Mostashari, Emanuel See A Future For Telehealth and Payment Reform

Farzad Mostashari and Ezekiel Emanuel agree: The COVID-19 experience could be what finally weans American healthcare off of its dependence on fee-for-service payment. But they have a slightly different vocabulary and different notions about what might lead to a tipping point. 

Emanuel uses the managed care c word, capitation, and sees it as instrumental to maintaining telehealth's current popularity.

Mostashari uses the touchier, feelier “person-based payment” and foresees a COVID-19-related economic downturn as finally getting employers to push for value-based care.

“I think that this is a very propitious moment to switch payment from fee for service to capitation — and that will drive docs to actually adopt telemedicine,” Emanuel said yesterday in an interview with Rick Berke, Stat’s co-founder and executive editor that concluded a four-day meeting called the Virtual Summit on Health System Recovery from the COVID-19 Pandemic.

“We have done $175 billion of bailouts for the loss of fee-for-service revenue. It is no way to pay for care, particularly for primary care,” Mostashari said in during an earlier session for which he was the lone speaker. “There is a window of opportunity here to get there — to guaranteed monthly payments with overall accountability for total cost and quality of care.”

It’s not surprising that the Emanuel-Mostashari Venn diagram has some intersection to it. They both served in the Obama administration, Emanuel as a top health adviser who had a hand in shaping the ACA and Mostashari as the national coordinator of health information technology.

Emanuel is now a professor at the University of Pennsylvania, and Mostashari, CEO and co-founder of Aledade, a company that operates ACOs for primary care practices. Both have stayed in the public eye as healthcare policy opinionistas. Emanuel has a new book out, titled Which Country Has the World’s Best Health Care, and an opinion piece that he co-authored with his brother, Rahm Emanuel, calling for making Medicaid a national system was recently published in the New York Times. Mostashari is active on Twitter (36.5K tweets and counting ), writes opinion pieces and speaks at meeting like this one.

Telehealth took off during the early months of the COVID outbreak for assorted reasons: safety, convenience, the loosening of CMS restrictions that private insurers in various ways followed. Reimbursement on par with in-person visits was certainly a not-minor player.

But Mostashari told his online audience that he doesn’t expect payment parity to continue: “We are going to see 20% or 30% lower payments than in-person visits because of the facility fee.“ He said there has already been some decline in the use of telehealth as in-person visits have bounced back. “I think that is a mistake,” said Mostahari. “I think we can make telehealth visits as efficient — more efficient, more productive — but it is going mean honing the workflows so that we are not merely substituting a video-screen window for a face-to-face interaction.”

Mostashari also made a useful distinction between the different types of telehealth that often gets glossed over as nearly everyone involved in healthcare waxes enthusistic about telehealth's zooming growth. There’s the telehealth provided by national companies that often have contracts with insurers and there’s the telehealth that traditional, office-based providers have ramped up for their panels of patients. Mostashari is wary of the former, a fan of the latter.

“What we want," he said, "is integration of telehealth into existing primary care, not creating an end-run around the existing, local, relationship-based primary care practice, further putting them in peril of going out of business.”

Mostashari did not directly link telehealth to payment reform as Emanuel did, but he said the pandemic and its consequences for American healthcare have strengthened the case for value-based care and, more particularly, for the ACOs that are Aledade's reason to be.

“ACO work is COVID work in the time of COVID,” he said. “For us, keeping patients healthy and out of the hospital is value-based care and it is COVID care, and I think we will see that we have been effective as being arms of public health in that way." Mostashari said value-based contracts have been “pretty stable” with only modest modifications by CMS and “our commercial partners.”

“We haven’t had to make drastic change in those value-based contracts, and many of our practices are going to be seeing $100,00 to $200,00 of additional revenue coming in not tied to fee-for-service revenue.”

CMS and its Center for Medicare and Medicaid Innovation have spearheaded ACOs and other value-based payment arrangements, and Mostashari upbraided self-insured employers mildly for “not being active enough” in pushing payment and delivery in the value-based direction. But he also predicted that is going to change because of the financial pressure that employers are going to be under a COVID-19-relatedeconomic downturn.

Berke and Emanuel discussed the politics and perception of Medicare for all. “Yes it preoccupied the country for the better part of a year,” Emanuel said. “Ironically, COVID has sort pushed it to the side.” He referenced the power of private insurers (“you are not, as I see it, going to get rid of them; the question is how do we make peace with them”) and talked up a “Medicare Advantage kind of structure” as a plausible alternative to Medicare for all.

Emanuel said he expected public demand for telehealth to continue: “If I don’t have to go to the doctor, and I can just check in from my bedroom, that seems like a great deal.” In the future, he said, telehealth could be reserved for routine care and in-person visits for more complex cases. “I think that kind of change would be excellent for everyone.” But Emanuel said that the shift has to be facilitated by how healthcare is paid for. “Insurers really need to use this opportunity to make the conversion to capitation.”