The Centers for Medicare & Medicaid Services recently announced that Medicare will not continue to cover audio-only telehealth visits when the COVID-19 public health emergency (PHE) ends, citing that the statutory provision for telehealth coverage refers to an “interactive telecommunication system” ... which CMS understands to exclude audio-only contact.  

This decision will have a particularly tough impact for geriatric psychiatry patients in hospital outpatient departments (HOPDs), since significant proportions of older adults are tele-video unready, lacking the means, equipment or technology savvy to adopt such a mode of communication for their household. 

Take my hospital, Northwell Health’s psychiatry HOPD at Zucker Hillside Hospital in Queens, N.Y. Over the first quarter of 2021, we were unable to conduct 51% of remote geriatric psychiatry patient visits using tele-video, which instead had to be accomplished telephonically. Compare that to only 29% of non-geriatric adult visits that used audio-only technology. With a PHE deadline likely looming, strategies to achieve tele-video capability in elders are imperative. 

From a clinical perspective, face-to-face (tele-video or in-person) visits are of course preferable and should be mandatory (with few exceptions) for initial intake assessments.  However, for many older patients, follow-up behavioral health visits have been provided effectively through audio-only communication throughout the COVID-19 pandemic – a real lifeline that should encourage CMS to revisit reimbursement for certain types of audio-only visits.

When the COVID-19 outbreak exploded, a remarkably rapid transformation to tele-psychiatry visits ensured continued access to behavioral health care services. CMS expanded telemedicine eligibility to all Medicare beneficiaries – not just those in rural communities – including, with certain stipulations, service delivery to patients’ homes. CMS also enabled comparable payments for audio-only visits.

At that time, the decision to support reimbursement for audio-only services seemed to recognize that for many of  the aforementioned “unready” older adults, tele-video visits were not feasible because of a lack of broadband or WiFi connectivity; no home desktop or laptop computer, tablet or smartphone; technological inexperience; and hearing/vision loss, physical handicaps, and cognitive impairment.

In August 2020, two research publications in JAMA Internal Medicine reported that approximately 40% of Medicare beneficiaries lacked digital access and were tele-video unready. Notably higher proportions were found in elders who were widowed, Black or Hispanic, in poor health, with low incomes or very old. Several such characteristics were found to be more commonly seen in HOPDs as compared to independent physician offices in a just-published AHA-commissioned study.

Taken together, psychiatric HOPDs treating older patients must mobilize to overcome tele-video capability disparities that ensure service delivery and reimbursement. To this end, in our geriatric psychiatry outpatient clinic, we now screen all new referrals for telemedicine readiness by utilizing a standardized questionnaire that addresses digital access, technological literacy and personal disabilities. Patients are then categorized according to tele-video and -audio functionality, including based on availability of technology enabling significant others (e.g., family, friends or care aides). In addition, our hospital and health system will support a digital navigator to integrate responses with as-needed home assessments to develop a digital access care plan that encompasses educational, training, equipment and environmental needs.

Vulnerable elderly patients have disproportionately suffered in the COVID-19 pandemic. Shepherding older adult patients across the “digital divide” is now an access-to-care health equity issue that demands attention and creative solutions. Until achieved, Medicare reimbursement for some post-PHE audio-only services should be reconsidered and provided.


Blaine Greenwald, M.D., is vice chair and director of geriatric psychiatry in the department of psychiatry at Zucker Hillside Hospital, Northwell Health's behavioral health center.

Opinions expressed by the authors do not necessarily reflect the policy of the AHA.
 

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