Dive Brief:

• President Donald Trump late Monday signed an executive order directing the administration to permanently extend Medicare's broader telehealth coverage after the public health emergency, and CMS followed by proposing a rule that does so — albeit on a piecemeal, service-by-service basis.
• The proposed changes, in its 2021 physician fee schedule released Monday night, would allow Medicare providers to conduct evaluation and management (E/M) home visits for established patients virtually, allow an emergency room E/M virtual visit for minor to moderately severe health issues and expand some telehealth services similar to telehealth services already covered by Medicare, like for group psychotherapy or care for patients with cognitive impairment. Nine new telehealth codes will be permanent, and 13 will be covered through the calendar year in which the public health emergency ends, to give physicians a chance to deliver services virtually before CMS decides whether or not to permanently allow them.
• Notable exclusions are payment for audio-only telehealth visits conducted over the telephone, though CMS noted consumer demand could remain as Medicare beneficiaries, of which an estimated 40% don't have access to a computer with internet, look to receive care while avoiding potential infection. CMS asked for public input on any services it temporarily included for the scope of the emergency that it's not proposing to cover permanently. Comments are due Oct. 5.

Dive Insight:

Telehealth utilization has skyrocketed since the administration broke down regulatory barriers to access and governors enacted widespread stay-at-home orders beginning in March, though there are some initial signs it began to plateau starting two months ago as states prematurely opened their economies.

Medtech companies including at-home colorectal cancer screening test maker Exact Sciences and continuous glucose monitor manufacturer Dexcom have talked up efforts to grow the teleprescribing and ease of adoption of their products during a time when typical visits to the doctor have been limited.

In the week ended March 7, only 11,000 elderly and disabled Americans in Medicare used telehealth. By the week ended April 25, that had snowballed to 1.7 million Medicare beneficiaries.

The biggest question mark hanging over the industry is how many of the regulatory changes that spurred unprecedented adoption will remain post-COVID-19. Prior to Monday's rule, CMS temporarily allowed more than 135 additional services through telehealth, and signaled it wanted to make many permanent beyond the scope of the public health emergency announced in March and renewed late July.

The agency started with permanently allowing the use of virtual care in home health late June, though it can't be reimbursed as a visit.

The most meaningful changes would require congressional intervention. Lawmakers on both sides of the aisle have introduced a series of bills to expand telehealth availability, though it's unclear what provisions if any will make it into a planned fifth round of COVID-19 relief.

Either way, the order and the proposal are a net positive for telehealth vendors like Teladoc, Amwell, Doctor on Demand and MDLive. The moves entrench the modality more firmly into the regulatory landscape, lessening the fear coverage for virtual care could disappear along with the national emergency.

In the physician fee schedule for 2021, CMS also proposed lowering the conversion factor used to calculate rates, which would reallocate Medicare dollars, benefiting general medicine at the expense of some specialists, Jefferies analysts said.

Rates for physical therapy, anesthesiology, nurse anesthetists and emergency medicine would fall 9%, 8%, 11% and 6%, respectively.

Surgeons would be particularly hard hit: If the proposed fee schedule is finalized, Medicare reimbursement would be cut by 9% for cardiac surgery, 8% for thoracic surgery, 6% for ophthalmology and 7% for vascular surgery, general surgery and neurosurgery.

The American College of Surgeons lashed out against the cuts. "The middle of a pandemic is no time for cuts to any form of health care, yet this proposed rule moves ahead as if nothing has changed," ACS Executive Director David Hoyt said in a statement Tuesday morning.

Rates for nurse practitioners and general practice would both rise 8% and family practice would rise 13%, benefiting primary care clinics.

The proposed rule would also simplify billing and coding requirements for office and outpatient visits, and up payments for a variety of bundled payments, including for maternity care.

CMS also clarified certain provisions around remote patient monitoring. Following the public health emergency, providers will have to have an established relationship with a patient to provide RPM. RPM is considered an E/M service, and only eligible physicians and nurse practitioners can bill for it, CMS said.

The agency also proposed changes to the Medicare Shared Savings Program for accountable care organizations for the 2020 performance year, including modifying how quality is benchmarked by changing how shared savings and shared losses are determined. CMS also proposed a new scoring methodology for ACOs beginning in 2021 under "extreme and uncontrollable" circumstances, to try and cushion the value-based providers from unforeseen circumstances, like a pandemic.

The physician fee schedule came hours after the president signed a narrow executive order for HHS to promote telehealth use and access, particularly for the approximately 57 million Americans living in rural areas.

Along with directing HHS to review temporary telehealth expansions and propose regulations to permanently codify them, the order calls on the health department to move rural facilities away from fee-for-service by introducing a novel rural payment model in CMS' innovation center within 30 days.

Providers with diversified revenue streams, such as those operating in subscription models, have fared better amid the pandemic as they're more insulated from volume collapse.

The order also directs HHS to create a "rural health action plan" to focus on sustainably preventing deleterious health outcomes down the line by increasing technology and access to care, and get on the same page with the Federal Communications Commission and the Department of Agriculture to increase broadband connectivity in rural areas.

The executive order was not the sweeping Affordable Care Act replacement plan Trump has long promised over the three-and-a-half years of his presidency to justify his support of a lawsuit to deem the decade-old law unconstitutional. In one interview about two weeks ago, the president promised a "full and complete healthcare plan" would be made public by Aug. 2.

Trump at a press conference Monday night said a comprehensive healthcare plan would be released before the end of the month.