CHESTERFIELD, Mo. -- From a glassy four-story building in the St. Louis suburbs, doctors and nurses at Mercy Virtual Care Center give checkups and monitor vital signs for patients located miles away -- sometimes even in other states.
Yet much of its long-distance treatment isn't yet compensated by Medicare, the largest insurance payer in the United States.
Mercy Virtual -- often referred to as the country's first hospital without beds -- is part of a new frontier in medical care. Virtual care, or telehealth, is increasingly adopted by hospitals and clinics not only to fill in shortages in rural areas but also to care for patients more proactively than many hospitals have resources for.
Mercy and other hospitals say virtual care has allowed them to achieve better patient outcomes with fewer staff. Doctors and nurses can oversee many more patients virtually than if they were to make their rounds on foot, and they're able to simultaneously monitor blood pressure, pulse, temperature and other vital signs for dozens of patients -- and intervene early if needed.
In one wing of Mercy's virtual care center, nurses and assistants sit at six-monitor workstations where they might video into a patient's hospital room on one screen while viewing vital signs and medical records on another. In another wing of the building, staffers hold video calls with patients in their own homes who have been equipped with iPads and medical equipment for remote monitoring.
The idea is "to meet the patients where they are, as opposed to expecting the patients to come to us," Mercy Virtual President Gavin Helton told me during my visit last month to the hospital. "To me, that's foundational."
But every hospital must ultimately be paid to be sustainable, and that's still an open question when it comes to treating patients with diabetes, congestive heart failure or other serious conditions via virtual care.
Under a long-standing restriction in federal law, the Medicare program generally only pays for telehealth services when they're provided to patients in rural settings, where there are often doctor shortages.
From within the walls of Mercy Virtual, doctors and nurses supplement in-person care to patients in the health system's 32 acute care hospitals. But they don't get reimbursed by the traditional Medicare program for telemedicine in nearly half of those hospitals because of where the facilities are located.
Fourteen of the hospitals don't qualify for telemedicine coverage for most services, under Medicare's strict reimbursement rules.Maureen Kozlowski, director of support services for Mercy Virtual, told me they still offer virtual services throughout the hospital network because "Mercy sees providing the same level of telemedicine care in urban areas as the right thing to do for our patients."
It's a similar story for Providence St. Joseph Health, the nation's third-largest hospital network, based in Washington state. Of the 110 hospitals where it provides virtual care services, at least several dozen of the facilities are ineligible for Medicare telehealth payments.
Rather than operating an entirely virtual hospital, like Mercy, Providence deploys physicians and nurses from its hospitals in Seattle and Portland to deliver virtual care to other facilities with fewer specialists present. The approach has helped rural hospitals lower their overhead costs, said Amy Compton-Phillips, Providence's executive vice president and chief clinical officer.
"If they're paying people to sleep in the hospital for every specialty service, that's a lot of sunk costs," Compton-Phillips told me. "One stroke doctor can probably cover 50 hospitals versus one hospital."
Helton said the same. "You leverage technology to take limited clinical resources across a much larger area . . . as opposed to a facility having to hire that specialist, hire that physician," he told me.
Rural hospitals are undoubtedly facing steep challenges. The rate of rural hospital closures doubled between 2013 and 2017 compared with the five years before that, the Government Accountability Office found. The closures were generally linked to financial distress and were concentrated in the South and in states that haven't expanded Medicaid.
In light of this reality, there are some exceptions to the tight set of Medicare rules around payment for virtual care. Chief among them is a geographic provision allowing telehealth reimbursement if the patient is located within a rural area as defined by the U.S. Census Bureau or within an area designed by HHS as lacking enough health professionals.
But telehealth advocates say it's insufficient. It's not only rural areas that lack access to enough health providers, said Christa Natoli, deputy executive director of the Center for Telehealth and eHealth Law. Natoli pointed to low-income areas of the District where many reports have detailed a lack of medical facilities.
"You have patients literally living all over the country . . . and we're not able to provide them access to good care," Natoli said. "We have the solution that could bridge that gap but the regulations for reimbursement are not in line with what our pragmatic, modern-day need is."
Congress has recently lifted some of the telehealth restrictions for specific illnesses, and there's evidence the Trump administration is also on board with expanding payment opportunities as much as it's able under current law.
As of January, providers may bill Medicare for services provided to hospital-based stroke patients and at-home patients with end-stage renal disease located in urban or suburban areas. Both changes were approved by Congress as part of a bipartisan spending agreement early last year.
The Centers for Medicare and Medicaid Services has also removed the geographic limitations on end-stage renal disease treatment if the patient is located in a renal dialysis facility where stroke patients are also being treated via telehealth.
This article was written by Paige Winfield Cunningham, a reporter for The Washington Post.