Access to Services

Background

In a 2016 report, the Medicare Payment Advisory Commission (MedPAC) found that nearly all physicians take part in the Medicare program and among those about 95 percent agree to accept the Medicare fee schedule amounts as full payment. Less than 1 percent of physicians opt out of Medicare and do not receive any Medicare payment, directly or indirectly, for any Medicare beneficiaries they treat.

The MedPAC report concluded that Medicare beneficiaries’ access to physician services is similar to or better than that of privately insured people age 50–64. In 2015, 82 percent of Medicare beneficiaries needing an appointment for illness or injury during the prior 12 months reported that they never had to wait longer than they wanted, as did 72 percent of those seeking an appointment for routine care. However, among beneficiaries who were looking for a new primary care provider, about 14 percent reported facing significant problems finding one. Medicare beneficiaries who are also eligible for Medicaid report more difficulty accessing services than beneficiaries who are solely Medicare recipients.

AARP has heard reports of access problems in certain geographic areas, which in some cases seem to reflect general provider shortages. In other cases, beneficiaries have to travel long distances for certain kinds of specialty care. If MedPAC analyses identify a national problem, a broader discussion of workforce and payment policies should take place. Even if the problem is more localized, it may merit the development of policies to improve beneficiaries’ ability to receive appropriate, high-quality services.

Services provided by telehealth have great potential to help consumers more easily connect with various health care clinicians, maintain their quality of life, and remain in their communities longer by providing an opportunity to manage their care. Tele-health gives people the ability to schedule health-related appointments, request prescription refills, can remind them to take medications, and serves as a method to link to a health care provider when time or distance is a barrier. Telehealth can also support family caregivers’ efforts to take care of their loved ones.

Services provided by telehealth use telecommunications technology to deliver health care, health information, or health education at a distance. While the term “telemedicine,” generally indicates physician services, “telehealth” is a more universal term for the current array of applications in the field. Services provided by telehealth can be used in long-term services and supports and home- and community-based services settings.

Telehealth encompasses four distinct domains of applications:

  • live video (synchronous): Live, two-way interaction between a person (patient, caregiver, or provider) and a provider using audiovisual telecommunications technology;
  • store-and-forward (asynchronous): Transmission of recorded health history (for example, pre-recorded videos and digital images such as x-rays and photos) through a secure electronic communications system to a practitioner;
  • remote patient monitoring (RPM): Personal health and medical data collection from an individual in one location via electronic communication technologies, which is transmitted to a provider (sometimes via a data processing service) in a different location for use in care and related support; and
  • mobile health (mHealth): Health care and public health practice and education supported by mobile communication devices such as cell phones, tablet computers, and personal digital assistants.

While services providing telehealth are increasing rapidly in many states, there are a number of restrictions that can limit beneficiary access, including:

  • Medicare’s narrow definition of “site of origin.” Medicare fee-for-service only pays for telehealth care when the site of origin, or site of care, is provided in a clinical office and the telehealth service connects to a specialist. This definition restricts Medicare beneficiaries who have trouble getting to a clinical setting—for geographic reasons or the lack of transportation.
  • Medicare fee-for-service pays for chronic care management that is provided via telehealth only for those who fit limited criteria;
  • the lack of high-speed broadband cable in various communities across the country; and
  • the inability of clinicians to work across state lines. Interstate licensing compacts can resolve this issue.

Access to Services: Policy

Monitoring

In this policy: Federal

CMS and the MedPAC should regularly and in a timely manner evaluate and monitor Medicare beneficiaries’ access to quality care, including physician services and other Part B-covered services, in all Medicare settings, regionally as well as nationally and for racial and ethnic groups that have experienced discrimination, and other population subgroups.

Public information and special populations

In this policy: Federal

CMS should continue making public the Medicare Current Beneficiary Survey data on access, health care utilization, and other relevant information. The agency also should pay particular attention to access problems of special populations, including those beneficiaries in rural areas and US territories and commonwealths; people with disabilities; low-income individuals; racial and ethnic groups that have experienced discrimination; beneficiaries with end-stage renal disease; and people living in institutions such as nursing facilities and in communities where access problems are common because of a shortage of health care personnel.

Research

In this policy: Federal

Both CMS and MedPAC should increase research into the causes of access problems, especially those the commission identified in its analyses. Special attention should be given to research in which clinical trials include older people with multiple chronic conditions and disabilities.

Telehealth

In this policy: FederalState

Federal and state governments should encourage coverage and payment of health services provided by telehealth for eligible patients and family caregivers to improve access and quality of care, allow patients to remain safely in the community, and assist with care transitions from institutional to community settings.

Federal and state governments should remove unnecessary restrictions that limit beneficiary access to health services provided by telehealth.

Congress should remove geographic restrictions on Medicare coverage for telehealth services.

States should adopt interstate licensure compacts for physicians, APRNs, nurses, and other licensed health professionals to expand provider networks and reduce barriers to the use of telehealth between states.

Services provided by telehealth should offer quality and ensure that patient-related records and communications are protected from fraud (see this chapter’s sections Health Care Coverage: Medicare—Quality Improvement in Medicare; Reforming the Delivery of Health Care Services—Privacy and Confidentiality of Health Information).

Telehealth clinicians should be required to follow all standards of care and regulations appropriate to their profession and inform patients of their credentials.

Policymakers should ensure that individuals have access to the technologies that enable telehealth. (See also the Broadband Services section of Chapter 10, Utilities: Telecommunications, Energy, and Other Services.) The mode of care provided to the individual should align with the preferences of the person and family caregiver and be appropriate to meet their needs.

Mental health and substance abuse

In this policy: Federal

CMS should ensure Medicare beneficiaries’ access to appropriate, high-quality mental health and substance abuse services, such as outpatient services and partial hospitalization services, as well as ensure access to such preventive services as screening for depression and alcohol misuse.

CMS should ensure that Medicare beneficiaries with mental health or substance abuse problems, particularly those residing in nursing homes or enrolled in managed care plans, have access to appropriate services. Data collection and other oversight activities must preserve beneficiary privacy and confidentiality.