaries who have an established relationship with their providers. See 85 Fed. Reg. 19230 (April 6, 2020). 2 CMS, Medicare Telemedicine Health Care Provider Fact Sheet, March 2020. Accessed at https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet on May 24, 2021. 3 MedPac, Telehealth in Medicare after the coronavirus public health emergency, March 2021. Accessed at http://www.medpac.gov/docs/default- source/reports/mar21_medpac_report_ch14_sec.pdf?sfvrsn=0 on August 2, 2021. 4 Thisanalysis is based on telehealth services rendered and billed by individual clinicians, such as office visits, psychotherapy, and other patient evaluation and management services. It does not include telehealth services billed for hospital services, psychological testing, and behavioral assessments because beneficiaries are not expected to commonly have established relationships with providers of these services. 5 To determine if a beneficiary had an established relationship with each provider, we identified the date of the first telehealth service with the provider and looked back to January 2018 to determine if the beneficiary had a prior in-person visit or other service with that same provider (i.e., any provider with the same billing number, such as providers in the same practice). 6A home visit is defined as evaluation and management services provided by a physician to a beneficiary in their private residence. Unlike with home health services, the beneficiary does not need to be confined to their home to receive a home visit. See CMS, Medicare Claims Processing Manual, Ch. 12 - Physicians/Nonphysician Practitioners, section 30.6.14.1, March 2021. Accessed at https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/clm104c12.pdf on May 28, 2021. 7 Medicare made exceptions to the geographic restrictions in traditional Medicare for services related to acute stroke, dialysis, and substance use disorder. Beginning in January 2019, Medicare allowed beneficiaries to receive renal dialysis and acute stroke related services in their own homes via telehealth, regardless of geographic location. See 84 Fed. Reg. 15680 (April 16, 2019). Beginning in July 2019, it allowed beneficiaries to receive telehealth services in their own homes regardless of their geographic location if the services are to treat a substance use disorder or a co-occurring mental health disorder. See Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT, Pub. L. No. 115-271), October 24, 2018. 8 See 84 Fed. Reg. 15680 (April 16, 2019). 9 The analysis is based on services rendered and billed by individual clinicians. In addition, we did not include telehealth services billed for hospital services, psychological testing, and behavioral assessments because beneficiaries are not expected to commonly have established relationships with providers of these services. 6