2025-01044. Continuity of Care via Telemedicine for Veterans Affairs Patients

Table 1—Patients Loaded Hourly Wage

Occupation	Hourly wage ($)	Load for benefits ($)	Loaded hourly wage ($)
All Occupations	23.11	10.47	33.58

Therefore, the patient's cost of time to travel and wait for a practitioner's visit—and thus the time cost savings achieved by telemedicine patients who could forego such a trip—equals $25.19 (0.75 × $33.58), as can be seen in table 2 below.

Table 2—Patient Cost of Time

[per Practitioner's Appointment]

Cost savings	Hourly opportunity cost ($)	Travel and wait time (hours)	Cost per appointment ($)
Time cost savings	33.58	0.75	25.19

b. Patient's Net Cost of Travel per Practitioner Visit

DEA estimates there will be cost savings to VA patients as a result of not having to travel to a VA practitioner for a visit. The patient's net cost of travel is the cost of travel net of reimbursements received from the VA. To determine the cost of travel to and from a practitioner's appointment, DEA used data from the Southwest Rural Health Research Center in the Texas A&M School of Public Health, and mileage reimbursement rates from the U.S. Internal Revenue Service (IRS). According to a 2017 survey by the Southwest Rural Health Research Center, the average national round-trip travel distance for a doctor's visit was 9.9 miles, or 19.8 miles round-trip.^[58] Using the IRS travel reimbursement rate for businesses of 67 cents per mile as an estimate of travel cost,^[59] the estimated patient's cost of travel to and from a practitioner's appointment is $13.27 ($0.67 × 19.8), as can be seen in table 3 below.

Table 3—Patient Travel Cost per Trip

Cost savings	Travel cost per mile ($)	Travel distance (miles)	Per appointment cost ($)
Patient travel cost	0.67	19.8	13.27

The VA reimbursement rate is $0.415 per mile for approved, health-related travel, with a current deductible of $6 round-trip for each appointment, up to $18 total each month.^[60] Assuming VA patients generally do not reach the $18 monthly deductible limit, the estimated VA mileage reimbursement is $8.22 ($0.415 × 19.8) per visit. After a $6 deductible, the net VA reimbursement after deductible is $2.22 ($8.22 − $6) and the patient's net cost of travel is $11.05 ($13.27 − $2.22). Table 4 summarizes the VA reimbursement and patient's net cost of travel.

Table 4—VA Reimbursement and Patient Net Travel Cost per Trip

	Travel cost per mile ($)	Travel distance (miles)	Per appointment cost ($)
VA mileage reimbursement per trip	0.415	19.8	8.22
Deductible (paid by patient)	N/A	N/A	6.00
Net VA mileage reimbursement per trip	N/A	N/A	2.22
Patient net travel cost per trip	N/A	N/A	11.05

( print page 6534)

c. Total Number of Telemedicine Visits

This final rule's patient cost savings results from eliminating the need for an in-person medical evaluation or visit. Subsequent telemedicine visits are allowed after that initial in-person medical evaluation or visit, even without the COVID-19 PHE telemedicine flexibilities. So, to calculate the total patient cost savings under this rule, DEA needed to estimate the total number of first-time telemedicine visits resulting in prescriptions for controlled substances.^[61] Given the absence of direct information on this point, however, it was necessary for DEA to perform a multi-step analysis or derivation using different available data sources at each step to derive an estimate. First, the number of practitioner visits conducted via telemedicine was reduced to those that constituted first-time telemedicine visits. Second, DEA determined the proportion of the first-time telemedicine visits that would result in prescriptions. Third, it refined the total number of first-time telemedicine visits resulting in prescriptions of controlled substances. And lastly, DEA considered the impact of the rule's requirements and determined the total number of first-time telemedicine visits resulting in prescriptions of controlled substances under this rule. DEA performed this multi-step analysis to derive an estimate of the number of first-time telemedicine visits resulting in prescriptions for controlled substances, which resulted in an estimate of the current value for the total patient cost savings.

Step 1: First-Time Visits. Based on a VHA 2023 annual report there were over 9.4 million telehealth encounters to veterans in the home or other offsite locations.^[62] DEA needed to further refine the total number of telemedicine practitioner visits to those that constituted first-time telemedicine visits. DEA's focus on first-time telemedicine practitioner visits, rather than all telemedicine visits, was to prevent an overestimation of the total patient cost savings. Under the status quo, after one bona fide in-person medical evaluation, patients are typically permitted to be seen via telehealth thereafter when receiving prescriptions for controlled substances. A potential overestimate of total patient cost savings arises from the fact that patient cost savings under this rule primarily hinge on the bypassing of a first-time, in-person medical evaluation, but not subsequent telemedicine visits.

A 2022 study analyzing trends between 2017-2020 in interstate telehealth use by Medicare beneficiaries, a subset of the population impacted by this rule, shows that the vast majority of practitioner visits are for returning patients, and approximately 10 percent of those practitioner visits are new visits.^[63] This is in line with the Center for Disease Control and Prevention's (CDC) 2019 National Ambulatory Medical Care (NAMC) non-Federal survey where 16.8 percent of office visits were for new patients. The CDC's 2019 NAMC survey, however, was not limited to telehealth visits, so DEA decided that the 10 percent estimate from the 2022 interstate telehealth study was more applicable to this analysis.^[64] Taking 10 percent of 9,400,000 practitioner visits conducted via telemedicine would provide a total of approximately 940,000 first-time, telemedicine practitioner visits, as can be seen in table 5.

Table 5—Number of First-Time Telemedicine Visits

Telemedicine visits	9,400,000
First-time telemedicine visit rate	0.1
First-time telemedicine visits	940,000

Step 2: Visits Resulting in Prescriptions. DEA needed to determine the fraction of first-time telemedicine visits that would result in prescriptions. Looking again at CDC's 2019 NAMC survey, DEA determined, as reflected in table 6, that 291,394,000 visits did not include any prescribing, which means 745,090,000 of the 1,036,484,000 visits, or approximately 72 percent of the visits, did in fact result in the issuance of prescriptions. Because only 72 percent of visits resulted in a prescription, DEA applied the 72 percent to the calculated 940,000 first-time, telemedicine visits resulting in approximately a total of 676,800 first-time telemedicine visits resulting in the issuance of prescriptions, as can be seen in table 7.

Table 6—Estimate of Number of Prescriptions Using Visit Data

Number of prescriptions	Number of visits (thousands)	Total number of prescriptions (thousands)
0	291,394
1	192,488	192,488
2	129,561	259,122
3	84,898	254,694
4	60,766	243,064
5	52,613	263,065
6	34,041	204,246
7	28,900	202,300
8	29,043	232,344
9	23,393	210,537
10	15,320	153,200
11	17,034	187,374
12	14,744	176,928
13	13,419	174,447
14	10,635	148,890
( print page 6535)
15+	38,236	* 573,540
Total	** 1,036,485	3,476,239
* Used 15 as an approximation for 15+.
** The published total shows 1,036,484, so there is a rounding error of 1.

Table 7—Estimate of Number of First-Time Telemedicine Visits With Prescriptions

First-time telemedicine visits		940,000
NAMC survey visits—total	1,036,484,000
NAMC survey visits—0 prescriptions	291,394,000
NAMC survey rate—0 prescriptions	0.28
NAMC survey rate—with prescriptions	0.72	0.72
First-time telemedicine visits with prescriptions		676,800

Step 3: Prescriptions for Controlled Substances. DEA then refined the total number of first-time telemedicine visits resulting in prescriptions for controlled substances. According to the Federal Trade Commission (FTC), Surescripts has 95% market share in e-prescribing services as of 2023.^[65] DEA was able to use 2021 data from the Surescripts National Progress Report to determine that approximately 16 percent of all prescriptions (paper and electronic) are for controlled substances.^[66] Applying this 16 percent to the total number of 676,800 telemedicine visits resulting in the issuance of prescriptions, provides a value of approximately 108,288 first-time telemedicine visits resulting in prescriptions for controlled substances, as can be seen in table 8.

Table 8—Current Estimate of Number of First-Time Telemedicine Visits Resulting in Prescriptions of Controlled Substances

First-time telemedicine visits with prescriptions	676,800
Controlled substance (CS) rate	0.16
First-time telemedicine visits with CS prescriptions	108,288

Step 4: Effect of this Rule. Lastly, DEA determined the total number of first-time telemedicine visits resulting in prescriptions of controlled substances under this rule. Under this final rule, patients would not have an in-person follow-up visit after the first-time telemedicine visit; they would never have to see the prescribing practitioner in person. Based on a study by Epic Research of primary care visits between March 1, 2020 and October 15, 2022, 61 percent of telehealth visits did not require an in-person follow-up.^[67] A similar study by Epic Research on specialty visits provided that 85 percent of mental health and psychiatry telehealth visits did not have an in-person follow-up visit.^[68] Because this rule is not limited to mental health, DEA applied the broader and lower 61 percent to the 108,288 first-time telemedicine visits resulting in prescriptions of controlled substances. The multi-step analysis ultimately derived a current estimate of 66,056 first-time telemedicine visits resulting in prescriptions of controlled substances under this rule, as can be seen in table 9.

( print page 6536)

Table 9—Current Estimate of Number of First-Time Telemedicine Visits Resulting in Prescriptions of Controlled Substances Under This Rule

Telemedicine visits	9,400,000
First time telemedicine visit rate	0.1
First-time telemedicine visits	940,000		940,000
NAMC survey visits—total		1,036,484,000
NAMC survey visits—0 prescriptions		291,394,000
NAMC survey rate—0 prescriptions		0.28
NAMC survey rate—with prescriptions		0.72	0.72
First-time telemedicine visits with prescriptions			676,800	676,800
Controlled substance (CS) rate				0.16
First-time telemedicine visits with CS prescriptions				108,288
First-time telemedicine visits that do not have an in-person follow up visit.				0.61
First-time telemedicine visits under this rule with CS prescriptions				66,056

d. Total Patient Cost Savings

Each telemedicine visit saves patients time and travel costs of $25.19 and $13.27, respectively, for a total savings of $38.46. Applying the cost savings of $38.46 to the estimated number of first-time telemedicine visits under the proposed rule with controlled substance prescriptions results in a total patient cost savings of $2,540,514 ($38.46 × 66,056) per year.

Additionally, from table 4, DEA estimates VA will reimburse the patient $2.22 per trip. Applying this reimbursement amount to the number of trips, the VA reimbursement amount (transfers to the patient) is $146,644 ($2.22 × 66,056). Subtracting the VA reimbursement amount from the total cost savings, DEA estimates a total patient net cost savings of $2,393,870 ($2,540,514 − $146,644) per year. Table 10 summarizes this calculation.

Table 10—Total Cost/Transfer Savings

	Total cost savings ($)	VA reimbursement ($)	Patient net cost savings ($)
Patient cost savings (per visit)	38.46	2.22	N/A
Patient cost savings	2,540,514	146,644	2,393,870

e. Patient Benefit: Increased Access to Care

While DEA estimated the patient cost savings for the estimated 66,056 patient visits that would fall under this final rule, DEA is unable to quantify the number of patients that will be treated that would not have been treated absent this regulation. In recent years, telemedicine has emerged as a vital solution for enhancing healthcare accessibility for VA patients, especially in the face of healthcare shortages. Notably, telemedicine extends its benefits to patients in remote and other underserved areas, including by offering access to specialized care. While DEA is unable to quantify the number of patients that will be treated that would not have been treated absent this regulation, it is reasonable to assume there will be VA patients that will fall in this category and the benefits of increased access to care are not negligible.

3. VA Costs and Transfer Savings

Impact on the VA is primarily due to two primary factors, additional burden for VA patient EHR and PDMP reviews prior to prescribing and reduced travel reimbursements to VA patients.

Prior to prescribing, the practitioner must conduct a review of both the patient's VA medical record, to include in the VA's internal prescription database, and the PDMP of the state in which the patient is located at the time of the telemedicine encounter (if the State has such a program) for controlled substance prescription(s) for the patient's previous twelve (12) months preceding the controlled substance prescription(s), or if less than a year of data is available, for the entire prescription period. Additionally, the VA practitioner must annotate in the VA patient's EHR their attempts to obtain the PDMP of the state in which the patient is located and VA internal prescription database data. DEA estimated the cost of this requirement by estimating the cost per review and applying the cost to the number of patient visits.

Based on the BLS wage data, DEA estimated the cost per review for physicians, nurse practitioners (NPs), and physician's assistants (PAs), then calculated a weighted average cost per review based on the number of physicians, NPs, and PAs.^[69]

The mean wage data for physicians is $129.71 and the median wage for PAs and NPs are $62.51 and $60.70, respectively.^[70] Additionally, BLS reports that average wages and salaries for civilians are 68.8 percent of total compensation. The 68.8 percent of total compensation equates to 45.3 percent (100 percent/68.8 percent−1) load on wages and salaries.^[71] The load of 45.3 percent is added to wages and salaries by multiplying the wages and salaries by 1.453 (1 + 0.453). The resulting loaded hourly rates are $188.47 ($129.71 × 1.453), $90.83 ($62.51 × 1.453), and $88.20 ($60.70 × 1.453), for physicians, PAs, and NPs, respectively.

Based on a 2018 study, it takes a practitioner 27 seconds to log in and 37 seconds to retrieve a report once logged ( print page 6537) in.^[72] The total time it takes to retrieve a PDMP report is roughly a minute (27 + 37 = 64 seconds) or 0.017 (1/60) hours. Applying 0.017 hours to the loaded hourly rates, the estimated labor cost to complete the review for physicians is $3.20 ($188.47 × 0.017), for physician assistants is $1.54 ($90.83 × 0.017), and for nurse practitioners is $1.50 ($88.20 × 0.017). Table 11 summarizes the results.

Table 11—EHR and PDMP Check Time Cost

Occupation	Hourly wage ($)	Load for benefits ($)	Loaded hourly wage ($)	PDMP check time (hours)	Cost per PDMP check ($)
Physicians	129.71	58.76	188.47	0.017	3.20
Physician Assistant	62.51	28.32	90.83	0.017	1.54
Nurse Practitioners	60.70	27.50	88.20	0.017	1.50

As of October 19, 2024, DEA estimates there were 15,148 physicians, 5,351 NPs, and 1,513 PAs registered with DEA that meet the VA employment requirements of this final rule.^[73] For simplicity, DEA calculated a single cost of a review based on the weighted average of the three occupations. The weighted average of the cost of review is $2.67. Table 12 details the calculation.

Table 12—EHR PDMP Check Time Cost

Occupation	VA registrants	VA registrant weights	Cost per PDMP check ($)	Weighted cost per PDMP check ($)
Physicians	15,148	0.6882	3.20	2.20
Physician Assistant	1,513	0.0687	1.54	0.11
Nurse Practitioners	5,351	0.2431	1.50	0.36
Total	22,012	N/A	N/A	2.67