Managed Care Update

Web Exclusives —August 5, 2020



“COVID-19 has been like a 9/11 moment in healthcare,” said Michael Kolodziej, MD, Senior Advisor, ADVI Health, during a webcast on managed care, oncology, and the COVID-19 pandemic, hosted by the Association for Value-Based Cancer Care on July 28, 2020. “We don’t have a playbook. It’s required us to rethink.”

It is hard to think of an aspect of the healthcare payment system that has undergone more rapid or significant “rethinking” than the reimbursement structure for telehealth services. Telemedicine, still in relative infancy when the pandemic hit, exploded virtually overnight, with visits growing exponentially. Public and commercial payers adapted their reimbursement structures, with telemedicine visits for most types of medical care now being paid at parity with in-person visits.

A few months into the COVID-19 pandemic, although there have been many technical glitches and growing pains, many practices and patients have found that, for at least a subset of visits, telehealth serves them as well as or better than in-person visits. But how long will reimbursement parity continue?

“Telehealth has been a good solution to a bad problem, and it was the right thing to do to reimburse at parity—but I am concerned that payers will reduce reimbursement as foot traffic picks up, and when reimbursement goes down, providers will stop using it,” said Dr Kolodziej.

That is already happening, suggested Lee Newcomer, MD, Former Senior Vice President, Oncology and Genetics, UnitedHealth Group. “We’re already seeing payers begin to reduce reimbursement as COVID-free clinics are set up. But I think it is a very efficient way to use physician time, and I would like to see it established as another tool in the toolbox for the future.”

Harvard Pilgrim Healthcare continues to pay for telemedicine visits at parity, and does not charge any cost-sharing to individuals who are getting virtual care, said Michael Sherman, MD, MBA, MS, the organization’s Senior Vice President and Chief Medical Officer. “But I’m not sure if that is sustainable long-term. Who is paying for it? It is everyone. It is the insurance pool.”

Some of these discussions may be premature, suggested Bryan Loy, MD, MBA, Physician Lead, Oncology, Laboratory, and Personalized Medicine, Humana. “I don’t think COVID is done with us and we’re not done with COVID. We are still learning. From oncology providers, I hear over and over, ‘Don’t take this away.’”

One challenging area is the question of reimbursement for virtual visits that are strictly by phone call, with no video component. “Historically, we did not count phone calls as reimbursable for telehealth, out of concern that they would be used for things that were not bona fide visits and did not merit separate reimbursement. COVID changed that, and we are covering phone calls for now. But there’s a real question as to which ones you should reimburse for.”

But Dr Newcomer said he didn’t begrudge paying a primary care provider or a specialist a little more margin for a phone call. “I’d rather have that doctor talking to me and helping me to monitor my disease than doing another $3000 procedure. I’m happy to give them the extra margin.”

When Dr Kolodziej polled the panel as to whether they thought managed care payers would still be reimbursing telehealth at parity in 6 months, they were divided. Dr Newcomer was the only one to offer an unqualified “yes.” Steven Peskin, MD, MBA, FACP, Executive Medical Director, Population Health and Transformation, Horizon Blue Cross Blue Shield, gave a “qualified yes,” whereas Dr Kolodziej said “no,” and Dr Sherman said that it will all depend on the persistence of the COVID crisis. “It is not a simple answer,” concluded Dr Loy.

Related Articles
Cancer Doesn’t Quarantine: A “Thank You” to Cancer Nurses and Navigators
June 2022 Vol 13, No 6
As a little girl, Tamika Felder dreamed of being on TV. She loved watching the news even at a very young age, had an unwavering curiosity about what was going on in the world, and set her sights on a career in television, which she later achieved. What she didn’t set her sights on was a cervical cancer diagnosis at the age of 25, a radical hysterectomy, and the devastating complete loss of her fertility.
Navigation as a Catalyst to Reignite Cancer Screenings
August 2021 Vol 12, No 8
With concerted efforts by navigators, we can increase preventive screening rates.
The Need for a Complete Cancer Care Team Is Critical as We Move Out of the Pandemic
Christian Downs, JD, MHA, Linda Fleisher, PhD, MPH, Lillie D. Shockney, RN, BS, MAS, HON-ONN-CG, Mandi Pratt-Chapman, MA, PhD, HON-OPN-CG, Rani Khetarpal, MBA
May 2021 Vol 12, No 5
Leaders from the Academy of Oncology Nurse & Patient Navigators deliver a statement on appropriate planning to serve patients and their families in the wake of the COVID-19 pandemic.
Last modified: November 15, 2022

Subscribe Today!

To sign up for our print publication or e-newsletter, please enter your contact information below.

I'd like to receive:

  • First Name *
    Last Name *
    Profession or Role
    Primary Specialty or Disease State