September 29, 2022

Doggett tries to slow down a speeding train, as evidenced by the House’s 416-12 vote. Enthusiasm for the convenience of telehealth has grown, even as fears of Covid-19 that prompted the Trump administration and Congress to expand it have abated.

But Doggett’s stance reflects long-standing concerns that telehealth could become a fraud driver, allowing scammers, doctors and healthcare companies to order unnecessary lab tests and medical equipment, or prescribe unnecessary drugs, and charge Medicare.

A separate, but arguably more expensive, problem could arise if the ease of use of telecare prompts patients to contact their physician more frequently, driving up the cost of frivolous visits without ill motives.

While Doggett was one of the few to voice his fears with a no vote, others acknowledge the possibility of fraud and overuse. Chair of Energy and Trade Frank Pallone (DN.J.) said so last week, calling the expansion of telehealth a “major change” that necessitated surveillance and research.

The problem for Congress is a lack of data and limited time. To try and get more data, Congress this spring mandated a Department of Health and Human Services watchdog report on fraud risks.

More and more information is coming in about how patients used telehealth during the pandemic, but the clock is ticking. Congress must soon decide what to do as existing telehealth flexibility will expire five months after HHS lifts the Covid-19 public health emergency. HHS has extended the state of emergency 10 times since it was first announced in January 2020, but Biden officials are considering sticking to the current expiration date in October.

“When it comes to fraud, it’s a lot of anecdotes,” said Ateev Mehrotra, a professor of health care policy who studies telemedicine at Harvard University. “I don’t blame anyone. It’s just hard to measure.”

Doggett argues Congress needs to build more crash barriers before pandemic-era flexibility can continue. But too strict a line can hinder the access to care that millions of Americans have come to rely on.

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The evidence about fraud

As with personal care, fraud is taking place in telehealth — but to what scale and how much relative to personal care is not yet clear, with little solid evidence available, researchers say. The House law would give lawmakers more time to study the risks while preserving the status quo.

Amid relaxed pandemic regulations, the HHS inspector general was concerned that fraudsters will see the waivers that allow doctors to charge telehealth services as another way to make a profit. The Inspector General’s Office is planning to release a report as required by Congress about the risks of telehealth fraud in the next month or two, said Andrew VanLandingham, senior adviser at the watchdog office.

So far, scammers aren’t charging too much for telehealth services under the new rules “on a widespread basis,” he said.

But VanLandingham was careful to distinguish overbilling from bribe schemes where doctors receiving payments for providing unnecessary serviceshe said.

The Justice Department has made a number of arrests, including recently indicted dozens of people in connection with alleged bribe schemes totaling more than $1 billion in which telemedicine companies tricked suppliers into ordering unnecessary tests and equipment.

But telehealth advocates and experts argue that much of what the DOJ has found is not specific to telemedicine and should not be cited as a reason to limit access to telehealth.

“The headline says telemedicine, but in reality, there wasn’t really any telemedicine going on,” said Chad Ellimoottil, an assistant professor at the University of Michigan Medical School and a telemedicine researcher. “It was just a corrupt practice taking place, clearly targeting seniors and the Medicare program.”

For Doggett, the distinction is largely beside the point.

“No matter what label is applied, it’s all fraud,” Doggett said. “We should be taking reasonable steps to prevent this, not just responding with prosecutions that usually don’t make more than pennies on the dollar of stolen billions.”

The cerebral effect

Fraud is not the only threat to the expansion of telehealth. There is also concern that companies, especially startups looking to make a profit, could abuse virtual care by overprescribing drugs.

Those fears have taken on new seriousness in light of the allegations against digital health company Cerebral. A former executive sued the company, claiming it was trying to prescribe stimulants to all of its attention-deficit/hyperactivity disorder patients, when some may not need them.

“When Cerebral determined that patients prescribed stimulants were more likely to remain Cerebral customers, the CEO instructed Cerebral employees to find ways to prescribe stimulants to more ADHD patients to improve retention.” increase,” the lawsuit said.

The DOJ is now investigating. CEO David Mou has said the coverage has “biased our excellent care”, and the company has said it follows relevant laws and deliberately denies overprescribing drugs.

But the temptation to do so is there. STAT reported earlier this month on a “wild west” of weight loss websites offering quick prescriptions through telehealth. The article quoted public health experts expressing concerns about telehealth companies that have “apparently sprung up to profit from prescriptions” and potential harm to patients.

“That’s the real problem with telehealth that you’re starting to see,” Miranda Hooker, a partner at Troutman Pepper and a former federal prosecutor, told POLITICO. “Are these services we should pay for?”

However, as with fraud, it is not clear whether overprescribing is a widespread problem.

Regardless, many major pharmacies are paying attention and have stopped filling prescriptions from Cerebral and other digital health companies.

over-utilisation

Policymakers seeking to limit health care costs also have reason to worry that telehealth could lead to resource over-utilisation. The convenience of online care can lead to people scheduling more appointments and doctors requesting more services than necessary.

The jury is still out on whether that is the case.

There is some evidence of increased digital health claims amid expanded access. JAMA Internal Medicine published a research letter by Harvard faculty earlier this month who said Medicare claims for devices that measure blood pressure, diabetes and other health conditions exploded after the government approved them for home use in 2019. The growth was most pronounced during the pandemic.

“Sometimes it’s easy for us to talk about the fraud because it resonates more, but the bigger policy problem is over-exploitation,” Mehrotra said. “The next question is whether that increase in care has a low value or a high value.”

Other research is more encouraging for telehealth advocates. Ellimoottil and colleagues at the University of Michigan found that: pandemic exemptions did not increase use as feared.

Telehealth visits accounted for about 9 percent of outpatient visits among Medicare beneficiaries at the end of 2021, the study found, and total outpatient visits were about 289 million in 2019, before dropping to 255 million in 2020 and 261 million in 2021.