October 13th, 2020

Specialty Telehealth Expands the Value of Medicare Advantage


 Dr. Jonathan Wiesen, M.D., founder and chief medical officer, MediOrbis


Medicare Advantage (MA), also referred to as “Medicare Part C,”  a Medicare benefits plan  provided to Medicare registered patients through a private sector health insurer,  typically provides benefits beyond the standard Medicare benefits, including dental, health, specialty pharmacy, transportation and, in many instances, telemedicine. [1]

It is no surprise that enrollment in MA plans has doubled over the last decade and, to date, represents approximately 40% of all those enrolled in Medicare. [2]

The following series reviews the key societal, social and medical changes that have taken place since the onset of the COVID19 pandemic, thereby underscoring the importance of specialty telemedicine as a crucial benefit for ALL MA plans.

Post COVID19 Societal Changes for Medicare Advantage Beneficiaries


The societal changes and adaptations that we have witnessed in the last four months are nothing short of astounding.  Almost overnight, humanity transitioned to virtual interactions, reliant upon high definition video meeting software and ubiquitous broadband Internet for business, social “gatherings,” and family “visits.”


These adaptations were not limited to only the young, technology savvy populations.  More senior citizens than ever before have been using mobile platforms for everything from social interactions to mundane tasks such as paying bills and ordering food.  Healthcare for the elderly is similarly being transformed to a virtual, home based enterprise:  a recent Advisory Board Study survey demonstrated that 75% of individuals over 60 years of age used a telehealth – related monitoring device routinely, [3] and a recent study indicated that a majority of MA participants used telemedicine services during the COVID pandemic, with over 90% satisfaction with the experience. [4]


Global healthcare has also changed dramatically during this time.  Telemedicine has become routine both for primary and specialty care, from rural hospitals to tertiary care university hospitals.  Moreover, digital devices and monitoring modalities are more commonplace.  Not only are individuals utilizing cloud – based telehealth patient platforms, but they are also commonly being linked to clinical remote monitoring programs, now reimbursable by CMS.[5]






Specialty Telemedicine: Towards the Next Important Value Proposition


The value of general telemedicine for MA plans is a foregone conclusion as evidenced by the extraordinary rate of adoption and utilization during the COVID19 pandemic.


General telemedicine – routine urgent or acute care consultations with on-call physicians – has recently been demonstrated to be among the most cost-effective benefits in MA plans.[6]


A Government Accountability Office (GAO) report from early 2019 attributed MA savings of over $500 million to telemedicine services.  With massive attributable cost savings to telemedicine, the GAO report advocated establishing telemedicine services a routine benefit in MA programs and estimate that an allocation of almost $100 million to CMS’s Medicare Trust Fund will be delivered as a result.   [7]


Cost savings attributed to telemedicine are over $200 per episode, according to a recent study published by Anthem, which was largely the impetus for expanding and encouraging telemedicine services among their MA plans. [8]  They expect that greater engagement in telemedicine services will lead to greater savings.  Moreover, the study demonstrated fewer ancillary tests and unnecessary medications as compared with routine brick and mortar care for MA beneficiaries, without any decrement in outcomes.  [9]



Specialty Telemedicine and Medicare Advantage: Post-COVID Safety  


Undoubtedly, there is perhaps no more compelling benefit of telemedicine than patient and provider SAFETY, which has gained such importance during the COVID-19 pandemic.   Specialty telemedicine, in particular, has been hailed as an imperative for any and all healthcare services since it provides high quality care while still maintaining appropriate distancing measures, necessary to prevent viral transmission.


With the advent of turnkey, user-friendly specialty telemedicine platforms, MA beneficiaries can access their primary care physicians or their specialists – routinely, frequently and with relative ease.  This is particularly relevant for MA beneficiaries whose underlying comorbid medical conditions place them at high risk for severe COVID-9 sequelae, yet simultaneously also necessitate relatively frequent medical consultations.

How does one manage elderly patients who require frequent interactions with their primary care provider, as well as their endocrinology and cardiology specialists, while still maintaining safe distancing practices for them?


Although caution should be expressed for  all close social interactions, close attention should be paid for risks associated to visits with medical professionals who are routinely exposed to, and potential carriers of, of infectious agents.  With the advent of turnkey, user friendly specialty telemedicine platforms, MA beneficiaries can access their primary care physicians, or their specialists, routinely, frequently and with relative ease.   Therefore, specialty telemedicine can allow continued monitoring and care, despite the risk of in – person viral communication.


Careful and thoughtful care of MA beneficiaries necessitates that all telemedicine, particularly specialty services, be utilized as often as possible to protect both patients and their caregivers.  After all, this is a population which requires the routine care of specialty physicians, and in whom telemedicine has been demonstrated to be cost effective and appreciated with high satisfaction.














How Specialty Telemedicine Can Address Specialty Provider Shortages


Prior to the current pandemic, reports noted the shortage of at least 50,000 specialty providers in the United States.  Reasons for the shortfall include uneven distribution of providers, a shortage of training facilities, and physicians leaving practice owing to burnout and retirement.   This finding is not novel, with reports going back years that have been documenting this trend.

The onset of the COVID19 Pandemic, and the subsequent closure of many primary and specialty care outpatient clinics, will likely exacerbate this deficiency.


Specialty telemedicine has been proposed as an intuitive solution for a number of reasons:

1)         Telemedicine levels the playing field and streamlines physician availability.  Physicians can remotely cover multiple locations at once, thereby increasing their accessibility to accept consultations.  Moreover, inefficiencies in the system such as travel time, delays during patient intake, etc. do not prevent the physician from seeing patients, but rather the astute telemedicine physician can simply recalibrate and see other patients during these down times.  Lastly, lifestyle considerations, which may prevent physicians from residing personally or with their family in the rural locations of the greatest physician deficiencies would not preclude the doctor’s ability to still see patients in that region.


2)         Telemedicine is cost effective and has demonstrated a great return on investment both patients, healthcare providers, and payers.   For patients, telemedicine related costs are at least (if not more than!) half of the alternative modalities of treatment.  The range of telemedicine costs reaches a maximum of just $79, compared to $146 for outpatient physician consults or $1734 for an ER visit.


The reasons for this are simple: in a telemedicine consult, the only two required parties are the physician and the patient, whereas in a patient visit, infrastructure which includes buildings, office personnel, test equipment, nurses and various other expense items.  Vendor data from WHO also shows that telemedicine reduces the need for urgent healthcare visits by 45%, as simple conditions can be treated easily, and more complex ones can be detected and solved early on. Furthermore, 83% of conditions can be solved through telemedicine consultation instead of scheduled doctor’s visit.




How Can Telemedicine Be Cost Effective for Medicare Advantage Plans

The potential benefits of telemedicine for MA – or for that matter all patients – are numerous:  provider and patient safety, cost savings, improved outcomes, high satisfaction, beneficiary engagement, and chronic disease management.



  • General Telemedicine: On demand urgent care telemedicine visits have proven to be time and cost effective for MA beneficiaries. Moreover, providing primary care via telehealth platforms will allow MA beneficiaries the convenience of continuous access to physician services, particularly when issues related to managing their chronic medical conditions arise. Studies have indicated that telemedicine is also associated with improved outcomes in the MA population, particularly in rural locations where access to healthcare is limited.
  • Annual primary care examination: Primary care physicians from a telemedicine network can supplement a patient’s existing PCP services, and even provide additional services as convenient for the patient.  One component includes the annual primary care assessment.  Since MA payments are typically adjusted based on the beneficiary’s personal condition, having a comprehensive evaluation via telemedicine can ensure that patients are receiving the maximal amount provided by CMS.  A thoughtful telemedicine PCP must be mindful and creative in remotely performing the physical examination components of the traditional annual primary care assessment.
  • Establishment of HMO In-Network Primary Care Provider (PCP) and Specialty Coverage: In most instances (emergencies aside), MA programs cover in- network PCP and specialty services. Telemedicine allows patients to maintain a PCP and conveniently access a physician with whom they feel comfortable and trust. Additionally, specialty physicians can be accessed via telemedicine as an in–service network benefit.
  • Wellness, Preventive Care: Medicare Advantage enrollees tend to have chronic medical conditions when compared with the general population. Wellness programs can ensure that patients maintain optimal health, and chronic disease management programs can provide patients with digital tools and clinical services to manage chronic conditions.  [10]







The Next Step: Utilizing Telemedicine for Primary Care and Chronic Disease Management


An AAMC report in 2019 estimated a physician shortage in the United States of over 100,000 providers was estimated, distributed relatively evenly between primary and specialty doctors.  Compounding the challenge of the physician shortage is the increased burden of chronic medical conditions. [11]


For Example, a Milken Institute report indicated that the U.S. health care costs for chronic diseases such as heart disease, cancer, diabetes, and Alzheimer’s disease totaled $1.1 trillion in 2016. When lost economic productivity is included, the total economic impact was $3.7 trillion. This is equivalent to nearly 20 percent of the U.S. gross domestic product.


Current telemedicine initiatives have not targeted lowering the cost of this major driver of healthcare expenditures, and coaching and wellness programs lack crucial physician engagement and involvement necessary to manage more complex components of the diseases.


Telemedicine and Telehealth have been associated with improvements in patient’s HbA1c (17%, over 50% of patients) and 70% improvement in cholesterol management.  Telemedicine was also associated with significantly decreased wait times and improved visit attendance for patients with chronic conditions.  This improved care led to 75% fewer hospitalizations and cost savings of $45,000 per patient per year.



Moving Forward and Riding the Wave: Lowering Costs, Improving Outcomes


The remarkable clinical and cost – saving data, compounded by the safety profile of telemedicine in protecting patients and providers from COVID-19 infection should drive MA plans to strongly consider offering to their beneficiaries not only general telemedicine, but also virtual primary care and chronic disease management.


Today’s environment is primed for success of such a program – beneficiaries are more comfortable than ever with telemedicine and telehealth, and there is a dire need to bend the healthcare cost curve domestically and globally.  Forward thinking, progressive MA plans are  encouraged to offer this type of unique telemedicine program and can be reassured that it will enhance healthcare safety, quality and cost savings.





[1] https://www.medicare.gov/sign-up-change-plans/get-started-with-medicare

[2] https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/medicare-advantage-plans/how-do-medicare-advantage-plans-work

[3] https://www.timesrecordnews.com/story/news/local/2020/04/10/covid-19-moves-seniors-embrace-technology-coronavirus-survey/5122728002/

[4] https://www.fiercehealthcare.com/payer/poll-shows-ma-seniors-who-use-telehealth-are-excited-to-use-service-again

[5] https://www.bettermedicarealliance.org/sites/default/files/2018-02/BMA_OnePager_Telemedicine%20in%20Medicare%20Advantage_2018_01_26_v2a.pdf

[6] https://medcitynews.com/2019/11/humana-estimates-3-5b-in-2018-savings-from-value-based-care/

[7] https://www.gao.gov/assets/700/698923.pdf

[8] https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

[9] https://www.healthcarefinancenews.com/news/telehealth-eliminates-time-and-distance-save-money

[10] https://www.kff.org/medicare/issue-brief/a-dozen-facts-about-medicare-advantage-in-2020/

[11] https://www.aarp.org/content/dam/aarp/ppi/2019/08/telehealth-medicare-what-is-covered.doi.10.26419-2Fppi.00080.001.pdf