Payment Parity for Telehealth Linked to Better BP Treatment

Paying clinicians for a telehealth visit the same amount as for an in-person visit appears to translate into better treatment of hypertension, a new study shows.

In states with payment parity laws—rules that require private payers to reimburse telehealth visits at an equivalent rate to in-person visits—patients had more frequent contact with the healthcare system and better adherence to antihypertensive medication.

Coverage parity laws, which require private payers to cover the same services for telehealth as in-person visits but not always at the same rate, had no impact on medication adherence or the number of telehealth visits.  

“Given that hypertension affects roughly half of the adult population, our study holds significant implications for the evolving US healthcare system in the digital age,” Donglan Zhang, PhD (Centers for Disease Control and Prevention, Atlanta, GA), and colleagues write in a paper published online July 29, 2024, in Circulation: Cardiovascular Quality and Outcomes. “Our results offer insights into the potential role of telehealth parity laws for private payers in facilitating hypertension management.”

Ami Bhatt, MD, the chief innovation officer at the American College of Cardiology (ACC), said this study reinforces the importance of payment parity when it comes to telehealth and access to care, the latter being arguably the biggest driver of cardiovascular health.

“Hypertension is at epidemic proportions in the US, so hypertension programs matter,” Bhatt told TCTMD. “More frequent touchpoints with the healthcare system leads to better medication adherence. I think it's evidence that if we work in a fee-for-service world, payment parity matters [as a way] to offer patients those increased touchpoints from home.”

It's not reasonable to expect healthcare providers to provide services that aren’t reimbursed. Jason Wasfy

Jason Wasfy, MD (Massachusetts General Hospital, Boston, MA), who co-chaired an ACC roundtable on virtual patient care with Bhatt, said the bottom line is that services need to be adequately reimbursed.

“There's been so much innovation in so many fields, but comparatively less innovation in healthcare,” he told TCTMD. “The value has not improved in healthcare the way that it has in other industries. Part of the problem is that doctors and hospitals provide services according to a fee schedule. If something is adequately reimbursed, and that's the critical point here, [then] the service will be provided, but there's plenty of things in medicine that probably help patients that are not reimbursed adequately. And it's not reasonable to expect healthcare providers to provide services that aren’t reimbursed.”

While the observational study comes with limitations, Wasfy said, it appears that patients are receiving better-quality care—more contact with providers, better adherence to medical therapy, in this case for hypertension—when physicians are compensated adequately for telehealth.

Increased Adherence With Payment Parity

With the COVID-19 pandemic, telehealth rapidly expanded as a way to safely conduct outpatient visits. The US Congress facilitated a transition to telehealth by easing some restrictions, and the Centers for Medicaid and Medicare Services also expanded coverage for telehealth. Since the pandemic, though, in-person visits are once again the most frequent way patients see their physicians.

Adoption of telemedicine is largely influenced by state policies, particularly reimbursement from private insurance. As Zhang and colleagues explain, different states have adopted different parity policies. With payment parity, payments for telehealth must match the same rate as in-person visits. With coverage parity, payers are required to reimburse for all services as an in-person visit; while the same services might be covered, reimbursement may differ for telehealth versus in-person visits, they write.

For this study, the researchers assessed the impact of parity laws on hypertension management using data from a large commercial claims database of more than 30 health plans between 2016 and 2021. The analysis included 353,220 individuals (mean age 49.5 years; 45.5% women) with at least one drug claim for antihypertensive medication. In 2018, one state had a payment parity law, 20 had coverage parity laws, and six had both. In 2021, five states had payment parity laws, 24 had coverage parity laws, and 16 had both.

After controlling for confounding variables, the medication possession ratio (MPR), which is the ratio of days with antihypertensive prescription supply to the number of days in the year, increased 0.43% in individuals treated in states with payment parity. Payment parity was associated with a 0.46% increase in medication adherence—defined as an MPR ≥ 80%—and an increase in the average days of antihypertensive prescription supply by 2.14 days per patient per prescription.

There also was an increase in the number of hypertension-related telehealth visits (2.61 visits per 1,000 patients) and CVD-related telehealth visits (0.92 visits per 1,000 patients) in states with payment parity laws.

In contrast, coverage parity was not associated with MPR, medication adherence, or with the number of telehealth visits. However, there was an increase in the average days of prescription supply by 2.13 days per patient per prescription with coverage parity.

Investigators say the increase in medication adherence with payment parity may appear modest, but that there are approximately 48 million Americans aged 20 to 64 years with hypertension. Adopting telehealth payment parity laws across all states could translate into roughly 150,000 more people adhering to their antihypertensive medication, they estimate. 

In an editorial, Yasser Sammour, MD (Houston Methodist DeBakey Heart and Vascular Center, TX), and John Spertus, MD (Saint Luke’s Mid America Heart Institute, Kansas City, MO), say they “cannot be more appreciative” of the research, stating that the findings should influence policymakers. “By enacting laws that support telehealth, which is often more convenient for patients, it is possible that the observed improvements in treatment could reduce subsequent clinical events that limit economic productivity and increase costs of care,” they write.  

Show Me the Money

Hypertension, said Wasfy, is “the eye of the storm” given its prevalence and because everything known about the condition suggests it can be managed in ways that don’t involve a trip to the doctor’s office.

Given the attachment to fee-for-service schedules, however, it isn’t practical for healthcare organizations to provide services that might be in the best interests of all involved.

“The fee schedules are incredibly influential,” he said. “They have to be, because organizations can't provide services that either are not reimbursed or are reimbursed at low levels. They won't be financially viable if they do that. But fee schedules have to keep up with the science, they have to move more quickly to align with the best ways of delivering healthcare.”

The idea is if I'm paid the same for a phone, video, or in-person visit, I will use whichever I think is best. Ami Bhatt

Bhatt, who started a telemedicine program in cardiology back in 2013 when she was at Massachusetts General Hospital, said there is an increasing focus on equitable care and reaching patients “where they live.” This study, she said, suggests that telehealth encourages more frequent contact with the healthcare system and may result in patients being more likely to take prescribed medication.

“The idea is if I'm paid the same for a phone, video, or in-person visit, I will use whichever I think is best,” she said. “Oftentimes, what’s best for the patient is to be comfortable in the community in which they live, to not miss work because of travel or have to find childcare or eldercare.” They might be anxious about going to a clinic, but are at ease when “on their own turf,” Bhatt added. “It makes a big difference and gives patients agency.”

Being in a more comfortable environment, telehealth visits may catch patients in that “right mode” where they’re more likely to understand why they’re taking certain medications, which also enhances adherence, said Bhatt. In terms of moving telemedicine forward, payment parity laws are important, as are continued advocacy efforts, she said.

“We also need to think about value-based care,” said Bhatt. “We're moving there at a glacial pace, partly just because we're constructed as a capitalist society, but as we move towards the quality of care—how well did we do with blood pressure control? How well are people adhering to their medications?—then we will see the benefit of telemedicine in helping us achieve those important value-based goals.

“Patient outcomes matter, access to care enables better clinician-patient partnership leading to those good outcomes, and telehealth is an important driver of access and empowerment,” she stressed.