Doggett tries to slow down a speeding train, as seen in the House’s 416-12 vote. Enthusiasm for the convenience of telehealth has grown, even as Covid-19 fears that prompted the Trump administration and Congress to expand it have waned.
But Doggett’s position reflects long-standing concerns that telehealth could become an enabler of fraud, allowing scammers, doctors and healthcare companies to order unnecessary lab tests and medical equipment, or prescribe unnecessary medications and billing Medicare.
A separate, but possibly more costly, problem could arise if the ease of use of telehealth causes patients to contact their physicians more regularly, driving up costs with frivolous visits without any ill intent.
Although Doggett was one of the few to make his apprehension known with a no, others acknowledge that the possibility of fraud and overuse exists. Energy and Trade Chair Frank Pallone (DN.J.) said so last week, calling the expansion of telehealth a “major shift” that needs monitoring and investigation.
The problem for Congress is lack of data and limited time. To try to get more data, Congress this spring mandated a monitoring report from the Department of Health and Human Services on fraud risks.
More and more information about how patients used telehealth during the pandemic is coming in, but time is running out. Congress must decide what to do soon, as existing telehealth flexibilities will expire five months after HHS lifts the Covid-19 public health emergency. HHS has extended the emergency 10 times since it was first announced in January 2020, but Biden administration officials plan to stick with the current October expiration date.
“When it comes to fraud, there are a lot of anecdotes,” said Ateev Mehrotra, a health policy professor who studies telemedicine at Harvard University. “I don’t blame anyone. It’s just a hard thing to measure.
Doggett argues that Congress should build more guardrails before allowing pandemic-era flexibilities to continue. But taking too strict a line could hamper access to the care that millions of Americans rely on.
Evidence of fraud
As with in-person care, there is fraud in telehealth — but on what scale and to what extent compared to in-person care is still unclear, with little hard evidence available, researchers say. The House bill would give lawmakers more time to study the risks while leaving the status quo in place.
Amid relaxed pandemic regulations, the HHS inspector general worried that fraudsters saw waivers allowing doctors to charge for telehealth services as another way to profit. The Office of the Inspector General plans to issue a report as required by Congress on the risks of telehealth fraud over the next two months, said Andrew VanLandingham, senior adviser at the oversight office.
So far, scammers are not overcharging telehealth services under the new rules “on a pervasive basis”, he said.
But VanLandingham was careful to differentiate overcharging from kickback schemes in which doctors receive payments for providing unnecessary serviceshe said.
The Justice Department has made a number of arrests, including recently indicting dozens of people in connection with alleged kickback schemes totaling more than $1 billion in which telemedicine companies have asked suppliers to order unnecessary tests and equipment.
But telehealth advocates and experts argue that much of what the DOJ found is not specific to telemedicine and should not be cited as a reason for restricting access to telehealth.
“The title talks about telemedicine, but in reality there was no telemedicine,” said Chad Ellimootil, an assistant professor at the University of Michigan School of Medicine and a telemedicine researcher. “It was just a corrupt practice happening, obviously targeting the elderly and the Medicare program.”
For Doggett, the distinction is largely irrelevant.
“Whatever label is applied, it’s all still fraud,” Doggett said. “We should take reasonable steps to prevent it, not just respond with lawsuits that typically yield no more than pennies on the dollar of stolen billions.”
The cerebral effect
Fraud is not the only threat to the expansion of telehealth. There are also concerns that companies, especially profit-seeking startups, could abuse virtual care by prescribing too many drugs.
This fear has taken on new gravity in light of allegations made against digital health company Cerebral. A former executive has sued the company, saying it tried to prescribe stimulants to all of its patients with attention deficit/hyperactivity disorder when some may not need them.
“When Cerebral determined that patients who were prescribed stimulants were more likely to remain Cerebral customers, the CEO asked Cerebral employees to find ways to prescribe stimulants to more ADHD patients in order to ‘increase retention’, according to the lawsuit.
The DOJ is currently investigating. CEO David Mou said media coverage gave a “distorted view of our exceptional care”, and the company said it was following applicable laws and denied deliberately over-prescribing drugs.
But the temptation to do so is there. STAT reported earlier this month on a “Wild West” of weight loss websites offering rapid prescriptions via telehealth. The article quoted public health experts who were concerned about telehealth companies “appearing just to produce prescriptions for profit” 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 for which we should pay? »
As with fraud, however, it’s unclear whether overprescribing is a widespread problem.
Either way, many big pharmacies are taking notice and have stopped filling prescriptions from Cerebral and other digital health companies.
Policy makers looking to limit the cost of health care also have reason to fear that telehealth will lead to an overuse of resources. The convenience of online care could encourage people to schedule more appointments and doctors to request more services than needed.
The jury is still out on whether that is the case.
There is evidence of an increase in demands for digital health as part of 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 skyrocketed after the government approved them for home use in 2019. Growth was most pronounced during the pandemic.
“Sometimes it’s easy for us to talk about fraud because it sounds more resonant, but the bigger political problem is overuse,” Mehrotra said. “The next question is whether this increase in healing is of low value or high value.”
Other research is more encouraging for telehealth advocates. Ellimootil and his colleagues at the University of Michigan found that pandemic waivers did not increase use as dreaded.
Telehealth visits accounted for about 9% of outpatient visits among Medicare beneficiaries at the end of 2021, the study found, and overall outpatient management visits were about 289 million in 2019 before dropping to 255 million in 2020. and 261 million in 2021.