COVID-19 renews momentum for Kansas to tackle telehealth pay parity ― but questions persist

Titus Wu
Topeka Capital-Journal
Telehealth usage increased dramatically during the COVID-19 pandemic.

Long before the COVID-19 pandemic, Blue Cross Blue Shield Kansas City provided telehealth services through Amwell and Teladoc Health, two major telehealth platforms. 

"We didn't have a lot of uptake. There were people that said, 'No, I want to go see my doctor,'" said Coni Fries, a lobbyist for BCBS Kansas City, on when the program first rolled out. "We made it less co-payment, but people were resistant to that type of technology."

But when the pandemic reached Kansas spring of last year, everything changed.

"The demand was incredible for telehealth services," Fries said, as doctor's offices closed and people tried to limit in-person exposure.

As vaccinations increase and the pandemic shows signs of subsiding, Kansas health care advocates are hoping to take advantage of this consumer shift to finally push through legislation establishing payment parity for telehealth services.

It's expected that telehealth services will be reimbursed at lower rates than in-person services after the pandemic, just like it was before.

The last time state lawmakers took real action on the topic was in 2018, when they passed the Kansas Telemedicine Act

But that act only mandated coverage parity, not payment parity. Insurers have to cover a telehealth service if it could also be provided in-person, but they could set their own rates for telehealth reimbursement.

A pandemic-caused acceleration

In the early months of the COVID-19 pandemic, Gov. Laura Kelly issued an executive order that significantly expanded access to telehealth.

Along those changes was expanded reimbursement and payment parity for certain services through Medicaid, while private health insurers also temporarily enacted more pay parity for telehealth.

Advocates seized upon the moment to study the effects of pay parity in Kansas, as well as any changing attitudes. 

According to a February poll on behalf of the United Methodist Health Ministry Fund and REACH Healthcare Foundatio, nearly half of Kansans said they have used telehealth for a wide variety of reasons. Around 86% supported expanding or maintaining telehealth access post-pandemic.

Compare that to before the pandemic, when just 11% of Americans had used telehealth services.

“Kansans have eagerly adopted telehealth and now choose it for everything from medication consultations, to annual check-ups, to regular therapy sessions," said CEO David Jordan, with the ministry fund. "Protecting and expanding access to telehealth is a common-sense approach to ensure that Kansans continue to receive quality health care when and where they need it."

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Another survey, released last December and conducted by the ministry fund and the University of Kansas Medical Center, revealed that pay parity was essential in boosting telehealth. 

Reimbursement prior to COVID-19 didn't cover costs according to 60% of providers surveyed, and 85% of knowledgeable respondents said telehealth reimbursement was worse than that for in-person visits. But after Kansas allowed for equal reimbursement rates during the pandemic, only 38% of knowledgeable respondents said the same.

Now, 85% of providers said pay parity is the top issue in ensuring telehealth continues, according to the report.

Kansas Rep. Brenda Landwehr, R-Wichita, chairs the House committee overseeing discussions on telehealth pay parity.

The new shift in habits have stirred quite a few legislators to at least look into doing something about pay parity.

"I would urge this to happen," said Rep. Jim Kelly, R-Independence, on legislation being hashed out. "I think if we don't do it, we'll end up back to where we were when I asked the question, 'What's it going to take to get telehealth really going and used properly?'"

Beyond just capturing the momentum, for some, it's also just a matter of fact that laws will need to reflect the changing landscape of how people access healthcare.

"Telehealth has gone from being a small piece of the medical ecosystem to being a much larger piece in the last year and will likely continue," said Scott Latimer, chief medical director at Sunflower Health Plan. 

'It's a lot more complex'

Efforts in 2017 and 2018 in the Kansas Legislature only ended up with requiring coverage parity, partly because health insurers opposed payment parity. Three years later, the pandemic hasn't changed insurers' minds.

The exact effects of pay parity on the health insurance marketplace aren't necessarily positive, they say.

"It's a lot more complex than just a number, or a matter of saying we're going to pay the same as something else," said Rep. Brenda Landwehr, R-Wichita, acknowledging the nuances.

More:Topeka and Shawnee County leaders encouraged COVID-19 vaccinations. Did they get the shot?

Fries, the BCBS Kansas City lobbyist, portrayed parity as unnecessary government intervention. Rate negotiations should be left between the insurer and provider, and if telehealth services by their nature cost less than in-person and can be reimbursed less, then being forced to reimburse the same amount as in-person doesn't make sense.

Consumers know "if I do telehealth, instead of an in-office visit or ER or urgent care, it's going to cost me less," she said. Parity "would tell that consumer, 'Now we need to charge you more,' because there are certain players in the market that can't deliver telehealth at the cost that others can, and we're going to subsidize those."

It's that competition which parity proponents are arguing on. They say small, brick-and-mortar providers who want to continue providing expanded telehealth services have to be able to compete with big, insurance-housed providers like Amwell, who have little to no overhead costs.  

Blue Cross Blue Shield Kansas in general has opposed payment parity for telehealth services.

While BCBS said in-network providers are already paid the same rate for in-person and telehealth services, it's virtually remote companies like Amwell that pose a problem, said Rachelle Colombo, executive director of the Kansas Medical Society.

"If it's not reimbursed at the same rate as a different telemedicine provider, even though it's the same rate they would get for in-person care, it's non-competitive," Colombo said.

In other words, there are two types of payment disparity that can be addressed: between providing remote and in-person services within one provider, or between a local physician providing telehealth services and a telehealth platform like Amwell or Teladoc Health.

"That's where I would say that this is complicated," said Colombo. "It isn't quite as straightforward."

It gets even more complicated when considering other factors, such as the fact employers can opt out of using a health insurance company and self-fund health claims. As insurance costs rise, more small businesses have turned to this.

"Doing something on the fully insured side does not mean it's going to happen on the self-funded side," said Sunee Mickle, with Blue Cross Blue Shield Kansas  "And if anything, it's going to drive more people towards the self-funded market so they can carve themselves out."

A screenshot of Teladoc's licensed platform on a tablet device.

It ultimately comes down to either going by the free market and believing it knows best, or having some policies to ensure all can offer telehealth.

"I'm really concerned about just leaving this up to market forces in Kansas," said Jennifer Findley, with the Kansas Hospital Association. "Small, rural facilities, they're not part of systems, they don't have negotiation power. They have to take what the insurance company gives them, and just accept it if they want to participate."

To telehealth or not?

In addition to the marketplace debate, there's the more fundamental question of whether society should rely more heavily on remote health care.

Some questioned the effectiveness of telehealth, now and in the future.

Mickle noted that when BCBS Kansas began to offer parity, the majority of its telehealth claims were actually related to just behavioral health. Not a lot of other services were being performed, and if they were, it was "questionable."

She urged caution against acting upon data from a pandemic, as more people come back into doctor's offices with vaccinations increasing. There's the fear that parity would accelerate a shift away from essential, in-person care. 

We "like the ability to direct and try to pay those providers who are doing God's work out in western Kansas and rural areas," she said. "We want to be able to encourage and incentivize them to see people in their offices."

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Putting in set reimbursement rates could hamper efforts to financially incentivize in-person providers to put roots in underserved, rural areas, she said.

No one agreed with the notion that telehealth should replace in-person care, but advocates said there are benefits that can't be ignored.

Barriers like lack of transportation or the inability to afford childcare or to miss work will still exist after COVID-19. Some may still be uncomfortable with face-to-face services after the pandemic. Staff shortages of health workers, especially in rural areas, can also be helped by telehealth. 

"It's not just about the savings. It's about the convenience," said Claudia Tucker, lobbyist for Teladoc Health. "If you're working at an hourly wage, and you've got to take two hours off to go to the doctor's office, that could be your electric bill."

But not all health services are best done remotely, and reimbursement will have to be done in a way so it won't undermine certain crucial in-person care, advocates said.

A photo shows a road sign pointing to the nearest hospital. The Kansas Hospital Association has tried to initiate some conversations on possible legislation regarding telehealth pay parity.

Still in the works

Payment parity was never brought up in legislation this year, as lawmakers have made it clear it would wait until after the pandemic.

It's an issue, however, that could come up in 2022's session, as Rep. Landwehr directed health providers and insurers to work together on forming some compromise related to payment parity.

"I would much rather that you help us figure this out than that we figure this out for you," said Rep. John Eplee, R-Atchison, to the stakeholders. 

As of now, those conversations ended in April and have yet to resume, said Findley, and no formal bill has been written.

Given the unclear data around the impacts of pay parity, the hospital association had suggested each side mutually pick a set of conditions that would be reimbursed the same whether provided in-person or via telemedicine for the next year.

An independent third party could then analyze that impact, and then more discussion could be had based on that.

Ultimately, there will be a lot of moving parts, and an agreement that satisfies everybody will be a large hill to climb.

"There's a whole lot of ways that this conversation breaks out," Colombo said. "And it really is complicated."