[Senate Hearing 117-546]
[From the U.S. Government Publishing Office]
S. Hrg. 117-546
COVID 19 HEALTH CARE FLEXIBILITIES:
PERSPECTIVES, EXPERIENCES,
AND LESSONS LEARNED
=======================================================================
HEARING
before the
COMMITTEE ON FINANCE
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
__________
MAY 19, 2021
__________
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Finance
_________
U.S. GOVERNMENT PUBLISHING OFFICE
50-344-PDF WASHINGTON : 2023
COMMITTEE ON FINANCE
RON WYDEN, Oregon, Chairman
DEBBIE STABENOW, Michigan MIKE CRAPO, Idaho
MARIA CANTWELL, Washington CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey JOHN CORNYN, Texas
THOMAS R. CARPER, Delaware JOHN THUNE, South Dakota
BENJAMIN L. CARDIN, Maryland RICHARD BURR, North Carolina
SHERROD BROWN, Ohio ROB PORTMAN, Ohio
MICHAEL F. BENNET, Colorado PATRICK J. TOOMEY, Pennsylvania
ROBERT P. CASEY, Jr., Pennsylvania TIM SCOTT, South Carolina
MARK R. WARNER, Virginia BILL CASSIDY, Louisiana
SHELDON WHITEHOUSE, Rhode Island JAMES LANKFORD, Oklahoma
MAGGIE HASSAN, New Hampshire STEVE DAINES, Montana
CATHERINE CORTEZ MASTO, Nevada TODD YOUNG, Indiana
ELIZABETH WARREN, Massachusetts BEN SASSE, Nebraska
JOHN BARRASSO, Wyoming
Joshua Sheinkman, Staff Director
Gregg Richard, Republican Staff Director
(ii)
C O N T E N T S
----------
OPENING STATEMENTS
Page
Wyden, Hon. Ron, a U.S. Senator from Oregon, chairman, Committee
on Finance..................................................... 1
Crapo, Hon. Mike, a U.S. Senator from Idaho...................... 3
WITNESSES
Farb, Jessica, Director, Health Care, Government Accountability
Office, Washington, DC......................................... 6
Davis, Kisha, M.D., MPH, FAAFP, member, Commission on Federal and
State Policy, American Academy of Family Physicians, Leawood,
KS............................................................. 7
DeCherrie, Linda V., M.D., clinical director, Mount Sinai at
Home; and professor of geriatrics and palliative medicine,
Icahn School of Medicine at Mount Sinai, Mount Sinai Health
System, New York, NY........................................... 9
Murali, Narayana, M.D., board member, America's Physician Groups;
and executive director, Marshfield Clinic, Marshfield, WI...... 11
Berenson, Robert A., M.D., institute fellow, Urban Institute,
Washington, DC................................................. 12
ALPHABETICAL LISTING AND APPENDIX MATERIAL
Berenson, Robert A., M.D.:
Testimony.................................................... 12
Prepared statement........................................... 51
Responses to questions from committee members................ 56
Crapo, Hon. Mike:
Opening statement............................................ 3
Prepared statement........................................... 60
Davis, Kisha, M.D., MPH, FAAFP:
Testimony.................................................... 7
Prepared statement........................................... 61
Responses to questions from committee members................ 65
DeCherrie, Linda V., M.D.:
Testimony.................................................... 9
Prepared statement........................................... 71
Responses to questions from committee members................ 73
Farb, Jessica:
Testimony.................................................... 6
Prepared statement........................................... 81
Responses to questions from committee members................ 94
Murali, Narayana, M.D.:
Testimony.................................................... 11
Prepared statement........................................... 101
Responses to questions from committee members................ 107
Wyden, Hon. Ron:
Opening statement............................................ 1
Prepared statement with attachment........................... 115
Communications
Adventist Health................................................. 127
Advocate Aurora Health........................................... 129
Alliance for Connected Care...................................... 133
America's Health Insurance Plans................................. 138
American Association of Nurse Practitioners...................... 144
American Hospital Association.................................... 147
American Medical Association..................................... 151
American Medical Rehabilitation Providers Association............ 157
American Occupational Therapy Association........................ 161
American Pharmacists Association................................. 165
American Physical Therapy Association............................ 168
American Telemedicine Association................................ 172
Association for Clinical Oncology................................ 174
Association of American Medical Colleges......................... 181
Better Medicare Alliance......................................... 186
Center for Fiscal Equity......................................... 190
ERISA Industry Committee......................................... 193
Healthcare Leadership Council.................................... 199
HealthEquity..................................................... 201
Kaiser Permanente................................................ 202
Medically Home Group, Inc........................................ 205
Moving Health Home Coalition..................................... 207
National Association of Chain Drug Stores........................ 209
National Indian Health Board..................................... 212
98point6......................................................... 216
Ochsner Health................................................... 218
Partnership for Employer-Sponsored Coverage...................... 226
Premier Inc...................................................... 229
Psychiatric Medical Care, LLC.................................... 231
TechNet.......................................................... 233
Teladoc Health, Inc.............................................. 234
COVID-19 HEALTH CARE FLEXIBILITIES:
PERSPECTIVES, EXPERIENCES,
AND LESSONS LEARNED
----------
WEDNESDAY, MAY 19, 2021
U.S. Senate,
Committee on Finance,
Washington, DC.
The hearing was convened, pursuant to notice, at 10:06
a.m., via Webex, in the Dirksen Senate Office Building, Hon.
Ron Wyden (chairman of the committee) presiding.
Present: Senators Stabenow, Cantwell, Menendez, Carper,
Cardin, Brown, Bennet, Casey, Warner, Whitehouse, Hassan,
Cortez Masto, Warren, Crapo, Grassley, Cornyn, Thune, Portman,
Cassidy, Lankford, Daines, Young, Sasse, and Barrasso.
Also present: Democratic staff: Joshua Sheinkman, Staff
Director; and Beth Vrable, Deputy Chief Counsel and Senior
Health Counsel. Republican staff: Brett Baker, Deputy Health
Policy Director; and Gregg Richard, Staff Director.
OPENING STATEMENT OF HON. RON WYDEN, A U.S. SENATOR FROM
OREGON, CHAIRMAN, COMMITTEE ON FINANCE
The Chairman. The Finance Committee will come to order. And
before we begin today's hearing, I particularly want to thank
my colleagues on both sides of the aisle for the exceptional
participation yesterday on the infrastructure hearing, because
I thought we got a lot of good ideas out, hearing from Senators
on both sides, and I want to thank my colleagues.
Today we are going to turn to another important area. And I
particularly want to thank our Ranking Member Senator Crapo,
because he and I have been talking about telehealth, talking
about a variety of ideas that the committee could work on in a
bipartisan way. And we thought in particular it made some sense
as part of our duties, from time to time to step back and take
a look at what happened during the pandemic, areas where we can
do better, ideas where this committee can lead with bold
changes, and particularly in the health-care area prevent
dramatic disruptions of health care in our country.
We all understand that when COVID hit, it was no longer
safe to meet face to face, take a bus to the doctor's office,
even in many instances walk into a hospital for care. So when
we talk about changes and what ought to stick around and what
we ought to build on post-pandemic, Senator Crapo and I both
thought telehealth was an ideal place to start.
Now the telehealth challenge has always been about
balancing the speed and efficiency of new technologies with the
need for health-care quality and accountability. During the
pandemic, some patients have felt that they had to jump through
too many hoops, too many bureaucratic challenges, in order to
get access to telehealth.
My view, as a general proposition, is that patients ought
to be able to have more accessible opportunities for
telehealth. And particularly after they have seen a provider
for the first time, we ought to be able to work together to
clear out the bureaucratic hoops so that they can get access to
telemedicine.
In some cases, the right approach may in fact be to give
the green light to telehealth from the get-go, at the very
beginning. So we are looking forward today to discussing how to
go about striking that balance, after a year of experience
during the pandemic.
Just so we get back to the question of the history here,
the committee led the effort to shoehorn coverage for
telehealth in Medicare as part of the CARES package. That was a
particularly important part of CARES because it allows health-
care providers in Medicare to offer telehealth services to all
older people, regardless of whether they live in big cities or
small rural towns.
And that particularly badly needed health-care measure
provided care safely into the homes of tens of millions of
seniors nationwide.
The CARES Act also allowed Federally Qualified Health
Centers, including community health centers and Rural Health
Clinics, to receive Medicare payment for telehealth services,
which meant that still more health-care providers could be
involved in stepping up, as they did, to provide assistance,
particularly for health-care services that would otherwise be
very remote, and possibly beyond the reach of millions.
Now again, for just a short bit of history, the Finance
Committee actually paved the way for a lot of those changes in
Medicare. Because for years we pressed the case on a bipartisan
basis to update the Medicare guarantee, and to in effect say
Medicare was not like it was in the days when I was director of
the Gray Panthers. It is not primarily an acute care program
any longer; it is a chronic care program. And so we led the
effort to update the Medicare guarantee.
And for too many years, the Congress simply fell behind in
terms of recognizing the transformation of the flagship health-
care program at the Federal level. And telemedicine exists now
largely because it was kicked off by work done by the Senate
Finance Committee. Telehealth is going to be a big part of the
transformation going forward, moving beyond acute care to
dealing with chronic disease.
The CHRONIC Care Act, which was passed by the committee
when Orrin Hatch was the chair, marked the very first time
seniors, for example, could get telehealth in-home for kidney
disease. The law also made it easier to use telehealth to
diagnose and treat strokes. It allowed more flexibility for
Medicare Advantage plans and Accountable Care Organizations.
So when the pandemic hit, because of the work of the Senate
Finance Committee, the Centers for Medicare and Medicaid
Services already had a head start for telehealth.
I would also like to mention, as Senator Crapo knows, we
have had a number of colleagues in the Senate who have been
interested in the telehealth issue, and I want to particularly
commend Senator Schatz and Senator Wicker, who also have spent
considerable time on this.
So Federal agencies have taken advantage of existing law to
allow providers to care for their patients in fresh ways. For
example, certain hospital doctors and nurses were able to
travel out into their communities and provide services at home
that would typically be reserved for inpatient care. Others
could set up temporary spaces, like tents, near hospitals
themselves. They were not allowed to do this prepandemic--in
ordinary times. So these steps to increase capacity kept
patients safe and helped maintain care.
Today we are going to hear from physicians and hospitals
who have been on the front lines, and health-care experts who
have seen how the fresh approaches I have just mentioned
transformed care. And as we have indicated, there is bipartisan
interest in building on these changes that work for seniors and
providers, and that can allow us to use Medicare, and
particularly the telehealth breakthroughs, as a model for other
parts of the health-care system.
In the last year we also made progress on legislation that
lets seniors on Medicare receive mental health services via
telehealth, including at home. My view is, mental health
services ought to be available via telehealth for all
Americans. That provision was part of a bill that I authored
that would also permit telehealth for routine health-care
visits in Medicare, known as evaluation and management.
I believe the committee can work together on a bipartisan
basis to make that and other changes a reality.
Let me recognize Senator Crapo, and I am again going to
express my thanks for his partnership in making sure that we
got this issue front and center, and we are starting to look at
how to build on the lessons of the pandemic.
Senator Crapo?
[The prepared statement of Chairman Wyden appears in the
appendix.]
OPENING STATEMENT OF HON. MIKE CRAPO,
A U.S. SENATOR FROM IDAHO
Senator Crapo. Thank you, Mr. Chairman. Thanks for holding
this important hearing.
Congress and the administration provided certain health-
care flexibilities during the pandemic so that patients could
continue to receive high-quality care. Making permanent changes
based on these lessons learned is a top priority.
I shared my interest with President Biden's nominees for
the key health-care positions that have come before this
committee, and I appreciate their commitment to work with us on
this committee. Republicans and Democrats often disagree on the
best way to achieve our shared health-care goals. This hearing,
however, highlights an area of common ground. In fact, Senator
Wyden and I asked the majority and minority staff to jointly
plan this hearing, demonstrating strong bipartisanship.
Acting on legislative changes and using administrative
authority, the Centers for Medicare and Medicaid Services
waived over 200 payment rules during the pandemic in Medicare
alone. Needless to say, there is a lot we can learn. Today's
witnesses will provide insight into our efforts that we need to
take to evaluate these flexibilities.
Hearing firsthand about the patient experience during the
pandemic from providers who overcame challenges to provide care
will be invaluable. Understanding how the flexibilities are
used in fee-for-service, Medicare Advantage, and alternative
payment models will be insightful.
Much of the hearing will focus on care provided during the
pandemic through telehealth. Telehealth has been a lifeline for
patients and providers, especially in the early months of the
pandemic. The reliance on telehealth increased in rural and
urban areas alike, allowing patients to receive remote care
from the safety of their own home.
Telehealth services have been especially useful for
Idahoans. According to the Idaho Department of Insurance,
telemedicine visits went from an average of about 200
appointments per month to 28,000 telehealth visits in April
2020 alone.
To ensure financial stability, providers have been paid at
the same rate as if the service was furnished in person. This
has facilitated care that otherwise would be risky or
unavailable, and patients have appreciated the convenience. It
has reduced the frequency of missed appointments and assisted
provider investment in the infrastructure needed for remote
care.
This long period of expanded telehealth will help us
understand the impact on quality of care and program costs.
This serves as a robust test project on a scale few could have
imagined. The promise of telehealth is clear, but it is
important that we gather evidence on its impact on access,
quality, and cost.
There are approaches to providing care in the most
efficient setting that go beyond telehealth. Some hospitals are
using a waiver that provides flexibility to triage patients who
present to the hospital to see if they can be best cared for in
their home. Whether through telehealth, Hospital at Home, or
other innovative care arrangements, it is important to find
ways to get patients care that best meets their needs, and at
the lowest cost possible.
Congress has taken permanent steps to do just that in
recent years. Nephrologists can conduct remote evaluations of
patients receiving home dialysis. Providers can administer
certain drugs to vulnerable patients in their own homes.
Hearing from our provider witnesses helps us to continue down
this path.
The Government Accountability Office will supplement what
we hear from our provider experts, offering a perspective on
how to track and evaluate flexibilities in Medicare and
Medicaid as we chart the right course forward.
I fully expect that we will take what we learn from this
hearing to continue our bipartisan efforts to help providers
give patients the best care possible. Permanent changes based
on lessons learned from the pandemic can modernize our Medicare
payments and systems and lend to the pressing need to address
Medicare's financial struggles.
Identifying smart reforms that make Medicare more efficient
will be better for patients and better for taxpayers. Such
changes alone will not put Medicare on a sustainable path, but
they should be a part of that broader conversation. Addressing
Medicare solvency should be a bipartisan issue, with time best
spent determining how to shore up the current system instead of
expanding it to a broader population.
Finding the right path on these priority issues is
important to patients and the health programs in the
committee's jurisdiction. This hearing will help us to
capitalize on that bipartisan opportunity.
Thank you again, Mr. Chairman. I yield back.
[The prepared statement of Senator Crapo appears in the
appendix.]
The Chairman. Thank you, Senator Crapo. And I especially
appreciate the focus on smart reform. And if we tie smart
reforms to the whole notion of updating the Medicare guarantee,
then I think we have really done a service in terms of the
health-care debate, and I thank you for it.
We have virtually every member of the committee signed up
to ask questions after we hear from the witnesses, so we are
going to have a particularly busy morning. And we are just
going to move ahead, our first witness being Ms. Jessica Farb,
Director of Health Care at the Government Accountability
Office. She has an extensive portfolio there.
Then we will hear from Dr. Kisha Davis, a family physician
and a member of the American Academy of Family Physicians'
Commission on Federal and State Policy. She is also a vice
president of health equity for Aledade and cares for patients
at a primary care clinic in Baltimore, MD. We thank her.
We then have Linda DeCherrie, M.D., a geriatrician and
palliative medicine physician who serves as clinical director
of Mount Sinai, part of the Mount Sinai Health System in New
York.
After that, we will have Dr. Narayana Murali, a
nephrologist and the executive director of the Marshfield
Clinic in Wisconsin.
And finally, we will hear from Dr. Robert Berenson, whom we
have had a chance to work with often over the years, an
internal medicine physician and institute scholar at the Urban
Institute, who is an expert on health policy, particularly
Medicare.
So I would also like at this point--and I think we will not
have any objection to this--to enter into the record, by
unanimous consent, the statement of the Medicare Payment
Advisory Commission, or MedPAC, on pandemic flexibilities in
Medicare. Hearing no objection, we will make that part of the
record.
[The statement appears in the appendix on p. 117.]
The Chairman. We will go right to our witnesses, and then
today, colleagues, because we have so many Senators who are
going to be asking questions, we are going to have to stick to
the 5-minute rule pretty scrupulously or you will be eating
your corn flakes tomorrow morning when everybody is still
waiting to ask questions.
Ms. Farb?
STATEMENT OF JESSICA FARB, DIRECTOR, HEALTH CARE, GOVERNMENT
ACCOUNTABILITY OFFICE, WASHINGTON, DC
Ms. Farb. Chairman Wyden, Ranking Member Crapo, and members
of the committee, thank you for the opportunity to discuss
GAO's ongoing work examining Medicare and Medicaid waivers and
flexibilities implemented by CMS in response to COVID-19.
We undertook this work as part of GAO's broader
responsibility to conduct monitoring and oversight under the
CARES Act. To increase access to medical services during a
public health emergency, the Secretary of HHS can use several
different authorities to temporarily waive or modify certain
Federal health-care program requirements.
Since the beginning of the pandemic, CMS has issued over
230 waivers related to the Medicare program and approved more
than 600 different Medicaid waivers and other flexibilities.
Many of the Medicare waivers offer flexibilities for providers,
hospitals, nursing facilities, and hospices. They generally
were intended to increase capacity at facilities, expand the
available workforce and beneficiary access to care, and reduce
administrative burdens.
As examples, CMS, one, allowed hospitals to provide patient
care at non-hospital buildings or spaces, also known as ``a
hospital without walls;'' two, created an expedited process for
new provider enrollment, including waiving certain criminal
background checks; and three, increased flexibility for
providers to treat beneficiaries through telehealth.
Similarly, CMS approved Medicaid waivers and flexibilities
aimed at addressing obstacles that affect beneficiary care,
provider availability, and program enrollment. For example, CMS
allowed out-of-State licensed providers to care for Medicaid
patients across State lines, and permitted virtual patient
assessments needed to qualify for long-term care services in
Medicaid.
The full effects of most of these waivers and flexibilities
are not yet known, but CMS has reported some data on the use of
telehealth in both programs. For example, over the first 8
months of the pandemic, utilization of telehealth services by
Medicare fee-for-service beneficiaries sharply increased from
about 325,000 services per week at the start of the pandemic,
to a peak of about 1.9 million about a month later. Since then,
utilization has slowly declined, and as of mid-October was
slightly over 700,000 services per week, still much higher than
pre-pandemic levels.
This utilization varies in a number of ways, including by
service type, provider specialty, and beneficiary demographics.
For example, telehealth was used more frequently for mental
health services and by beneficiaries under the age of 65, as
well as those located in urban areas. CMS has also reported
variation in the use of telehealth in the Medicaid program
across the States and across age groups within the States.
The waivers and flexibilities implemented in Medicare and
Medicaid during COVID-19 likely benefited providers and
beneficiaries, yet determining whether and, if so, how to
continue them post-
pandemic warrants consideration.
Factors to consider include program spending, program
integrity, beneficiary health and safety, and health equity.
Both the Medicare and Medicaid programs are on GAO's high-risk
list in part due to concerns about fraud, waste, and abuse.
Telehealth and other waivers pose some risks of unnecessary
program spending. The lower but stable telehealth utilization
trend we saw last fall in Medicare suggests that demand for
telehealth may continue after the pandemic.
Medicare currently pays the same for telehealth and in-
person services, and one provider group we interviewed
cautioned that this could create incentives for specialties
that can provide and be paid for both in-person and additional
telehealth services to generate telehealth visits without
obvious clinical benefit.
In addition, the lack of complete data for oversight and
suspension of some program safeguards may have increased
program risks. For example, CMS lacks complete data to
determine the telehealth modality being used, audio-only or
audio-video, or where the services are originated--important
information to consider, given payment incentives and the lack
of evidence so far about the quality of telehealth services in
Medicare.
Extending or ending waivers and flexibilities may affect
beneficiary health and safety in unknown ways. For example,
expedited processes for provider enrollment in both programs,
including waivers of normal screening and criminal background
checks, could affect the quality and safety of care provided to
beneficiaries.
And finally, the health disparities we have observed during
the pandemic also extend to beneficiaries' access to services
and may be exacerbated by differences in access to things such
as technology used to support telehealth in rural areas. Thus,
health equity may be an important factor in decisions about the
continuation of these flexibilities.
Careful contemplation of the benefits and risks of
continuing these waivers and flexibilities will be key to
determining the path forward. We look forward to working with
Congress and this committee as we continue our oversight of the
Federal response to the COVID-19 pandemic.
Chairman Wyden, Ranking Member Crapo, and members of the
committee, this completes my prepared statement. I would be
pleased to respond to any questions that you may have.
[The prepared statement of Ms. Farb appears in the
appendix.]
The Chairman. Thanks very much, Ms. Farb.
We go now to Dr. Davis.
STATEMENT OF KISHA DAVIS, M.D., MPH, FAAFP, MEMBER, COMMISSION
ON FEDERAL AND STATE POLICY, AMERICAN ACADEMY OF FAMILY
PHYSICIANS, LEAWOOD, KS
Dr. Davis. Good morning, Chairman Wyden, Ranking Member
Crapo, and members of the committee. I am Dr. Kisha Davis, a
member of the American Academy of Family Physicians' Commission
on Federal and State Policy, and I am honored to be here today
representing over 133,000 physician and student members of the
AAFP.
I am a practicing family physician providing primary care
to patients in Baltimore, MD, and I also serve as vice
president of health equity at Aledade, working to reduce health
disparities in physician-led ACOs across multiple States.
I have experienced the impact of COVID-19 and resulting
Federal policy changes first-hand, as well as through the
shared experiences of the physicians that I support. I am
appreciative of the flexibilities granted due to the public
health emergency. These have allowed all patients, especially
some of the most vulnerable, isolated, elderly, and
disadvantaged patients, to maintain their relationship with
their trusted primary care physician, while many offices had to
close or severely limit in-person visits due to social
distancing restrictions.
They have also allowed these practices to remain
financially solvent, whereas their mass closure would have been
devastating at a time when medical care was needed most.
Lastly, the ability to connect with one's trusted primary
care physician via telehealth helped to alleviate the burden on
emergency rooms and hospitals.
As a physician myself, I want telehealth to be a tool in my
toolbox that I can deploy based on a clinical judgment, not
based on whether I get paid. As Congress considers whether to
extend these flexibilities beyond the public health emergency
and how to build upon recent advances, it is vital that
Medicare and Medicaid policy changes are designed to advance
health equity, protect patient safety, and enable clinicians to
provide the right care at the right time.
To this end, I suggest the following four recommendations
regarding telehealth flexibilities.
First, Congress should permanently remove the section
1834(m) geographic and originating site restrictions, to ensure
that all Medicare beneficiaries can access care at home.
Expanded access to telehealth visits has allowed me to observe
my patient's home or work environment, identify factors that
may be affecting their health, and develop more personalized
treatment plans. While some worry that telehealth will cause
patients to become disconnected from their doctor, I have seen
just the opposite. For patients, telehealth enables timely
first contact access to care, while building and maintaining
long-term trusting relationships. I have numerous examples of
physicians ensuring patients were still getting the preventive
care they needed by conducting annual wellness visits via
telehealth, the monitoring and treatment of chronic diseases
such as diabetes and hypertension, addressing acute concerns,
and most notably conducting transitional care management
visits--visits done post-hospital discharge aimed at preventing
readmission.
Prior to COVID, coming into the doctor's office after being
hospitalized was often a barrier. Providing these services for
patients in their home increases accessibility for patients who
may be homebound or lack transportation, and creates
opportunities to engage distant family and caregivers.
Eliminating geographic and originating site requirements is
essential and improves utilization of high-value care and
patient outcomes.
Second, Congress should require Medicare to cover audio-
only E&M services beyond the public health emergency. It is
vital to ensure equitable access to telehealth services for
patients who may lack broadband access or be uncomfortable with
video visits. For many of our patients, especially rural, low-
income, elderly, and non-English speakers, voice calls are
simply the most accessible option. Payments should support
patients' and physicians' ability to choose the most
appropriate modality of care, whether it be telephone, audio-
video, or in-person, and ensure appropriate payment for care
provided.
Third, Congress should ensure the permanent equitable
coverage and payment of telehealth services provided by
community health centers, and modify existing payment
methodologies to provide timely, appropriate payment for
telehealth. Community health centers have been stalwarts during
the COVID-19 pandemic, providing testing services, remaining
open during staffing shortages, and now leading in vaccine
distribution, while ensuring quality of care for millions of
low-income persons.
Fourth, policymakers should monitor the impact of
telehealth on access and equity, and invest in infrastructure
to promote digital health equity. While the rapid expansion of
telehealth has yielded many benefits for patients and
clinicians, not everyone has benefited equally. To achieve the
full promise of telehealth, Congress must proactively address
structural barriers to virtual care. Additional studies to
inform the direction of permanent telehealth policies should
include the collection and reporting of data stratified by
race, ethnicity, gender, language, and other key factors.
Thank you for the opportunity to discuss with this
committee the impact of these flexibilities on family
physicians and the AAFP's recommendations for permanent
policies to advance accessible, equitable, high-quality health
care beyond the pandemic.
[The prepared statement of Dr. Davis appears in the
appendix.]
The Chairman. Dr. Davis, thank you. You said so many
sensible things, but I especially appreciate your bringing up
and advocating for the voice calls, because I heard that
repeatedly again and again. Thank you.
Our next witness will be Dr. Linda DeCherrie, a
geriatrician.
STATEMENT OF LINDA V. DeCHERRIE, M.D., CLINICAL DIRECTOR, MOUNT
SINAI AT HOME; AND PROFESSOR OF GERIATRICS AND PALLIATIVE
MEDICINE, ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI, MOUNT SINAI
HEALTH SYSTEM, NEW YORK, NY
Dr. DeCherrie. Thank you.
The Chairman. There she is. Good.
Dr. DeCherrie. Chairman Wyden, Ranking Member Crapo, and
the members of the Senate Finance Committee, it is my distinct
pleasure on behalf of the Icahn School of Medicine at Mount
Sinai, and the Hospital at Home Users Group, to be part of this
panel to discuss Hospital at Home, specifically extending the
current acute hospital care at home flexibilities being offered
under the public health emergency.
Hospital at Home is patient-centered model of care which
provides hospital-level care at home for patients with select
acute illnesses who would otherwise be hospitalized. Multiple
Hospital at Home studies have demonstrated improved patient
safety, reduced mortality, enhanced quality, and reduced costs.
It was a model that many Medicare Advantage commercial and
Medicaid Managed Care plans already covered before the
pandemic. Adding the rest of the Medicare beneficiaries allows
equitable care and has been extremely helpful since November
2020 when the Acute Hospital Care at Home waiver was approved.
I believe the coverage of Acute Hospital Care at Home
should be covered beyond the pandemic, preferably as a 30-day
bundle of care. In 2014, Mount Sinai applied and received a
Center for Medicare and Medicaid Innovation award to develop
and test Hospital at Home for the fee-for-service Medicare
population. From this work, we submitted a proposal to the
Physician-Focused Payment Model Technical Advisory Committee.
The PTAC recommended our proposal in 2018 to the Secretary
of the Department of Health and Human Services for
implementation. The Secretary expressed interest in testing
home-based
hospital-level care models, but no payment model was advanced
for beneficiaries in fee-for-service Medicare.
In 2017, when our CMMI award was finished, our Hospital at
Home program was no longer able to provide care for fee-for-
service Medicare patients, as there was no reimbursement, and
the program shifted to focus on Medicare Advantage commercial
and Medicaid Managed Care plans.
We believe congressional action to extend the current
waivers and flexibilities is necessary and particularly
valuable for patient care. During the initial surge of COVID-19
in March of 2020, we were an important part of helping the
Mount Sinai health system open up more capacity for patients
needing higher levels of care, such as ICU, by completing Acute
Hospital Care at Home for patients already hospitalized.
However, we were still unable to admit fee-for-service
Medicare patients from the emergency departments. We were very
excited to be part of the original group of hospitals approved
for the Acute Hospital Care at Home waiver in November 2020. In
addition, we formed a Hospital at Home Users Group with support
from the John A. Hartford Foundation, which provides technical
assistance and office hours to other hospitals seeking to
respond to the waiver.
To date there have been 129 hospitals approved for the
Acute Hospital Care at Home waiver, with 56 health systems in
30 States, all since November. This shows that there is great
interest. However, it does take significant start-up resources
and time, and many hospitals are not planning to launch until
this summer.
I believe even more hospitals would implement Hospital at
Home if they knew this program would be extended or made
permanent.
Therefore, we request Congress and HHS to consider a
permanent extension of Acute Hospital Care at Home waivers
beyond the PHE to mitigate the residual impacts of COVID-19 on
the public health, and to encourage broader adoption of
providing patient-
centered health-care services in the home.
Thank you for the opportunity to present today.
[The prepared statement of Dr. DeCherrie appears in the
appendix.]
The Chairman. Thank you very much, Dr. DeCherrie.
Next will be Dr. Murali.
STATEMENT OF NARAYANA MURALI, M.D., BOARD MEMBER, AMERICA'S
PHYSICIAN GROUPS; AND EXECUTIVE DIRECTOR, MARSHFIELD CLINIC,
MARSHFIELD, WI
Dr. Murali. Thank you, Chairman Wyden, Ranking Member
Crapo, and members of the committee. I serve as the executive
vice president of care delivery and chief strategy officer of
the Marshfield Clinic Health System. I also serve as the
executive director. What I am advocating for, and strongly
believe, is that permanently supporting the flexibilities
created in response to the COVID-19 pandemic, and broadband,
particularly in middle America, will combat the rising cost of
health care in America and its economic impact on both patients
as well as their employers.
The potential that telehealth infrastructure has advanced
in the American health-care system in enhanced equity, access
to health care, as well as prosperity for all Americans, cannot
be overstated.
It is my honor and privilege to testify on behalf of
America's Physician Groups. APG is a national professional
association representing 300 physician groups and their members
with approximately 195,000 physicians who provide care to
nearly 45 million patients from coast to coast.
Our vision is to transition from legacy transaction fee-
for-service reimbursement to a capitated value-based system,
where physician groups are held accountable for the total cost
of care, the quality of care that they provide for their
patients, and are incentivized to innovate to provide the best
possible care.
Marshfield Clinic Health System is one of the Nation's
largest fully integrated systems, serving a predominantly rural
population in the State of Wisconsin. Our 1,400 primary care
and specialty providers provide approximately 3.5 million
encounters annually.
Our primary service area encompasses over 80 percent of
Wisconsin's rural population. In fact, over half of our 60-plus
facilities serve populations of less than 2,000 people. We have
more cars than people. Our mission to provide health care for
the large area greater than the State of Maine led to the
genesis of our telehealth program in 1997, where we performed
heart and lung exams over the Internet.
Today we use telehealth for Hospital at Home care, acute
care, arterial care, dental screenings in schools, and much
more. We were one of the first hospitals in the country granted
a Hospitals Without Walls waiver by CMS; this, because we were
already providing hospital-level care in the comfort of our
patients' homes since 2016, using telehealth even when there
was no formal incentive to do so. We knew that for a subset of
our population, there is no place like home for inpatient
recovery.
Compared to matched hospital cohorts, we saw our patient
satisfaction increased by 22 percent, hospital readmission
decreased by 44 percent, length of stay decreased by 37
percent, and ER visits halved.
Together, this created a 15-percent cost savings per
episode per patient for the health plan. Since the onset of the
pandemic, APG physicians have adopted a lifeline of telehealth,
ensuring access to care for all patients who were terrified to
leave their homes.
In 2020, MCH provided a quarter of a million telehealth and
telephone encounters. Presently, they average about 15 percent
of all encounters. Telehealth is here to stay. It is convenient
and economically beneficial for patients, as well as employers.
Our patients are older, sicker, and poorer than average in the
State of Wisconsin, as well as in the Nation.
Almost half our children are eligible for reduced or free
lunches. Public transportation is virtually nonexistent. Our
patients are geographically isolated, and travel 2 hours in
treacherous winter weather to come and get essential care. Such
obstacles deny care. Telehealth addresses these disparities,
ensuring proactive care that reduces ER visits, as well as
enhancing equity and access to health care and stabilizing the
economy.
My heart tugs at the story of a 67-year-old diabetic woman
whom I had managed for heart failure as well as kidney disease
back in 2007. Since then, we managed her care virtually, except
for one visit in a year. For the last 13 years, every year she
has sent me a Christmas card.
Telehealth has the power to become the norm of this
country. We are at a critical juncture at this point. Here are
some obstacles.
First, given our experience with the current waivers, the
site visit restrictions are no longer justifiable. The location
for a physician or a patient should not deny care for a
patient.
Second, the greatest obstacle for patient satisfaction is
access to broadband or Internet that is stable. Our patient
appointments are taken by patients at schools, as well as
library parking lots. It would be important for us to focus, at
least as a stopgap, on using phone care for increasing access
for Medicare Advantage people. Our members agree with that,
that restricting care denies care.
Finally, and most importantly, permanently reviewing and
renewing the waivers, including acute care without walls, will
trigger commercial investments to go faster. I thank you for
your service, as well as your support.
I would like to share this in the historical context. The
U.S. Congress has acted decisively in the past, creating great
infrastructure like the Hoover Dam, the Tennessee Valley
Authority, and the highway system. We look forward to working
with you in advancing America's health care Thank you.
[The prepared statement of Dr. Murali appears in the
appendix.]
The Chairman. Thank you, Dr. Murali. I can tell you,
millions of Americans would be clapping for your proposition
that, with respect to health care, there is no place like home.
So thank you very much for your valuable testimony.
Dr. Berenson?
STATEMENT OF ROBERT A. BERENSON, M.D.,
INSTITUTE FELLOW, URBAN INSTITUTE, WASHINGTON, DC
Dr. Berenson. Thank you very much, Chairman Wyden, Ranking
Member Crapo, and members of the committee.
Telehealth offers the promise of an important disruptive
innovation in health-care delivery, improving access and
quality, while reducing spending. However, decisions on how to
pay for expanded use of telehealth will determine whether that
promise is achieved.
As a practicing internist, the government official in
charge of Medicare payment policy at CMS, and now as a policy
researcher at the Urban Institute, I have spent much of my
professional life exploring better ways of paying health
professionals. I have also worked on Medicare payment issues as
the Vice Chair of MedPAC, and as an initial member of the PTAC,
which was established under the MACRA legislation.
On PTAC, I often argued for a straightforward fee schedule
change, rather than the proposed alternative payment model, to
achieve the purpose sought. My objections to some alternative
models are that they are not operationally feasible. The
converse is the case for telehealth. Fee-for-service for
telehealth is not operationally feasible as long-term payment
policy. I will briefly outline three major reasons.
First, fee schedules function reasonably well when the code
descriptions are concise and clinically relevant, producing
reliable and accurate coding. Codes for telehealth services are
anything but concise. Telehealth code descriptions specify the
specific modality employed, the patient's location during the
communication, which party initiated the service, the duration
of the virtual encounter, and a range of other specifications
for each code that was described as part of the telehealth
expansion.
These coding parameters were established for payment
purposes alone. They are not useful clinically. Using the
standard fee schedule to pay for telehealth services would
likely produce a quagmire of confusion, inadvertent or
intentional miscoding, and lots of clinician and patient
complaints about burden and counterproductive rules.
Second, for many telehealth services, fee-for-service
payments generate high billing costs relative to the payment
actually received. A recent study found that the cost for
billing and related documentation for an office visit was more
than $20. And that is just the billing cost for the first
submitted claim from the practice. A typical claim bounces
between the practice, the Medicare contractor, the supplemental
insurer, back to the practice, and then to the patient for
applicable cost-sharing. Proper and fair payment levels will
often be lower than the billing cost. So they either will not
be billed or, even worse, they will not be provided post-COVID.
Yet, raising the fee to make it financially worthwhile, as
under pay parity, would ignore the 30-year process for setting
relative values in Medicare. Paul Ginsburg, who is the current
Vice Chair of MedPAC, and I wrote that that process needs to be
changed, but it should not be changed on an ad hoc, one-off
basis just for telehealth.
Third, patients face substantial time costs and
inconvenience in traditional travel, waiting rooms, and actual
time with the clinician. I recently waited 20 minutes after my
annual wellness visit just to check out. My time commitment for
the visit was 3 hours. Patients will often prefer virtual
visits, but there should be brakes on demand and spending,
especially if paying for fee-for-service at parity.
RAND researchers found in the pre-COVID period that 90
percent of telehealth services were additional services, rather
than substitutes for in-person services. Used properly,
telehealth services often should be add-ons, such as for
chronic care managers but also for lots of other sound clinical
reasons, and those communications can certainly be done by
telephone calls in many cases. But those add-on services need
to be managed by the practice, within a spending constraint, to
help assure that virtual visits are used appropriately.
CMMI has developed a primary care alternative payment model
called ``Primary Care First.'' The approach needs to be tested
in an expedited fashion on a regional, mandatory basis, in my
opinion. It has the potential to be the permanent payment model
for primary care practices generally, while also addressing
payment for telehealth services. My written testimony also
provides initial thoughts on using lump sum payments to
practices for specialists' use of telehealth, rather than fee-
for-service.
So in conclusion, I would just suggest that this is an
important time and a real opportunity to fundamentally examine
how Medicare pays physicians and other health professionals,
and it should not be just sort of a default ``let's just
continue the current payment flexibilities and high payment
levels'' without full consideration.
Thank you very much.
[The prepared statement of Dr. Berenson appears in the
appendix.]
The Chairman. Doctor, thank you. And we have virtually
every member participating, so we are going to have to stay
pretty close to the 5-minute rule today, colleagues.
My first question really speaks to the question of balance.
We love the speed and efficiency of new technologies like
telehealth, and at the same time, as Dr. Berenson just
mentioned, we have to ensure quality care and accountability.
And he described this horror story of bills just bouncing from
place to place to place. So we are going to have to move
around.
In terms of questions, I think I will start with our GAO
person, and Dr. Berenson, on this. What are the lessons learned
from how we did telehealth during the pandemic in striking this
balance that I described as speed and efficiency and quality
and accountability? Why don't we start with the GAO person, and
then we will go to you, Dr. Berenson.
Ms. Farb. Sure. Thank you, Chairman Wyden. I think what we
have learned so far is that we do not have the complete
information that we need to study what we need to study in
order to make some determinations about some of the issues that
Dr. Berenson was raising.
I believe that is why MedPAC actually recommended that some
of these flexibilities continue with some guard rails in place
so that we can study the effects of these issues on the quality
of care, which is still not quite known in Medicare at this
point, and on sort of program spending and provider and
beneficiary behavior.
The Chairman. Dr. Berenson?
[Pause.]
The Chairman. You are muted, Doctor.
Dr. Berenson. Okay, I am on. I will make two points. One is
that we learned that if you simply pay what the sort of process
is for generating relative values and fees that has been used
in Medicare, you will not get the services you are desiring.
In 2019, Medicare, CMS, put into effect something called a
check-in visit, which was a payment to physicians to call their
patients to discuss whether they needed to come in for an in-
person visit. The payment by the traditional method was about
$14 and change. And guess what? Nobody did the visits. It was
less. The practices are not stupid, so they may have made the
call but they sure did not bill for it, and I would suspect
that many practices did not even do it because of the
inadequate payment.
And within 2 weeks of announcing that there would be a
whole new list of telehealth services, CMS raised that payment
level from $14 and change to $56. And guess what? Doctors did
it. And I think it was a very smart move by CMS to get money
out the door to beleaguered practices that suddenly saw their
revenues decrease dramatically and patients who could not get
care. So the payment level matters a lot. And so that is one
point.
The second point I want to make is that--actually I am
blanking on what my second point is, and so I will move on.
The Chairman. Thank you.
Let's go to the equity question. And by the way, all of you
can give us additional information for the record. I just felt
that this question of striking a balance is what practitioners
and patients are always asking me. They want the speed. They
like the efficiency. But they want the quality, and they want
answers to these kinds of questions. So apropos of what we
heard from GAO, we will be interested in more information, for
example, on your work apparently in the guard rail kind of
area.
A question for you, Dr. Davis. We have said in our work on
this committee, every single time out, we are going to focus on
equity issues, because we know in America much of health care
is really a desert for vulnerable people. If you are affluent,
and you are white, and you are in the suburbs, you have the
world in front of you. If you are in the BIPOC community, very
often these options just pass you completely.
So our first work was on maternal mortality, but we want to
make sure that the principles of fairness extend to new
technology as well. Wave your wand and tell us a couple of
things you think you would be doing if you were on the Finance
Committee to promote racial equity in telehealth.
Dr. Davis. Thank you, Senator Wyden. That is a great
question, and it is a concern that we have as well. What we
have seen from the pandemic is that there has been unequal
access, and the communities that have been most likely to
access telehealth have been whiter, richer, more urban, and
with more access.
And so I think the first thing is--really as we are
exploring and expanding telehealth--really being sure to make
sure that the data that we collect is stratified by race,
ethnicity, gender, language, and other key factors, making sure
that we are taking customer and patient reviews into account as
we are expanding outward. And then also, continuing to invest
in infrastructure, in broadband for our rural communities, for
our underserved communities, making sure that they continue to
have access so that we are not inadvertently creating a two-
tiered system where all have access to in-person and only some
have access to telehealth.
The Chairman. Good. I am over my time.
Senator Crapo?
Senator Crapo. Thank you very much, Mr. Chairman.
I will start with you, Ms. Farb. The waivers have clearly
been successful in increasing patient access. The impact of
telehealth on the quality and cost of care is more complicated
to measure, as you have indicated.
Focusing on the quality part of the equation, what metrics
do you use to measure the quality of telehealth services,
including in comparison to in-person care?
Ms. Farb. Well, Chairman Crapo--Senator Crapo, sorry--thank
you for that question. Organizations like the NCQA and AQF have
been working during the past year to retool their quality
measurement sets and the frameworks that they use to develop
quality metrics specifically for telehealth.
The key areas that AQF has noted include things like the
timeliness of care--and obviously, telehealth may have an
advantage in that regard--how well it encourages care
coordination, and patient empowerment and engagement.
So there are a number of different metrics and sort of
categories of metrics along which the quality organizations are
suggesting telehealth be measured. We at GAO have not yet
looked into specific quality measures for telehealth yet. We
have been asking about those as part of our ongoing work to try
to understand how providers and others are viewing that.
Senator Crapo. All right; thank you.
And, Dr. Murali, it seems the ideal way to deploy
telehealth is for a physician working with the patient to
decide which care modality works best for each patient visit.
But payer policies related to billing, documentation, and
payment play a large role in the extent to which providers
offer telehealth.
Understanding that physicians provide the same level of
patient care regardless of the type of insurance, is telehealth
more feasible in a capitated payment arrangement?
[Pause.]
Senator Crapo. You are muted. There you go.
Dr. Murali. Senator Crapo, thank you very much. Absolutely.
Transactional fee-for-service does not help people to innovate
because it is transactional. If you need transformation, you
need prospective payments. Capitated payments allow the
physician groups to focus on what is important as well as
invest in the infrastructure required to provide optimal
telehealth that is integrated in the electronic medical
records.
As I shared in my documentation, presently physicians have
worked as heroes. They do the video chats, the e-coms, as well
as all the transactions while they are doing telehealth, but
the systems are not optimally designed to get at patient care.
So if you want to get the efficient care and adoption at a much
higher rate, that is absolutely necessary, and you are right
on.
Senator Crapo. Well, thank you.
And, Dr. Berenson, could you comment on the same question?
You are muted.
Dr. Berenson. I don't know who is muting me. In any case, I
agree very much with Dr. Murali. Capitation does not--the
problems that I described in fee-for-service where you have all
these rules and requirements as to the circumstances that you
have to follow and on which you can bill, in my practice I have
found often a 2- or 3-minute phone call follow-up the week
after I either made a tentative diagnosis or changed the
medication, was the proper way to follow up with a patient.
Yet, that would not qualify for payment under fee-for-service.
With capitation, you have essentially an account that can
be deployed to appropriately use capitation without artificial
rules and regulations, to use telehealth without artificial
rules and regulations. So I think that is the way to go.
CMMI has actually developed a model which is sort of half
fee-for-service and half capitation. It seems like with
expedited testing it could, within a couple of years, become a
national model for moving primary care practices. It is a
little trickier to figure out how to pay specialists for their
telehealth because, with capitation, it is not easily done for
specialty services.
Senator Crapo. All right; thank you.
And back to you, Dr. Murali. We have talked about broadband
and some of the infrastructure aspects of getting this issue
resolved. You stated that telehealth was a fundamental element
of caring for patients in rural Wisconsin, even before the
pandemic. And can you speak to how Marshfield Clinics made the
necessary investment in infrastructure and physician training
to make that possible?
Dr. Murali. Yes; some before the pandemic, some during the
pandemic. Before the pandemic, we invested in optic fiber
cables, along with our community of three-quarters of a million
in Marshfield, to expand the capacity to provide that service;
invested in a stand-alone data warehouse; as well as focused on
trying to get the intelligence required for providing good care
with quality outcomes that are measured.
In addition to what needs to be done--so if you want to
provide telestroke coverage or ER coverage, or you want to do
Hospital at Home, you need to invest in equipment and platforms
that translate to roughly about $4\1/2\ million a year for us
as a health system.
And so we have been doing that without any concern, because
there is no other way to optimize labor and recruit physicians
to provide the care in populations that are less than 2,000 in
a 45,000 square mile geography.
Senator Crapo. Thank you very much.
The Chairman. Doctor, thank you.
With 26 Senators waiting to ask questions, we are going to
move quickly.
Senator Stabenow?
Senator Stabenow. Well, thank you very much, Mr. Chairman.
And you know, I have been smiling this morning as I am thinking
back to when so many of us pulled together before the CARES Act
was put together. At the time, Senator Thune and I were charged
with getting together to make some recommendations, bipartisan
recommendations on Medicare. And we quickly came together
around telehealth. And of course the committee embraced those
recommendations.
And I am just so pleased that we were, all of us together,
willing to move forward on telehealth. And I support yours and
the ranking member's desires to make these things permanent,
certainly dealing with the issues around accountability that we
need to do.
So when we look at the issues around telehealth, I wanted
to specifically ask about mental health and addiction services.
We did include these areas for behavioral health clinics to be
able to use telehealth, as well as community health centers and
others.
And while we are seeing that there has been dramatically
expanded access to telehealth--CMS reported a 2,700-percent
increase in telehealth utilization for Medicaid and children's
health insurance beneficiaries. That is amazing.
But in behavioral health treatment for Medicaid and for
CHIP, actually at the same time, it dropped dramatically
overall during the pandemic--22 percent for adults, and 34
percent for children. So we definitely want to move ahead and
do what we need to do to strengthen all these policies. But I
do want to ask, Dr. Davis, if you could speak to the mental
health addiction services piece of this, and what we need to do
to be able to make sure we are reaching out to everyone who
needs help, because obviously in this space, we are not
reaching people.
Dr. Davis. Thank you, Senator Stabenow. Yes, telehealth for
mental health and behavioral care is so important, and it
really can help remove barriers to access, to stigma in terms
of patients who may be hesitant to get out and meet somebody in
person--and being able to see them face to face makes a huge
difference.
In the practice that I work in, we have a strong connection
with mental health. And so it has been absolutely beneficial to
our patients to be able to provide them with behavioral health
services through telehealth.
We also provide addiction services. And so being able to
provide substance use disorder and MAT treatment through
telehealth has been essential for our patients. I cannot
explain why we have not seen the increase that we might have
expected, but I can tell from patient experience that it is an
essential service.
Senator Stabenow. Thank you.
And let me take my last moments just to ask Dr. DeCherrie
about home health, more about home health, because we know that
as we were expanding eligibility for more people to get care at
home during COVID-19, how important that was. And many Medicare
beneficiaries can now receive that care at home that they would
previously have had to travel, or risk exposure, to be able to
receive. And we know that home health care helps in many
different ways.
But, Dr. DeCherrie, could you discuss the benefit to
meeting patients' needs in their communities, including at
home, when medically appropriate? Just a little bit more about
why you think it is important that we focus on that.
Dr. DeCherrie. Yes. Thank you for that great question. So
yes, I provide care both in Hospital at Home--home-based
primary care, home-based palliative care--so I believe in
multiple models of home-based care. They all have their place,
and we have seen increased need during this pandemic, where
patients want to be home and get that care at home.
So yes, I think all of those are things that we should
think about how to expand.
Senator Stabenow. Thank you. Thank you, Mr. Chairman. I am
going to yield back 30 seconds, for the good of order.
The Chairman. Thank you for your good work.
Senator Grassley is next.
Senator Grassley. Thank you, Mr. Chairman. I am glad to be
with you for a very important issue of lessons learned from the
pandemic, but we are still going to continue to learn a lot.
Thank you very much.
So I am going to ask questions of all the panelists, pretty
much, so if you can save some time by not repeating each other,
I would appreciate it.
So my first question to the panel is, while the pandemic
has shown many flexibilities in health care take place without
compromising patient safety and quality, there are still areas
in health care that are restricted by Federal laws and
regulations. I sponsored the Pharmacy and Medically Underserved
Areas Enhancement Act with Senators Casey and Brown. This bill
would let pharmacists operate in a medically underserved area,
offer health services like wellness screening in diabetes
management, and be paid by Medicare.
For each of the panelists, which additional flexibilities
should Congress consider, to improve patient access and remove
Federal red tape?
Dr. Murali. Senator Grassley, if I may, at this point in
time in the Marshfield Clinic Health System, we do about 53,000
to 55,000 telepharmacy visits using the pharmacist at one
center to help with respect to mixing in a sterile environment
all the medications that are required across the large
geography. So promoting programs that will help, like you have,
is going to be very, very valuable in this space.
Senator Grassley. Is there anybody else who wants to add,
although you do not all have to speak if you do not have
something to add.
Dr. Davis. Sure. This is Dr. Davis. I will say, I
appreciate the extension of pharmacy, and as long as that is
done as part of the medical home, I think that is important.
Speaking of other flexibilities beyond telehealth that
should be considered, one is Medicare and Medicaid coverage for
all AAFP- and also ACIP-required recommendations, not just the
COVID-19 vaccines, but access without cost sharing beyond the
public health emergency.
In addition, allowing physicians to provide direct
supervision and teaching services via real-time two-way audio/
video communication, which would expand access to primary care
and increase training opportunities. This is already being done
in rural areas, but extending that to all communities.
And then permanently removing or reducing the volume of
prior authorizations, step therapy, and other administrative
requirements, and allowing those to be done via telehealth or
in person.
Senator Grassley. Okay. Since you brought up telehealth, I
am going to go to my next question. It is really a positive
thing, I think, that has resulted from the pandemic, if you
want to say anything good can come out of a pandemic. The
public health emergency permitted more than 140 services to be
administered through telehealth. Last Congress, we made mental
services by telehealth a permanent Medicare benefit.
For each of the panelists who are physicians, telehealth
was widely adopted throughout the pandemic, with its current
utilization greater than pre-pandemic but less than its peak
last spring. What type of medical services are most utilized
today through telehealth? And which ones are most effective for
patients and providers? And maybe the last half of that
question is the most important part of it.
Dr. Murali. Senator Grassley, so from the standpoint--I
heard Senator Stabenow's comment. In the Marshfield Clinic
Health System, the number of behavioral and psychological
consults that go through telehealth has more than doubled
compared to the average.
So more than 30 to 40 percent of home visits are actually
for behavioral visits, for substance abuse, as well as with
other elements. So that is an important factor from the
standpoint of telehealth. I leave it to the others to comment.
Dr. Berenson. I will just make a brief comment on that as
well. I am going to agree again with Dr. Murali about the role
of behavioral health by telehealth. I was involved with
interviewing primary care physicians, nearly 20, and they all
said, even though they are not specifically behavioral health
physicians, that that has been the biggest uptake and the most
valuable thing that has occurred.
The only issue that I can raise there is that, in some
families there may be a confidentiality issue, where we are
doing the telehealth when the patient is at their home. But
that can usually be worked around.
I do not think there is a comprehensive analysis yet of
which services--we heard anecdotally, for example, that
hypertension was good to manage by telehealth because patients
had their own blood pressure machines and could take their
blood pressure, whereas for diabetes the patient needed to come
in for a blood test to check the hemoglobin A1C. And this will
evolve over time.
I think, however, that for the most part virtually all,
sort of general medical and--not surgical, which needs a
procedure in many cases--but general medical issues can be
dealt with with telehealth being a central part of the
management strategy.
Senator Grassley. Thank you, Mr. Chairman. I am going to
submit other questions for answers in writing.
The Chairman. That will be fine.
Senator Cantwell, chair of the Commerce Committee, and an
expert, is next.
Senator Cantwell. Thank you, Mr. Chairman. Thanks for
having this hearing.
If I could just get a quick ``yes'' or ``no'' answer from
all the witnesses, do you think we need more affordable health-
care options for people in America?
Dr. Davis. Yes.
Dr. DeCherrie. Yes.
Ms. Farb. Yes.
Dr. Murali. Yes.
Dr. Berenson. Yes.
Senator Cantwell. Thank you.
Ms. Farb, one plan that is out there that could help reduce
the cost is the Essential Plan in New York, or better known as
the Basic Health Program from the legislation. It has allowed
people under 200 percent of the Federal poverty line to see a
huge savings in their costs.
Should we be doing more to drive the value of expansion of
this program to other States?
Ms. Farb. Senator Cantwell, thank you for the question. We
have not done any work looking at that plan in New York at GAO,
so I cannot really comment on whether or not it should be
expanded. I defer to my colleagues.
Senator Cantwell. Yes, Dr. DeCherrie, you are a New Yorker.
What do you think?
Dr. DeCherrie. That is also not in my area of expertise, so
I do not have anything to add to that.
Senator Cantwell. Okay. Anybody else?
[No response.]
Senator Cantwell. Okay, so I guess we have a mystery here
that maybe I can try to illuminate for the future. But I can
tell you this. My constituents are tired of subsidizing
expensive health insurance plans when we do not have to. If
there are ways to buy in bulk, which New York and Minnesota
have done, and bundle up a large percentage of the population,
then, yes, they believe they should get discounts. That is what
is happening.
So, Mr. Chairman, mark me down as someone who is not going
to go along, even if it is a Democratic proposal, not going to
go along until we do something about lowering the investments
we are making in expensive subsidies to insurance companies for
health care.
This plan has worked in two States, and we should be using
it as a way to save dollars and expand coverage to more people.
Americans cannot, even with our tax subsidies, continue to have
expensive health insurance costs.
Okay, great discussion on telehealth. I really appreciate
all of that. The University of Washington has gone from doing
about 20,000 people a year to 20,000 a month. And I am curious,
Dr. DeCherrie or Dr. Berenson, what do you think that--what
else do we need to do to change the actual reimbursement rate?
Does it have to be on exact parity? Can it be a little off of
parity? What do we need to do to make sure the reimbursement
rate is fair? Or is there something else we need to do to
differentiate?
Dr. DeCherrie. I think that is probably Dr. Berenson's
field to answer.
Dr. Berenson. Again, my compulsion would be that we
continue fee-for-service as an interim strategy. I do not have
the magic number for you. If we pay based on the traditional
resource-based relative value scale approach, the payments for
the low end of telehealth would be too low to actually have
them perform.
Pay parity, where we are now paying three times what that
sort of proper amount should be, is too high. So I think some
smart people could get into a room and come up with some middle
ground so that it was high enough that physicians and practices
would actually bill it. But RAND has pretty well demonstrated
in a prior study, and I have not seen it challenged, that the
costs for telehealth are less than the costs for in-person. It
just makes sense. And telehealth becomes sort of standard in
most practices. They will--practices will reduce some of their
infrastructure, and maybe work with less space, and their costs
may come down. But in the interim, I think we can find some
middle ground. But it should be in the context that we are
moving to something different at some date, if not certain----
Senator Cantwell. Thank you for that honest answer. Do you
think that is rocket science? Or do you think that is just
coming to terms on numbers--and yes, people will obviously have
strong opinions. But do you think that is something we could
achieve in the next several weeks?
Dr. Berenson. The next several months. I think we have seen
surveys of practices to get some answers.
Senator Cantwell. Thank you so much. I do not know if I
have any time left, Mr. Chairman. I cannot see the clock here,
so----
The Chairman. You are pretty much on the line, but do you
have one other one you want to ask?
Senator Cantwell. I just want to say that I hope that Dr.
DeCherrie could answer some questions in writing about--
MultiCare got a CMS waiver on helping integrate doctor care and
home care. So it is basically better ways for the home health-
care programs to work with health-care providers, and I hope
that we could look at that also as a cost savings in keeping
patients in their homes longer.
So thank you very much, and we will write something for the
record on that.
The Chairman. Great. And, Senator Cantwell, I want
everybody to know I am with you all the way on this proposition
that States ought to be given the opportunity to be able to do
more to hold down health-care costs. And I think you said it
very well.
Senator Cantwell. Thank you.
The Chairman. Senator Cornyn is next.
Senator Cornyn. Well, thank you, Mr. Chairman. We all know
that in an effort to maintain adequate capacity in our
hospitals and doctors' offices, we limited the amount of
elective procedures that were performed to deal with the
potential surge of COVID-19 patients. And as a result, a lot of
health-care screenings, colonoscopies, other life-saving
diagnostics, dropped dramatically.
We know that about a third of adults have not received
recommended screenings for age-associated risks during the
pandemic, and 43 percent of patients have missed routine
preventative health appointments as a consequence of these
precautions.
Fortunately, now that more people are being vaccinated,
hopefully those numbers will improve. But I want to add my
voice to the chorus, I guess, here today of advocating the
enhanced use of telehealth. I tell my friends and constituents
back in Texas there are only two good things that came out of
COVID-19. One is telehealth, and the second is margueritas to
go. Those are the only two good things I can think of.
So let me ask. We are all very familiar with the digital
divide. And this is very true, particularly of big States like
mine, and we are working on that diligently. Senator Manchin
and I have a Digital Divide Act which would provide grants to
Governors to help them work with Internet service providers to
connect underserved areas.
But I want to ask the panel about audio telehealth. It
seems to me that this could be an interim solution to make sure
that low-income earners could get access to a doctor or health-
care advice over the telephone. So maybe starting with Ms. Farb
and Dr. Davis, could you explain how telehealth services
furnished by audio-only communications could increase access to
care, particularly in rural and underserved areas?
Ms. Farb. Sure. I'll start, and then I think Dr. Davis can
speak more fully to this. But what we have observed--and even
talking to some of the provider groups you have spoken with--is
not only the beneficiaries not having access, but providers not
having access is also an issue. And so a lot of providers
initially started off using audio-only telehealth services,
especially for the office visits, the evaluation and management
codes. And that has probably continued throughout the pandemic.
But in the early days, that was definitely a source of
modality that really was working for a number of groups that we
have spoken to.
Senator Cornyn. Dr. Davis?
Dr. Davis. Thanks for that question. I would also echo that
the need for audio-only is essential, both for our under-
represented communities and under-serviced. We realize that
sometimes broadband is just not there, and we will try and try
to connect with patients via video, and the resource is just
not there. The patient is not comfortable with it. They cannot
get their smartphone or device to work, or they just do not
have one. And as we build infrastructure, we should build it in
a way that is mindful of that.
I also want to call out specifically around translation
services for our non-English-speaking patients. And being able
to get that language translation is often easier through an
audio-only visit than it is through an audio-video visit.
Senator Cornyn. So, Dr. Murali, I saw you nodding when I
asked about audio-only telehealth. What is your view?
Dr. Murali. Well, out of the quarter-million or so
encounters that we have in Wisconsin, more than 50 percent of
the visits are by audio only. Unfortunately, even Medicare
Advantage does not consider it for risk evaluation or
adjudication, and that is a bad deal for patients because it
increases disparities. And I think when you think about the
digital divide, as well as racial disparities, we also need to
think about the fact that even white people in rural America
are poor. They basically do not have access to care. And there
is also the question of literacy that needs to increase.
So all of those are disparities that we have to keep in
mind. So, right on.
Senator Cornyn. I have time for one more question. You
know, one of the concerns we have is about security of,
specifically, personal health information. Obviously HIPAA
provides that generally speaking, but as we continue to provide
more telehealth, I am worried about the protection of the
privacy of the doctor/patient relationship.
In closing here, do any of you have any particular
observations or experience about how we can make sure that that
is preserved?
Dr. Murali. Yes. So I think it is important to invest in
the infrastructure for security breaches. What is happening in
Ireland right now with Conti is a good example of a security
breach. And that can be addressed by infrastructure.
And then from the psychiatric care side, patients actually
prefer to do that from home because it gives them the
psychological safety of having that discussion in the comfort
of the home, as opposed to sitting in a public health waiting
room.
So those are all factors that should be factored in, and
that is why payment parity is necessary to get us moving
forward on this.
Senator Cornyn. Thank you very much, Mr. Chairman.
The Chairman. Thank you, Senator Cornyn. And we are with
you on the audio question, particularly if the take-up rate is
as low as Dr. Murali said; it is probably even worse when you
are talking about traditional Medicare. If the take-up rate is
low on MA, think about what it is like on traditional Medicare.
So we are going to follow that up. Thank you.
Our next questioner is Senator Menendez.
Senator Menendez. Thank you, Mr. Chairman.
Dr. Davis and Dr. Murali, in your testimony you both
highlight the importance of audio-only telehealth. Can you tell
the committee a little bit more about why coverage of audio-
only telehealth services is so critical to ensure that we do
not further fall behind on health-care equity?
Dr. Murali. Senator Menendez, I would like to invite you to
visit us in Marshfield. You can go from one location to any of
our 60 locations for 2 hours without having access to the
Internet. And the only thing that works is the old-fashioned
telephone network.
So if we are really trying to address geographic isolation,
that phone call is the most critical piece. In the Hospital at
Home program that we started, we were trying to work those
pieces back in 2016, and we were looking for one bar out of
five to make sure that we could provide some kind of virtual
help.
So it is not just the access to broadband, it is also the
degree to which broadband is available in these rural areas
that causes the disparity. So I hope that answers your
question.
Senator Menendez. Dr. Davis?
Dr. Davis. And I would second everything that Dr. Murali
just said. The extension to rural areas is so important, and
really investment in primary care is helpful in bridging that
digital divide so that patients have timely access to in-person
care and audio-video telehealth.
But the audio-only is really just essential for getting
past some of those barriers. And we do not want to create a
two-tiered system, so we need to make sure that payment is
adequate to support the flexibility and modalities of care.
Senator Menendez. Thank you.
Dr. DeCherrie, building on the previous question, the
COVID-19 pandemic did not create inequity in our health-care
system. Inequity is in fact a hallmark of American health care.
What role can telehealth play in addressing longstanding
health disparities in our health-care system?
Dr. DeCherrie. Yes. I mean, I witnessed this firsthand in
my home-based primary care program where, again, most patients
did not own a cellphone and had no ability to do any video
visits. And we, like Dr. Murali mentioned, did everything by
telephone those first couple of months.
In my Hospital at Home program, we actually provide every
patient with a telehealth kit. And even here in New York City,
one kit that is set up with Verizon does not always work when
they switch to the AT&T one. You know, even here in New York
City we have these issues.
So, to be able to provide care for patients in their homes,
we need to think through these things and make sure we have all
options available.
Senator Menendez. Ms. Farb, data collection has been an
ongoing issue throughout this pandemic. I sent letters to the
administration, as well as the last one, about the need for
better data collection during the pandemic.
I am disappointed that HHS has still not consolidated data
collection into one site with standardized reporting
requirements. What data is needed about the flexibilities
extended during this public health emergency to show the
committee the impact of these flexibilities? And what, if any,
flexibilities should be made permanent?
Ms. Farb. We do not have any recommendations yet on any
flexibilities that should be made permanent. One thing I did
want to point out that might be worth considering as the
committee undertakes some of this work is ensuring that some of
the program requirements between both Medicare and Medicaid--
you know, looking at how well they align and what are some of
the differences. Because I think the providers on the panel
probably agree that having two very different sets of rules
around how telehealth works can make it difficult for them to
operate in that environment where they are dealing with that.
As far as data collection goes, yes, we have made a number
of recommendations during the pandemic around providing better
data, as well as ensuring that the data are contained in a site
that is publicly accessible on cases, hospitalizations, et
cetera.
For flexibilities, I think what we do not have is some of
the information we need about differences between different
telehealth modalities and some of the patient information
demographics that we need and the sites of care so that we can
look at quality and other things that would be important to
measure.
Senator Menendez. Thank you.
Finally, Mr. Chairman, I know we are all committed to
building back a stronger health system, ensuring our Nation is
ready for the next pandemic, and dealing with the inequities in
our system, but if we are going to do that, I think one of the
most effective and informed ways that we can come together on a
nonpartisan basis is to conduct a thorough examination of the
United States' COVID-19 response. What went right? What went
wrong? How can we do it better? That is why we have a
bipartisan, bicameral National Coronavirus Commission Act that
my friend and colleague, Susan Collins, has joined me on. I
appreciate your support as well, Mr. Chairman, as well as
Senator Brown and Senator Kaine. And the House has
Representatives Malinowski and Diaz-Balart on a bipartisan
basis leading an effort. And I hope we can get that, because I
think that would provide us an unvarnished and fair process of
understanding what went right and what went wrong. Thank you.
The Chairman. We will be supporting you. Thank you.
Senator Cardin is next.
Senator Cardin. Well, thank you, Mr. Chairman, and I want
to thank all of our witnesses. And I want to just join the
overwhelming number of our members on lessons learned from
COVID-19 about telehealth. But I just really want to follow up
with Senator Menendez.
It also shows the inequities in our health-care system. And
those communities that do not have the same degree of
infrastructure, health infrastructure, or access to
infrastructure, health care, were the ones who suffered the
most during COVID-19. There is no question about that.
So it means we have to strengthen that. So as we look at
telehealth--which was critically important for mental health--I
hope we go forward with permanent changes in our reimbursement
structures and in the reciprocal regulatory issues among States
so that we can expand telehealth, because I think it gives
timely access to care for so many individuals.
I just really want to underscore the point that Senator
Menendez made about not developing a two-tiered system. It is
very clear to me that, as a practical matter, having audio-only
is better than not having any care. But if we set up a
structure that has a two-tier system, those who have access to
high-speed Internet or have the ability to access providers
that can provide a much more comprehensive telehealth service,
and other communities that do not have that same degree given
only audio, we run the risk of a two-tier system. And if the
reimbursement structure incorporates that, it then becomes also
a two-tier system.
So I guess my question to all of you is, as we look at the
reciprocal regulations, as we look at the reimbursement
structures, as we look at access to broadband, and not just
access to high-speed but the capacity to be able as an
individual person to properly access that--some of our elderly
have difficulty with this--what steps should be our top
priority to make sure that, as we expand telehealth, which we
all agree needs to be done, we do it in a way that does not set
up a two-tier system?
Dr. Berenson. I would be glad to start with----
Senator Cardin. Jessica Farb, do you want to start? Or
whoever wants to start?
Ms. Farb. I think one option that has been suggested,
although it does not sort of completely align with what the
panel has been talking about, is to make sure to cover audio-
only where there is a documented barrier to audio-visual
visits, and look at that for a brief period of time so that
data could be collected to study the quality of care and
determine the comparability to in-person visits.
And as I said earlier, we have heard from providers--and we
have already heard from this panel--that they have had to
resort to audio-only when the patient did not have access. And
as you pointed out, Senator Cardin, just having something is
better than nothing.
So trying to do some kind of targeted study of differences
would be one way to try to make sure that we are giving
comparable care.
Senator Cardin. Dr. Davis?
Dr. Berenson. If I could go next?
Senator Cardin. Sure.
Dr. Berenson. I have not had a chance to say this yet, but
I will take this opportunity. I actually got interested in how
to pay for telehealth after our Professor Ed Wagner at the
University of Washington--who I am sure the chairman and
Senator Cantwell know--proposed his chronic care model. And the
chronic care model included--this was in 2003--it called for
robust use of telephones, before we had video. I see video as
being hyped a little too much here.
In many situations such as chronic care management, you
only need a few minutes with a patient. You have already seen
them, either in person or through a video conference, and you
want to be checking on how they are doing. We have created in
Medicare a chronic care management code, but that is for very
sick people who need really intensive care management.
Most patients with hypertension or diabetes or congestive
heart failure will benefit from a follow-up phone call. And so
my view is that the phone calls are the encounters that take
place for minutes. The video visit is for something longer,
like an annual visit, or for something that really requires 20
or 25 minutes, and where visual contact is necessary.
And that would, I think, help a lot on the equity issue. I
think that phones, audio-only as it is being called, should be
equal. And that was one of my points, that the coding is sort
of arbitrary. So I will pose the question, is the Zoom call
with the video off, is that an audio-only? Or is that a
defective video call?
Senator Cardin. I think I will just underscore Ms. Farb's
point. It would be good to have a study as to how audio works.
Obviously follow-up conversations with health-care providers
are one thing. But to do a diagnostic-type of interview is a
lot of times easier and more effective with video.
Anyway, I look forward to that study, and thank you, Mr.
Chairman; an excellent hearing.
The Chairman. Thank you, Senator Cardin. And I will tell
you, Dr. Berenson, you are spot-on with respect to the history
on chronic care. Senator Hatch and I always conceded that there
would be a significant audio/phone component of it, and that is
what we really envisioned in the first part of the bill.
Okay. Senator Portman, I believe, is next, if he is there.
[Pause.]
The Chairman. Senator Portman, are you out in cyberspace
somewhere?
[No response.]
The Chairman. Senator Brown?
[No response.]
The Chairman. Senator Cassidy, a physician?
[No response.]
The Chairman. Senator Bennet?
[No response.]
The Chairman. Senator Lankford?
[No response.]
The Chairman. I do see Senator Whitehouse on the screen,
and he is not even on our list, but we have no other Senators,
so let's have Senator Whitehouse, who is a very knowledgeable
person on health care.
Senator Whitehouse?
Senator Whitehouse. Thank you, Mr. Chairman. Every once in
a while, you get lucky and can jump the queue. I just wanted to
pass along to the panelists the success that Rhode Island has
had with these waivers during the COVID pandemic.
We have made very good use of the Hospitals Without Walls
program, and I would love to see that continued. We kind of
broke the back of opposition to telehealth generally, and I do
not think there is really any going back on that. It has been
particularly welcome in the behavioral health, mental health,
addiction area, where practitioners report to me not only
better compliance with showing up and participating, but also
better substantive content.
It is hard for them to quantify that, but it is a repeated
theme that there is something about being able to talk from
your own home, from a comfortable place, rather than having to
drive across town and fill out the clipboard and sit in
somebody else's office. It just seems better.
And the medication-assisted treatment element, and allowing
access to buprenorphine, for instance, with telehealth, has
been a godsend for that population.
And the last thing I will mention is that I have been
working for a long time to try to get CMMI to sign off on a
bunch of waivers to deal with people who are nearing the end of
life, for whom a lot of waivers make a lot of sense. It does
not make any sense to fuss too much on how home-bound somebody
is at that stage of their life. Home health services, waivers
that we have seen through COVID, are very helpful.
Respite care is not ``respite'' if you have to stuff granny
in the hospital and not get help to come to her in the house.
And the whole 3-day/2-night rule is ridiculous for those
patients. And those waivers, I hope we can extend.
I would ask Director Farb, with respect to the homebound
and home health service and 3-day/2-night waivers, has GAO seen
any evidence of heightened utilization as a result, heightened
cost?
Ms. Farb. Senator Whitehouse, no, we have not examined that
directly. We also tried to look to see what CMS has been
reporting, and so far they have created an accomplishment
report sort of describing effects of many of the waivers.
They have not included anything thus far in their
reporting, but it is something that we are going to be tracking
going forward, as we start to work on the additional waiver
study that we are planning to do.
Senator Whitehouse. Good. It is particularly important to
me for people nearing the end of their lives, because it just
does not make any sense. It is kind of cruel to the family to
deny them those supports because of some funding requirement
that is not even designed for that population but has terrible
effects on families and their access to care.
Dr. DeCherrie, are you familiar with the Hospitals Without
Walls program? And would you like to comment on the wisdom of
extending that?
Dr. DeCherrie. Yes, and it is specifically the Hospital at
Home portion of that that we made use of during this pandemic.
I want to also go back to one thing that you mentioned earlier
about the comfort of someone in their home. You mentioned it in
the context of behavioral health, but I would broaden that.
When we are in the home--and that could be either in person
for the Hospital at Home, the nurses in person in the home, or
through the video when a provider might be doing a video
visit--seeing someone in their own context, to see what they
are actually eating, might actually have long-term real impacts
in their lives. And so these little snippets of getting into
someone's home have really improved health for people long-
term.
So I just wanted to make sure that that was understood.
Senator Whitehouse. Let me close out with a little brag on
Rhode Island ACOs. We have two--Rhode Island Primary Care
Physicians, which operates an Integra ACO, and Coastal Medical
in Rhode Island--and both of them are absolutely top-performing
ACOs nationally. I mean they are right up in the upper corner
of savings, and quality of outcome, and patient satisfaction.
And part of what they have done is to engage with patients
in their home in order to get better information, and that is
part of what has made it work so well. I will go as far as you
want to go, Dr. DeCherrie, on this. My problem is, I have been
jammed up in CMMI for 10 years trying to get it just for those
patients. So that is our beachhead. But I do think a lot more
can be done, and the ACOs have shown a lot of good results on
that.
So I will yield back, because I think I am probably out of
time, but I really appreciate this conversation. There is a lot
to be done, and if people at CMMI are listening, I think we
gave them these powers for a reason. Let's use them.
The Chairman. Well said.
Senator Brown?
Senator Brown. Thank you, Mr. Chairman. I appreciated the
comments of my friend from Rhode Island, and I know that
Senators Cornyn and Menendez asked about audio health, audio-
only telehealth. So I would like to follow up with a couple of
questions, particularly about folks who live in more urban and
suburban settings who may not have access to video conferencing
or Internet capabilities to access video telehealth.
So my question is starting with Dr. Murali. Speak briefly,
if you would, about the increased reimbursement for audio-only
telemedicine, how it helped you stay connected with hard-to-
reach populations throughout the pandemic, both in underserved
urban areas and underserved rural areas, if you would, Dr.
Murali.
Dr. Murali. Thank you, Senator Brown. So as I said
previously, out of the quarter-million visits that we did at
the Marshfield Clinic Health System, greater than 50 percent of
those visits were done by audio visits. So what it allowed us
to do is manage patients with heart failure. In fact, we had
studies that demonstrated that we were able to save close to
$2.7 million while managing 600 patients. Just imagine the
power of that if you were to take that across the entire
country.
From the standpoint of behavioral health, I have already
made my point about audio, because it gives you pretty much all
of what you need to know from the standpoint of that care. So
there are several benefits, but that is just a snippet of what
audio can do.
Senator Brown. Thank you, Dr. Murali----
Dr. Murali. The other piece is----
Senator Brown. Sorry.
Dr. Murali. The other piece is that it is extremely
difficult to get broadband access in rural Wisconsin. And so,
if you do not provide that support on the audio side, you are
geographically isolating these patients from seeking the care
that they need, and therefore you are not being proactive. And
that will increase your emergency care visits, as well as your
urgent care visits, and overall costs from the standpoint of
care.
Senator Brown. Thank you.
Dr. DeCherrie, I appreciated your comments about nutrition
and what the window into the home can provide.
Dr. Davis, my questions, my next couple of questions are
for you. You recommend Congress act to require Medicare to
cover audio-only evaluation and management services beyond the
public health emergency to ensure equitable access to care.
Talk, if you would, about two questions: how audio-only
telemedicine services could help reduce disparities in access
to care, and how should CMS monitor the impact of telehealth,
including audio-only telehealth, in access inequity?
Dr. Davis. Sure. Thanks, Senator Brown. You know, as a
primary care provider and also working in an Accountable Care
Organization, we have lots of experience with this. And audio-
only care, when used appropriately, is high-quality care. And
so I want to make sure that we note that distinction, that
studies comparing telephone-only visits to telehealth visits
conducted prior to the pandemic found no significant difference
in health outcomes or patients' reported satisfaction.
And so it certainly is an additional tool in the toolbox in
order to be able to provide equitable care for patients,
regardless of whether patients are rural or suburban. I have
provided care for those patients; the docs I work with have
provided care for those patients; and across the board, we have
had challenges when they are restricted to only video services.
And so being able to interact with our elderly patients who
may have trouble connecting and not have a family member close
by who can help, or our non-English speakers who may have
trouble connecting and using translation services, and for
those who do not have access to broadband in a robust way,
audio-only is essential for providing good care for them.
Senator Brown. And CMS can monitor the impact of that?
Dr. Davis. Yes. I mean, I think we have coding and an
ability to do that, paired with patient satisfaction, paired
with care outcomes, the ability to collect data. Now I feel
like, as a physician, my quality is monitored in many different
ways and getting back to health outcomes. And I think it is
important to distinguish that telehealth audio-only and with
video should be differentiated between what happens in the
primary care patient-centered medical home, versus a vendor
that is providing just that service.
And so audio telehealth is provided best when it is part of
the care continuum that a primary care provider is providing.
You have the background and the history on the patient, the
access to their chart, and that long-term trusting
relationship.
Senator Brown. Thank you, Dr. Davis.
I am on my last 30 seconds, Mr. Chairman, and thank you for
your indulgence. I wanted to bring up another issue--no
question, just an issue. Senator Capito and I have proposed,
related to Medicare's hospice respite benefit, the COVID-19
Hospice Respite Care Relief Act of 2020, giving the Secretary
of HHS the authority to allow hospice patients to receive
respite care at home, and for longer periods of time during any
public health emergency, including obviously the one we are in.
It was not able to make a difference for family caregivers over
the past year. So I hope the committee, Mr. Chairman, can
consider ways to strengthen the hospice respite benefit moving
forward.
So thank you, and thanks to the witnesses today for their
insight.
The Chairman. We will follow up with you, Senator Brown,
and Senator Capito. Very important.
Senator Lankford is next.
Senator Lankford. Mr. Chairman, thank you, and thanks to
all of our witnesses and the insight that you are bringing, and
for all your work during the pandemic. There is a great deal of
work that was done and a lot of innovation that happened at
your places to be able to actually take care of people. So
thanks for that level of engagement that you have as we work
our way through this.
There were over 200 flexibilities that were given by CMS
during this time period. Congress is obviously very engaged. My
office was engaged, as well as all the other offices here in
this hearing today, trying to be able to go back and forth on
it. We have talked a lot about telehealth, and I want to
mention some of those things in a moment.
But, Dr. Berenson, I do want to be able to bring up an
issue about the 3-day rule for skilled nursing facilities. When
I called back to touch base with a lot of our hospitals and
facilities and such and ask, of all the flexibilities that are
there, which one really stands out as one that needs to last,
everyone brought up telehealth, but then this 3-day rule for
the skilled nursing facilities came up.
Can you talk about that a little bit?
[Pause.]
Senator Lankford. You are on mute, still.
Dr. Berenson. I apologize for forgetting that I am on mute.
It has been around since the beginning of the program,
basically, because of the concern that Medicare would be turned
into a long-term care program if you did not have a requirement
that skilled nursing was associated with an inpatient
hospitalization.
It is clear that an MA functions very well without the 3-
day rule. There are exceptions for ACOs, and there is sort of
general agreement that it has a perverse incentive, and it
involves a lot of gaming, in fact. I have been involved with a
family member who was kept an extra day just to qualify for the
3-day rule.
So for me, if we can figure out a way to sort of eliminate
it without running into the concern that we have created a
long-term care benefit, I think we should do so. And the more
we sort of move towards risk-taking and capitated type of
arrangements where the organization itself has an incentive not
to abuse the hospitalization, I think we can make good
progress.
But I agree with you completely that it is very
frustrating. It even affects the observation stay rule in
Medicare where beneficiaries do not qualify because they
actually were not on an inpatient stay, they were just in an
observation stay, and therefore they do not get the same access
to skilled nursing. It really is a problem that deserves real
attention.
Senator Lankford. It is a serious issue. I would be
interested in any other practitioners who have had observations
on this 3-day rule.
Dr. Davis. Sure. This is Dr. Davis with AAFP. I would like
to second that AAFP would be in favor of reducing that. And
just to share an example from a patient that I had, a patient
that I was actually doing home visits on, which is rare, but we
still do home visits. And we could see in his home that he
needed a higher level of care. He did not need to go to the
emergency room or hospital. He just needed to be at a skilled
nursing facility to receive some rehab. But in order to get him
there, he had to go to the hospital.
He developed an infection in the hospital, which lengthened
his length of stay and raised his Medicare costs. He eventually
did end up in the nursing home, but the relationship that I had
with that patient--I knew his history. I knew what the
appropriate next level of care was, and it just created
barriers and increased costs that were unnecessary.
Dr. Murali. Senator Lankford, at Marshfield in 2014 we
started our process for creating comfort and recovery suites,
got skilled nursing facility bed licenses, and did all of our
orthopedic surgery, our gall bladder surgery, our gynecological
surgery, thyroid surgeries, and kept them in the SNF a little
longer than 24 hours, and then we could send them home.
Phenomenal cost savings that can be achieved on the commercial
side as well as in Medicare Advantage, which we have shown in
our data. And so I think it is an archaic rule that needs to be
looked at, because its costs are wastefully spent.
The other piece is in the Hospital at Home. When somebody
comes into the ER, you wind up putting them in an observation
bed from the standpoint of 24 hours or whatever duration of
time. If you have the skilled nursing facility option
available, if somebody comes in the middle of the night and
cannot go back home, you prop them up in the skilled nursing
facility bed for 12 hours and then make arrangements for
Hospital at Home care at home.
So that is what we do in the rural environment. Because,
when you have the little old lady who is 84 years old come into
the ER at midnight, you cannot possibly arrange for oxygen. It
is easier to deliver pizza in Manhattan at midnight than it is
to get oxygen delivered to a home at midnight.
So I think for all of those reasons, thinking about skilled
nursing facilities differently and creatively is important on a
risk basis model. So I will rest there.
Senator Lankford. All right; thank you.
Mr. Chairman, thank you very much.
The Chairman. Thank you very much.
And, Doctor, you really highlighted the importance of care
over some other things people are thinking about sometimes.
Senator Casey?
Senator Casey. Mr. Chairman, thanks very much for having
this hearing. It is critically important, the number of issues
that we are learning so much about in the last more than a year
now.
I will have a question for Dr. DeCherrie and Dr. Davis. The
question for Dr. Davis will be about mental health for children
and teens. But I wanted to ask you, Dr. DeCherrie, about the
PACE program and the expansion of it.
We are learning so much and exploring today innovative
models of care. I think if there is one thing we have learned
over the course of the pandemic, it is the importance of
services that allow seniors and people with disabilities to
remain in their homes, in their communities, as we have heard
over and over again today.
And that is of course the setting that they would prefer.
They prefer to get care in the home, or in the community. And
like the Hospital at Home model, which provides hospital-level
care for people with acute illnesses, the PACE program, or the
so-called Program of All-Inclusive Care for the Elderly--we
refer to it in Pennsylvania by a different acronym, the LIFE
program--is similarly a way that seniors and people with
disabilities can receive wraparound care while remaining at
home.
So I think we have to take the lessons we learned in the
last year to improve and expand upon services like PACE to
ensure that seniors and people with disabilities have access to
the supports that they require.
I have introduced the PACE Plus Act just last month. This
would provide funding for existing PACE programs to service
more people. And it would allow these specialized programs to
expand into areas that do not currently offer PACE as a long-
term care option.
So, Doctor, I would ask for your perspective on what is the
value of expanding programs like PACE that provide these
wraparound services for seniors and people with disabilities?
Dr. DeCherrie. Thank you for that excellent question. I
have not worked at a PACE program since my residency. I was
fortunate enough to get that opportunity to work at a PACE
program for an entire year during my residency, and so I have
familiarity with the model. But it is very much like home-based
primary care, which I do every day. And so I do believe that
expanding access for home-based programs, Hospital at Home,
Home Based Primary Care, and PACE, is very important.
We have seen here in the pandemic that patients absolutely
want that type of care, and we should act to expand it.
Senator Casey. Doctor, I appreciate that.
I want to ask a question for Dr. Davis, as I mentioned
earlier, about children. We know that if there was one problem
that was terribly, terribly exacerbated by the pandemic, it was
the crisis in mental health, especially for children and teens.
Some of the most horrific stories and some of the numbers
that are so horrific, I think will stay with us a long time. We
are told, for example, of a 24-percent increase in emergency
room visits for mental health crises among children ages 5 to
11, increased wait times to access inpatient mental health
treatment, and so much else. And as we recover from the
pandemic and the restrictions are lifted, children with mental
and behavioral health needs, of course, are not going to be
going away.
We have to make sure that we have programs in place and
strategies to make sure we have the appropriate care for them.
We need to make sure that they have the appropriate treatment
in the appropriate setting at the appropriate time.
So, Dr. Davis, are there ways and existing tools or options
in both Medicaid and CHIP that can be used to address mental
and behavioral health needs of children and teens?
Dr. Davis. Thank you, Senator Casey. You know, as a mom of
three school-aged sons, this is acutely aware to me, in the
challenges that they have had in virtual schooling and not
being able to connect with their friends. And I see it in my
patients as well.
So, one, the expansion of telehealth for mental health is
crucial for children. One of the biggest barriers as a primary
care physician is just being able to find a therapist, or a
psychologist, or psychiatrist in the area to be able to treat
children. And so being able to expand that treatment network is
really huge.
I think the second is creating parity in payment with
Medicaid, continuing that. And we especially see low
reimbursement for mental health providers who are offering
Medicaid services. And so, if we really are trying to address
that divide, we need to make sure that Medicaid is having
reimbursement for mental health services, especially for
children.
Senator Casey. Doctor, thank you.
Mr. Chairman, thank you.
The Chairman. Thank you, Senator Casey.
Next is Senator Thune.
Senator Thune. Thank you, Mr. Chairman and Ranking Member
Crapo. I think if we can find a bright spot from this pandemic,
the embrace of telehealth across the Nation is certainly one.
For four Congresses, the Senate Telehealth Working Group has
advocated for increased access to telehealth, and working with
this committee, many provisions from past versions of our
group's CONNECT for Health Act have become law. In fact,
CONNECT informed a lot of our discussions on the CARES Act,
which Senator Stabenow already mentioned.
So that bring us to where we are today. And I think the
question is, what have we learned?
Dr. Murali, you represent a health system that utilized
telehealth long before the pandemic, like many of the systems
in South Dakota have. Do you support the CONNECT Act? And which
provisions, in your view, are most important to improve access
for rural and urban patients?
Dr. Murali. First, I thank you for cosponsoring the CONNECT
Act. It is one of the most important acts, especially in the
space of rural health care, particularly the provision to waive
the requirements of geographic restrictions to allow FQHCs and
RHCs to do the work that they need to do. It is one of the
craziest rules.
For instance, you have a physician who can see say 20
patients a day. They are in a rural center as part of an FQHC
or RHC, and they only have four patients to see that day. If
they need to provide that service in some of the remote areas,
they could not do it if not for the Act. So that is a wonderful
piece of what that act has achieved, at least in remote and
rural parts of Wisconsin.
So I hope I have answered your question as to the value of
the CONNECT Act. And I think Sanford, which is in your State,
has some of the same issues, and they are part of the Clinic
Club, and we spent a lot of time trying to see how we can
provide service.
So that is my response.
Senator Thune. In your testimony, you discussed what could
be the, quote, ``new norm'' with telehealth and phone. You
predict that 15 or 16 percent of all appointments per month may
be handled this way moving forward. Could you talk to us a
little bit more about how you came to that conclusion, and if
your data includes both Medicare and commercially insured
patients?
Dr. Murali. As to the last question, our answer is ``yes,''
for both commercial as well as Medicare patients at this point
in time for that calculation.
So let me just make a quick illustration. My wife is a
pediatric neurologist. She is one of three pediatric
neurologists in the 45,000 square miles where we provide care.
If a mother has to bring her child for general epilepsy care,
which is a 30-minute visit, she needs to bundle those kids in
winter gear, in the peak of winter, and travel 2 hours, and
then back 2 hours, for a 30-minute visit. This can be done
through telehealth.
Like that, there are lots of established visits that can be
done through telehealth, once you have had the first physical
visit, and can be done efficiently. Think about the impact of
that to the employer; think of the impact to the mother; the
cost of driving these kids, paying for their lunches, paying
for the gas, and losing 1 day's work. That is happening all
across rural America. So that is the number one point.
You can extend that to E&M visits for dermatology. You can
do that for pretty much all specialties in terms of how you can
manage that care. And that number is about 15 to 16 percent in
our present numbers, and could go up to 20 percent if we are
actually allowed to adopt these services in a creative manner.
And that is confirmed by my colleagues in APG who also do some
of that same work, and further confirmed--when the pandemic
happened, when we shut down all services, 22 percent of all
care, even by physicians who were unwilling to do telephone or
telehealth visits, was the number that we had in our
institution.
So it is a phenomenal step if we can go down that
direction.
Senator Thune. So as Congress continues to discuss which of
these pandemic flexibilities should be made permanent, there
have been discussions about whether increased program integrity
measures are needed. And some have suggested a requirement for
a face-to-face encounter.
Concerning this from a health disparity standpoint, I think
we have to be careful about a one-size-fits-all approach that
could prevent rural patients in particular from taking the
first step to seek care.
So as things stand today, is there any reason that a
clinician could not tell their patient that an in-person visit
is needed, without having a mandate to do that?
Dr. Murali. Yes; so all clinicians will do the right thing
for their patients. If we believe a physical visit is required,
we will do it, because we have signed the Hippocratic Oath and
we want to provide the best care for our patients. And we carry
the burden of their sickness or outcomes.
So I do not think that that is a concern at all. Like I
said in my testimony, I manage a 67-year-old lady for complex
heart failure at a distance of 200 miles, and she came to visit
me once a year for 4 years, and she is well even now 13 years
after the episode. She still sends me a Christmas card. A lot
can be done from the standpoint of how care is provided.
Senator Thune. Good. Thank you, Mr. Chairman.
The Chairman. Senator Carper? Senator Carper, I think you
are out there somewhere?
[No response.]
The Chairman. Okay, we are missing Senator Carper. Let's
see; yes, Senator Daines would be next, and then Senator Warner
and Senator Hassan.
Senator Daines?
Senator Daines. Yes.
The Chairman. All right.
Senator Daines. Thank you, Mr. Chairman. I appreciate it.
Well, I appreciate this hearing today. We are a rural State
in Montana, and we have faced the access challenge to health
care before the pandemic. And so when folks were told to stay
home to prevent the spread of COVID and avoid exposure to the
virus, virtual care became even more important. It was a
lifeline in many cases for Montana patients.
Montanans now are telling me that that test drive of COVID
health-care flexibilities was a success, especially when it
comes to expanded access to telehealth. I believe we need to do
what we can to make expanded access to telehealth permanent for
Montanans and all Americans, especially in rural areas, and not
cut access back once we are in the post-pandemic period.
Back in March of last year, I introduced the Telehealth
Expansion Act to allow American workers and families to access
virtual care without the burden of first meeting their
deductible. My bill was signed into law as part of the CARES
Act, allowing these high-deductible health plans with Health
Savings Accounts to offer cost-free telehealth services. This
ensures patient access to critical care during the pandemic.
Today I am teaming up with my colleague Senator Cortez
Masto, and we are introducing legislation to make this policy
permanent. One of the lessons certainly we learned from the
pandemic is the value of leveraging telehealth to meet rising
demand for health-care services.
Access to virtual care should not solely be considered a
COVID-19 policy. Our legislation, entitled The Telehealth
Expansion Act of 2021, will meaningfully expand access to care
by permanently allowing first-dollar coverage of virtual care
under high-deductible health plans.
My question for Dr. Murali is, practicing in Wisconsin, you
are all too familiar with rural health-care challenges. Could
you speak to the value of reducing barriers to telemedicine,
and specifically the advantage of making this particular policy
permanent?
Dr. Murali. We actually strongly support that policy. I
think you are talking about your first-dollar policy with
respect to high-
deductible health plans, and we believe that that brings
immense value to our communities. And if that is expanded to
behavioral health and other pieces, I think it is a wonderful
thing.
I have discussed this with our health plan CEO, as well as
our folks who are on the ground, and the information I received
from them is, it will be extremely well received from the
standpoint of care, and for providing access to care, which is
critical in rural Wisconsin.
Senator Daines. Thank you, Doctor.
When it comes to accessing telehealth in Montana, our
people in rural communities who lack sufficient broadband
Internet connectivity do not have the option of that face-to-
face virtual care. In some cases, audio telehealth using a
phone is the only option.
In fact, I just met with some of my primary care docs from
Montana this morning. They talked about being forced to audio
telehealth when we sometimes do not have the visual option. And
that is why I worked with my colleagues last year to ensure
payment parity for audio-only telehealth, ensuring that rural
Montanans can access telehealth no matter where they live, and
no matter what access they might have.
Dr. Murali, how important is payment parity when it comes
to ensuring that folks in rural communities can access care?
Dr. Murali. I think, as I have said before, there is a lot
of investment that goes into infrastructure to maintain that
ability to provide telehealth and actually lower the cost of
care. So payment parity is absolutely important from that
standpoint.
Senator Daines. So expanded access to telehealth services,
including physical therapy, has helped our seniors in Montana
and around our country who have been the most vulnerable to the
virus. It also helped demonstrate that therapy needs to be, and
can be met with the use of technology, and that patients can
have improved access in rural areas particularly.
Ms. Farb, what has GAO found when it comes to the value of
expanded telehealth, including physical therapy, during this
pandemic? And is there evidence that using telehealth has
helped remove delays, or perhaps barriers to people accessing
preventive services that have helped to prevent the
deterioration of a patient's condition?
Ms. Farb. So, Senator Daines, we are still working on our
study looking at the effects of telehealth on the beneficiaries
who have received it. I can say from some of the interviews we
conducted with beneficiary advocacy organizations that much of
what you just said in terms of serving as a lifeline, and
serving as a way for beneficiaries to access services that they
otherwise would not have been able to do--we definitely have
heard that.
We will be breaking out some of the utilization both pre-
pandemic and during the pandemic in terms of looking at some of
the data by various demographic characteristics, including
urban areas, as well as particular services, as you mentioned,
such as physical therapy and other services that were
available.
So I do not have any preliminary data yet to share on that,
but that is what we are currently working on in our study that
we are doing right now.
Senator Daines. Thank you, Ms. Farb.
Mr. Chairman, thank you.
The Chairman. Thank you, Senator Daines.
Senator Crapo is going to help us keep this going. So I
believe our next three will be Senator Carper, Senator Warner,
and Senator Hassan. We can get all three in before the vote.
Senator Carper?
Senator Carper. Thanks, Mr. Chairman. I was out during our
last recess, Mr. Chairman and colleagues, I was out in the Bay
Area and visited a number of technology companies. Some of them
were startups, some have been around for a while. One of the
companies I visited--I think her name was, I want to say
Ginger--and they are involved in behavioral science. And they
work with helping people who have behavioral science challenges
in their lives, mental health and so forth, and it is a company
that uses telemedicine to try to bring some help to more people
early on in their illnesses.
So for me it is something in real life, and I saw it for
myself, and it is, I think, another way to get results, and
hopefully better results, for less money in helping people who
are dealing with those kinds of challenges in their lives.
But I very much welcome this hearing today. During the
pandemic, telehealth has been an essential, and is becoming a
more essential, tool in our toolbox to try to make sure that
not just adults, but children receive the care that they need,
while minimizing risk.
And although telehealth in Medicare has been a focus, close
to 40 million children, I am told, are enrolled in Medicaid or
the Children's Health Insurance Program--close to 40 million.
And across our Nation, families experience barriers that
prevent them from accessing routine health services, like a
limited availability of providers, or long lead times for an
appointment.
And for many in Medicaid and the Children's Health
Insurance Program, increased access to telehealth services can
mitigate those barriers to improve the timeliness and
convenience of care delivery, while also improving health-care
outcomes, and do so at reduced cost.
I have a question for Dr. Berenson, if I could. What are
the main policy changes, Dr. Berenson, that we need to ensure
the broader use of telehealth can be continued for children
beyond the pandemic? Dr. Berenson?
Dr. Berenson. Well, I--there is an echo--it tends to be a
Medicare effort, and I am not a CHIP expert, but I think
basically States need to have generous telehealth policies. But
I am not the person who really can tell you precisely what we
should do for children in this area.
Senator Carper. Okay; thank you. Anybody else among the
panelists who would like to take a shot at that, please?
Dr. Davis. This is Dr. Davis. Again, Medicaid payments for
children are really important [much echoing] to ensure they
have access.
Senator Carper. All right; thank you. Anyone else, please?
[No response.]
Senator Carper. All right; let me move to the next
question. This is my follow-up question that deals with
guidance for State Medicaid and CHIP programs. And during the
COVID-19 public health emergency--which we are still struggling
to get out of, but making progress--a wide variety of policy
waivers have been put in place across our country to expand
access to telehealth services, unleashing the power and
potential of telehealth to safely and effectively provide care
to children and to their families.
However, there is a wide variation in telehealth policies
among State Medicaid programs. And as States consider how to
expand coverage of telehealth services, there is limited
guidance or information to aid in their planning.
Moreover, there are limited comprehensive studies
specifically looking at the impact of telehealth on the
Medicaid population, including during national public health
problems.
And if I could, Dr. Davis and Ms. Farb, according to
MACPAC's March 2018 report on telehealth in Medicaid, States
looking to expand telehealth in their Medicaid and CHIP
programs would benefit from additional research and a more
robust understanding of the impact of telehealth.
My question of Dr. Davis and Ms. Farb: do you believe that
further study in this space is still needed? And do you think
the real-world evidence gathered during the pandemic could
provide further insights that support the expansion of
telehealth for our children? Dr. Davis, Ms. Farb, please.
Dr. Davis. Thank you, Senator Carper. There has been a lot
of study already, and I think from MACPAC's work and work that
we have seen, we can start to move forward and recognize the
importance of Medicaid, especially for the benefit of our
children who are participating in the CHIP program and in the
Medicaid program.
Ms. Farb. And I will just add, we are actually studying
telehealth and the Medicaid program as we speak, as well. My
statement today has been based on the ongoing work that we are
doing both in Medicare and Medicaid. So we are looking at the
effects of the use of telehealth during the pandemic and trying
to garner some lessons learned.
As far as guidance from CMS, we understand that they are
planning to issue some additional guidance to States, but some
of that guidance is still in review within the agency. So, in
our ongoing work, we have talked to CMS about what plans they
have to provide that guidance, especially in looking at sort of
program integrity types of things that they need to be aware
of.
But we are doing work. So it is hard for me to say we
should not study it more, I think, given where I sit at GAO,
but I definitely think there is a lot of evidence out there, as
Dr. Davis pointed out.
The Chairman. There is an important vote, and let us get
Senator Warner and Senator Hassan in before we have to run. And
we are going to keep this going.
Senator Warner?
Senator Warner. Thank you, Mr. Chairman. I will try to make
sure I address the quick timelines.
First, I think we all know that obviously COVID exposed
some of the racial disparities we see in health-care coverage.
I think this committee and others have tried to do a better job
of making sure we get good data on some of those racial
disparities.
One of the things that I have worked with the chairman and
others on is making sure that we encourage States to go ahead
and expand Medicaid, and that we increase our premium payments.
I actually hope on the ACA, I hope we can make some of those
things permanent.
But, Dr. Berenson, do you want to weigh in on this issue of
whether the expansion of Medicaid in States that were not
covered, whether the ACA additional premium payments support
that we put in place in some of the legislation recently will
actually start to help diminish some of the racial disparities
that were exposed by COVID-19?
[Pause.]
Senator Warner. I think you are on mute, Dr. Berenson.
Dr. Berenson. Sorry about that. Again, I am not a Medicaid
expert, but my understanding of the results from Oregon, which
had that study where they sort of randomly selected people into
Medicaid, demonstrated better access when people did get
Medicaid. And I think that the outcomes were a little mixed,
but the study was not conducted long enough to be able to
demonstrate those.
So I basically agree with the premise of your question
there. There need to be incentives for all States without
Medicaid as an expansion.
Senator Warner. Well, thank you. I think I am going to,
obviously, continue working with the chairman and others on
this.
Let me move to a slightly more probing question for Dr.
Davis and Ms. Farb. You know--and let me preface this question
with, obviously we all realize the opioid abuse and substance
abuse issues are a huge challenge, and this committee again,
with folks like my friend Senator Portman, has been grappling
with that for some time.
On the other hand, I have been trying to get the DEA,
literally for close to 10 years, to allow for physicians to--
and frankly, for the DEA to promulgate rulemakings, which they
were supposed to have done by law, to allow certain physicians
to prescribe certain controlled substances via telehealth. We
have made sure to make this happen in legislation called The
SUPPORT Act last Congress. But the DEA continues to refuse to
take up this rulemaking.
I have reached out to them multiple times on this. I do
believe that the Biden administration is trying to work in good
faith, but with the importance of telehealth being accentuated
by COVID, by this panel, Dr. Davis, I would like to hear from
you, given your experience with patient care, and, Ms. Farb,
maybe GAO may have taken a look this issue as well.
I know we want to make sure there is not abuse,
particularly when it comes to controlled substances, but I do
think we have been waiting 10 years. It is in the law. And
while we need to put appropriate protections in place, we need
to let physicians have these tools.
So, Dr. Davis and Ms. Farb, will you comment on that
subject?
Dr. Davis. Sure. Thank you, Senator Warner.
I do also want to go back to your previous question. As
Vice Chair of MACPAC, I do want to echo that we have already
started to see a reduction in health disparities in those
States that have expanded Medicaid. And we need to continue to
study that and look and see those drivers.
In terms of substance abuse treatment, as a buprenorphine
provider myself, I have seen the benefit, especially throughout
COVID-19, of being able to conduct those services by
telehealth. Being able to prescribe remotely and
electronically, being able to keep patients from relapsing, has
been essential, especially with all of the stresses that have
happened over the last year.
And so I encourage continuation of, as well as passing new
legislation getting us further along to be able to conduct that
service electronically, both in terms of prescription and in
terms of the visit by telehealth or audio.
Senator Warner. Thank you, Doctor. I agree with you. And
again, DEA, on some of this rulemaking, has just been dragging
its feet.
Ms. Farb, do you want to make a comment?
Ms. Farb. Sure. So GAO does have prior work kind of looking
at some of the barriers to medication-assisted treatment for
opioid use disorder. And we have noted that some of what you
are discussing did occur, in terms of prior authorization
requirements, and restrictions on distribution, and just the
Federal waiver that providers need to prescribe or administer
some of the prescriptions that are needed.
So we did not make any recommendations out of that study,
but we definitely did enumerate all the barriers that are being
faced by providers and various health-care programs.
Senator Warner. Well, I hope we can keep working on this. I
think I will turn it back now to, I guess, Senator Crapo, you
are filling in. Thank you.
The Chairman. Thank you, Senator Warner. This is great.
We are--let's see. It is Senator Hassan there, and Senator
Crapo is back, and I will run and vote and come right back. But
Senator Hassan is up now, Senator Crapo.
Senator Hassan. Well, thank you so much, Chairman Wyden and
Ranking Member Crapo, for this hearing. I want to echo what
Senator Warner was just talking about when it comes to
facilitating medication-assisted treatment, and I look forward
to working with colleagues on both sides of the aisle on that.
And before I get to my questions, I also want to reinforce
my colleagues' calls to continue to expand telehealth access,
including in rural communities. The dramatic expansion in
telehealth services during the pandemic has benefited a large
number of patients, including in my home State of New
Hampshire.
I want to turn now to Dr. Davis. The news that there could
be an authorized COVID-19 vaccine for all children by the end
of this year is truly an exciting development for many
families. However, I am very concerned that over the past year
routine child wellness visits and pediatric vaccinations have
declined significantly, particularly for children enrolled in
Medicaid and the Children's Health Insurance Program.
Telehealth expansions have improved access to many routine
primary care services, but unfortunately you cannot get a
vaccination over Zoom.
So, Dr. Davis, as telehealth becomes more integrated into
primary care services, how can we ensure that children will
continue to attend routine, in-person wellness visits that help
ensure that children are receiving lifesaving vaccinations, as
well as critical developmental and physical screenings? And how
do we get children who missed their routine vaccinations over
the past year back on track?
Dr. Davis. Thank you, Senator Hassan. The answer is, you
know it is very important, and I do worry about the kids who
are delayed in their vaccines because of hesitancy in going
into care. But I have seen the resilience of our family
physicians and pediatricians, especially at our community
health centers, in getting creative and innovative and making
sure that kids are getting their vaccines in terms of drive-up
clinics, parking lot operations, and being able to make sure
that they are getting them.
I am not worried that telehealth is going to replace what
we do as physicians. And in combination with the primary care
relationship, doctors are going to make sure that their kids
are coming in for their vaccines, and I have really seen them
being stalwarts and champions in continuing that.
I think that there are other things that we can do to
encourage vaccines, requirements that happen at schools, you
know, to make sure that kids are getting the vaccines. But I am
not worried that--there is a lot of catch-up to do, but I think
that we can get there.
Senator Hassan. Thank you so much for that.
To Dr. DeCherrie, I want to talk with you a little bit
about home and community-based services. The American Rescue
Plan increases Federal funding for home and community-based
Medicaid services. However, while this initial investment is an
important step, we need to do more to ensure that older adults
and individuals with disabilities have access to this care.
Many of us on the committee are continuing to work towards
some long-term solutions here, but what changes do you believe
are needed to expand the home health workforce and improve the
quality and accessibility of home and community-based services?
Dr. DeCherrie. Thank you so much for this question. We
cannot--you know, in geriatrics we cannot do what we do without
the family support, without the aides who are there to care for
our patients. Our work is like one-tenth of the daily work that
these people do to help support our patients. And it is so
important that we are able to support the caregivers.
So I agree with you that we need to think about how to
expand that workforce, how to make sure that patients are able
to get quality care through that workforce. And it could be
through family caregivers or paid caregivers.
Senator Hassan. Thank you. Is it fair to say that families
who can get some support and relief from home care health
aides, for instance, often are able to support their loved ones
better at home than when they try to do it all by themselves?
Dr. DeCherrie. Yes. Definitely.
Senator Hassan. Thank you.
Dr. Davis, one more question. The COVID-19 pandemic has
demonstrated the value of providing critical vaccines to
vulnerable populations at no cost. Women covered through
Medicaid are less likely to receive the tetanus and influenza
vaccines during pregnancy than those who have commercial
insurance.
Earlier this year, Senator Cassidy and I reintroduced the
Maternal Immunization Coverage Act to help address this
disparity. This is a bipartisan bill that would ensure that
State Medicaid programs cover ACIP-recommended vaccines for
pregnant beneficiaries at no cost.
Dr. Davis, how should we parlay the lessons that we have
learned from this public health emergency about the benefits of
providing vaccines to vulnerable populations at no cost in
order to ensure that all Americans have access to life-saving
vaccinations?
Dr. Davis. You know, we have really learned from the COVID-
19 vaccination that when you are able to offer it without cost,
that removes a significant barrier. And the AAFP agrees that we
should expand access to all ACIP-recommended vaccines at no
cost through Medicare and Medicaid, CHIP, and all other
commercial insurers.
Senator Hassan. Thank you very much.
And thank you, Senator Crapo.
Senator Crapo [presiding]. Thank you.
And Senator Young is next on the list, but I do not see him
on the screen. Is Senator Young with us?
[No response.]
Senator Crapo. All right, Senator Warren, I see you. Go
ahead, please.
Senator Warren. Thank you, Mr. Chairman.
So when coronavirus hit, patients still needed access to
basic health services like primary care and mental health
visits, but COVID made it harder for patients to get the care
that they needed. On top of the usual struggles like taking off
time from work, people now had to keep themselves safe from
infection. Services that were already difficult to manage even
in the best of times became much harder to get.
Take hearing loss, which affects 48 million Americans. On
average, it takes 7 years for patients to seek treatment for
hearing issues, even when we are not in a global pandemic. And
COVID-19 only added additional burdens.
So that is a key reason why the Centers for Medicare and
Medicaid Services made it easier for providers like
audiologists to offer hearing services remotely during the
pandemic.
Ms. Farb, what steps has CMS taken to make it easier for
patients to access care from audiologists through telehealth
during this pandemic?
Ms. Farb. Well, Senator, as you pointed out, CMS initially
expanded the types of providers that could furnish telehealth
services to include all those eligible to bill, which included
physical therapists and speech language pathologists, as well
as audiologists.
At the beginning, they were able to bill for certain codes
starting in March of 2020, and some of those codes are not
typically the codes that are billed by audiologists, but CMS
added additional codes to the list at the end of March of 2021.
And that coverage is effective retroactively back to January of
2021. The list included services such as tone decay tests and
assessments of tinnitis. And so that expanded sort of the
ability for audiologists to provide those services.
We spoke with ASHA, the association that covers speech
language pathologists as well as audiologists, and they were
very supportive of those changes.
Senator Warren. So, Ms. Farb, if I can just summarize, CMS
considered all the audiologists to be important enough to
include in the response to the pandemic, but audiologists
usually are not treated equally in the Medicare program.
Despite their years of schooling and training, audiologists are
considered, quote, ``suppliers'' not, quote, ``practitioners''
in the program. And outdated Medicare rules require patients to
get their doctor's permission to see an audiologist rather than
letting patients make the decisions they need to improve their
hearing.
So let me ask, Dr. DeCherrie, why is it so important that
seniors with hearing loss can access the providers they need,
including audiologists, without bureaucratic limitations that
make it harder for them to get care?
Dr. DeCherrie. Thank you for that question. Yes, I mean
being able to hear is so important, especially for our elderly
patients. I mean, there have been numerous studies that have
shown reduced risk of falls, improved mood, improved memory,
all by being able to hear better. I mean, we see this every day
on home visits now when we are trying to do something by video.
If they cannot hear, just turning up the volume does not work.
So these patients really do need their hearing assessed,
and then potentially a hearing aid or whatever is needed.
Senator Warren. In other words, audiologists provide
critical services to people with hearing loss. That is why I am
joining Senator Paul and Senator Grassley in reintroducing the
Medicare Audiologist Access and Services Act. This is a bill
that would expand seniors' access to hearing services by
reclassifying audiologists as practitioners in the Medicare
program. And that will allow them to bill for services without
a physician referral, and to provide patients with both the
diagnostic and treatment services that are within an
audiologist's scope of practice.
It seems to me that the COVID-19 pandemic has forced us all
to reconsider bureaucratic limitations to health care,
including hearing care. So I believe that the Senate should
prioritize the passage of our bill to help seniors get the care
that they need.
Thank you, Mr. Chairman.
Senator Crapo. Thank you, Senator Warren.
And I see Senator Cortez Masto, so, Senator, you may
proceed.
Senator Cortez Masto. Senator Crapo, thank you. And thank
you to the panelists. This has been a very, very informative
conversation. And let me echo and agree with my colleagues. I
think making telehealth permanent is so important for the
reasons that we are discussing today. But I also recognize and
really appreciate the challenges that we still need to
understand, the data. We need to capture the accurate data, the
diversity in the data. We need to make sure we put up guard
rails but still to study it. But for the many reasons we have
talked about, I think it is so important.
I have seen the benefits in Nevada alone, but here is one
thing--and we have talked about this already this morning--
which is audio-only diagnostic information. I absolutely have
concerns that we are not allowing the diagnostic information
for audio-only to occur. This is information that I have been
talking to CMS about.
And so, because I think it is so important that we address
this--and clearly my colleagues feel the same way after
listening to the conversation this morning--Senator Tim Scott
and I introduced a bill, the Ensuring Parity in Medicare
Advantage for Audio-Only Telehealth Act.
It would really require CMS to include diagnosis obtained
via an audio-only telehealth visit in a Medicare Advantage risk
adjustment program. And it is so important for the very reasons
that you talked about.
So I want to get that out there. But let me also--Dr.
Davis, let me ask you this. In your experience, are patients
with high-
deductible health plans more or less likely to seek regular
treatment?
Dr. Davis. Pre-public health emergency, I certainly saw
patients who were hesitant to come in because of the high-
deductible health plans, and just not being able to afford it.
The AAFP supported temporarily waiving the deductible for
telehealth visits, because the investment was necessary for
providers to really be able to make that investment in
telehealth. We are concerned, though, with the permanent waiver
of that and the possibility of creating a two-tiered system
where low-income enrollees are only able to afford virtual
care.
And so we recommend that the committee pass legislation to
allow high-deductible health-care plans to waive the deductible
for primary care and mental health services, both in person and
telehealth, to promote timely access to high-value care and
preserve patients' freedom to choose the most appropriate
modality of care.
Senator Cortez Masto. Yes, I could not agree more. And I
thank you for that.
And so let me jump to Ms. Farb. There was conversation
about identifying the quality of telehealth health services.
And I know you were asked what were the metrics that GAO was
looking at. And you said that GAO had not defined yet the
metrics for identifying the quality of telehealth services.
Can you give me a timeline? Is this something that is a
priority now for GAO? And is this something you will be further
looking into, or GAO will, in identifying those metrics?
Ms. Farb. Yes, Senator. So, as far as identifying and
creating the metrics, that is a role that GAO does not play. We
rely on the institutions that are sort of responsible and
contracted with HHS, such as the National Quality Forum, to
develop consensus-based quality metrics.
And as I mentioned earlier, both the NCQA, another quality
organization, and NQF have been working this past year to sort
of adapt some of the metrics and frameworks that they use to
incorporate telehealth, the concept of telehealth, and focusing
it on things that are clinically meaningful for patients and
providers to measure quality.
So that is sort of what we are waiting on: to see what
these other institutions are going to do in terms of how they
are going to define quality. There are ways to compare
particular end points and outcomes where you could compare
telehealth to in-person care. But that is still a ways away for
us in terms of our work that we are doing right now.
Senator Cortez Masto. Well, thank you. And so then, let me
jump to Dr. DeCherrie, because I think it is important. In your
testimony you really talked about the acute Hospital at Home
waivers, and particularly the front-end costs of getting things
started, whether it is telehealth, acute Hospital at Home
waivers, whatever is needed--that the hospitals were not making
some of these investments long-term because they were not sure
if the waivers would become permanent.
And I guess my question to you is, what is it that you need
from us on a Federal level, or you would think that the
hospitals need, to really be thinking long-term that we want to
move in this direction, short of passing legislation?
Dr. DeCherrie. Yes, well, the Hospital at Home waiver came
about last November. Obviously we do not know exactly when the
public health emergency is going to end, but it is tied to the
public health emergency. Right now, that date is July. And so,
making an investment now for a program that might end in July,
that is a big decision for a hospital.
So making the waiver permanent for another year, or another
2 years, or extending the waiver while things are being
analyzed, I think that that would be one way that would entice
the hospitals to apply for it.
Senator Cortez Masto. Thank you. Thank you again.
Thank you to the panel members.
The Chairman. Thank you, Senator Crapo, for filling in. It
has gotten to be a tradition. We juggle all of this.
Senator Young, I believe, is next. We are moving into the
home stretch, colleagues, if members have not gotten a chance
to ask questions. We are putting out the word that we are
almost done.
Senator Young?
Senator Young. Thank you, Mr. Chairman.
Well, I welcome our panelists, and I will begin with the
topic of telehealth. Even prior to the pandemic, I heard from
my constituents in Indiana, particularly those in rural areas,
about the ways in which telehealth can both increase access to
underserved Americans and reduce health-care costs.
Since the start of the public health emergency, the
telehealth flexibilities provided by Congress and the
Department of Health and Human Services have been a lifeline
for vulnerable seniors. I have seen it up close and personal.
It is amazing how we have been able to leverage telehealth to
provide vital services, to our seniors in particular.
But others have taken advantage of this as well to access
all manner of care from the safety of their own homes.
Currently, authorizations are included in the CARES Act to
create additional flexibility for patients and providers using
telehealth that only extend through the pandemic.
So I will ask some questions of Dr. Murali. The Federal
Government has relaxed, waived, or changed many regulations to
extend access to telehealth during COVID-19. What regulatory
flexibilities are key to providing telehealth today and should
be made permanent after COVID-19?
Dr. Murali. So I personally think that all the telehealth
waivers that came in during the pandemic need to be extended.
The particular focus on behavioral health is something that you
have been a strong proponent of, and looking at what is
happening in the rural geography. And I heard a story of a 63-
year-old farmer who had to sell all his cows and would not come
in to our institution for psychiatric care if telehealth was
not available. So it is fundamentally important to extend that.
In terms of the acute care without walls, that is something
that we are all invested in, and we know it works very well.
The outcomes from the standpoint of fall prevention, the
outcomes from the standpoint of reducing infections, length of
stay, cost of care, safety, patient satisfaction, patient
acceptance rates, are all phenomenal and off the charts. And
that is something that should be extended beyond the pandemic.
So those are two things.
And then in terms of the geographic site requirements, I
think that that also has to be remote because the geographic
site requirements restrict care. So it does not make sense that
a Medicare Advantage patient can go to an MSA and seek care,
when the Medicare fee-for-service patient cannot go to the same
location and seek care. So it works for one, but it does not
work for the other.
So there are several of these waiver programs that just
need to be disposed and done with. And if there are prospective
payment mechanisms for groups that are taking risk or
capitation, they will figure a way of how to manage the cost of
health care within the budget that they are allocated. But
actually making sure that outcomes and quality are tied to the
provider who is providing care is important. So you want to
take the middle man out of the equation and say, physician
groups, care delivery groups, you are responsible for
delivering on this, and this is the expectation, and they will
telework. Because if you have front-end money to invest on
that, we can provide care creatively, just as we did during the
pandemic.
And so those are things we would support.
Senator Young. So you just provided a very concise and
compelling tutorial on the extension, I think, of these
waivers. I appreciate that.
Just from personal experience--I visited mental health
providers, and they have indicated to me that not only have
they seen an increase in the rate of maintaining appointments,
which increases their efficiencies, but there are certain
individuals, for private reasons, who would prefer to have
their initial consultation, or in some instances all their
consultations, through telehealth, irrespective of the public
health condition at a particular period of time.
The providers are generally very happy with the ability to
provide telehealth. It took a period of time for many of them
to become used to it, but one could envision hybrid services,
here again even for those who have access to or are able to
physically go into the office. But there are just so many
efficiencies, conveniences to the consumer as well as to the
provider, that can be realized here.
And as we talk about bending the cost curve down--actually
we stopped talking about that, because we have utterly failed,
for a number of reasons. Number one, I do not think we have
invested enough in prevention across a number of different
areas. But this is another area where I see just sort of a
fertile opportunity to reduce the actual cost of care, and
therefore reduce the cost of insurance for my constituents and
others.
So it is very important. Thank you for your quick summary.
How much time do I have left, Mr. Chairman? It looks like
30 seconds. And so, for that reason, I will yield back the
balance of my time.
The Chairman. All right. If my colleague, because he is the
last one, has a last question, I do not want to see him
stifled.
Senator Young. I have a vote to cast, but thank you for
your time, Mr. Chairman.
The Chairman. Great. Thank you.
All right, I believe we have heard from all of our members.
I have a brief closing statement, and I always like Senator
Crapo to have a chance to do one as well.
Senator Crapo, would you like to go now?
Senator Crapo. Well, certainly. I will be very brief, Mr.
Chairman. I again thank you for holding this hearing, and I
thank our witnesses. I think we have had a very strong support
for a number of the provisions that you and I, Mr. Chairman,
think we need to address on a permanent basis, particularly
telehealth. I appreciate your helping us confirm what the
issues are, and what the benefits are of making that loop.
And, Mr. Chairman, I turn it back to you.
The Chairman. Okay. Let me say ``thank you'' to all our
witnesses.
Back in the days when I was director of the Gray Panthers,
we dreamed of being able to tap the technology treasure trove
that exists today. It is extraordinary what can be
accomplished. And you all made so many important points.
Certainly this question of equity is fundamental.
I would probably say telemedicine during the pandemic was a
godsend for people who could get access to it. And you all have
made a compelling case that a number of people could not. We
started, I guess, 3 hours ago.
Dr. Davis, you and I were talking about the importance of
making sure that audio-only telehealth is expanded. I also
share your view about the fact that it ought to be accessible
in other languages as well. And you could hear the strong
sentiment from my colleagues of both political parties on that.
Because you know, audio-only can be a lifeline in rural
communities and communities of color where access to telehealth
is limited at best.
We also got a lot of good recommendations. Dr. DeCherrie
made the recommendation to allow permanent waivers for Hospital
at Home. It strikes me as a very good suggestion.
I think several of you made the point that it was time for
Congress to remove geographic site restrictions on telehealth.
I think you, Dr. Davis, and maybe the good souls at GAO
recommended that, but several of you said that there really was
not a substantive case for doing that.
And Dr. Murali, off on the corner of my screen, really
brought it home when he said there is no place like home for
American health care, and probably if Americans could have
heard the news you were giving, you would have gotten a digital
standing ovation for that one.
Now in terms of the challenges, I was really struck when
Dr. Berenson described, several hours ago, the process of
billing and approval bouncing from office to office to office,
leaving both patients and providers in something resembling a
bureaucratic Never-Never Land.
And, Dr. Berenson, you and I have known each other for a
lot of years. We have appreciated your good work. But we would
like to conscript all of you good people into this question of
sorting out the bureaucracy. And Senator Crapo and I have made
this kind of a special priority, because if we are really going
to get it right and squeeze out every bit of value for both
patients and providers, as well as taxpayers, we have to sort
this out. And I will tell you, Dr. Berenson, you brought it
home, because I have been hearing that at home too about
billing and approval and the like. Because this was something
that was put together so quickly--and that is another story,
because then-Chairman Hatch and I thought it would have been
done well before the pandemic, because the CHRONIC Care Act was
passed in 2017. It was stood up very quickly. And when you
painted that picture of billings and approvals, it was almost
like the days when I ran the legal aid office for the elderly
and we just bounced bill after bill after bill, and program
after program from office to office, and eventually they said,
``Well, Ron is going to run it down.''
Well now, Senator Crapo and I are going to do this
together. We are going to sort this bureaucracy challenge out,
and we are going to conscript all of you. But it has been a
terrific panel. In my time in public service, we have had a
chance to talk to a lot of thoughtful people, and we managed to
get everybody together who was thoughtful this morning. So a
big thanks, and with that the Senate Finance Committee is
adjourned--excuse me. One bit of business. For members, all
questions in writing for our guests are due a week from today.
And with that, the Finance Committee is adjourned, and we
thank you all.
[Whereupon, at 12:45 p.m., the hearing was concluded.]
A P P E N D I X
Additional Material Submitted for the Record
----------
Prepared Statement of Robert A. Berenson, M.D.,*
Institute Fellow, Urban Institute
---------------------------------------------------------------------------
* The views expressed are my own and should not be attributed to
the Urban Institute, its trustees, or its funders.
---------------------------------------------------------------------------
Chairman Wyden, Ranking Member Crapo, and members of the committee,
telehealth offers the promise of an important disruptive innovation in
health-care delivery. With broad adoption, the approach could
simultaneously (1) increase access to care for the American public, (2)
raise the quality of that care, and (3) substantially reduce spending
growth. However, decisions on how to pay for expanded use of
telehealth--decisions that need to be made in the near future--will
determine whether that promise is achieved or, alternatively, whether
telehealth adoption will raise spending substantially without
corresponding benefits to patients or society.
I have spent a good part of my professional career, first as a
practicing, general internist in a Washington, DC, group practice; then
as a government official in charge of Medicare payment policy at the
Centers for Medicare and Medicaid Services (CMS) in the Clinton
administration; and for nearly 20 years as a policy researcher at the
Urban Institute, exploring better ways of compensating physicians and
other health professionals. (The views expressed here are my own and
should not be attributed to the Urban Institute, its trustees, or its
funders.) I have focused both on making improvements to the predominant
fee schedule method of paying practitioners and on seeking workable
payment alternatives to fee-for-service. I have also worked on these
payment method issues as vice chair of the Medicare Payment Advisory
Commission, better known as MedPAC, and more recently as an initial
member of the Physician-Focused Payment Model Technical Advisory
Committee, or PTAC, which was established under the Medicare Access and
CHIP Reauthorization Act of 2015, or MACRA.
Payment reform has not been easy or particularly successful. Over
the past 40 years, ``alternative payment models'' (APMs) have come and
gone as clinicians and hospital providers have continued to battle more
for their share of the fee-for-service pie rather than embrace
alternatives that in the long run would enhance their own practice
environment and sense of professionalism, provide economic stability to
practices, and better serve their patients.
Although I am sure that with so many other issues to address
following the COVID-19 pandemic, there is temptation to simply ratify
as permanent what were intended to be temporary policies during this
public health emergency. But Congress needs to recognize that it has a
unique (though maybe short-lived) opportunity to act decisively to move
away from nearly complete dependence on the Medicare Physician Fee
Schedule (MPFS) to more successful, alternative payment approaches that
will open the door to further APM development and adoption. In my view,
making permanent the temporary public health emergency work-arounds
could be a years-long setback to the compelling need for fundamental
provider payment reform for Medicare and, because Medicare typically
establishes the model for other payers, the entire health-care system.
The committee should understand that over the past decade as public
policy has encouraged the development of so-called ``value-based
payment,'' I have been something of a contrarian, pointing out that all
payment methods have strengths and weaknesses, including fee-for-
service. Accordingly, I argue that the legacy payment models (for
physicians, the MPFS) need attention to improve value and to better
complement proposed APMs. I have also argued that many proposed APMs,
although conceptually compelling, are operationally challenged if not
impossible, yet they consume a lot of what economists call
``opportunity costs.'' The result is that I sometimes defend the MPFS
and point to recent improvements that have clearly added to the value
produced by the MPFS (i.e., that improve access and quality at an
acceptable cost). But as I will try to make clear in this testimony,
fee-for-service is a particularly inappropriate payment method for most
telehealth services.
My interest in finding a payment method appropriate for what we are
calling virtual care (i.e., not in person, using a growing range of
communication technologies) is not new. I co-authored a paper in 2003
commenting on the Chronic Care Model, which had been recently developed
by Edward Wagner and colleagues at the University of Washington.\1\
Besides advocating for other innovative approaches to caring for the
increasing number of individuals living with one or more chronic
condition, the Wagner Model called for robust communications with
patients outside of the occasional in-office visit (largely by
telephone at the time). In the paper, I explained why payment for what
should be high-frequency communications should not be through fee
schedules; instead I called for telehealth payment primarily through
per person per month (PPPM) payments. In essence, these would be
telehealth accounts that would provide practices a lump sum that
patients spend down to support virtual care. It is fair to say that
that paper was thoroughly ignored. However, the urgency and interest in
finding an alternative to fee schedule payments for telehealth has now
increased substantially. In this testimony I will expand on that
perspective, laying out the main barriers to fee schedule payment for
telehealth services and suggesting alternatives.
---------------------------------------------------------------------------
\1\ Berenson, RA and Horvath J. ``Confronting the Barriers to
Chronic Care Management in Medicare,'' Health Affairs, 22, Suppl 1
(2003): W3-1--W3-14.
Last year, CMS acted with decisive speed to provide a safety net
for practices and ongoing access for patients during the public health
emergency. CMS (1) introduced flexibility in the requirements for a
qualifying telehealth video visit by permitting the patient's home
(rather than only a medical facility) to be an accepted telehealth
originating site; (2) reversed a long-standing policy, now designating
phone calls as short as 5 minutes as a reimbursable service; (3)
softened security and privacy requirements to permit usage of a broad
range of communication devices and methods; and as I will discuss in
more detail below, (4) raised fees substantially, in the process
ignoring the resource-based relative value scale approach that the
organization has followed since 1992, however imperfectly. The public
health emergency modifications also expanded the range of clinicians,
---------------------------------------------------------------------------
such as physical therapists, eligible to bill telehealth services.
I will identify three major reasons why maintaining most of these
rule flexibilities and increased payments should not be maintained over
the long term. Adele Shartzer (an Urban Institute colleague) and I
outlined these concerns in a recent paper in JAMA Forum.\2\
---------------------------------------------------------------------------
\2\ Robert Berenson and Adele Shartzer, ``The Mismatch of
Telehealth and Fee-for-Service Payment,'' JAMA Health Forum 1, no. 10
(2020): e201183.
---------------------------------------------------------------------------
1. administrative complexity
Fee schedules can function reasonably well when code descriptions
are concise and specific, thereby producing reliable and accurate
coding. For example, there are about 20 different payment codes for
colonoscopies, with each one detailing whether there was a polyp
removed, a biopsy taken, or some other distinctive feature of the
procedure. Colonoscopies represent a clearly defined procedure.
Operationally, it is easy to bill for and receive fee schedule payment
for a colonoscopy. Most procedures, tests, and imagings lend themselves
operationally to payment by fee schedule. But codes for telehealth
services are not concise; indeed, CMS telehealth codes attempt to
delineate the specific communication technology employed, the patient's
location during the communication, which party initiated the service,
the duration of the virtual encounter, the time interval from prior and
subsequent office visits, the frequency of allowed billing for the
service, and other characteristics specific to the particular
telehealth services. Importantly, these coding parameters were
established for payment purposes alone: they do not provide useful
clinical distinctions. Given rapidly evolving technological
capabilities, telehealth codes will quickly become outdated. The tangle
of telehealth codes (now numbering about 250 and counting in the MPFS),
combined with lots of code requirements, will lead to fraud in some
cases, but also more commonly to ``gaming behavior'' by provider
practices. For example, if a phone call needs to last at least 5
minutes to qualify for payment, how will Medicare ferret out 4-minute
calls that were billed (many of which will be as clinically important
as calls lasting a minute longer). Will the agency require use of
timing devices on phones?
Especially if overly generous payments are made through pay parity
for telehealth visits and phone calls, CMS will feel compelled to
impose additional burdensome (and ultimately ineffective) documentation
requirements as these telehealth services proliferate. In short,
following the COVID-19 pandemic, using the standard MPFS to pay for
telehealth services would likely produce a quagmire of confusion,
inadvertent or intentional miscoding, and lots of clinician and patient
complaints about burden and counterproductive rules.
2. billing costs in relation to payment levels
For reasons that practices and hospitals know well but policymakers
rarely acknowledge, fee-for-service payments can generate high billing
costs relative to the payment sought and received. The result is that
it is imprudent to pay for high-frequency, low-payment services by fee
schedule, at least when the low-priced service is the only service
billed rather than one line on a larger claim. A recent study from an
academic health center found that the cost for billing and related
documentation activities for an office visit was $20.49, including 13
minutes of work for various individuals, including clinicians.\3\ There
is no obvious reason why billing and documentation costs for submitting
telehealth services would be much less than that. Indeed, studies have
documented that the costs of billing and related functions make up 10
to 15 percent of operating revenue for practices.\4\ In short, because
a major portion of billing costs are fixed and apply to any service
regardless of the payment level, practices would bear transaction costs
approaching or exceeding the payment they would receive.
---------------------------------------------------------------------------
\3\ Phillip Tseng, Robert S. Kaplan, Barak D. Richman, Mahek A.
Shah, and Kevin A. Schulman, ``Administrative Costs Associated with
Physician Billing and Insurance-Related Activities at an Academic
Health Care System,'' JAMA 319, no. 7 (2018): 691-97.
\4\ Bonnie B. Blanchfield, James L. Heffernan, Bradford Osgood,
Rosemary R. Sheehan, and Gregg S. Meyer, ``Saving Billions of Dollars--
and Physicians' Time--by Streamlining Billing Practices,'' Health
Affairs 29, no. 6 (2010): 1248-54; James G. Kahn, Richard Kronick, Mary
Kreger, and David N. Gans, ``The Cost of Health Insurance
Administration in California: Estimates for Insurers, Physicians, and
Hospitals,'' Health Affairs 24, no. 6 (2005): 1629-39; Julie Ann
Sakowski, James G. Kahn, Richard G. Kronick, Jeffrey M. Newman, and
Harold S. Luft, ``Peering into the Black Box: Billing and Insurance
Activities in a Medical Group,'' Health Affairs 28, no. 4 (2009): w544-
54.
And that is just the billing cost for the first submitted claim
from the practice. A typical claim for a MPFS service is generated by
the practice and sent to a Medicare administrative contractor, which
adjudicates the claim and makes a payment to the practice for
Medicare's portion. The contractor passes the claim to a supplemental
insurer, such as a Medigap carrier, which determines its portion and
informs the practice what it can bill the patient for applicable
beneficiary cost-sharing, at which point the practice generates another
bill for the patient. Even with electronic transfer, this cycle of
claiming and paying requires many manual steps, and the cumulative
---------------------------------------------------------------------------
costs clearly exceed the $20 for the initial claim.
Practices understand this billing reality. CMS adopted a ``virtual
check-in'' code in the 2019 MPFS for short (5- to 10-minute) phone
calls with patients to sort out whether patients needed to come in for
an office visit. The ``correct'' national fee according to usual
relative cost determination was about $15. Although the check-in call
may make good clinical sense in some situations, it failed from a
financial point of view. Not surprisingly, practices rarely billed for
the service, suggesting that practices considered the relatively meager
payment too little to justify the even higher billing costs. The result
was that Medicare allowed less than $200,000 for this code in 2019
(compared with total spending under the MPFS of more than $90 billion.)
Perhaps CMS learned the lesson of payment levels below billing
costs. Within a few weeks of adopting payment for phone calls during
the public health emergency, CMS raised the payment for a 5- to 10-
minute phone call from $15 to a more acceptable $46--the rate for a
level 2 office visit. It made perfect policy sense during the public
health emergency to get money out to financially strapped practices
while also facilitating needed access for beneficiaries to their
practitioners. However, retaining this three-fold increase in the
proper fee (indeed, adopting complete pay parity) presents an
unresolvable dilemma for policymakers. Using standard, relative cost
calculations, the fees for many desirable ``small-ticket'' items would
be too low to justify practices performing them and/or billing for
them. Yet raising the fees to make it financially worthwhile for the
practices would create a major precedent for ignoring relative values
based on relative resources, thereby opening up the fee schedule to
special pleadings from many stakeholders.
Paul Ginsburg (the Vice Chair of MedPAC) and I wrote a paper in
2019 arguing that it is time for the MPFS to move off of strict
adherence to relative costs to determine fees (Berenson and Ginsburg
2019).\5\ This could be accomplished by both (1) altering fee levels
for likely overpriced services by examining service volume changes that
occur in response to initial fee changes, usually fee reductions, and
(2) seeking to accomplish specific policy objectives that could be
supported by fee changes, usually providing increases in underpriced
services, such as to increase the attractiveness and supply of primary
care health professionals. Pay parity for telehealth services in the
face of research that shows substantially lower production costs \6\
should not be adopted as a policy ``one-off'' under the current
pressure to generously expand telehealth. Rather, such parity should be
considered only as part of a more comprehensive approach to modifying
how MPFS fees are determined. Doing otherwise could lead to a policy
free-for-all in which plausible (but self-interested) pleadings are
advanced outside of a disciplined process for weighing the merits of
fee changes. Dr. Ginsburg and I argued that CMS, under the guidance of
a formal Federal Advisory Committee Act--compliant committee, should
have the authority to change fees considering factors other than
relative costs.
---------------------------------------------------------------------------
\5\ Robert A. Berenson and Paul B. Ginsburg, ``Improving the
Medicare Physician Fee Schedule: Make It Part of Value-Based Payment,''
Health Affairs 38, no. 2 (2019): 246-252.
\6\ J. Scott Ashwood, Ateev Mehrotra, David Cowling, and Lori
Uscher-Pines, ``Direct-to-
Consumer Telehealth May Increase Access to Care but Does Not Decrease
Spending,'' Health Affairs 36, no. 3 (2017): 485-491.
---------------------------------------------------------------------------
3. increased volume and spending
I anticipate that patients and their families will love the
alternative of video-based telehealth and much greater use of phone
communications with their practitioners and primary care team members.
Patients face substantial time costs and inconvenience in traditional
travel, waiting rooms, and actual time with the practitioner. I
recently waited 20 minutes after my visit just to check out. The
routine annual wellness visit took about three hours altogether
(admittedly with some delays created by COVID-19 concerns).
I would reiterate that telehealth should be advanced substantially
as a potential game-changer in how care is delivered. My objection lies
in using fee schedule payments as the way to compensate the practices
when alternatives exist that can be adopted and adapted over time.
Without the constraints of consumer time and inconvenience, the
potential for a spending explosion is real, especially if policymakers
resolve the pricing dilemma posed above by paying far above production
costs, as pay parity would do. Furthermore, important work by
researchers at RAND (performed before the COVID-19 pandemic) found that
90 percent of telehealth services were additional services rather than
substitutes for in-person services.\7\
---------------------------------------------------------------------------
\7\ Ashwood et al., ``Direct-to-Consumer Telehealth May Increase
Access to Care but Does Not Decrease Spending.''
Clearly, that has not been the case during the public health
emergency, during which virtual visits became the only way for patients
to receive timely care for a period of time. Nevertheless, used
properly, telehealth very often should be an add-on to often
insufficient in-person care, especially for chronic care management but
also, for example, to clarify whether a tentative diagnosis was
correct, to monitor the effect of adding a medication or changing a
dosage, or for myriad other potential clinical reasons. But those add-
on, virtual services need to be managed by the practice within a
spending constraint to help assure that virtual visits are used
appropriately.
4. alternative payment methods for telehealth
Fee schedule payments should be limited to virtual visits
equivalent to high-level office visits and paid somewhat less than
office visits, in line with relative cost calculations as usual. There
may be compelling reasons to pay fee-for-service for unique provider
types. A challenging issue is whether Medicare should routinely pay for
telehealth vendors that do not have established relationships with
beneficiaries as do many private insurers (but not Medicare). Younger
patients often do not have established relationships such that an
occasional telehealth vendor encounter can make good clinical sense as
a reasonable convenience for patients. But for Medicare beneficiaries,
policy in general should encourage continuous, established
relationships, not occasional telehealth vendor visits supported
through fee-for-service.
Assuming established relationships between clinicians and patients,
telehealth is best paid through PPPM payments to cover the costs of
robust telehealth. Currently, CMS is working to test various forms of
hybrid payment models that would pay partly by fee schedule and partly
by a monthly PPPM, called capitation. The latter approach pays the
practice for patients who are expected to seek care initially from
their chosen or assigned practice (but remain free to seek care
elsewhere). The payment is adjusted for the person's underlying health
risks and represents an average amount for the population of
beneficiaries with similar health risks.
Capitation incentives are fundamentally different from fee-for-
service: the practice receives the funds regardless of how many
services they provide an individual for whom payment is received. The
incentives are reversed--the practice is rewarded for keeping patients
healthy and not in need of health services.And the approach should
reward broad use of telehealth when a virtual visit or phone call
suffices without need for an in-office visit. There would be no billing
costs associated with the telehealth provision, and, indeed,
beneficiary cost-sharing for the capitation portion of the hybrid
payment could be waived altogether under a well-functioning hybrid
model. Initially, maintaining fee schedule payments for some services
(including in-office visits) would help mitigate the expressed concern
about stinting on care (i.e., accepting the PPPM payments but stinting
on actually providing care).
In my view, the compelling need to find an alternative to fee
schedule payments for telehealth calls for expediting the design and
testing of the Center for Medicare and Medicaid Innovation's (CMMI)
model called Primary Care First on a regional and mandatory basis. It
has the potential to be the alternative permanent payment model for
primary care practices while also addressing payment for telehealth
services.
Paying for telehealth for specialists presents a different
challenge, because many specialists do not and should not have
continuous, established relationships. Based on analyzing the use of
telehealth by specialty during the public health emergency, specialty
practices that provide a large amount of telehealth services could
receive lump sum, monthly payments that they control and use for
appropriate application of virtual care. The practices would allocate
the funds for telehealth services as they deem appropriate and not have
to submit claims for each instance. Some accounting would be necessary
to ensure that the telehealth services were actually provided.
5. conclusion
Congress and CMS face an urgent need to adequately fund telehealth
services as an essential component of 21st-century health-care
delivery. However, payment should not simply continue public health
emergency-based flexibilities and generous payments that are important
to allow during the COVID-19 pandemic. It would be a policy mistake not
to use this unique opportunity not only to provide a better payment
method to support virtual health care and other evaluation and
management services, including in-office services, but also to reform
how Medicare Physician Fee Schedule fees are determined in the first
place.
Telehealth should not be supported primarily through fee-for-
service, but rather through hybrid payment methods that should include
capitation for primary care practices and periodic lump sum payments
for specialists. The latter approach has not been tested and will need
immediate development and pilot testing. Continued fee schedule
payments for telehealth should be limited to lengthy, virtual care
encounters and for particular clinicians and other providers that do
not have continuous, established relationships with patients. Policy
should encourage development of established relationships, especially
for the Medicare population, who often have multiple, interacting
chronic conditions.
Admittedly, pursuing these recommendations would be challenging; it
would be easier politically and operationally to simply ratify the PHE
changes going forward, as many stakeholders advocate. That would be a
mistake both because it could produce sustained increases in Medicare
spending for years to come and because of the missed opportunity
presented by telehealth to adopt alternative payment models that would
produce greater value than even improved fee-for-service is able to
produce. True value-based payment, although aspirationally worthy, has
been difficult to accomplish. Telehealth provides a ready opportunity
to make a virtue of necessity. Congress should not allow the
opportunity to pass by.
______
Questions Submitted for the Record to Robert A. Berenson, M.D.
Questions Submitted by Hon. Catherine Cortez Masto
Question. More than a quarter of Medicare beneficiaries lacked
digital access at home in 2018, a figure that is higher among those
with low socioeconomic status, those 85 years or older, and in
communities of color. States have just received unprecedented funding
from the American Rescue Plan to support COVID-19 response and recovery
efforts, including expanding digital infrastructure that communities
need to get up and running again.
What could be done at the State level to leverage the funding
provided in the American Rescue Plan to close the gap in access to
telehealth services?
What more could be done at the Federal level to support
communities?
Answer. The prospects for passage of the American Rescue Plan are
uncertain at this time. I suggest that a large portion of unspent funds
from the Provider Relief Fund of the CARES Act be reprogrammed for the
purpose of building comprehensive, national digital infrastructure. On
June 21, 2021, The Washington Post again documented that many large
non-profit health systems actually improved their financial margins in
2020. In addition, research work that I have helped lead and is now in
the process of journal peer review, when published, will demonstrate
that many health systems have many billions of dollars readily
available as cash and marketable securities and have no need for
additional CARES Act bailout. They have substantial surpluses as days
cash on hand to meet their expenses, even if they had no new revenues
at all, in some cases exceeding 365 days. Building up digital
infrastructure to support telehealth and for a range of other purposes
should take priority over further funding of already flush health
systems.
In the longer term, Federal and State action to increase antitrust
scrutiny of mergers and acquisitions and of anticompetitive behavior
from extant health system oligopolies would reduce health-care spending
increases, again freeing up funds to support access to basic health-
care services in all communities.
Questions Submitted by Hon. Thomas R. Carper
Question. During the pandemic, telehealth has been an essential
tool to get children the care that they need while minimizing risk.
Although telehealth under Medicare has been a focus, close to 40
million children are enrolled in Medicaid.
What are the main policy changes we need to ensure this broader use
of telehealth can continue beyond the pandemic for children?
Answer. I have limited expertise on Medicaid and CHIP issues and,
so, will not respond.
Question. During COVID-19, many States adopted temporary changes to
their telehealth policies, such as expanding the scope of services and
providers able to furnish telehealth, relaxing of licensure
requirements and modifying reimbursement policies. Many States
legislatures have also begun the work to adopt more permanent
telehealth policy changes.
How can the Federal Government best support State Medicaid programs
in their efforts to expand telehealth?
Are there Medicaid supports, incentives, and learnings that Federal
policymakers could provide?
Answer. I have limited expertise on Medicaid and CHIP issues and,
so, will not respond.
Question. COVID-19 has introduced additional stress and trauma for
children and families. Telehealth, and particularly audio-only
telehealth has been a crucial tool to connect children and adolescents
to needed mental health-care services.
How can telehealth be best utilized to meet kids' mental health-
care needs, and can you speak to the use of audio-only telehealth
specifically?
Answer. I will repeat two points I emphasized in my testimony and
in response to questions raised by Senators at the hearing. One, fee-
for-service is a particularly poor payment method for telehealth.
Public and private payers need to promptly move away from total
dependence on fee schedule payments to health professionals in include
a substantial amount of lump sum payments that allow clinicians to
deploy telehealth appropriately, rather than be dependent on incomplete
and changing code-level descriptions of fee schedule services. Two,
audio-only services (which used to be called phone calls) should be
considered an essential, ``must include,'' component of telehealth
services. When patients are well known to their clinicians, video-based
calls in health-care delivery often is needed only for group
conversations or for visual display of clinically-relevant physical
appearance and data transfer. In many situations, the phone can be as
effective and certainly more efficient than a video visit, assuming
appropriate attention to security and confidentiality. At the same
time, fee-for-service payment for audio-only services would be
particularly challenging in the long term and would likely generate
intrusive and ultimately counterproductive compliance requirements. The
solution, again, is moving telehealth payment to lump sum payments,
such as primary care capitation (per person month payments for patients
empaneled with a primary care practice).
Question. As State Medicaid programs look at expanding their use of
telehealth, it is particularly important that vulnerable populations
like children are not negatively impacted. Policies must be looked at
through a health equity lens, considering access to reliable and
affordable broadband services, access to devices that support HIPAA-
compliant telehealth platforms and coverage policies.
How can Medicaid programs work to ensure telehealth policies are
equitable for children and mitigate potential inequities that may
arise?
Answer. Again, given my lack of expertise on Medicaid, I will not
respond to this question.
______
Question Submitted by Hon. Patrick J. Toomey
Question. In your testimony, you cited pre-pandemic research
undertaken by RAND that found 90 percent of telehealth services were
additional services rather than substitutes for other in-person
services and consultations. Moreover, other witnesses' testimony
clearly demonstrates that telehealth utilization in Medicare and
Medicaid has increased over the past year in light of the COVID-19
pandemic.
Given the unsustainable fiscal trajectory of the Medicare program
and the need for payment reforms, what types of tools exist or may be
needed in the Medicare fee-for-service program or Medicare Advantage
program that will ensure appropriate utilization management of
telehealth services?
Answer. In my writing and speaking on Medicare, I do not refer to
the ``Medicare fee-for-service program,'' for the simple reasons that
most of the payment methods in this program are no longer fee-for-
service and calling it fee-for-service supports an inaccurate, negative
caricature of the program. For example, the inpatient prospective
payment system in 1984 abandoned fee-for-service by adopting case rate
payment, known as diagnosis-related groups (DRGs). Nearly two dozen
other countries have now adopted various versions of DRGs, precisely
because this payment method is not fee-for-service. The Medicare
Physician Fee Schedule stands out as true fee-for-service and in need
of reform.
It is true, however, that most Medicare payment methods, remain
volume-based, if not fee-for- service. That is total payment depend on
the number of payment units generated and billed for, whether at the
individual service level or whether bundled into larger payment units.
Many payment policy experts are currently recommending that the
traditional Medicare program adopt a hybrid payment model for primary
care practices, consisting of a hybrid of equal parts fee schedule and
capitation relying on patient empanelment with their preferred primary
care practice. Such a payment system would substantially restrain the
potential explosion of telehealth services; telehealth services would
be covered under the capitation portion of the hybrid paymemt. Limited
exceptions to permit fee schedule payments for telehealth should be
considered, e.g., for other categories of health professionals, such as
physical therapists, or for especially long and unusual telehealth
visits. Nevertheless, I strongly recommend that Medicare generally
should not pay mainstream physician practices for telehealth through
the fee schedule payments.
Medicare Advantage plans are in a position to pioneer the use of
innovative payment methods. They need not--and sometimes do not--adopt
traditional Medicare's payment methods for various reasons.
Unfortunately, MA plans have tended to be followers rather than
innovators, perhaps because of their limited market shares compared to
traditional Medicare's. Ideally, payment reform would occur as a
collaboration between traditional Medicare, Medicaid agencies and MCOs,
and both MA plans and commercial insurers. That kind of collaboration
has not been very successful over the past decade, but needs to be
reinvigorated, with CMS taking the lead.
______
Questions Submitted by Hon. Chuck Grassley
Question. Throughout the public health emergency, the Centers for
Medicare and Medicaid Services (CMS) issued over 200 waivers under
Medicare and approved more than 600 waivers and other flexibilities
under Medicaid. While some of the regulations waived are specifically
for responding to a pandemic, ensuring patient safety, controlling
costs, and maintaining program integrity its clear innovation and
common sense ideas in our health-care system have been stifled too
often by Federal regulations. For example, CMS permanently added
certain new services (including mental health and care planning
services) that it had temporarily added to the approved list of
Medicare telehealth services during the pandemic. Some regulations play
an important role in protecting safety and maintaining program
integrity but others may stifle good ideas.
Is health care too regulated that it's stifling good ideas?
Should executive agencies sunset regulations in the future to
enable more innovation in health care?
Answer. Unfortunately, a primary reason for relative lack of
innovation in health-care results from fee-for-service and other
volume-based payment incentives. Providers with well-established,
profitable revenue streams typically are not eager to consider
disruptive innovation that might undermine these streams. Both
horizontal and vertical integration based around hospitals has resulted
to a significant extent in non-responsive, health systems that dominate
health delivery to the detriment of independent practitioners and
patients. The Nation has needed more and more creative antitrust
enforcement. Although some deride assertive antitrust enforcement as
``over-regulation,'' antitrust serves to preserve competition and
choice, which is where innovation takes place.
Currently, in the face of increasingly non-competitive health
provider markets, policy is needed to actively regulate the ``monopoly
prices'' that health systems demand of commercial insurers. Indeed,
regulated, rather than market- determined, prices have allowed Medicare
Advantage plans to thrive as a choice that 40 percent of Medicare
beneficiaries have exercised. In short, regulating prices now would
allow markets to work better to reward innovation rather than preserve
what economists call ``monopoly rents.'' Regulations can have negative
effects on innovation, but in my opinion are not a major source of the
current high spending, poor quality health system the U.S., regrettably
now exhibits. And, as I emphasized in my testimony and in other
responses here, paying telehealth through fee-for-service would
undoubtedly produce substantially increased, intrusive and
counterproductive regulation to try to protect against the inevitable
fraud and abuse that telehealth would spawn if paid for that way.
Questions Submitted by Hon. John Barrasso
Question. Before coming to the Senate, I had the privilege of
practicing medicine in Wyoming. Rural health care faced challenges
prior to the pandemic. In particular, we know since 2010 more than 135
rural hospitals have closed.
In the Senate, I am proud to help lead the bipartisan Rural Health
Caucus. This group is committed to ensuring patients in rural America
can get access to the care they need.
Can you specifically discuss the changes in Federal health-care
policy that you believe have helped rural providers the most during
this pandemic?
Can you please discuss any specific changes that Congress should
consider to better support rural health-care providers?
Answer. The Affordable Care Act authorized creation of a Workforce
Commission, which was constituted with appointments of commissioners
but never met because of the absence of the requisite appropriation.
Workforce policy is desperately needed to address access to basic
health services for rural populations, which now face a drastic
shortage of health professionals. Medicare Graduate Medical Education
policy needs overhaul to redistribute funds to primary and preventive
care education and to require academic health centers to better educate
and provide ongoing educational support to rural practitioners. The
workforce issues have mostly been ignored over the past decade, partly
because the Workforce Commission has not been able to carry out its
legislated mission.
Telehealth provides a new opportunity to reconfigure workforce
needs for rural communities, once the requisite electronic
infrastructure is deployed, Again, there is need for a dedicated
commission to present a set of comprehensive recommendations for
congressional consideration.
Question. Prior to the pandemic, I introduced bipartisan
legislation with Senator Tina Smith, which among other things, would
allow Rural Health Clinics (RHCs) to provide more telehealth services.
I was pleased that Congress through the CARES Act authorized both
Rural Health Clinics and Federally Qualified Health Centers to furnish
telehealth services to Medicare beneficiaries during the public health
emergency.
Can you discuss the importance of Rural Health Clinics and
Federally Qualified Health Centers continuing to provide telehealth
services after the public health emergency has ended?
Answer. RHCs and FQHCs are crucial for access to basic health
services in rural areas and underserved urban areas. As I emphasized in
my testimony, fee-for-
service is a poor way to compensate for telehealth services, even if
based on costs, as in these two programs. Both RHCs and FQHCs receive
cost-based per visit payments subject to limits relying on rates from
2000 trended forward 20 years. That method will not work to encourage
telehealth services. There has been interest in moving payment for RHCs
and FQHCs away from per visit rates. Telehealth can be a catalyst for
moving to a population-based payment method for these important
centers.
Question. My wife Bobbi and I are passionate about improving access
to mental health services. This pandemic has clearly impacted the
mental, as well as the physical health of our Nation.
For people living in rural America, getting help from a mental
health provider was challenging before the pandemic. This is why
Senator Stabenow and I have long supported professional counselors and
marriage and family therapists participating in Medicare. We believe
that increasing the number of mental health providers able to care for
our Nation's seniors is an important priority.
Please discuss how telehealth has impacted the ability of patients
to receive mental health services during the pandemic.
Can you please identify ways Congress can improve access to mental
health services, including expanding the number of providers that can
participate in Medicare?
Answer. I have no expertise in provision of mental health and other
behavioral health services. However, in interviews with primary care
physicians and other discussions I have participated in, I have heard a
consensus viewpoint expressed that mental health services are
particularly amenable to telehealth interactions with health
professionals, who do not have to reside in the community. An
operational issue that needs ongoing attention is the need to assure
confidentiality and security of the telehealth services. But that is a
soluble problem.
Question. I agree telehealth is transforming the way we are
providing care. However, in Wyoming, most of our providers are part of
smaller hospitals and practices. We need to make sure government
regulation is not making it more difficult for these providers to serve
their patients.
Can you discuss specific ways Congress can reduce the
administrative burden in providing care through telehealth?
Answer. One of the responses to the telehealth imperative for
adoption use during the public health emergency was the relief
expressed by clinicians to the lessened administrative burden that
disappeared because of the regulatory waivers. That said, maintaining
the flexibility waivers and continuing to pay fee-for-service is a
dangerous mix and likely to encourage even more fraud and abuse. To
avoid that outcome I called for prompt adoption of new payment
methods--capitation for primary care physicians, and telehealth-based,
lump sum payments for specialists--as substitutes for fee schedule
payments for telehealth services. Doing so should substantially reduce
administrative burden for providing care through telehealth while also
reducing the likelihood of fraud and abuse. There surely will need to
be accountability for the telehealth services provided when using these
alternative payment methods, but such accountability would likely
require much less burden for practices than what would be required
under standard fee schedule payments.
Question. Wyoming has many passionate advocates supporting both
hospice and palliative care. These folks are committed to ensuring
patients have the highest quality of life and are able stay out of the
hospital and with their families. This is why I help lead the
bipartisan Comprehensive Care Caucus. Our mission is to improve both
palliative and hospice care for patients.
Can you please discuss how telehealth flexibilities have impacted
access to palliative care and how we can continue making progress in
this area?
Answer. I have no knowledge about impact of telehealth
flexibilities on the provision of palliative care.
______
Prepared Statement of Hon. Mike Crapo,
a U.S. Senator From Idaho
Thank you, Mr. Chairman, for holding this important hearing.
Congress and the administration provided certain health-care
flexibilities during the pandemic so that patients could continue to
receive high-quality care. Making permanent changes based on lessons
learned is a top priority.
I have shared my interest with President Biden's nominees for the
key health-care positions who have come before this committee, and I
appreciate their commitment to work with me and this committee.
Republicans and Democrats often disagree on the best way to achieve
shared health-care goals. This hearing, however, highlights an area of
common ground.
In fact, Senator Wyden and I asked the majority and minority staff
to jointly plan this hearing, demonstrating strong bipartisanship.
Acting on legislative changes and using administrative authority, the
Centers for Medicare and Medicaid Services waived over 200 payment
rules during the pandemic in Medicare alone.
Needless to say, there is a lot we can learn.
Today's witnesses will provide insight to guide our efforts in
evaluating these flexibilities. Hearing firsthand about the patient
experience during the pandemic from providers who overcame challenges
to provide care will be invaluable. Understanding how the flexibilities
are used in fee-for-service, Medicare Advantage, and in alternative
payment models will be insightful.
Much of the hearing will focus on care provided during the pandemic
through telehealth. Telehealth has been a lifeline for patients and
providers, especially in the early months of the pandemic. The reliance
on telehealth increased in rural and urban areas alike, allowing
patients to receive remote care from the safety of their home.
Telehealth services have been especially useful for Idahoans.
According to the Idaho Department of Insurance, telemedicine visits
went from an average of about 200 appointments per month to 28,000
telehealth visits in April 2020 alone. To ensure financial stability,
providers have been paid at the same rate as if the service was
furnished in-person. This has facilitated care that otherwise would be
risky or unavailable, and patients have appreciated the convenience. It
has reduced the frequency of missed appointments, and assisted provider
investment in the infrastructure needed for remote care.
This long period of expanded telehealth will help us understand the
impact on quality of care and program costs. It serves as a robust test
project on a scale few could have imagined. The promise of telehealth
is clear, but it is important that we gather evidence on its impact on
access, quality, and cost.
There are approaches to providing care in the most efficient
setting that go beyond telehealth. Some hospitals are using a waiver
that provides flexibility to triage patients who present to the
hospital to see if they can be best cared for in their home.
Whether through telehealth, Hospital at Home, or other innovative
care arrangements, it is important to find ways to get patients care
that best meets their needs, and at the lowest cost possible. Congress
has taken permanent steps to do just that in recent years.
Nephrologists can conduct remote evaluations of patients receiving
home dialysis. Providers can administer certain drugs to vulnerable
patients in their own homes.
Hearing from our provider witnesses helps us to continue down this
path. The Government Accountability Office will supplement what we hear
from our provider experts, offering a perspective on how to track and
evaluate flexibilities in Medicare and Medicaid as we chart the right
course forward. I fully expect we will take what we learn from this
hearing to continue our bipartisan efforts to help providers give
patients the best care possible.
Permanent changes based on lessons learned from the pandemic to
modernize Medicare payment systems lend to the pressing need to address
Medicare's financial struggles. Identifying smart reforms that make
Medicare more efficient will be better for patients and better for
taxpayers. Such changes alone will not put Medicare on a sustainable
path, but they should be part of that broader conversation.
Addressing Medicare solvency should also be a bipartisan issue,
with time best spent determining how to shore up the current system
instead of expanding it to a broader population. Finding the right path
on these priority issues is important to patients and the health
programs in the committee's jurisdiction.
This hearing will help us to capitalize on the bipartisan
opportunity.
Thank you, Mr. Chairman. I yield back.
______
Prepared Statement of Kisha Davis, M.D., MPH, FAAFP, Member, Commission
on Federal and State Policy, American Academy of Family Physicians
Chairman Wyden, Ranking Member Crapo, and members of the committee,
I am Dr. Kisha Davis, a member of the American Academy of Family
Physicians (AAFP) Commission on Federal and State Policy, and I am
honored to be here today representing the 133,500 physician and student
members of the AAFP.
I am a practicing family physician and the vice president of health
equity at Aledade. In addition to seeing patients in Baltimore, MD,
through my role at Aledade, I support physicians in private practices
and community health centers across the country. I have experienced the
impact of the COVID-19 pandemic and resulting Federal policy changes
firsthand as a front-line physician, and I have had the opportunity to
observe them on a broader scale.
Many of the emergency flexibilities that the Centers for Medicare
and Medicaid Services (CMS) made available during the COVID-19 pandemic
have improved patients' access to primary and preventive care,
bolstered the physician workforce in rural and underserved communities,
and alleviated administrative burdens on clinicians, enabling us to
focus on patient care. As Congress considers whether to extend these
flexibilities beyond the public health emergency and how to build upon
recent advances, it is vital that Medicare and Medicaid policy changes
are designed to advance health equity, protect patient safety, and
enable clinicians to provide the right care at the right time.
The AAFP offers the following recommendations.
Adopt telehealth policies that enhance the physician-patient
relationship rather than disrupt it, and incentivize coordinated,
continuous care provided by the medical home.
Adopt payment models that support patients' and clinicians'
ability to choose the most appropriate modality of care and ensure
appropriate payment for care provided.
Permanently remove geographic and originating site
restrictions to ensure that all Medicare beneficiaries can access
telehealth care at home.
Require Medicare to cover audio-only evaluation and management
services beyond the public health emergency to ensure equitable access
to care.
Permanently cover telehealth services provided by Federally
Qualified Health Centers (FQHCs) and rural health clinics and ensure
adequate payment.
Monitor the impact of telehealth on access and equity by
ensuring that data collection and evaluation include race, ethnicity,
gender, language, and other key factors.
Invest in infrastructure to promote digital health equity.
Mandate Medicaid coverage of all Advisory Committee for
Immunization Practices (ACIP)--recommended vaccines for all adults.
Permanently allow physicians to provide direct supervision and
teaching services via telehealth to expand access to primary care
services and increase training opportunities.
Reduce the volume of prior authorization requirements to
decrease unnecessary administrative burden on physicians.
Grant HHS the authority to waive reporting and other
administrative requirements for the Quality Payment and Medicare Shared
Savings programs in future public health emergencies without rulemaking
to enable physicians to focus on patient care during emergencies.
Restore Medicare and Medicaid physician supervision
requirements to safeguard patient safety and maintain access to
appropriate, high-quality care.
Over the last year, family physicians rapidly changed the way they
practice to meet the needs of their patients amid a global pandemic.
Arguably, the most dramatic shift was the unprecedented uptake and
increase of telehealth services. Last spring, out of necessity,
physicians quickly pivoted from providing a majority of care in-person
to caring for their patients virtually to promote social distancing and
infection control. This would not have been possible without the swift
legislative and regulatory action that expanded coverage, increased
payment, and added flexibility for telehealth services.
Prior to COVID-19--due in large part to Medicare restrictions and
inadequate reimbursement--fewer than 15 percent of family physicians
were providing virtual visits to their patients, and during the public
health emergency that number surged to more than 90 percent. Despite
technical challenges on the part of patients and physicians, both
quickly came to realize the value of virtual care. According to a
recent survey of AAFP members, seven in ten family physicians want to
continue offering more virtual visits in the future.
Telehealth benefit expansions must increase access to care and
promote high-quality, comprehensive, continuous care. Telehealth, when
implemented thoughtfully, can improve the quality and comprehensiveness
of patient care and expand access to care for under-resourced
communities and vulnerable populations. As outlined in our Joint
Principles for Telehealth Policy,\1\ in partnership with the American
Academy of Pediatrics and the American College of Physicians, the AAFP
strongly believes that the permanent expansion of telehealth services
should be done in a way that advances care continuity and the patient-
physician relationship. Expanding telehealth services in isolation,
without regard for previous physician-
patient relationship, medical history, or the eventual need for a
follow-up hands-on physical examination, can undermine the basic
principles of the medical home, increase fragmentation of care, and
lead to the patient receiving suboptimal care. In fact, a recent
nationwide survey found that most patients prefer to see their usual
physician through a telehealth visit, feel it is important to have an
established relationship with the clinician providing telehealth
services, and believe it is important for the clinician to have access
to their full medical record.
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\1\ https://www.aafp.org/dam/AAFP/documents/advocacy/health_it/
telehealth/LT-Congress-TelehealthHELP-070120.pdf.
Telehealth can enable timely, first-contact access to care and
supports physicians in maintaining long-term, trusting relationships
with their patients, both of which are central to continuity of care.
Allowing physicians to provide telehealth services from their home
enables them to extend their availability beyond traditional office
hours for patients who, due to work or childcare constraints, are
unable to take time off work for an appointment. This not only advances
equitable access to care but also can prevent unnecessary trips to
urgent care or the emergency room. Telehealth can also be a tool to
help alleviate physician burnout by facilitating better work-life
balance. One example: Some employers allow physicians to be on
``telehealth duty'' in the period leading up to and following their
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maternity leave.
Given these benefits, patients and physicians agree that some
current telehealth flexibilities should continue beyond the public
health emergency.
Congress should permanently remove the section 1834(m) geographic
originating site restrictions to ensure that all Medicare beneficiaries
can access care at home. The COVID-19 pandemic has demonstrated that
enabling physicians to virtually care for their patients at home can
not only reduce patients' and clinicians' risk of exposure and
infection but also increase accessibility for patients who may be
homebound or lack transportation. It can also offer opportunities to
engage distant family members and caregivers. Telehealth visits allow
physicians to get to know their patients in their home and observe
things they normally cannot during an in-office visit. This helps us to
identify environmental factors that may be affecting their health, and
to develop more personalized treatment plans.
Transitional care management (TCM) services are another example of
how permanently eliminating geographic and originating site
requirements could improve utilization of high-value care and
ultimately improve care coordination and patient outcomes. TCM services
are provided after a patient is discharged from a hospital stay, with
the goal of ensuring care continuity once they return home. Prior to
the public health emergency, patients were hesitant to come into the
office after just being discharged from the hospital. Once TCM services
were available to all Medicare patients via telehealth, many more
received TCM services, allowing me as their primary care physician to
check on them, update their medications, schedule follow-up visits with
specialists, and prevent hospital readmissions.
There are many more examples of how telehealth visits can be used
to promote prevention through conducting Medicare Annual Wellness
visits as well as for monitoring and treatment of chronic diseases such
as diabetes and hypertension for patients in their home thereby
increasing accessibility for patients who may be homebound or lack
transportation and create opportunities to engage distant family and
caregivers.
Require Medicare to cover audio-only Evaluation and Management (E/
M) services beyond the public health emergency. Coverage of audio-only
E/M services is vital for ensuring equitable access to telehealth
services for patients who may lack broadband access or be uncomfortable
with video visits. In September, after using telehealth for several
months due to the pandemic, more than 80 percent of family physicians
responded to an AAFP survey indicating they were using phone calls to
provide telehealth services. Together with ongoing reports from
physicians that phone calls are vital to ensuring access for many
patients, this survey data indicate that phone calls are more
accessible for many patients than video visits. This may be
particularly true for Medicare beneficiaries. According to the Pew
Research Center, only about 53 percent of patients over the age of 65
own smartphones, while 91 percent own any type of cell phone. Recent
studies of telehealth utilization by patients with limited English
proficiency show that non-English speakers have used telehealth far
less than English-speakers. Many physicians routinely use telephone
translation services to provide linguistically appropriate care, and
these services can be more seamlessly integrated into telephone visits,
whereas integrating translation services into audio-video platforms can
be costly and complex. Outside of the PHE, Medicare allowed physicians
to bill for brief phone calls as ``virtual check-ins.'' During the PHE
we conducted telephone visits, realizing that we would not get
reimbursed appropriately, but did so because it was the right thing for
our patients. Unfortunately the payment rate for those services does
not adequately reflect the level of time and effort required, and often
the cost to bill the services exceeds that amount.
Payment should support patients' and clinicians' ability to choose
the most appropriate modality of care (i.e., audio-video, audio-only or
in-
person) and ensure appropriate payment for care provided. Some patients
and some cases are better suited to virtual care, and others require
in-person care; some issues can be effectively treated through a phone
call, whereas others require a visual examination. As a physician, I
want telehealth to be a tool in my toolbox, and I want to choose when
and how to deploy it based on my clinical judgment, not based on
whether I will get paid.
Permanently ensure that beneficiaries can access telehealth
services provided by Federally Qualified Health Centers (FQHCs) and
Rural Health Clinics (RHCs). FQHCs and RHCs serve as the primary source
of care for millions of low-income and underserved patients across the
country. In order to promote care continuity and ensure that
beneficiaries have access to affordable, comprehensive care, Medicare
should permanently cover telehealth services provided by these health
centers. Medicare and Medicaid payment methodologies should also be
modified to provide appropriate and timely payment to community health
centers for telehealth services.
In order to make long-term investments in telehealth platforms and
workflow modifications, physician practices need advanced notice of
changing Medicare and Medicaid telehealth policies. While more data
will be needed to make determinations on whether to permanently
continue certain telehealth services, temporary policies should be
avoided for well-established, high-value telehealth services such as E/
M office visits and mental health services.
The AAFP is supportive of broadly expanding access to telehealth
services. However, we recognize that Congress and CMS are concerned
about preventing waste, fraud, and abuse and considering policy options
to reduce those risks. In addition to promoting the use of telehealth
within the medical home, we also recommend relying on existing Medicare
policies to minimize confusion and administrative burden imposed on
physician practices. For example, Medicare defines an established
patient as one that has received professional services from a clinician
in the same practice and of the same medical specialty within the last
3 years. This definition should be repurposed in any new telehealth
policies, instead of creating a new definition for an established
patient that could conflict with current coding guidelines.
While the rapid expansion of telehealth has yielded many benefits
for patients and clinicians, not everyone has benefited equally.
Without sufficient investment and thoughtful policies, telehealth could
actually worsen health disparities. Prior to the COVID-19 pandemic,
evidence suggests that telehealth uptake was higher among patients with
higher levels of education and those with access to employer-sponsored
insurance. Another study found that patients with limited English
proficiency utilized telehealth at one-third the rate of proficient
English speakers. Anecdotes from family physicians suggest that the
same trend may hold true for the past year--that those benefitting most
from telehealth are those who already had better access to care. As the
committee seeks additional studies to inform the direction of permanent
telehealth policies, you should ensure the collection and reporting of
data stratified by race, ethnicity, gender, language, and other key
factors.
One in three households headed by someone over the age of 65 do not
have a computer, and more than half of people over age 65 do not have a
smartphone. Children in low-income households are less likely to have
access to a computer, and 30 percent of black or Hispanic children do
not have a computer, compared to 14 percent of whites. Digital literacy
also varies with age, income, and ethnicity. In order to achieve the
full promise of telehealth, Congress must act to address these
structural barriers to virtual care. The AAFP supports the creation of
a pilot program to fund digital health navigators; development of
digital health literacy programs; and deployment of digital health
tools that provide interpretive services at the point of care, are
available in non-English languages, easily and securely integrate with
third-party applications and include assistive technology. Such a pilot
should include a robust evaluation to demonstrate how the interventions
addressed gaps in care or increased access for underserved populations.
Beyond telehealth, CMS implemented several other flexibilities to
facilitate access to care and prevent the spread of COVID-19. We
recommend making several of these flexibilities permanent, while others
should remain in place only during this and future public health
emergencies.
Congress took several actions to secure access to the COVID-19
vaccine for free for most Medicare, Medicaid, and CHIP beneficiaries.
We recommend that Congress explore further actions to facilitate
affordable, equitable coverage of routine adult immunizations.
Currently, only 43 percent of State Medicaid agencies cover all
recommended adult vaccines, and overall adult utilization remains low.
The AAFP believes \2\ that all public and private insurers should
include as a covered benefit immunizations recommended by the ACIP
without co-payments or deductibles.
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\2\ https://www.aafp.org/about/policies/all/immunizations.html.
CMS should allow physicians to provide direct supervision and
teaching services via synchronous audio/video communication nationwide.
During the public health emergency, CMS allowed this to improve access
to care in areas with physician shortages and prevent the transmission
of COVID-19. The flexibility to provide these services virtually had
clear benefits, as evidenced by CMS's recent decision to permanently
allow virtual teaching and supervision in rural areas. If made
permanent nationwide, it would increase training opportunities in rural
and other underserved communities and improve patients' access to
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comprehensive, continuous care.
A similar permanent policy was finalized for all levels of E/M
office visits provided at a primary care center during the PHE:
Teaching physicians can permanently use video conferencing to supervise
residents providing primary care in rural areas. The AAFP is supportive
of this policy being made permanent, and we believe that, applied
nationwide, it would bolster primary care training opportunities and
improve access to primary care in other underserved areas. The rural
designation may not capture many areas of the country that are
experiencing primary care shortages.
Medicare and Medicaid both waived prior authorization requirements
for durable medical equipment (DME) and other services early on during
the public health emergency. While these requirements have since been
reinstated, Congress should permanently reduce the volume of prior
authorization requirements across Medicare and Medicaid payers. Prior
authorization requirements delay care for patients and contribute to
alarming rates of physician burnout. Commonsense solutions are needed
to preserve and strengthen our physician workforce. For example, prior
authorization should not be required for most DME ordered by a primary
care physician for an established patient, regardless of whether it is
ordered during a telehealth or in-person visit.
Family physicians were relieved when CMS took swift action to delay
and/or waive reporting requirements for the Quality Payment Program,
Medicare Shared Savings Program, and other programs. However, many
practices were frustrated that CMS delayed the implementation of the
extreme and uncontrollable circumstances policy for the 2020
performance year. This policy, along with other waivers, should be
quickly applied in future PHEs so physicians can focus on providing
patient care with minimized administrative tasks without fearing
negative financial repercussions. The AAFP also has urged CMS to update
measure benchmarks used across various programs to account for changes
in utilization of health-care services during the pandemic.
CMS waived requirements for physician supervision, including
requiring certain services to be ordered by a physician, in Medicare,
Medicaid, and the VA system. To safeguard patient safety and maintain
access to appropriate, high-quality care, these waivers and
flexibilities should not be made permanent, because patients are best
served by a physician-led care team. Family physicians are particularly
qualified to lead the health-care team because they possess distinctive
skills, training, expertise and knowledge that allow them to provide
medical care, health maintenance and preventive services for a range of
medical and behavioral health issues. While certain flexibilities
during the PHE addressed the historic nature of the pandemic,
flexibilities to loosen supervision requirements should be restricted
by Congress to ensure continuity of care and high-quality, accessible
health care for all patients.
Thank you for the opportunity to discuss with this committee the
impact of health care regulatory flexibilities made available during
the current public health emergency on family physicians and the AAFP's
recommendations for permanent policy to advance accessible, equitable,
high-quality health care beyond the pandemic.
______
Questions Submitted for the Record to Kisha Davis, M.D., MPH, FAAFP
Questions Submitted by Hon. Thomas R. Carper
Question. During the pandemic, telehealth has been an essential
tool to get children the care that they need while minimizing risk.
Although telehealth under Medicare has been a focus, close to 40
million children are enrolled in Medicaid.
What are the main policy changes we need to ensure this broader use
of telehealth can be continued beyond the pandemic for children?
Answer. Telehealth, when implemented thoughtfully, can improve the
quality and comprehensiveness of patient care and expand access to care
for vulnerable populations, including children enrolled in Medicaid.
Children have unique medical needs and the appropriateness of virtual
care can differ between children and adults and based on the amount of
information that the treating clinician has about the patient. Family
physicians and pediatricians form long-term, trusting relationships
with their patients and parents, which not only enables them to provide
personalized care but also to assess and recommend the optimal mode of
care. Some care such as treatment for mild illness, follow-up care and
behavioral health services may be well-suited for telehealth; whereas
other health needs require hands-on examination or treatment, and
essential preventative services such as immunizations and health
screenings must be done in-person. In most instances children can
benefit from a hybrid of in-person and virtual care, which is optimized
when all care is coordinated through the patient's medical home. The
AAFP joined with the American Academy of Pediatrics to develop these
joint principles \1\ for permanent telehealth policy that support the
medical home. Congress should support coverage and payment models that
enable primary care clinicians to provide virtual care to their
patients and discourage the proliferation of direct-to-consumer,
virtual-only telehealth vendors as a substitute for primary care.
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\1\ https://www.aafp.org/dam/AAFP/documents/advocacy/health_it/
telehealth/LT-Congress-TelehealthHELP-070120.pdf.
The AAFP also encourages Congress to invest in initiatives to
bridge the digital divide including expanding broadband coverage and
subsidizing access, providing lower-income individuals with end devices
(i.e., tablets, laptops, remote monitoring tools) and/or access points
and ensuring that digital health platforms and tools are culturally and
linguistically appropriate and accessible for vision and hearing
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impaired.
Question. During COVID-19, many States adopted temporary changes to
their telehealth policies, such as expanding the scope of services and
providers able to furnish telehealth, relaxing of licensure
requirements and modifying reimbursement policies. Many States
legislatures have also begun the work to adopt more permanent
telehealth policy changes.
How can the Federal Government best support State Medicaid programs
in their efforts to expand telehealth?
Are there Medicaid supports, incentives, and learnings that Federal
policymakers could provide?
Answer. States have adopted a broad range of telehealth
flexibilities during the pandemic, including waiving restrictions on
distant and originating sites, adjusting provider reimbursement rates,
and issuing guidance on the use of telehealth in particular areas
(behavioral health, reproductive health, physical therapy). Most
flexibilities expire with the end of the public health emergency and
coverage of particular services provided via telehealth is inconsistent
across the States. With information and data on the most effective and
beneficial State policies during the pandemic, incentives and guidance
on best policies would be helpful to facilitate information sharing
among States who wish to make changes permanent.
Federal financial support to States is critical in increasing both
provider and patient access to telehealth technologies, starting with
the need for investment in broadband Internet for rural areas across
the country and additional funding for telehealth technologies for
underserved areas and populations. There is a significant digital
divide that is even more visible in the context of telehealth. Adults
in rural areas lack access to broadband Internet and are more likely to
be covered by Medicaid than those in other areas. Expanded broadband
can lead to increased access to telehealth, giving adults in rural
areas the access to care they need, especially those living in health
professional shortage areas.
The AAFP encourages Federal policymakers to provide clear guidance
to States on ways to adopt alternative payment models that provide
sustainable funding for clinicians to incorporate telehealth into the
medical home. The AAFP also encourages CMS and States to provide
guidance and oversight to Medicaid managed care plans to ensure
coverage and payment policies are not inappropriately steering patients
toward one modality of care or limiting their choice of provider.
Question. COVID-19 has introduced additional stress and trauma for
children and families. Telehealth, and particularly audio-only
telehealth has been a crucial tool to connect children and adolescents
to needed mental health-care services.
How can telehealth be best utilized to meet kids' mental health-
care needs, and can you speak to the use of audio-only telehealth
specifically?
Answer. Telehealth has been shown as highly effective mode of
delivering mental health care and can reduce access barriers and
stigma. One model for expanding access to mental health services that
the AAFP supports is the Collaborative Care Model (CCoM) for
integrating behavioral health into primary care, and services provided
virtually could extend the benefits of CCoM.
The AAFP strongly supports extending coverage of audio-only
telehealth services beyond the PHE to ensure that patients in rural
areas and who lack access to broadband or technology devices can access
services.
Question. As State Medicaid programs look at expanding their use of
telehealth, it is particularly important that vulnerable populations
like children are not negatively impacted. Policies must be looked at
through a health equity lens, considering access to reliable and
affordable broadband services, access to devices that support HIPAA-
compliant telehealth platforms and coverage policies.
How can Medicaid programs work to ensure telehealth policies are
equitable for children and mitigate potential inequities that may
arise?
Answer. Prior to the COVID-19 pandemic, evidence suggests that
telehealth uptake was higher among patients with higher levels of
education and those with access to employer-sponsored insurance.
Another study found that patients with limited English proficiency
utilized telehealth at one-third the rate of proficient English
speakers. Anecdotes from family physicians suggest that the same trend
may hold true for the past year--that those benefitting most from
telehealth are those who already had better access to virtual care. At
a minimum, Congress, CMS, and State Medicaid programs should ensure the
collection and reporting of data on telehealth utilization by Medicaid
beneficiaries is stratified by race, ethnicity, gender, language, and
other key factors. Such data will be critical for identifying access
disparities and informing equitable policy decisions.
The AAFP also encourages Congress to invest in initiatives to
bridge the digital divide including expanding broadband coverage and
subsidizing access, providing lower-income individuals with end devices
(i.e., tablets, laptops, remote monitoring tools) and/or access points
and ensuring that digital health platforms and tools are culturally and
linguistically appropriate and accessible for vision and hearing
impaired. In the interim, the AAFP also supports Medicaid coverage for
audio-only services to ensure all patients can access virtual care.
Medicaid coverage and payment for telehealth should promote virtual
care that is connected to patients' medical home and should support
physicians and patients' freedom to choose the most appropriate
modality of care--video, telephone, asynchronous, in-person, etc.
______
Questions Submitted by Hon. Benjamin L. Cardin
Question. We have seen licensure limits substantially restrict
access to cross-State medical care during this unprecedented COVID-19
emergency period. To maximize the utility of telehealth options and
ensure provider accountability, some experts have suggested that States
should do more to ensure mutual licensing reciprocity in the post-
pandemic environment.
I am a cosponsor of Senator Murphy's Temporary Reciprocity to
Ensure Access to Treatment Act (TREAT Act, S. 168/H.R. 708)--a narrowly
tailored bill to enable providers licensed in good standing in one
State to treat patients in any State for the duration of the COVID-19
Public Health Emergency.
In 2018, Congress allowed clinicians working within the U.S.
Veterans Affairs health system to practice both in-person and
telehealth across State lines, as long as they were licensed in good
standing in their home States. Congress did the same thing for Homeland
Security providers in the CARES Act last year.
Would the American Academy of Family Physicians support a
temporary, time- limited reciprocity proposal like that in the TREAT
Act given the extraordinary public health crisis?
How should Congress help remove licensure barriers caused by the
current patchwork of State laws in the post-pandemic environment?
Answer. State-based licensure is part of the larger State-based
infrastructure to ensure patient safety. Monitoring medical practice
and performing disciplinary actions is performed by State medical
boards. Removing State licensure would bypass that consumer protection
performed by State medical boards. As well, the standard of care and
the practice of medicine does vary across States to support the varied
needs of individuals in the different States. We recommend that
Congress should look at options that strengthen and ease participation
in the Interstate Medical Licensure Compact \2\ by both physicians and
States.
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\2\ https://www.imlcc.org/.
To prepare for the next public health crisis, Congress should look
to support research of the varied approaches that were performed by
States during the COVID-19 public health emergency with the goal of
providing States with analysis of potential best practices. This would
inform State Governers and Legislators on how best to prepare their
State for the next public health emergency. Such research could also
inform the Federal Government on best practices for their action in the
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next public health emergency.
______
Questions Submitted by Hon. Chuck Grassley
Question. Throughout the public health emergency, the Centers for
Medicare and Medicaid Services (CMS) issued over 200 waivers under
Medicare and approved more than 600 waivers and other flexibilities
under Medicaid. While some of the regulations waived are specifically
for responding to a pandemic, ensuring patient safety, controlling
costs, and maintaining program integrity its clear innovation and
common-sense ideas in our health-care system have been stifled too
often by Federal regulations. For example, CMS permanently added
certain new services (including mental health and care planning
services) that it had temporarily added to the approved list of
Medicare telehealth services during the pandemic. Some regulations play
an important role in protecting safety and maintaining program
integrity but others may stifle good ideas.
Is health care too regulated that it's stifling good ideas?
Answer. Family physician practices continue to be deeply
overburdened by administrative functions at the point of care and after
patient care hours, which hinders their ability to provide high-quality
care and contributes to physician burnout. The AAFP and other frontline
physician organizations developed joint principles \3\ on reducing
administrative burden in health care.
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\3\ https://www.aafp.org/dam/AAFP/documents/advocacy/legal/
administrative/ST-Group6-AdministrativeBurden-061118.pdf.
The AAFP urges CMS to adopt our recommendations \4\ on prior
authorization (PA) and step therapy to promote efficiency, reduce
administrative complexity and improve patient access to treatment
including exempting physicians participating in financial risk-sharing
agreements from PA, exempting generic medications from PA, and not
requiring step therapy for patients already on a course of treatment.
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\4\ https://www.aafp.org/dam/AAFP/documents/advocacy/legal/
administrative/BKG-PriorAuthorization.pdf.
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The AAFP has called on CMS to simplify Medicare rules
surrounding prescription of diabetic supplies and other DME ordered by
a primary care physician for an established patient for the treatment
of ongoing health conditions.
The AAFP remains concerned that Medicare Incentive Payment
System (MIPS) reporting requirements necessitate expanded human and
technological infrastructure that many smaller physician practices
cannot afford. To reduce reporting burden for all MIPS clinicians, CMS
should provide scoring flexibility through multi-category credit. There
should be a single set of performance measures across all payers that
are universal, meet the highest standards of validity, reliability,
feasibility, importance, and risk-adjustment. The measures should focus
on outcomes that matter most to patients and that have the greatest
overall impact on better health of the population, better health care,
and lower costs.
The AAFP calls on Congress and CMS to work together to repeal
Meaningful Use requirements for physicians' utilization of health IT
and reform the MIPS promoting interoperability measure category. Health
IT vendors should be held accountable for interoperability before
physicians are measured on EHR use. Health IT should be a means to
achieving desirable outcomes such as improved quality of care and
reduction of health disparities. Health IT utilization is not an end
goal in and of itself.
The AAFP urges \5\ Congress to delay implementation of the
Medicare Appropriate Use Criteria (AUC) program. Physicians led the way
in development of AUC for diagnostic imaging and use it, but the AUC
program as authored by Congress is outdated and, if implemented, would
add regulatory and financial burden to practices.
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\5\ https://www.aafp.org/dam/AAFP/documents/advocacy/coverage/
medicare/LT-Congress-AUCProgram-110720.pdf.
The AAFP calls on Federal agencies to provide financial, time and
quality-of-care impact statements for new regulations and
administrative tasks and to revise regulations or administrative tasks
that negatively affect the ability to provide timely, appropriate,
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high-value patient care.
Question. Should executive agencies sunset regulations in the
future to enable more innovation in health care?
Answer. While the AAFP supports efforts to reduce the regulatory
burdens on physicians, we believe that automatically sunsetting
regulations would increase regulatory complexity and lead to
disruptions for a myriad of health-care stakeholders. States, insurance
issuers, physicians, and other health-care professionals all rely on
existing regulations and the regulatory process in order to serve
patients. Patients themselves also rely on clear regulatory guidance on
the safety of food and medications, as well as health care coverage
programs. Sunsetting these regulations would undermine safety standards
and could result in barriers to accessing essential health services.
Further, we are concerned that sunsetting regulations would interfere
with agencies' ability to perform their essential functions and
promulgate important new regulations to implement legislation passed by
Congress. To ensure agencies can focus on administering vital health
care and public health programs that advance the health of our Nation,
we recommend against sunsetting regulations. However, we look forward
to working with Congress to find other legislative solutions for
reducing physicians' administrative burdens.
______
Questions Submitted by Hon. John Barrasso
Question. Before coming to the Senate, I had the privilege of
practicing medicine in Wyoming. Rural health care faced challenges
prior to the pandemic. In particular, we know since 2010 more than 135
rural hospitals have closed.
In the Senate, I am proud to help lead the bipartisan Rural Health
Caucus. This group is committed to ensuring patients in rural America
can get access to the care they need.
Can you specifically discuss the changes in Federal health-care
policy that you believe have helped rural providers the most during
this pandemic?
Can you please discuss any specific changes that Congress should
consider to better support rural health-care providers?
Answer. Rural physicians have benefited from nearly all telehealth
changes during the pandemic including removal of geographic and
originating site restrictions and coverage of audio-only E/M services.
The AAFP has advocated for CMS to permanently cover audio-only E/M
services to ensure access to virtual care for patients in rural areas
who lack access to reliable broadband.
The Teaching Health Center Graduate Medical Education (THCGME) is
one of the most successful, efficiently run programs in the country.
Since its inception, this program has trained 1,148 primary care
physicians and dentists, and evidence suggests that physicians who
train in community-based underserved settings are more likely to
practice in those settings. Data from the American Medical Association
Physician Masterfile show that the majority of family medicine
residents will stay within 100 miles of where they train, which often
includes rural areas. Congress reauthorized the THCGME program in 2020
for 3 years and should permanently reauthorize and expand the program
by passing the Doctors of Community (DOC) Act (S. 1958).
In the FY 2022 Inpatient Prospective Payment System (IPPS) proposed
rule, CMS laid out a proposed methodology for distributing one thousand
new Medicare GME residency positions that were enacted by Congress in
December. This is the first increase to the number of available
positions under the Medicare GME program in nearly 25 years. The same
legislation also allowed for the creation of new rural training track
sites. While the AAFP was largely supportive of CMS's proposals to
allow for the creation of new rural training track sites, we strongly
recommend that CMS allow existing rural track sites to increase the
number of physicians they are able to train. These existing sites are
successfully training rural physicians and addressing physician
maldistribution and CMS should invest in their expansion.
Specifically for rural areas, Congress should consider the impact
of low patient volumes on physician payment. As payment transitions
from volume to value, physicians are being increasingly held
accountable for quality and utilization performance. A physician's
performance is more easily skewed by outliers when they have a lower
patient volume. Congress should ensure value-based payment models make
appropriate adjustments on quality and utilization assessment for rural
practices. Practices should not be assessed on measures unless the
measure is both valid and reliable for low patient volumes, and payers
should consider the high resource burden associated with quality
reporting.
Increased funding for the National Health Service Corps (NHSC)
primary care physicians would allow more rural Health Professions
Shortage Areas (HPSAs) to qualify for family physician placements.
Primary Care HPSA scoring prioritizes population-to-provider ratio over
travel time to the nearest source of care. This leaves rural
communities at a disadvantage when there is not adequate funding of the
National Health Service Corps (NHSC) to provide a family physician for
areas with lower HPSA scores. Those areas need physicians, but the
funding does not extend far enough to provide a NHSC clinician.
The rising cost of liability insurance premiums contributes to the
growing loss of obstetrical services in rural communities. Higher
premiums threaten the viability of some rural hospitals and make it
difficult for rural areas to recruit or retain an adequate number and
mix of physicians. Through the Federal Tort Claims Act (FTCA), the
Federal Government offers a way for certain rural health centers to
lower their malpractice insurance costs. FTCA expansion could help
rural communities struggling to provide high-risk services due to the
increasing cost of private medical malpractice insurance.
Physicians utilizing J-1 visa waivers play an important role in
addressing the current physician shortage in rural areas. Conrad 30 has
been a highly successful program, enabling underserved communities to
recruit both primary care and specialty physicians after they complete
their medical residency training. The AAFP recommends streamlining the
green card program for the J-1 visa program.
Question. Prior to the pandemic, I introduced bipartisan
legislation with Senator Tina Smith, which among other things, would
allow Rural Health Clinics (RHCs) to provide more telehealth services.
I was pleased that Congress through the CARES Act authorized both
Rural Health Clinics and Federally Qualified Health Centers to furnish
telehealth services to Medicare beneficiaries during the public health
emergency.
Can you discuss the importance of Rural Health Clinics and
Federally Qualified Health Centers continuing to provide telehealth
services after the public health emergency has ended?
Answer. FQHCs and RHCs must continue to be allowed to be the
distant site in telehealth encounters beyond the PHE. This has improved
health-care access for historically marginalized populations and will
be beneficial as we continue to strive for health equity.
Question. My wife Bobbi and I are passionate about improving access
to mental health services. This pandemic has clearly impacted the
mental, as well as the physical health of our Nation.
For people living in rural America, getting help from a mental
health provider was challenging before the pandemic. This is why
Senator Stabenow and I have long supported professional counselors and
marriage and family therapists participating in Medicare. We believe
that increasing the number of mental health providers able to care for
our Nation's seniors is an important priority.
Please discuss how telehealth has impacted the ability of patients
to receive mental health services during the pandemic.
Answer. Often, the only access rural patients have to mental health
providers is through telehealth. It is not unusual for a family
physician to be the only health-care provider in the county or in
several counties driving distance. The pandemic has opened access to
mental health providers that were previously not accessible due to
Medicare's arbitrary geographic and originating site restrictions,
which previously only exempted certain substance use disorder
treatment.
Question. Can you please identify ways Congress can improve access
to mental health services, including expanding the number of providers
that can participate in Medicare?
I agree telehealth is transforming the way we are providing care.
However, in Wyoming, most of our providers are part of smaller
hospitals and practices. We need to make sure government regulation is
not making it more difficult for these providers to serve their
patients.
Can you discuss specific ways Congress can reduce the
administrative burden in providing care through telehealth?
Answer. We encourage Congress to adopt and support policies that
streamline coverage and payment for telehealth services across public
and private payers. Variations in coverage and coding requirements add
undue complexity that is especially burdensome for small and solo
physician practices. Telehealth services provided by a primary care
physician to an established patient should not be subject to different
oversight than comparable in-person services.
______
Prepared Statement of Linda V. DeCherrie, M.D., Clinical Director,
Mount Sinai at Home; and Professor of Geriatrics and Palliative
Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Health
System
Chairman Wyden, Ranking Member Crapo, and members of the Senate
Finance Committee, it is my distinct pleasure on behalf of the Icahn
School of Medicine at Mount Sinai and Hospital at Home Users Group to
submit this testimony in support of Hospital at Home, specifically
extending the current Hospital Without Walls and Acute Hospital Care at
Home flexibilities currently being offered under the public health
emergency (PHE).
The Mount Sinai Health System is New York City's largest academic
medical system, encompassing eight hospitals, a leading medical school,
and a vast network of ambulatory practices throughout the greater New
York region. Mount Sinai is a national and international source of
unrivaled education, translational research and discovery, and
collaborative clinical leadership ensuring that we deliver the highest
quality care--from prevention to treatment of the most serious and
complex human diseases. The Health System includes more than 7,200
physicians and features a robust and continually expanding network of
multispecialty services, including more than 400 ambulatory practice
locations throughout the five boroughs of New York City, Westchester,
and Long Island. The Mount Sinai Hospital is ranked No. 14 on U.S. News
and World Report's ``Honor Roll'' of the Top 20 Best Hospitals in the
country and the Icahn School of Medicine as one of the Top 20 Best
Medical Schools in the country. Mount Sinai Health System hospitals are
consistently ranked regionally by specialty and our physicians in the
top 1 percent of all physicians nationally by U.S. News and World
Report.
The Hospital at Home Users Group is a dynamic collaborative of
Hospital at Home programs around the United States and Canada. We are
sharing resources and best practices, working together to expand the
reach of our programs, and developing the program and policy standards
to inform regulatory and reimbursement policies necessary to spread
this hopeful model broadly throughout North America.
Hospital at Home (HaH) is a patient-centric model of care which
provides
hospital-level care at home for patients with select acute illnesses
and acuity level who would otherwise be hospitalized. The traditional
hospital can be dangerous for older adults with resultant functional
decline, iatrogenic illnesses, and other adverse events. Multiple HaH
studies have demonstrated improved patient safety, reduced mortality,
enhanced quality, and reduced cost. This was a model that many Medicare
Advantage, commercial, and Medicaid managed care plans already covered
before the pandemic. Adding the rest of Medicare beneficiaries allows
equitable care and has been extremely helpful since November 2020, when
the Acute Hospital Care at Home waiver was approved. I believe the
coverage of Hospital at Home or Acute Hospital Care at Home should be
covered beyond the pandemic as a 30-day bundle of care.
Typically, HaH starts in the emergency departments where a patient
is evaluated by the emergency physicians and staff and if they are
determined to need inpatient care they are screened for HaH. This
screening first starts with a clinical screen to see if the conditions
and treatment plan can be effectively delivered in the home, then the
patients home environment is screened through a bedside survey. Common
diagnoses are Pneumonia, Congestive Heart Failure (CHF), Chronic
Obstructive Pulmonary Disease (COPD), and Cellulitis. The patient then
is offered the opportunity to participate in the program and consents.
Other physicians see the patient and write admission orders. Patients
go home with an IV in place, in an ambulance, with a telehealth kit and
potentially with oxygen. The ambulance staff sets them up in the home
and within a couple of hours, a nurse arrives at the home and further
assesses the home for safety and starts the treatment plan. Multiple
deliveries typically occur such as IV and oral medications, equipment,
and supplies. In the subsequent days, nurses come twice a day (some
programs use mobile integrated health paramedics), and a physician or
nurse practitioner sees the patient daily (in person or via video
visit). They have access to other services such as physical therapy,
occupational therapy, speech therapy, social work, and nutrition--all
as needed based on the patient's individualized care plan. Patients
usually require frequent blood draws, IV fluids, antibiotics, x-rays,
or oxygen, all of which can be done in the home. Teams will round a
couple times a day to review the care plan. There is 24/7 immediate
availability of the team, including in person within 30 minutes if
needed. This care is inclusive, patient centric, and equitable, as 41
percent of our patients have some form of Medicaid. Once a clinician is
in the home many additional barriers to improved health care, including
health literacy, food insecurity, nutritional misinformation, and
medical equipment needs are all readily identifiable, allowing our
social worker to get involved, and referrals to be made to help improve
the patient's health longer-term.
There are other pathways into Hospital at Home, such as from a
patient's outpatient doctors' offices, urgent care, or from the
inpatient floors as long as the patient requires inpatient level care
and would otherwise have been admitted to the hospital.
The model of Hospital at Home has existed for several decades
internationally with Australia, France, Spain, and Israel being some of
the early adopters. In the mid-1990s the first trials of Hospital at
Home were performed in the U.S. at Johns Hopkins. It was shown to be
safe, efficacious and the patients desired this type of care. Never the
less, no payment was available and existing payment structures did not
adequately cover the costs of the program. Between the mid-1990s and
2014, a number of veterans' hospitals developed similar programs as
they had payment flexibilities. One integrated health system in New
Mexico with their own Medicare Advantage plan has offered a HaH program
since 2008. In 2014, we at Icahn School of Medicine at Mount Sinai in
New York City applied and received a Center for Medicare and Medicaid
Innovation (CMMI) award to develop and test Hospital at Home for a fee-
for-service Medicare population. We did one thing differently than
previous iterations of Hospital at Home, we cared for the patients for
30 days. It was split into two phases--the acute phase where the
patient would have been in the hospital and a transitional phase for
monitoring and ensuring the patient was stable and back under the care
of their primary care provider and outpatient specialists.
From our CMMI period, we examined more than 500 fee-for-service
Medicare beneficiaries who received HaH care. We received additional
funding from The John A. Hartford Foundation, and were able to compare
care to a group of patients who received traditional inpatient care.
For both groups of patients, the full 30 days of care were examined,
and more than 65 Diagnosis-Related Groups (DRGs) were included in this
analysis. Length of stay was reduced from 5.5 days to 3.2 days, 30-day
readmissions were reduced from 15.6 percent to 8.6 percent, and Skilled
Nursing Facility transfers on discharge were reduced from 10.4 percent
to 1.7 percent with a resultant higher use of Certified Home Health for
this HaH cohort. With regards to patient satisfaction, 45.3 percent of
traditionally hospitalized patients were highly satisfied with care,
while with HaH it increased to 68.8 percent.
While some programs may start with a limited number of DRGs for
which they can provide HaH care, we currently believe there are more
than 150 DRGs that HaH can serve, and believe this is probably a
conservative estimate. As many programs expand into oncology and
surgical cases, the number will increase.
From this work, we submitted a proposal to the Physician-Focused
Payment Model Technical Advisory Committee (PTAC)--``HaH Plus''
(Hospital at Home Plus)--Provider-Focused Payment Model. Moreover,
after evaluation, PTAC recommended two separate HaH proposals in 2018:
(1) our proposal, the Hospital at Home Plus Model (HaH-Plus); and (2)
the Home Hospitalization: An Alternative Payment Model for Delivering
Care in the Home (HH-APM), to the Secretary of the Department of Health
and Human Services for implementation. The Secretary expressed interest
in testing home-based, hospital-level of care models and agreed with
the PTAC that these models hold promise for testing. The agency has the
authority to further refine the recommended PTAC models; however, to-
date, they have not utilized this authority. While we recognize the
broader need for a refined HaH model, and we look forward to working
with the agency to advance such a model to ensure greater availability
of hospital care in the home to all patients, we believe congressional
action to extend the current waivers and flexibilities is necessary and
particularly valuable for patient care in the immediate and near term.
We believe these regulatory flexibilities should be made permanent
beyond the PHE and will be an effective foundation for establishing
Medicare reimbursement that is specific to Hospital at Home services.
We applaud The United States Department of Health and Human Services
(HHS) for providing these flexibilities to ensure hospital services in
the home during the PHE, and we encourage Congress and HHS to consider
extending these flexibilities as a new model of care that prioritizes
the patient's safety and care needs.
In 2017 when the CMMI award was finished, our Hospital at Home
program no longer provided care for fee-for-service patients as there
was no fee-for-service reimbursement and the program shifted to focus
on Medicare Advantage, commercial, and Medicaid managed care plans. We
created a joint venture with Contessa Health and together have
negotiated contracts with most of the major insurance providers in our
area.
During the initial surge of COVID-19 in March 2020 we were an
important part of helping the Mount Sinai Health system admit both
COVID negative and positive patients to open up more capacity for
patients needing higher levels of care like ICUs, but were still unable
to admit a fee-for-service Medicare patient from the emergency room.
The PHE has demonstrated the need to have Hospital at Home accessible
to fee-for-service Medicare patients.
We were very excited to be part of the original group of hospitals
approved for the Acute Hospital Care at Home waiver in November 2020.
Despite having operated since 2014, we still needed some time to set up
and meet the new requirements. We are appreciative that CMS made this
available to fee-for-service Medicare patients. My colleagues and I
have been happy to engage with CMS as stakeholders in this process. In
addition, we formed the Hospital at Home Users group with funding from
The John A. Hartford Foundation, which provides technical assistance,
office hours and a member community which has engaged in multiple work
groups. To date, there have been 129 hospitals approved for the Acute
Hospital Care at Home waiver, with 56 health systems in 30 States since
November. This shows that there is great interest. It does take
significant start up resources and time and many are not planning to
launch until this summer. I believe even more hospitals would apply if
they knew this program would be made permanent. This waiver allowed
many hospitals to jump start a program in the pandemic, which has been
helpful in many communities for the provision of high quality and safe
patient hospital inpatient care.
Having a payment model for Hospital at Home/Acute Hospital Care at
Home is needed to serve Medicare beneficiaries beyond the pandemic and
especially if an emergency of this type ever happens again. These
programs are complex to start, and many places could not start
instantaneously; therefore, if the flexibilities continue beyond the
PHE, I believe many additional hospitals will join. There is a strong
interest in the community of Hospital at Home programs to continue
this.
Due to the regulatory barriers outlined above, hospitals have been
wary about and disincentivized from implementing the innovations of
providing acute level care in the home. Therefore, we request Congress
and HHS to consider a permanent extension of the Hospital Without Walls
and Acute Hospital Care at Home waivers beyond the PHE to mitigate the
residual impacts of COVID-19 on public health and encourage broader
adoption of providing patient centered health-care services in the
home. Thank you for the opportunity to provide this testimony to the
committee. My colleagues and I look forward to continuing to work with
Congress and HHS on this important issue.
______
Questions Submitted for the Record to Linda V. DeCherrie, M.D.
Questions Submitted by Hon. Mike Crapo
Question. Mount Sinai health system was one of the first group of
hospitals that CMS approved for the Acute Hospital Care at Home waiver
last year. Medicare pays hospitals participating in the program at the
same reimbursement rate that the facility otherwise would have received
if the beneficiary had been admitted to the hospital. In your
testimony, as well as during interviews with my staff, you indicated
that the Mount Sinai Hospital at Home program has demonstrated improved
patient outcomes, increased quality of care, enhanced patient safety,
reduced mortality, and lowered costs. This committee wants to identify
smart Medicare payment reforms that show the greatest potential to
ensure beneficiaries get the right care, in the right setting, at the
right time, and in a cost-efficient manner. Not only do Medicare
beneficiaries deserve high-quality care, but any innovative payment
arrangements that we consider implementing beyond the PHE, must also
help put Medicare on a more sustainable fiscal path.
If it was less expensive for Medicare to furnish certain acute
inpatient services in the home during the pandemic, and beneficiaries
saw better health outcomes, then how do you think these efficiencies
should be factored into the Medicare hospital inpatient payment rates?
Answer. In my opinion, the services provided by Hospital at Home
(HaH) programs should be billed as a DRG based 30-day bundled value-
based payment to better manage the care of HaH patients, which was
studied through our CMMI Innovation Grant from 2014-2017. It is our
belief that this is the most cost effective and appropriate manner to
bill these services going forward. While this value-based payment model
is built, the current Acute Hospital Care at Home waiver should extend
to enable programs, like Mount Sinai, to continue providing and being
paid for hospital inpatient care in the home. I do not believe the two
offerings and approaches to hospital care in the home are mutually
exclusive, and do believe they collectively benefit patients,
providers, and the Medicare program.
Question. Should CMS calculate separate Medicare claims codes in
order to reimburse for these specific services?
Answer. No, it is not necessary to create separate Medicare claims
codes to reimburse for Hospital at Home specific services. The services
provided through HaH are indeed the same level of services provided in
an acute care setting for patients. Creation of a new set of Medicare
claims code would add unnecessary burden to providers needing to learn
a new set of codes for the same set of services. Importantly, the
patients seen under HaH receive higher quality, lower cost care, and
have a higher patient satisfaction scores than patients receiving the
same level of care in an acute care setting.
Question. The Congressional Budget Office (CBO) would analyze and
provide a cost-estimate for any legislative proposal seeking to make
the Acute Hospital Care at Home program permanent once the PHE expires.
CBO has previously indicated that Medicare fee-for-service programs are
generally subject to unnecessary utilization as well as potential
fraud, waste, and abuse.
What specific policies do you recommend in order to minimize these
risks?
Answer. HaH allows for treatment of patients that meet Milliman
Care Guidelines or other equivalent guidelines for medical necessity
for hospital admission by a qualified team of care providers. In order
to qualify for HaH, we advise that patients and their homes meet a
strict set of screening criteria, as per our study at Mount Sinai,
before being deemed eligible for HaH. Additionally, we believe based on
our experience with the HaH plus model that home-based acute care
services resulted in less waste than traditional hospital inpatient
care. Further studies could be conducted to confirm these findings and
expand upon the work previously done.
______
Questions Submitted by Hon. Thomas R. Carper
Question. During the pandemic, telehealth has been an essential
tool to get children the care that they need while minimizing risk.
Although telehealth under Medicare has been a focus, close to 40
million children are enrolled in Medicaid.
What are the main policy changes we need to ensure this broader use
of telehealth can be continued beyond the pandemic for children?
Answer. Telehealth and audio-only telehealth need to continue to be
reimbursed as they were during the Public Health Emergency. Allowing
the continuation of these services for Medicaid beneficiaries is an
important step to improving access to care and health equity for
children. During the PHE, Mount Sinai used grant funding from the
Federal Communications Commission (FCC) to provide 700 devices to
children and their families requiring telehealth monitoring and care,
on a rotating basis, in addition to another 150 tablets for homebound
adults in the Mount Sinai Visiting Doctors Program. Through innovative
partnerships, telehealth was provided to thousands of patients by
removing obstacles to receiving health-care services. This model could
be expanded upon to the larger population in order to provide
convenient, cost-efficient, high-quality home-based health-care
services to children and adults.
Question. During COVID-19, many States adopted temporary changes to
their telehealth policies, such as expanding the scope of services and
providers able to furnish telehealth, relaxing of licensure
requirements and modifying reimbursement policies. Many States
legislatures have also begun the work to adopt more permanent
telehealth policy changes.
How can the Federal Government best support State Medicaid programs
in their efforts to expand telehealth?
Answer. The Federal Government can help support State Medicaid
programs by ensuring telehealth and audio only telehealth continue to
be reimbursed for the care provided to beneficiaries. In addition, the
Federal Government can help support State Medicaid to cover Hospital at
Home (Acute Hospital Care at Home) services. HaH can provides acute
levels of care to all adults, and during the pandemic that has included
patients within the Medicare and Medicaid population, who often
struggle with access to convenient health-care services. Additionally,
the lifting of geographic restrictions for providers of health-care
services is another important step that will allow telehealth to be
provided across State lines and fill gaps of care where access is
limited. Lastly, enhancing the rollout of broadband Internet to rural
communities will ensure everyone has access to telehealth services.
Question. Are there Medicaid supports, incentives, and learnings
that Federal policymakers could provide?
Answer. Federal policymakers could help State Medicaid programs by
continuing to rollout access to broadband Internet services across the
country and subsidizing affordable technology provided to Medicaid
patients to allow telehealth and audio-only telehealth visits.
Extending the Acute Hospital Care at Home waiver beyond the PHE is an
additional step that should be taken to support the Medicaid
population. These supports and incentives would greatly improve access
to care and allow for continued innovation in how cost-efficient care
is delivered to Medicaid (and all) patients.
Question. COVID-19 has introduced additional stress and trauma for
children and families. Telehealth, and particularly audio-only
telehealth has been a crucial tool to connect children and adolescents
to needed mental health-care services.
How can telehealth be best utilized to meet kids' mental health-
care needs, and can you speak to the use of audio-only telehealth
specifically?
Answer. Telehealth effectively increases access to mental health
services for kids. It is a cost-efficient, barrier removing (i.e.,
travel, parent/guardian time, access) solution to provide much needed
mental health services to children in need. As we have seen during the
public health emergency, mental health in our country is at an
inflection point and desperately needs to be addressed. The CDC found
that suicide rates among teenagers increased by more than 50 percent
during the PHE, worsening mental health issues long ignored. As such,
audio only telehealth reimbursement needs to continue, as it provides
additional coverage to children without the financial and technological
capabilities to engage in video enabled telehealth visits and provides
further options of convenient, cost-effective care.
Question. As State Medicaid programs look at expanding their use of
telehealth, it is particularly important that vulnerable populations
like children are not negatively impacted. Policies must be looked at
through a health equity lens, considering access to reliable and
affordable broadband services, access to devices that support HIPAA-
compliant telehealth platforms and coverage policies.
How can Medicaid programs work to ensure telehealth policies are
equitable for children and mitigate potential inequities that may
arise?
Answer. Subsidizing access to affordable technological resources to
engage in video enabled telehealth, like the grant funding Mount Sinai
received from FCC to provide children and their families devices, will
help to improve equity of telehealth policies. Reimbursement should
also be allowed to continue for audio-only telehealth services and HaH
post-PHE. Additionally, Medicaid programs should enable providers to
treat patients across State lines in order to improve access to care
for States that do not have enough health services providers. Lastly,
it is crucial to fill the gap in rural broadband service to ensure
rural populations have the same access to telehealth services as other
populations.
Questions Submitted by Hon. Benjamin L. Cardin
Question. We have seen licensure limits substantially restrict
access to cross-State medical care during this unprecedented COVID-19
emergency period. To maximize the utility of telehealth options and
ensure provider accountability, some experts have suggested that States
should do more to ensure mutual licensing reciprocity in the post-
pandemic environment.
I am a cosponsor of Senator Murphy's Temporary Reciprocity to
Ensure Access to Treatment Act (TREAT Act, S. 168/H.R. 708)--a narrowly
tailored bill to enable providers licensed in good standing in one
State to treat patients in any State for the duration of the COVID-19
Public Health Emergency.
How have health systems and patients benefited from State licensing
reciprocity during the COVID19 public health emergency?
Answer. This allows providers to treat their patients regardless of
what State they are currently in. Patients have benefited from being
able to access the providers of their choice. If a patient is traveling
and needs their care managed by their PCP who is in another State, they
should be able to receive that care telephonically and by video and be
managed by the physician that knows them and their specific health
status best.
Question. I recently reintroduced the Home Health Emergency Access
to Telehealth Act (HEAT) Act with Senators Collins and Shaheen. This
bill would allow Medicare home health providers to be reimbursed for
the telehealth services during a public health emergency. I also have
heard from other home-based care providers, like hospice and palliative
care as well as home-based primary care about the importance of
telehealth during the emergency and into the future as services in the
home and community continue to grow.
Could you talk about your experiences using telehealth to
supplement care for the populations you take care of?
Answer. We have learned to be creative in this pandemic. In March
2020 a small portion of our home-based primary care patients were able
to access telehealth, mostly those who lived with their adult children.
However, with a grant from the FCC where we provided tablets to some
patients and working with other patients who had consistent home health
aides who had smart phones we were able to expand those we could use
video visit. However, it still did not reach all patients, and regular
telephone was utilized instead.
When a patient is able to use video technology it is tremendously
helpful to us, when the call with an urgent complaint such as leg
swelling, a new rash or ulcer, our nurses can immediately get a visual
on the issue and provide that to the provider who can decide how
urgently and in what way a patient needs to be seen. In the past we
would do that telephonically only and then next day send a provider out
to the home.
In our Hospital at Home program (Acute Hospital Care at Home) we
also heavily utilize video technology, which allows the provider and
care coordinator to participate in all visits to the home.
Question. What lessons from the pandemic would you like to see
brought forward into the future of care for home health, hospice,
palliative, and other home-based care providers?
Answer. The need for patient-centered, acute level care that can be
furnished in a patient's home is the biggest lesson from the PHE that
needs to be brought forward into the future of care. We learned that a
decades old model of care, Hospital at Home, which provided value pre-
pandemic despite lack of a Medicare payment structure could bring value
during the PHE by providing payment for and access to hospital
inpatient services. Moreover, this model can and should carry beyond
the PHE. While we recognize the broader need for a refined HaH model as
part of the shift to a value-based payment system, we believe
congressional action to extend the current Acute Hospital Care at Home
waiver and associated telehealth flexibilities is necessary and
particularly valuable for patient care in the immediate and near term.
We believe these regulatory flexibilities should be made permanent
beyond the PHE and will be an effective foundation for establishing
Medicare reimbursement that is specific to HaH services. We look
forward to working with Congress and the agency to advance such a model
to ensure greater availability of hospital care in the home to all
patients.
______
Questions Submitted by Hon. Chuck Grassley
Question. Throughout the public health emergency, the Centers for
Medicare and Medicaid Services (CMS) issued over 200 waivers under
Medicare and approved more than 600 waivers and other flexibilities
under Medicaid. While some of the regulations waived are specifically
for responding to a pandemic, ensuring patient safety, controlling
costs, and maintaining program integrity its clear innovation and
common-sense ideas in our health-care system have been stifled too
often by Federal regulations. For example, CMS permanently added
certain new services (including mental health and care planning
services) that it had temporarily added to the approved list of
Medicare telehealth services during the pandemic. Some regulations play
an important role in protecting safety and maintaining program
integrity but others may stifle good ideas.
Is health care too regulated that it's stifling good ideas?
Answer. In the case of the Hospital Without Walls and Acute
Hospital Care at Home waivers, policymakers have lifted critical
regulatory barriers that have prevented or at minimum dissuaded
hospitals and health systems from investing in Hospital at Home.
Specifically, these waivers have allowed the home to be a permissible
site for acute level care and allowed section 482.23 of the Medicare
Conditions of Participation for 24-hour nursing services to be
fulfilled virtually. These waivers have allowed for necessary
innovations to maintain patient safety, and we need to continue to
foster this innovation after the end of the PHE. This should be
extended as a distinct hospital program of hospital inpatient care as
an integrated model of hospital services, separate and distinct from
home care services.
Due to the pre-pandemic aforementioned regulatory barriers,
hospitals and health systems have been unable to receive Medicare fee-
for-service reimbursement. Hospitals and health systems need time,
funding, and predictability beyond 90-day intervals to build the
necessary infrastructure to administer Hospital at Home. Without the
continuation of these waivers, these regulatory barriers will resume
and innovations like the Hospital at Home program (Acute Hospital Care
at Home) will not be adopted across health systems and hospitals.
Question. Should executive agencies sunset regulations in the
future to enable more innovation in health care?
Answer. Prior to the public health emergency, Hospital at Home was
only reimbursed in certain circumstances under commercial arrangements.
With traditional Medicare covering 15 percent of the population, it is
vital that executive agencies consider a formal payment model for fee-
for-service patients. Having a payment model for Hospital at Home is
needed to serve Medicare beneficiaries beyond the pandemic and
especially in the event of a future public health emergency.
Moreover, executive agencies should allow a reinterpretation of
section 482.23 of the Medicare Conditions of Participation to allow
nursing services to be fulfilled virtually for Hospital at Home
programs. Agencies should also sunset regulations that limit the home
as an originating site for acute level services and telehealth.
Question. In March 2020, CMS announced an effort known as Hospitals
Without Walls designed to rapidly increase hospital capacity at the
start of the pandemic. In November 2020, CMS established the Acute
Hospital Care at Home demonstration model. This model allows approved
hospitals to deliver home-based care and meet patients' needs with
quality, convenience, and comfort. The model has proven to be effective
in better quality outcomes, shorter lengths of stay, and higher patient
satisfaction all while lowering overall cost of care. The UnityPoint at
Home, an Iowa health-care provider, was one of the first providers to
be approved by CMS and the first in the Nation in February 2021 to
admit and bill for patients. Hospitals under Medicare FFS were not
previously allowed to offer this type of care that is more intensive
than home health. This model was already utilized by Medicare
Advantage, commercial, and Medicaid managed care plans. I have
supported similar innovations for hospitals in rural areas. Last
Congress, we passed the Rural Emergency Hospital Designation (REH) that
will let rural hospitals right-size their infrastructure while
maintaining essential medical services in their communities like 24/7
emergency care and outpatient care.
Should CMMI extend the current waiver for the Medicare FFS program
to exist into the future?
Answer. Yes, the coverage of Hospitals Without Walls and Acute
Hospital Care at Home should be covered permanently beyond the PHE.
Multiple studies on the Hospital at Home program have demonstrated
improved patient safety, reduced mortality, enhanced quality, and
reduced cost. We applaud the Department of Health and Human Services
for providing these flexibilities to ensure hospital services in the
home during the PHE, and we encourage Congress and HHS to also consider
a CMMI model that allows a reimbursement pathway for a new Hospital at
Home 30-day bundle value-based model of care that reduces costs of care
and prioritizes the patient's safety and care needs.
Question. What efforts can be made to improve the model?
Answer. The shift of care in the community will require further
training of providers, alignment with community partners, and shifting
the current framework that usually results in hospitalization.
Successful treatment in the home of individuals with acute illness
requires a skill set that includes hospital care, home-based care, and
a strong focus on coordination of care and transitions. Hospital at
Home programs require home inspections and patient safety protocols
that can respond to abrupt changes in clinical status and needs when
certain clinical resources are not readily available. Leveraging the
experience of a home-based primary or palliative care program can help
create that infrastructure. While we recognize the broader need for a
refined Hospital at Home value-based model of care, and we look forward
to working with the agency to advance such a model to ensure greater
availability of hospital care in the home to all patients, we believe
congressional action to extend the current waivers and flexibilities is
necessary and particularly valuable for patient care in the immediate
and near term.
Question. What similar cost-effective innovations are being stifled
by Federal law and regulations?
Answer. Value-based arrangements have historically been stifled by
regulatory barriers. Cost-saving innovations such as care coordination
services have been difficult to implement with Federal laws restricting
information sharing and access to data between providers. Recently, CMS
published the Modernizing and Clarifying the Physician Self-Referral
Final Rule, which mitigated some of these barriers by giving greater
flexibility to providers to participate in value-based care delivery
models and provide coordinated care or patients. While this rule offers
exciting new opportunities for providers, payers, and others to
innovate, there are still limitations. The safe harbors and exceptions
in the Final Rule are highly prescriptive so existing value-based
arrangements will likely not satisfy all AKS or Stark Law value-based
requirements without review and amendment.
______
Questions Submitted by Hon. John Barrasso
Question. Before coming to the Senate, I had the privilege of
practicing medicine in Wyoming. Rural health care faced challenges
prior to the pandemic. In particular, we know since 2010 more than 135
rural hospitals have closed.
In the Senate, I am proud to help lead the bipartisan Rural Health
Caucus. This group is committed to ensuring patients in rural America
can get access to the care they need.
Can you specifically discuss the changes in Federal health-care
policy that you believe have helped rural providers the most during
this pandemic?
Answer. During COVID-19, CMS allowed many evaluation and management
codes to be furnished via telehealth. Telehealth has become an
essential service for patients and primary care providers have led the
charge in its use. Telehealth has allowed providers to maintain, and in
certain cases expand, the reach of their medical services to
populations in need. Many provider practices and the patients they
serve will remain reliant on telehealth services as a care tool for the
immediate future, if not longer.
Waiving originating and distant site requirements, allowing
Medicare reimbursement for audio-only, and increased funding for
broadband infrastructure have all helped rural health-care providers
and contributed to increased access for patients.
Question. Can you please discuss any specific changes that Congress
should consider to better support rural health-care providers?
Answer. There are a few avenues Congress can consider to better
support rural health-care providers:
Support extending the Acute Hospital Care at Home waiver:
There are already many rural hospitals participating, and this will
allow rural providers options of site of care for their patients.
Simultaneously or subsequently encourage and work with the Secretary to
finalize a 30-day bundle value-based payment model for HaH as proposed
to the PTAC in 2017.
Increase funding for telecommunications services and connected
devices for provider practices and patients: Small practices in rural
areas often do not have the upgraded technological platforms needed to
provide telehealth services for their patients. Additionally, funding
opportunities for these services and devices have been limited for
independent provider practices. Applications for additional funding
should be streamlined as much as possible to preclude any unnecessary
administrative burden for independent practices that may lack some of
the support services and administrative staff that larger entities can
take advantage of.
Increase support for broadband infrastructure: The expanded
use of telehealth, including video visits and remote patient
monitoring, require the use of broadband which many patients in rural
and underserved areas do not have. Congress should consider the needs
of this population and commit to providing universal broadband to all
who need it.
Permanent removal of originating and distant site
requirements: This ensures that providers can provide needed care for
patients without regulatory barriers and patients themselves have
continued access to telehealth services beyond the PHE when they need
it.
Permanently implement a separate payment for telephone-only
services: Post COVID-19, many physician practices and the patients they
serve will continue to rely on telehealth services for the foreseeable
future. Not covering these codes post-PHE will disproportionally put
patients without the means or access to technology and the Internet at
risk of not having access to care.
Question. Prior to the pandemic, I introduced bipartisan
legislation with Senator Tina Smith, which among other things, would
allow rural health clinics (RHCs) to provide more telehealth services.
I was pleased that Congress through the CARES Act authorized both
Rural Health Clinics and Federally Qualified Health Centers to furnish
telehealth services to Medicare beneficiaries during the public health
emergency.
Can you discuss the importance of Rural Health Clinics and
Federally Qualified Health Centers continuing to provide telehealth
services after the public health emergency has ended?
Answer. As you know, Rural Health Clinics and health centers are
required to offer comprehensive services in areas of high need, and
many are using telehealth to address geographic, economic,
transportation, and linguistic barriers to health-care access. During
the PHE, Medicare and Medicaid adopted policies that have allowed
health centers to provide primary and preventive care virtually. These
policies allow health centers to ensure their patients continue to
receive the care they rely on, often from the comfort and safety of
their own homes. Disparities will not disappear after the PHE, rather
they will be exacerbated as a result. It is vital now more than ever
that Rural Health Clinics and FQHCs continue to provide telehealth
services after the PHE has concluded.
Question. My wife Bobbi and I are passionate about improving access
to mental health services. This pandemic has clearly impacted the
mental, as well as the physical health of our Nation.
For people living in rural America, getting help from a mental
health provider was challenging before the pandemic. This is why
Senator Stabenow and I have long supported professional counselors and
marriage and family therapists participating in Medicare. We believe
that increasing the number of mental health providers able to care for
our Nation's seniors is an important priority.
Please discuss how telehealth has impacted the ability of patients
to receive mental health services during the pandemic.
Answer. Telehealth has greatly increased access to mental health
services during the pandemic. COVID-19 has far reaching mental health
implications for a large proportion of the US population. Prior to the
pandemic, nearly one in five U.S. adults reported living with a mental
illness, but only half received treatment. Many obstacles remain in
place for those living with a mental illness, including stigma and lack
of mental health services in urban and rural areas. With digital tools
and access to broadband Internet, patients can now consult with a
mental health professional remotely using live video. Patients living
in ``mental health professional shortage'' areas can use these tools to
speak with a licensed professional without driving long distances. They
can also receive care discretely if their loved ones or colleagues
perpetuate stigmas about receiving care. A large body of evidence has
demonstrated that telemental health programs help increase access to
care in areas with limited mental health resources, provide effective
treatment for mental health conditions, and improve medication
adherence.
Question. Can you please identify ways Congress can improve access
to mental health services, including expanding the number of providers
that can participate in Medicare?
Answer. There are multiple ways in which Congress can improve
access to mental health services, including:
Implementing a Federal statute permanently requiring payers to
reimburse telehealth encounters at the same rate as in-person or to
generally cover telehealth as parity remains an issue for widespread
implementation of telemental health.
Revision to section 123 of the Consolidated Appropriations Act
passed in December 2020, which expanded telehealth mental services but
imposed a requirement that the patient must be seen in person within 6
months of the telehealth visit and periodically in person thereafter.
This has imposed unnecessary obstacles to a service that is well suited
for telehealth.
Improving care reimbursement rates by enforcing parity laws
and developing new payment models for services such as telehealth group
therapy.
Increasing funding to train and develop more behavioral health
professionals.
Removing regulatory impediments to care coordination and
information sharing.
Partnering with community organizations, patients, and
caregivers to identify and expand programs that reduce stigma and
combat barriers to care.
Ensuring sufficient coverage for behavioral health services.
Increasing funding to schools to ensure administrators and
teachers have the tools and funding to help students deal with mental
health issues and promote wellness.
Question. I agree telehealth is transforming the way we are
providing care. However, in Wyoming, most of our providers are part of
smaller hospitals and practices. We need to make sure government
regulation is not making it more difficult for these providers to serve
their patients.
Can you discuss specific ways Congress can reduce the
administrative burden in providing care through telehealth?
Answer. It is critical that Congress remove originating and distant
site requirements to increase access for patients and reduce
administrative burden for providers. CMS added a few evaluation and
management codes to Category 1 of the Medicare telehealth list for the
CY 2021 Medicare Physician Fee Schedule and omitted many others.
Category 1 codes are considered permanently payable under the Medicare
Physician Fee Schedule. CMS notes that while the home is generally not
a permissible telehealth originating site, certain services could be
billed as telehealth only for treatment of a substance use disorder or
co-occurring mental health disorder under the flexibility afforded by
the SUPPORT for Patients and Communities Act. This rule is limiting as
many other patients with serious conditions also highly benefit from
telehealth visits. The home needs to be a permissible telehealth
originating site to ensure that patients have continued access to
telehealth services beyond the PHE.
Question. Wyoming has many passionate advocates supporting both
hospice and palliative care. These folks are committed to ensuring
patients have the highest quality of life and are able stay out of the
hospital and with their families. This is why I help lead the
bipartisan Comprehensive Care Caucus. Our mission is to improve both
palliative and hospice care for patients.
I was particularly impressed with your background in palliative
care.
Can you please discuss how telehealth flexibilities have impacted
access to palliative care and how we can continue making progress in
this area?
Answer. Telehealth flexibilities have created greater access to
palliative care for many patients, particularly with the reimbursement
of audio-only codes. In response to COVID-19, CMS permitted certain
services to be furnished using audio only telehealth. In the CY 2021
Medicare Physician Fee Schedule Final Rule, CMS noted that audio-only
evaluation and management codes will not be reimbursed after the end of
the PHE and proposed an interim final rule on coding and payment for
virtual check-in services to support reimbursement for lengthier audio-
only services outside of the PHE. However, these audio-only services
can only be used to determine whether the beneficiary requires an in-
person services and are not services that can be provided in lieu of
in-person services.
Many physician practices, and the patients they serve will continue
to remain reliant on telehealth services for the foreseeable future.
Discontinuing the use of these codes will disproportionally put
patients without a means to technology or access to the Internet at
risk of not having access to care. Many complex palliative care
patients are without Wi-Fi, computers, or smart devices and may be
cognitively or physically impaired in using video technology.
Therefore, they require medical intervention and guidance via audio-
only telephone calls when they are not receiving in-
person care. Congress needs to permanently implement a separate payment
for telephone-only services that specifies what is included in the
visit.
In our Home-based Primary Care and our Home-based Palliative Care
practices we utilized the telehealth flexibilities heavily during the
pandemic. We were able to quickly take patients from the emergency room
home under palliative care where we provided both video and audio only
telehealth to work with patients and their families.
______
Prepared Statement of Jessica Farb, Director, Health Care,
Government Accountability Office
why gao did this study
Medicare and Medicaid--two federally financed health insurance
programs--spent over $1.5 trillion on health-care services provided to
about 140 million beneficiaries in 2020. Recognizing the critical role
of these programs in providing health-care services to millions of
Americans, the Federal Government has provided for increased funding
and program flexibilities, including waivers of certain Federal
requirements, in response to the COVID-19 pandemic.
The CARES Act includes a provision for GAO to conduct monitoring
and oversight of the Federal Government's response to the COVID-19
pandemic. In response, GAO has issued a series of government-wide
reports from June 2020 through March 2021. GAO is continuing to monitor
and report on these services.
This testimony summarizes GAO's findings from these reports related
to Medicare and Medicaid flexibilities during the COVID-19 pandemic, as
well as preliminary observations from ongoing work related to
telehealth waivers in both programs. Specifically, the statement
focuses on what is known about the effects of these waivers and
flexibilities on Medicare and Medicaid, and considerations regarding
their ongoing use.
To conduct this work, GAO reviewed Federal laws, CMS documents and
guidance, and interviewed Federal and State officials. GAO also
interviewed six provider and beneficiary groups, selected based on
their experience with telehealth services.
GAO obtained technical comments from CMS and incorporated them as
appropriate.
what gao found
In response to the COVID-19 pandemic, the Centers for Medicare and
Medicaid Services (CMS), the Federal agency responsible for overseeing
Medicare and Medicaid, made widespread use of program waivers and other
flexibilities to expand beneficiary access to care. Some preliminary
information is available on the effects of these waivers. Specifically:
Medicare. CMS issued over 200 waivers and cited some of their
benefits in a January 2021 report. For example, CMS reported that:
Expansion of hospital capacity. More than 100 new facilities
were added through the waivers that permitted hospitals to provide care
in non-hospital settings, including beneficiaries' homes.
Workforce expansion. Waivers and other flexibilities that
relaxed certain provider enrollment requirements and allowed certain
nonphysicians, such as nurse practitioners, to provide additional
services expanded the provider workforce.
Telehealth waivers. Utilization of telehealth services--
certain services that are normally provided in-person but can also be
provided using audio and audio-video technology--increased sharply. For
example, utilization increased from a weekly average of about 325,000
services in mid-March to peak at about 1.9 million in mid-April 2020.
Medicaid. CMS approved more than 600 waivers or other flexibilities
aimed at addressing obstacles to beneficiary care, provider
availability, and program enrollment. GAO has reported certain
flexibilities such as telehealth as critical in reducing obstacles to
care. Examples of other flexibilities included:
Forty-three States suspended fee-for-service prior
authorizations, which help ensure compliance with coverage and payment
rules before beneficiaries can obtain certain services.
Fifty States and the District of Columbia waived certain
provider screening and enrollment requirements, such as criminal
background checks.
While likely benefiting beneficiaries and providers, these program
flexibilities also increase certain risks to the Medicare and Medicaid
programs and raise considerations for their continuation beyond the
pandemic. For example:
Increased spending. Telehealth waivers can increase spending
in both programs, if telehealth services are furnished in addition to
in-person services.
Program integrity. The suspension of some program safeguards
has increased the risks of fraud, waste, and abuse that GAO previously
noted in its High-Risk report series.
Beneficiary health and safety. Although telehealth has enabled
the safe provision of services, the quality of telehealth services has
not been fully analyzed.
_______________________________________________________________________
Chairman Wyden, Ranking Member Crapo, and members of the committee,
thank you for the opportunity to discuss flexibilities related to
Medicare and Medicaid that were made available during the current
public health emergency. More than a year after the Secretary of the
Department of Health and Human Services (HHS) first declared a public
health emergency for the U.S. and the World Health Organization
characterized the Coronavirus Disease 2019 (COVID-19) as a pandemic,
COVID-19 continues to result in catastrophic loss of life and
substantial damage to the global economy, stability, and security.\1\
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\1\ On January 31, 2020, the Secretary of HHS declared a public
health emergency for the U.S., retroactive to January 27th.
Subsequently, on March 13, 2020, the President declared COVID-19 a
national emergency under the National Emergencies Act and a nationwide
emergency under section 501(b) of the Robert T. Stafford Disaster
Relief and Emergency Assistance Act (Stafford Act). See 50 U.S.C.
Sec. 1601 et seq. and 42 U.S.C. Sec. 5121 et seq. The President has
also approved major disaster declarations under the Stafford Act for
all 50 States, the District of Columbia, and five territories.
In response to COVID-19, the Centers for Medicare and Medicaid
Services (CMS), the Federal agency responsible for overseeing Medicare
and Medicaid, provided increased Federal funding and made widespread
use of program waivers and other flexibilities to expand the
availability of services, maintain access for beneficiaries, and give
providers more flexibility in treating beneficiaries. For example, CMS
issued waivers to expand telehealth services in Medicare fee-for-
service (FFS).\2\ Many of these waivers and flexibilities CMS granted
were to States, which administer their Medicaid programs within broad
Federal rules and according to State plans that CMS approves.
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\2\ Medicare FFS consists of two separate parts: Medicare Part A,
which primarily covers hospital services, and Medicare Part B, which
primarily covers outpatient services. Medicare FFS beneficiaries may
also enroll in Medicare Part D, which offers prescription drug
coverage. Telehealth services include certain clinical services that
are typically furnished in person but are instead provided remotely via
telecommunications technologies. By law, Medicare FFS generally only
pays for these services under limited circumstances; such as when the
patient is located in certain health-care settings and certain (mostly
rural) geographic locations.
The CARES Act includes a provision for us to conduct monitoring and
oversight of the Federal Government's efforts to prepare for, respond
to, and recover from the COVID-19 pandemic.\3\ In response, we issued
government-wide reports on the Federal efforts, have examined and
reported on Medicare and Medicaid flexibilities during the pandemic,
and we have ongoing work examining related topics such as Medicare and
Medicaid telehealth waivers.\4\
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\3\ Pub. L. No. 116-136, Sec. 19010(b), 134 Stat. 281, 580 (2020).
\4\ GAO, COVID-19: Opportunities to Improve Federal Response and
Recovery Efforts, GAO-20-625 (Washington, DC: June 25, 2020); GAO,
COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal
Response, GAO-21-191 (Washington, DC: November 30, 2020); GAO, COVID-
19: Sustained Federal Action Is Crucial as Pandemic Enters Its Second
Year, GAO-21-387 (Washington, DC: March 31, 2021).
My testimony today will summarize key findings from issued reports
as well as preliminary observations from our ongoing work related to
expanded telehealth services in the Medicare and Medicaid programs and
flexibilities related to the provision of Medicaid home- and community-
based services during the COVID-19 pandemic.\5\ In particular, my
statement will address: (1) what is known about the effects of Medicare
waivers on the Medicare fee-for-service program; (2) what is known
about the effects of Medicaid waivers and flexibilities on the Medicaid
program; and (3) considerations for the ongoing use of these waivers
and flexibilities for Medicare and Medicaid.
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\5\ Medicaid home- and community-based services cover a wide range
of services and supports to help individuals remain in their homes or
live in a community setting, such as personal assistance with daily
activities, assistive devices, and case management services to
coordinate services and supports that may be provided from multiple
sources.
In developing this statement, we relied primarily on reports we
issued from June 2020 to March 2021. For our previously issued reports
on which my comments are based, we reviewed applicable Federal laws;
CMS documents, including guidance on program waivers and guidance to
States on resuming normal operations after the end of the public health
emergency; CMS written responses to questions regarding Medicare
waivers; and our prior work related to Medicare and Medicaid. We also
interviewed Medicaid officials from selected States regarding
flexibilities they requested during the COVID-19 pandemic.\6\ More
detailed information on the scope and methodology for our past work can
be found in these published reports.
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\6\ For more information about the scope and methods for our past
work, please see our enclosures on Medicaid Enrollment, Spending, and
Flexibilities; Medicaid Spending; Medicaid Financing, Waivers, and
Flexibilities; Medicare Telehealth Waivers; and Medicare Waivers.
My comments also include preliminary observations from ongoing
work, including interviews with CMS officials and representatives from
six beneficiary advocacy and provider groups, selected based on their
experience with telehealth services and Medicare telehealth waivers, as
well as Medicaid waivers and flexibilities.\7\ We reviewed CMS
documents and other published research on the effects of Medicare
telehealth waivers on these types of services during the pandemic. In
particular, we reviewed a January 2021 report from CMS on the
preliminary effects of some Medicare and Medicaid waivers on both
programs--including the effect of telehealth waivers on Medicare
utilization of services.\8\ We also reviewed data from the Kaiser
Family Foundation on Medicaid waivers and flexibilities.\9\ We reviewed
the utilization data and Medicaid waivers and flexibilities data for
any obvious errors and determined these data were sufficiently reliable
for the purpose of our objectives.
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\7\ The provider groups included umbrella organizations
representing four broad specialty types--primary care, medical,
surgical, and mental and behavioral health specialties. We also
interviewed two beneficiary advocacy groups with knowledge of Medicare
beneficiaries' experience with Medicare telehealth.
\8\ See Centers for Medicare and Medicaid Services, Putting
Patients First: The Centers for Medicare and Medicaid Services' Record
of Accomplishments from 2017-2020 (January 13, 2021). We refer to this
report as the CMS ``Accomplishment Report'' throughout this report.
\9\ See Kaiser Family Foundation, Medicaid Emergency Authority
Tracker: Approved State Actions to Address COVID-19, accessed May 10,
2021, https://www.kff.org/coronavirus-covid-19/issue-brief/medicaid-
emergency-authority-tracker-approved-state-actions-to-address-covid-
19/.
We shared our preliminary observations from this ongoing work with
CMS officials to obtain their views. CMS officials provided us with
---------------------------------------------------------------------------
technical comments, which we incorporated as appropriate.
We conducted the work upon which this statement is based in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
background
Medicare Waivers and Flexibilities
In 2020, Medicare--the federally financed health insurance program
for persons aged 65 or over, certain individuals with disabilities, and
individuals with end-stage renal disease--spent about $910 billion on
health-care services provided to about 62.8 million Medicare
beneficiaries.\10\ Providers and suppliers furnishing services to
beneficiaries must comply with Medicare requirements and conditions of
participation that are set in statute and regulations. In response to
COVID-19, CMS expanded the availability of Medicare services through
widespread use of program waivers. Specifically, section 1135 of the
Social Security Act authorizes the Secretary of HHS to temporarily
waive or modify certain Federal health-care requirements, including in
the Medicare program, to increase access to medical services when both
a public health emergency and a disaster or emergency have been
declared.\11\ The Administrator of CMS typically implements section
1135 waivers for Medicare.
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\10\ Total Medicare spending is for fiscal year 2020 and from the
Centers for Medicare and Medicaid Services' Office of Financial
Management. Count of Medicare beneficiaries is for calendar year 2020
and from the Centers for Medicare and Medicaid Services' Medicare
Enrollment Dashboard. See https://www.cms.gov/Research-Statistics-Data-
and-Systems/Statistics-Trends-and-Reports/CMSProgramStatistics/
Dashboard; accessed May 12, 2021.
\11\ See 42 U.S.C. Sec. 1320b-5 (authority to waive requirements
during national emergencies).
The president authorized HHS to issue waivers under section 1135
beginning March 1, 2020. This authority will end no later than the
termination of one of the underlying emergencies or 60 days from the
date the waiver is published, unless the Secretary extends it for
---------------------------------------------------------------------------
additional periods of up to 60 days.
There are two types of Medicare 1135 waivers:
Blanket waivers apply automatically to all applicable
providers and suppliers in the emergency area, which encompasses the
entire United States in the case of the COVID-19 pandemic. Providers
and suppliers do not need to apply individually or notify CMS that they
are acting upon the waiver. They are required to comply with normal
rules and regulations as soon as it is feasible to do so.
Provider/supplier individual waivers may be issued upon
application for States, providers, or suppliers only if an existing
blanket waiver is not sufficient.
Congress also enacted legislation to expand the Secretary's
authority to temporarily waive or modify application of certain
Medicare requirements, such as the geographic restrictions on where
telehealth services can be provided. The Coronavirus Preparedness and
Response Supplemental Appropriations Act, 2020, amends section 1135 of
the Social Security Act to allow the Secretary to waive certain
Medicare telehealth payment requirements during the emergency
period.\12\ The CARES Act further expands the Secretary's authority to
waive telehealth requirements during the emergency period.\13\
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\12\ Pub. L. No. 116-123, Div. B, Sec. 102, 134 Stat. 146, 155-157
(adding 42 U.S.C. Sec. 1320b-5(b)(8)).
\13\ Pub. L. No. 116-136, Sec. 3703, 134 Stat. 281, 416 (2020)
(amending 42 U.S.C. Sec. 1320b-5(b)(8)).
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Medicaid Waivers and Flexibilities
Medicaid is one of the Nation's largest sources of funding for
health-care services for low-income and medically needy individuals,
covering an estimated 77 million people and spending an estimated $673
billion (total Federal and State) in fiscal year 2020. Medicaid allows
significant flexibility for States to design and implement their
programs. For example, States can request waivers of certain Federal
requirements to target certain populations or to test new or innovative
approaches for managing the health-care needs of beneficiaries. In
addition to its normal authority to approve these State waiver
applications, CMS has additional authorities to waive Medicaid
requirements to help ensure the availability of care in certain
emergency circumstances.
Since the beginning of the COVID-19 pandemic, CMS has issued
guidance to States on implementing various flexibilities and on
resuming normal activities once the public health emergency has ended.
(See fig. 1.)
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
For example, CMS created and released four templates to help
States receive Federal waivers and assist them in identifying other
authorities to implement program flexibilities more efficiently.
Specifically, CMS issued templates for four authorities for the
following purposes:
Medicaid disaster State plan amendments: To revise or
implement new policies in Medicaid State plans related to eligibility,
enrollment, benefits, premiums and cost sharing, or payments in
response to a public health emergency or disaster.
Section 1115(a) demonstrations: To furnish medical assistance
in a manner intended to protect, to the greatest extent possible, the
health, safety, and welfare of individuals and providers who may be
affected by COVID-19.\14\
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\14\ Under section 1115 of the Social Security Act, the Secretary
of HHS may waive certain Federal Medicaid requirements and approve
expenditures that would not otherwise be eligible for Federal Medicaid
funds for certain experimental, pilot, or demonstration projects that,
in the Secretary's judgment, are likely to promote Medicaid objectives.
Section 1135 waivers: To temporarily waive or modify certain
Medicaid requirements to ensure that sufficient health-care items and
services are available to meet the needs of individuals enrolled in the
respective programs and that health-care providers that furnish such
items and services in good faith, but are unable to comply with one or
more of such requirements as a result of the COVID-19 pandemic, may be
reimbursed for such items and services and exempted from sanctions for
---------------------------------------------------------------------------
such noncompliance, absent any determination of fraud or abuse.
Section 1915(c), Appendix K waivers: To request amendment to
an approved section 1915(c) home and community-based waiver authority
to respond to an emergency, for example, expanding the pool of
providers authorized to provide waiver services such as personal
care.\15\
---------------------------------------------------------------------------
\15\ Under section 1915(c) of the Social Security Act, the
Secretary of HHS may waive requirements that States offering home- and
community-based services offer comparable benefits statewide and to all
eligible beneficiaries, and that they use a single standard for
eligibility.
---------------------------------------------------------------------------
full effects of medicare waivers not yet known; preliminary analysis
indicates medicare fee-for-service telehealth waivers increased
utilization and access
CMS Has Issued Hundreds of Medicare Waivers During the COVID-19
Pandemic
According to the CMS Accomplishment Report, as of January 2021, CMS
had issued over 130 blanket Medicare waivers nationwide since the start
of the pandemic. The blanket waivers cover flexibilities for hospitals,
skilled nursing facilities, home health agencies, and hospices, among
others. They also cover flexibilities for providers, including
licensing and enrollment, to the extent these flexibilities are
consistent with applicable State laws, State emergency preparedness
plans, and State scope of practice rules. For example, CMS waived or
modified certain telehealth provisions to increase access to services
and give providers more flexibility in treating beneficiaries.
In addition to blanket waivers of statutory requirements, CMS also
reported that as of January 2021, it had issued over 100 Medicare
waivers under its authority to waive or modify its policies or
regulations in response to the pandemic. CMS has since made some of
these waivers permanent.\16\ Table 1 provides examples of changes that
CMS approved, including under blanket waivers.\17\
---------------------------------------------------------------------------
\16\ For example, in December 2020, CMS announced it was
permanently adding certain new services (including mental health and
care planning services) that it had temporarily added to the approved
list of Medicare telehealth services during the pandemic.
\17\ For more information on all COVID-19 related waivers approved
by CMS, see Centers for Medicare and Medicaid Services, Coronavirus
Waivers and Flexibilities, accessed May 11, 2021, https://www.cms.gov/
about-cms/emergency-preparedness-response-operations/current-
emergencies/coronavirus-waivers.
Table 1: Examples of Medicare Waivers CMS Approved, PSince March 13,
2020
------------------------------------------------------------------------
Waiver Changes
------------------------------------------------------------------------
Increased capacity Expand hospital capacity--for example,
hospitals may provide patient care at
nonhospital buildings or spaces provided that
the location is approved by the State, and
hospitals may treat patients in their own
homes.a
Allow hospitals to set up alternative
screening sites on campus to perform medical
screening examinations as a triage function.b
Waive sanctions for certain referrals that
would otherwise violate the Physician Self-
Referral law that generally prohibits a
physician from making referrals for certain
health-care services to an entity with which
the physician (or an immediate family member)
has a financial relationship, unless an
exception applies.c
------------------------------------------------------------------------
Workforce expansion Expedite process for provider enrollment in
Medicare, including expediting pending or new
applications and waiving certain criminal
background checks.
Allow physicians whose privileges to
practice at a hospital will expire to
continue practicing at the hospital and
allowing new physicians to begin practicing
before full approval.
------------------------------------------------------------------------
Reducing administrative Temporarily eliminate certain reporting and
burdens other paperwork requirements that providers
must complete to be paid by Medicare, such as
program audits that may require additional
information from providers.
------------------------------------------------------------------------
Expansion of telehealth Allow telehealth services to be provided
services nationwide, rather than only in certain
locations.
Allow beneficiaries to receive, and
providers to furnish, telehealth services
from any setting, including beneficiaries'
and providers' homes.
Allow additional types of providers, such as
physical and occupational therapists, to
furnish telehealth services.
Temporarily add over 146 new telehealth
services.
Allow certain services to be furnished using
audio-only technology such as telephones,
instead of interactive systems involving
video technology.
------------------------------------------------------------------------
Source: GAO analysis of Centers for Medicare and Medicaid Services (CMS)
information. | GAO-21-575T
a Hospitals typically must meet certain requirements to participate in
Medicare, including providing services within their own buildings.
b By law, any Medicare-participating hospital with a dedicated emergency
department must provide a medical screening examination and, if
necessary, stabilizing treatment to any individual who arrives in its
emergency department for examination or treatment, regardless of the
ability to pay for the services.
c Entities that submit claims for services furnished pursuant to a
prohibited referral are subject to financial sanctions.
Full Effects of Medicare Waivers Are Not Yet Known
Information on the full effects of Medicare waivers and
flexibilities is not yet available. However, in its Accomplishment
Report, CMS provided information on certain flexibilities in January
2021. For example:
Expansion of hospital capacity. CMS reported that the waiver
permitting hospitals to use non-hospital buildings and spaces to be
used for patient care and quarantine sites (subject to State approval),
has expanded access to care during the pandemic. For example, according
to CMS, as of January 2021, 116 facilities in Texas were enrolled as
hospital sites under a waiver that allowed ambulatory care centers and
freestanding emergency centers to enroll as hospitals--thus increasing
access to care. Additionally, CMS reported as of January 7, 2021, it
had approved 63 hospitals in 21 States nationwide to participate in the
waiver that allowed hospitals to treat patients in their own homes.\18\
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\18\ These include six health systems with extensive pre-pandemic
experience providing acute hospital care at home--Brigham and Women's
Hospital (Massachusetts); Huntsman Cancer Institute (Utah);
Massachusetts General Hospital (Massachusetts); Mount Sinai Health
System (New York City); Presbyterian Healthcare Services (New Mexico);
and UnityPoint Health (Iowa).
Workforce expansion. CMS reported that the removal of certain
barriers regarding licensure and scope of practice has expanded the
provider workforce enabling health professionals to provide services
they were otherwise not eligible to provide, subject to State law. For
---------------------------------------------------------------------------
example,
Certain non-physician practitioners such as nurse
practitioners and physician assistants can supervise the performance of
diagnostic tests, subject to State law.
Occupational therapists from home health agencies can now
perform initial assessments on certain homebound patients, allowing
home health services to start sooner and freeing home- health nurses to
do more direct patient care.
However, the Accomplishment Report did not contain information on
the extent to which these added flexibilities have resulted in greater
access to services for Medicare beneficiaries.
CMS's Accomplishment Report also did not contain information on the
effects of other flexibilities--including waivers granting provider
enrollment flexibilities or waivers that reduced administrative
burdens--on Medicare services during the pandemic. In future work, we
will examine the impact of these and other waivers and flexibilities
that HHS issued in response to the pandemic.
Medicare Telehealth Waivers Increased Utilization and Access
As we reported in November 2020, Medicare telehealth waivers
resulted in increased utilization of telehealth services, and provided
beneficiaries access to services that would not have otherwise been
available during the early days of the COVID-19 pandemic. However, the
long-term effect of these waivers on spending and quality of care is
not yet known.\19\ In addition, we reported that careful monitoring and
oversight is warranted to prevent potential fraud, waste, and abuse
that can arise from these new waivers. Existing research and
preliminary observations from our ongoing work indicate the following
effects of telehealth waivers on service utilization and access to
care.
---------------------------------------------------------------------------
\19\ See GAO-21-191.
Available analysis from the CMS Accomplishment Report indicates
that over the first 8 months of the pandemic, utilization of telehealth
services in Medicare FFS sharply increased from about 325,000 services
in mid-March to a peak of nearly 1.9 million services in late-
April.\20\ Utilization then dropped to about 1.3 million services by
the beginning of June, and generally continued to slowly drop through
mid-
October, as shown in figure 2.\21\
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\20\ The data for this analysis are based on Medicare FFS claims
submitted through November 13, 2020. These figures include telehealth
services as well as other services such as virtual check-ins and e-
visits, which collectively CMS defines as telemedicine. Virtual check-
ins are short patient-initiated communications with a health-care
practitioner through different technologies including by phone or
video. E-visits are non-face-to-face patient-initiated communications
through an online patient portal. Medicare covered and paid for virtual
check-ins and e-visits prior to the pandemic.
\21\ CMS did not provide data on corresponding utilization of in-
person services for all services furnished via telehealth during this
time. An analysis of telehealth utilization of primary care services
from the Department of Health and Human Services' Office of the
Assistant Secretary for Planning and Evaluation showed similar trends
in telehealth utilization. Their analysis also showed that while
telehealth primary care services were peaking from mid-March through
mid-April, in-person services were precipitously dropping during this
time, and that the peak in telehealth services was not sufficient to
offset the drop in in-person services. See Department of Health and
Human Services, Assistant Secretary for Planning and Evaluation,
Medicare Beneficiary Use of Telehealth Visits: Early Data from the
Start of COVID-19 Pandemic (Washington, DC: July 28, 2020).
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
This utilization varied by the type of service, the specialty
of the provider, and the telehealth modality (audio-video or audio
only). For example, CMS reported that nearly 40 percent of
beneficiaries receiving office visits received them through telehealth
compared to nearly 60 percent for mental health services. CMS also
reported that internists and family practitioners furnished about one-
quarter of their services through telehealth compared to virtually none
for other specialties. In addition, CMS reported that many (89 out of
146) of the newly available types of telehealth services could be
---------------------------------------------------------------------------
furnished through landline phones.
Moreover, CMS reported that telehealth waivers played a critical
role in maintaining access to services when beneficiaries and providers
were concerned about the transmission of COVID-19. For example, before
the pandemic, approximately 13,000 beneficiaries in Medicare FFS had
received telehealth services in a week, compared to almost 1.7 million
in the last week of April. CMS also reported that there was some
variation in the levels of access among various groups of beneficiaries
utilizing telehealth services. For example, a slightly higher
proportion of beneficiaries below the age of 65 received a telehealth
service, compared to groups aged 65 and over; the proportion of
beneficiaries receiving telehealth services in urban areas was slightly
higher than in rural areas; but the proportion of beneficiaries
utilizing telehealth was similar across racial and ethnic groups. (See
fig. 3.)
Preliminary observations from our interviews with groups
representing providers and beneficiaries confirmed flexibilities
enabled beneficiaries to continue accessing care. Specifically,
representatives we interviewed from two provider groups said providers
quickly adopted and furnished telehealth services in the early days of
the pandemic, but as patients became more comfortable coming into the
office or clinic, in-person appointments resumed. Representatives from
one provider group also told us that they relied more heavily on audio-
only or phone visits rather than video visits in the early days of the
pandemic and switched later on to offering only in-person or video
visits. Interviews with two groups representing beneficiaries indicated
that telehealth flexibilities have enabled beneficiaries to access care
from home during the pandemic, as well as the ability to seek care in a
timely manner, reduce travel time, and triage their health issues to
determine if an in-person visit is needed.
However, as we noted in our June 2020 report, telehealth waivers
may not alleviate all access concerns.\22\ Further, a recent study
found that more than 26 percent of Medicare beneficiaries lack digital
access at home in 2018, making it unlikely that they could have video-
based telehealth visits with clinicians.\23\ The proportion of
beneficiaries in this study who lacked digital access was higher among
those with low socioeconomic status, those 85 years or older, and in
communities of color. Preliminary observations from our beneficiary and
provider group interviews is consistent with these findings. For
example, representatives from the two beneficiary groups and three
groups representing providers told us that some beneficiaries were
unable to access telehealth services due to lack of technology or
broadband needed for a telehealth visit or they did not understand how
to use the technology.
---------------------------------------------------------------------------
\22\ See GAO-20-625.
\23\ Eric Roberts and Ateev Mehrotra, ``Assessment of Disparities
in Digital Access Among Medicare Beneficiaries and Implications for
Telemedicine,'' The Journal of American Medical Association Internal
Medicine, vol. 180, no. 10 (2020): pp. 1386-1389.
Furthermore, the quality of telehealth services provided to
Medicare beneficiaries has not yet been fully analyzed, and evidence
from the few existing studies is inconclusive. According to MedPAC,
some researchers have concluded that, in addition to increasing access
to care, telehealth can also improve the quality of care.\24\ Other
researchers caution that the convenience of telehealth could harm the
quality of patient care.\25\ CMS officials told us in February 2021
that they are still exploring how to measure the quality of care when
services are delivered via telehealth.
---------------------------------------------------------------------------
\24\ For example, in 2018 MedPAC reported that telestroke services
both expanded access to care and likely improve the quality of care
because the timeliness of stroke treatment could be improved. MedPAC,
Report to Congress: Medicare Payment Policy (March 2018): 496.
\25\ For example, a 2015 study of patients receiving treatment for
acute respiratory infections found that physicians providing care
through telehealth prescribed more expensive antibiotics that could
increase antibiotic resistance in patients than antibiotics prescribed
by physicians providing in-person care. See L. Uscher-Pines, et al.,
``Antibiotic Prescribing for Acute Respiratory Infections in Direct-to-
Consumer Telemedicine Visits,'' JAMA Internal Medicine, vol. 175, no. 7
(2015).
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
NOTE: THESE FIGURES INCLUDE TELEHEALTH SERVICES AS WELL AS OTHER
SERVICES SUCH AS VIRTUAL CHECK-INS AND E-VISITS,
WHICH COLLECTIVELY CMS DEFINES AS TELEMEDICINE.
VIRTUAL CHECK-INS ARE SHORT PATIENT-INITIATED
COMMUNICATIONS WITH A HEALTH-CARE PRACTITIONER
THROUGH DIFFERENT TECHNOLOGIES INCLUDING BY PHONE
OR VIDEO. E-VISITS ARE NON-FACE-TO-FACE PATIENT-
INITIATED COMMUNICATIONS THROUGH AN ONLINE PATIENT
PORTAL. MEDICARE COVERED AND PAID FOR VIRTUAL
CHECK-INS AND E-VISITS PRIOR TO THE PANDEMIC.
temporary state medicaid flexibilities aimed to address obstacles to
beneficiary care, provider availability, and program enrollment;
effects not fully known
CMS-approved Medicaid waivers and flexibilities in all States were
aimed at addressing obstacles that affect beneficiary care and provider
availability, among other areas. In December 2020, CMS reported that
the agency had approved more than 600 different Medicaid waivers, State
plan amendments, and other flexibilities to offer States flexibility in
responding to the COVID-19 pandemic. Some of the Medicaid flexibilities
focused on facilitating beneficiary access to care and beneficiary
safety. For example, CMS approved flexibilities regarding the provision
of long- term services and supports to beneficiaries who receive care
in facilities or in their homes and who were particularly vulnerable to
exposure and disease. Other flexibilities focused on ensuring provider
availability, such as allowing licensed out-of-State providers to
enroll in a State's Medicaid program. (See table 2.)
Table 2: Examples of State Medicaid Waivers and Flexibilities Approved
by CMS, March 2020 to May 2021
------------------------------------------------------------------------
Focus Specific State Flexibilities Approved
------------------------------------------------------------------------
Beneficiary care and Forty-three States suspended fee-for-service
safety prior authorizations, which are used to
demonstrate compliance with coverage and
payment rules before beneficiaries can obtain
certain services, rather than after the
services have been provided.a
Forty-nine States extended the dates for
reassessing and reevaluating beneficiaries'
needs, which are normally required for
beneficiaries to retain eligibility for some
home- and community-based services.b
Fifty States permitted virtual evaluations,
assessments, and Pperson-centered planning
for beneficiaries receiving long-term
services and supports normally conducted in
person.b
Fifty-one States issued program guidance to
expand coverage and access to telehealth
services.c
Nine States allowed early refills for most
medications.c
------------------------------------------------------------------------
Provider availability Fifty-one States waived some requirements to
allow licensed out-of-State providers to
enroll in their programs to maintain provider
capacity.a, d
Twelve States modified facility requirements
to allow services to be provided from
practitioner's location via telehealth.c
Fifty-one States waived certain provider
screening and enrollment requirements during
the pandemic.
------------------------------------------------------------------------
Source: GAO analysis of Centers for Medicare and Medicaid Services (CMS)
information complied by Kaiser Family Foundation, Medicaid Emergency
Authority Tracker: Approved State Actions to Address COVID-19,
accessed May 10, 2021, https://www.kff.org/coronavirus-covid-19/issue-
brief/medicaid-emergency-authority-tracker-approved-state-actions-to-
address-covid-19/. | GAO-21-575T
Note: For purposes of the table, States include the 50 States and the
District of Columbia.
a States received approval under section 1135 of the Social Security
Act, which authorizes the Secretary of Health and Human Services to
temporarily waive or modify certain Federal health-care program
requirements, including Medicaid requirements, to ensure that
sufficient health-care items and services are available to meet the
needs of enrollees when both a public health emergency and a disaster
or emergency have been declared.
b States received approval to make changes to their section 1915(c) home-
and community-based services waivers under an Appendix K amendment in
order to respond to the emergency.
c States received approval to revise policies in their Medicaid State
plan related to eligibility, enrollment, benefits, premiums and cost
sharing, and payments. To make these changes, States must submit a
State Plan Amendment to CMS for approval.
d States approved to temporarily enroll licensed out-of-State providers
must follow certain requirements, which include screening providers to
ensure they are enrolled in the Medicaid program and licensed in the
State relating to their Medicaid enrollment. Waiver of these Federal
requirements does not affect State or local licensure requirements.
Among these flexibilities, we have reported that efforts to remove
obstacles to beneficiary access to care, such as the use of telehealth,
were among the most important during the COVID-19 pandemic.\26\ A
Medicaid official we interviewed in one State said that flexibilities
permitting virtual evaluations provided Medicaid beneficiaries with an
added sense of security and safety while providing needed care. We have
ongoing work examining States' experiences using waivers to maintain
safe access to home- and community-based services. To reduce in- person
contact between beneficiaries and providers, CMS has approved waivers
allowing family to become paid caregivers. In addition, waivers have
been used to make retainer payments to certain providers to support and
maintain the provider network.
---------------------------------------------------------------------------
\26\ See GAO-21-387.
In addition to waivers, recent statutory changes have aimed at
maintaining Medicaid enrollment. For example, the Families First
Coronavirus Response Act provided a temporary increase in the Federal
Government's matching rate for States' and territories' spending for
Medicaid services for all qualifying States through the end of the
quarter in which the public health emergency, including any extensions,
ends. To receive the increased matching rate, States and territories
were required to meet certain conditions, such as maintaining Medicaid
enrollment for certain beneficiaries through the end of the month in
which the public health emergency ends.\27\ In March 2021, we reported
that from February 2020 through August 2020, Medicaid enrollment
increased by 5.6 million, or 9 percent.\28\
---------------------------------------------------------------------------
\27\ Specifically, States must provide continuous coverage to
Medicaid beneficiaries who were enrolled in Medicaid on or after March
18, 2020, regardless of any changes in circumstances or
redeterminations at scheduled renewals that otherwise would result in
termination, through the end of the month in which the public health
emergency ends, among other requirements. States may terminate coverage
for individuals who request a voluntary termination of eligibility, or
who are no longer considered to be residents of the State.
\28\ See GAO-21-387.
Some preliminary effects of CMS-approved waivers and flexibilities
and other flexibilities States permitted through law are known. CMS has
reported an increase in telehealth utilization since the pandemic
began--in particular, soon after the national emergency was declared.
CMS has also reported variation in the use of telehealth across States
and across ages within States.\29\ As an example of this variation, in
January 2021, a North Carolina Medicaid official reported that
beneficiaries in urban geographies were more likely to use services
delivered via telehealth than beneficiaries in rural geographies.
---------------------------------------------------------------------------
\29\ See CMS, Medicaid and CHIP COVID-19 Summaries, Preliminary
Medicaid and CHIP Data Snapshot of Services through July 31, 2020,
accessed May 10, 2021, https://www.medicaid.gov/state-resource-center/
downloads/covid19-data-snapshot.pdf.
---------------------------------------------------------------------------
program integrity, beneficiary health and safety, and equity are among
considerations for the continued use of waivers and flexibilities
implemented during the pandemic
The waivers and flexibilities implemented in Medicare and Medicaid
during the COVID-19 pandemic likely benefited providers and
beneficiaries, yet determining whether--and if so, how--to continue
them post-pandemic warrants consideration. CMS has made some Medicare
waivers permanent, and, based on interest from policymakers and
stakeholders, is considering doing so for other waivers. With respect
to Medicaid, CMS has set an end date for some of the waivers and
flexibilities and has issued guidance to States in December 2020 on
resuming normal Medicaid operations after the end of the public health
emergency.\30\ In light of these impending decisions, our past work and
the work of others suggest there are several issues, including program
integrity, beneficiary health and safety, and equity, to consider.
---------------------------------------------------------------------------
\30\ See CMS, RE: Planning for the Resumption of Normal State
Medicaid, Children's Health Insurance Program (CHIP), and Basic Health
Program (BHP) Operations Upon Conclusion of the COVID-19 Public Health
Emergency (Baltimore, MD: December 22, 2020).
Potential for increased spending. As we have previously reported,
telehealth and other waivers pose risks of increased spending in both
---------------------------------------------------------------------------
programs. Specifically,
Recent data from the CMS Accomplishment Report indicates
telehealth services continued as in-person visits began to ramp up in
the third quarter of 2020. This suggests that increased demand for
telehealth may continue even after the pandemic--an important
consideration given payment incentives that may result from paying the
same for telehealth and in-person services. One provider group that we
interviewed also noted that these incentives may be particularly
relevant for specialties that can provide and be paid for both in-
person and additional telehealth services they generate compared to
other procedure-based specialties that receive more global payments
regardless of the number of visits they generate.
The temporary waiver of sanctions for certain referrals that
would otherwise violate the Physician Self-Referral Law may increase
the potential for increased spending in both programs given our prior
work indicating that providers who self-refer tended to use more
health-care services.\31\
---------------------------------------------------------------------------
\31\ GAO, Medicare Physical Therapy: Self-Referring Providers
Generally Referred More Beneficiaries but Fewer Services per
Beneficiary, GAO-14-270 (Washington, DC: April 30, 2014); GAO,
Medicare: Higher Use of Costly Prostate Cancer Treatment by Providers
Who Self-Refer Warrants Scrutiny, GAO-13-525 (Washington, DC: July 19,
2013); GAO, Medicare: Action Needed to Address Higher Use of Anatomic
Pathology Services by Providers Who Self-Refer, GAO-13-445 (Washington,
DC: June 24, 2013); GAO, Medicare: Referrals to Physician-Owned Imaging
Facilities Warrant HCFA's Scrutiny, GAO/HEHS-95-2 (Washington, DC:
October 20, 1994).
Program integrity. Both the Medicare and Medicaid programs are on
GAO's High-Risk List, in part due to concerns about fraud, waste, and
abuse.\32\ Increased program spending, the lack of complete data, and
suspensions of some program safeguards increase these risks. For
example:
---------------------------------------------------------------------------
\32\ GAO, High-Risk Series: Dedicated Leadership Needed to Address
Limited Progress in Most High-Risk Areas, GAO-21-119SP (Washington, DC:
March 2, 2021).
CMS lacks complete data to determine the telehealth modality
being used (audio only or audio-video technology) or if services are
originating from providers' and beneficiaries' homes, important
information to consider in light of the aforementioned payment
incentives and that the quality of telehealth services has not yet been
---------------------------------------------------------------------------
fully analyzed.
The non-enforcement of certain privacy and security rules to
allow for telehealth flexibility raises concerns about the transmission
of medical information over potentially insecure systems.\33\
---------------------------------------------------------------------------
\33\ The HHS Office of Civil Rights (responsible for enforcing
certain regulations relating to privacy and security of protected
health information) stated that it would exercise enforcement
discretion and not impose penalties for noncompliance with regulatory
requirements during the pandemic.
In our ongoing work, CMS officials have noted oversight activities
---------------------------------------------------------------------------
related to program integrity. As examples:
CMS is using its Fraud Prevention System to identify
potentially inappropriate Medicare claims for telehealth services prior
to payment and to flag providers with suspicious billing patterns
through post- payment screens.
CMS is conducting and updating program integrity risk
assessments for all Medicaid waivers and flexibilities issued as a
result of the pandemic.
Beneficiary health and safety. Providing services while limiting
beneficiary exposure to COVID-19 has been a difficult balance for CMS
and states--and telehealth has been a large part of these efforts. The
pandemic has also given rise to new levels of need for behavioral
health care--both mental health and substance use disorders--while
behavioral health service providers reported increasing demand and
decreasing staff size.\34\ Extending or ending waivers and
flexibilities may affect beneficiary health and safety in unknown ways.
---------------------------------------------------------------------------
\34\ GAO, Behavioral Health: Patient Access, Provider Claims
Payment, and the Effects of the COVID-19 Pandemic, GAO-21-437R
(Washington, DC: March 31, 2021).
In Medicare, we have previously reported that the effect of
COVID-19 related waivers on quality of care is not yet known. We also
noted earlier that the quality of telehealth services has not been
fully analyzed, and evidence from the few existing studies is
---------------------------------------------------------------------------
inconclusive.
In Medicaid, preliminary data from CMS show outpatient mental
health services for adults age 19 to 64 declined starting in March and
continuing through July--despite CMS approving waivers and
flexibilities to help ensure the availability of care.
Expedited processes for provider enrollment, including waivers
of normal screening and criminal background checks, could affect the
quality of care provided to beneficiaries in both programs.
Issues of equity. We have previously reported that communities of
color have been disproportionately affected by COVID-19 in terms of
cases reported, hospitalizations, deaths, and rates of testing and
vaccinations.\35\ Disparate effects from COVID-19 extend to
beneficiaries' receipt of services, as well. As we noted earlier,
beneficiaries in urban areas received or were more likely to use
telehealth services than beneficiaries in rural areas both in Medicare
and in one State's Medicaid program. To ensure that all beneficiaries
receive the best care possible, how waivers and flexibilities in both
programs account for equity is an important consideration.
---------------------------------------------------------------------------
\35\ For example, Non-Hispanic black persons were hospitalized at
almost 3 times the rate of non-Hispanic white persons when adjusting
for age, and their death rates were 1.4 times higher than non-Hispanic
white persons. See GAO-21-387.
In summary, my testimony highlighted the various flexibilities and
waivers implemented during the COVID-19 pandemic and provided
preliminary information on how these flexibilities have likely
benefitted providers and beneficiaries. Continuing these flexibilities
after the public health emergency declarations end could increase
certain risks to the Medicare and Medicaid programs. Careful
consideration of these benefits and risks will be key to determining
the path forward, especially given that both programs are on GAO's
High-Risk List. We look forward to working with Congress as we continue
---------------------------------------------------------------------------
our oversight of the Federal response to the COVID-19 pandemic.
Chairman Wyden, Ranking Member Crapo, and members of the committee,
this completes my prepared statement. I would be pleased to respond to
any questions that you may have at this time.
______
Questions Submitted for the Record to Jessica Farb
Questions Submitted by Hon. Catherine Cortez Masto
Question. In your written testimony, you noted that the quality of
telehealth services has not been fully analyzed.
What kind of information does GAO or CMS need to paint a complete
picture of care quality when it comes to telehealth?
Answer. We will report on CMS's progress on this topic in our
ongoing work on Medicare and Medicaid telehealth services, which we
expect to issue in late 2021 and early 2022, respectively. As we
reported in our testimony, CMS officials told us in February 2021 that
they are still exploring how to measure the quality of telehealth
services. Several organizations have been involved in developing
quality measures for services delivered via telehealth. For example, in
2017 the National Quality Forum (NQF) developed a framework for
measuring the quality of telehealth services, through a project funded
by CMS. In January 2021, NQF announced that CMS had tasked it with
updating the framework in light of the recent uptick in telehealth use.
Question. In your written testimony, you noted a couple of
instances where the COVID-19 flexibilities benefit different
populations disproportionately. Telehealth, for example, was utilized
more by urban populations than their rural counterparts. One of the
flexibilities enabled providers to deliver services within their scope
of practice that they're normally not eligible to provide to Medicare
beneficiaries. Typically, we see these scope expansions as
disproportionately benefitting rural areas where provider shortages are
more acute.
Has GAO found any patterns in the benefits of these scope
expansions?
Answer. As we reported in our testimony, CMS provided certain
Medicare scope of practice flexibilities during the pandemic to allow
health professionals to provide services that they were not otherwise
permitted to provide. For example, CMS allowed certain nonphysicians to
supervise the performance of diagnostic tests that they were otherwise
not eligible to provide, as permitted under State law. CMS data show
that the proportion of beneficiaries in rural areas using telehealth
significantly increased from October 2019 through June 2020. It is not
clear how much of this increase was due to expansion of scope of
practice versus lifting of other restrictions, such as allowing
beneficiaries to receive services at home. In our ongoing work, we will
report how these flexibilities affected beneficiary access to services
in rural areas during the public health emergency.
Questions Submitted by Hon. Thomas R. Carper
Question. During the pandemic, telehealth has been an essential
tool to get children the care that they need while minimizing risk.
Although telehealth under Medicare has been a focus, close to 40
million children are enrolled in Medicaid.
What are the main policy changes we need to ensure this broader use
of telehealth can be continued beyond the pandemic for children?
Answer. We have not done work specific to the broader use of
telehealth for children. CMS-approved Medicaid waivers and
flexibilities in all States were aimed at addressing obstacles that
affect beneficiary care and provider availability, among other areas.
Among these flexibilities, we have reported that efforts to remove
obstacles to beneficiary access to care, such as the use of telehealth,
were among the most important during the COVID-19 pandemic. The
temporary authorities CMS has approved will terminate based on the
conclusion of the public health emergency unless the States make
certain temporary changes permanent, for example, by submitting a State
plan amendment for CMS's review and approval. We will continue to
monitor CMS and State actions on temporary authorities, including in
our ongoing work examining telehealth in Medicaid during COVID-19,
which we expect to issue in early 2022.
Question. During COVID-19, many States adopted temporary changes to
their telehealth policies, such as expanding the scope of services and
providers able to furnish telehealth, relaxing of licensure
requirements and modifying reimbursement policies. Many States
legislatures have also begun the work to adopt more permanent
telehealth policy changes.
How can the Federal Government best support State Medicaid programs
in their efforts to expand telehealth?
Are there Medicaid supports, incentives, and learnings that Federal
policymakers could provide'?
Answer. Medicaid allows significant flexibility for States to
design and implement their programs. For example, States have the
option to determine: whether to cover services provided through
telehealth; which types of services provided through telehealth to
cover, as long as such telehealth providers are recognized and
qualified according to Medicaid statute and regulation; and how much to
pay providers for services delivered through telehealth, as long as
such payments do not exceed other program requirements.
Since the beginning of the COVID-19 pandemic, CMS created and
released four templates to help States obtain Federal waivers and
assist them in identifying other authorities to implement program
flexibilities more efficiently. In our ongoing work examining
telehealth in Medicaid during COVID-19, CMS officials have described
efforts to share practices with States, for example through technical
advisory group calls and Medicaid Integrity Institute offerings. We
will continue to monitor these efforts through our ongoing work.
Question. COVID-19 has introduced additional stress and trauma for
children and families. Telehealth, and particularly audio-only
telehealth has been a crucial tool to connect children and adolescents
to needed mental health-care services.
How can telehealth be best utilized to meet kids' mental health-
care needs, and can you speak to the use of audio-only telehealth
specifically?
Answer. We have not reviewed how telehealth can best be utilized to
meet children's mental health needs. According to preliminary data from
CMS, through October 31, 2020, primary, preventive, and mental health
service use declined among children under age 19 starting in March
2020. The agency also noted that of all services examined in their
analysis, the smallest rebound between March and October 2020 has been
the mental health service use rates. Our ongoing work examining
telehealth in Medicaid during COVID-19 will review selected States'
considerations for delivering services via telehealth after the end of
the public health. emergency, including via audio-only telehealth
modality. As part of that ongoing work, CMS officials told us that the
agency is monitoring services delivered via telehealth by modality, and
that for services delivered via live audio/video, the agency is also
examining monthly utilization of certain behavioral health services.
Question. As State Medicaid programs look at expanding their use of
telehealth, it is particularly important that vulnerable populations
like children are not negatively impacted. Policies must be looked at
through a health equity lens, considering access to reliable and
affordable broadband services, access to devices that support HIPAA-
compliant telehealth platforms and coverage policies.
How can Medicaid programs work to ensure telehealth policies are
equitable for children and mitigate potential inequities that may
arise?
Answer. We have not conducted work on how to ensure telehealth
policies are equitable for children and mitigate potential inequities
across the Medicaid beneficiary population. However, as part of our
ongoing work examining telehealth in Medicaid during COVID-19, we will
continue to monitor CMS and State telehealth policies. As noted in the
testimony statement, to ensure that all beneficiaries receive the best
care possible, how waivers and flexibilities account for equity is an
important consideration.
______
Questions Submitted by Hon. Elizabeth Warren
Question. The COVID-19 pandemic laid bare the deep systemic
inequities that exist in our Nation's health system. Telehealth creates
opportunities to combat racial disparities. But, if policymakers fail
to center health equity in their discussions around expanding
telehealth and making pandemic-era flexibilities permanent, future
telehealth policies could exacerbate inequity.
Ensuring that patients receive health services in a language they
can understand is critical to maximizing health outcomes, and studies
show that language-concordant care ``enhances trust between patients
and physicians, optimizes health outcomes, and advances health equity
for diverse populations.''\1\
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\1\ BMC Medical Education, ``The power of language-concordant care:
A call to action for medical schools,'' Rose L. Molina and Jennifer
Kasper, November 6, 2019, doi: 10.1186/s12909-019-1807-4.
What specific steps, if any, did CMS take to ensure that telehealth
services provided during the pandemic were offered in languages that
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patients could understand?
Were these steps sufficient in ensuring that patients with limited
English proficiency could access high-quality care during the pandemic?
What information, if any, exists on improvements that could be made
to telehealth regulations (both generally and regarding flexibilities
offered during the pandemic) to improve patient access to language-
concordant services?
Answer. During the pandemic, CMS compiled a variety of resources on
telehealth for minority populations, including individuals with limited
English proficiency. For example, CMS developed a telehealth guide for
health-care providers that included considerations for providing
telehealth to special populations, including non-English speakers.\2\
We have not assessed the effectiveness of these resources in ensuring
access to care for these individuals, but equitable access to care will
continue to be an important consideration in our work on delivery of
services to Medicare and Medicaid beneficiaries during the pandemic,
which we expect to report on in late 2021 and early 2022, respectively.
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\2\ See, U.S. Department of Health and Human Services, Stay Safe:
Getting the Care You Need at Home, Woodlawn, MD: revised May 2020,
accessed June 9, 2021, available at https://www.cms.gov/About-CMS/
Agency-Information/OMH/equity-initiatives/c2c/consumerresources/c2c-
covid-19-resources; and U.S. Department of Health and Human Services,
Telehealth for Providers: What You Need to Know, Woodlawn, MD: revised
March 2021, accessed June 14, 2021, available at https://www.cms.gov/
files/document/telehealth-toolkit-providers.pdf.
Question. The COVID-19 pandemic exacerbated substance use disorder
across the country, with impacts disproportionately felt by communities
of color.\3\ In your testimony, you noted that preliminary Medicaid
data ``show outpatient mental health services for adults age 19 to 64
declined'' from March through July 2020, ``despite CMS approving
waivers and flexibilities to ensure the availability of care.''
Medicare data on behavioral health was not yet fully analyzed or
conclusive.
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\3\ Mass.gov, ``Opioid-related overdose deaths rose by 5 percent in
2020,'' May 12, 2021, https://www.mass.gov/news/opioid-related-
overdose-deaths-rose-by-5-percent-in-2020.
What information, if any, exists explaining why Medicaid (and to
the extent data has become available, Medicare) mental health visits
declined, despite efforts to expand access to services via telehealth
---------------------------------------------------------------------------
and other flexibilities?
What lessons should policymakers take from this episode to app y to
future efforts to expand access to mental health services during public
health crises?
Answer. We do not have information explaining why Medicaid mental
health visits declined for either population during this time frame. As
you noted, preliminary CMS data show that Medicaid outpatient mental
health services for adults age 19 to 64 declined from March through
July 2020. In addition, preliminary CMS data through October 31, 2020
show that mental health service use also declined among children under
age 19 starting in March 2020.
Some of our ongoing work could also provide additional information
about efforts to expand behavioral health services to Medicaid
beneficiaries. In addition to our work examining Medicaid telehealth
services during COVID-19, we are also examining State demonstrations
that have established certified community behavioral health clinics,
including steps States have taken to assess the effects of the
demonstration on the health outcomes of beneficiaries, including
beneficiaries with substance use disorders.
With respect to Medicare, telehealth for mental health care may be
showing promise for beneficiaries. Specifically, CMS data show that 60
percent of beneficiaries receiving mental health services received them
through telehealth between March 17th and June 13, 2020. In our ongoing
work, we are examining trends in beneficiary use of Medicare services
in 2019 and 2020, including by service type, such as mental and
behavioral health services.
______
Questions Submitted by Hon. Patrick J. Toomey
Question. The improper payment rates in Medicare (6.27 percent in
FFS, 6.78 percent in MA) are the lowest in nearly a decade, whereas the
Medicaid improper payment rate has ballooned (21.36 percent).\4\
Bringing the Medicare improper payment rate down over the years was
surely not an easy feat. Given the propensity for our Federal health-
care programs to be susceptible to waste, fraud, and abuse,
policymakers and Federal agencies must continue to take action to
safeguard these programs. The Medicare Payment Advisory Commission
(MedPAC) previously noted that telehealth could enhance risks for
fraud, waste, and abuse in Medicare, and the Commission recommended
that the Centers for Medicare and Medicaid Services (CMS) implement
additional safeguards to curb the potential for telehealth-related
fraud and waste following the public health emergency.\5\
---------------------------------------------------------------------------
\4\ ``2020 Estimated Improper Payment Rates for Centers for
Medicare and Medicaid (CMS) Programs,'' CMS, November 16, 2020, https:/
/www.cms.gov/newsroom/fact-sheets/2020-estimated-improper-payment-
rates-centers-medicare-medicaid-services-cms-programs.
\5\ ``Telehealth in Medicare After the Coronavirus Public Health
Emergency,'' Medicare Payment Advisory Commission (MedPAC), http://
www.medpac.gov/docs/default-source/reports/
mar21_medpac_report_ch14_sec.pdf?sfvrsn=0.
What features of the Medicare and Medicaid programs make telehealth
services susceptible to fraud, waste, and abuse? Which feature has the
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greatest potential for such behavior?
Does CMS have the tools and resources necessary to expand
telehealth services or provide flexibilities in a manner that does not
exacerbate existing vulnerabilities in the Medicare and Medicaid
programs?
Answer. With respect to telehealth in the Medicare program, as we
reported in our testimony, the suspension of some program safeguards-
such as the non-enforcement of certain privacy and security rules to
allow for telehealth flexibility-can increase these vulnerabilities.
Telehealth waivers can also increase spending if these services are
furnished in addition to in-person services. As noted in our testimony,
assessing the impact of some flexibilities will be challenging because
CMS lacks complete data--for example, with respect to the telehealth
modality being used (audio-only or audio-video technology). In the
Medicaid program, one-third of improper payments are related to States'
noncompliance with provider screening and enrollment requirements-an
area where flexibilities have been increased, and oversight
decreased.\6\
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\6\ GAO, High-Risk Series: Dedicated Leadership Needed to Address
Limited Progress in Most High-Risk Areas, GAO-21 119SP (Washington, DC:
March 2, 2021).
Question. Your testimony noted that CMS is conducting program
integrity risk assessments for all of pandemic-related waivers and
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flexibilities in the Medicaid program.
Has the Department of Health and Human Services established a
timeline or plan for the completion of these integrity risk
assessments?
Answer. According to CMS officials, the risk assessments are an
ongoing process and may be updated, for example, when certain risk
mitigation strategies are implemented. In April 2021, CMS officials
said that the agency was developing a webinar and toolkit for States to
conduct risk assessments. We will continue to monitor these actions as
part of our ongoing work examining telehealth in Medicaid during COVID-
19.
Question. Your testimony also noted that CMS currently lacks data
on certain aspects of telehealth visits that could be important in
determining the quality outcomes of telehealth services.
What data is needed in order to measure the effects of telehealth
services on patient outcomes? Has the Department of Health and Human
Services established a timeline or plan for developing these type of
measures?
Answer. As reported in our testimony, regarding Medicare, CMS lacks
complete data to determine the telehealth modality being used (audio-
only or audio-video technology) or if services are originating from
providers' and beneficiaries' homes--important information to consider
in light of the fact that the quality of telehealth services has not
yet been fully analyzed. As part of our ongoing work examining
telehealth in Medicaid during COVID-19, CMS officials told us that the
agency is monitoring services delivered via telehealth by modality, and
that for services delivered via live audio-video, the agency is also
examining monthly utilization of certain services.
Several organizations have been involved in developing quality
measures for services delivered via telehealth. For example, in 2017,
the National Quality Forum (NQF) developed a framework for measuring
the quality of telehealth services through a project funded by CMS and
was tasked with updating this framework in January 2021, in light of
the recent uptick in telehealth use. As we reported in our testimony,
CMS officials told us in February 2021 that they are still exploring
how to measure the quality of telehealth services. We will report on
CMS's progress on this topic in our ongoing work on Medicare and
Medicaid telehealth services, which we expect to issue in late 2021 and
early 2022, respectively.
______
Questions Submitted by Hon. Chuck Grassley
Question. Throughout the public health emergency, the Centers for
Medicare and Medicaid Services (CMS) issued over 200 waivers under
Medicare and approved more than 600 waivers and other flexibilities
under Medicaid. While some of the regulations waived are specifically
for responding to a pandemic, ensuring patient safety, controlling
costs, and maintaining program integrity its clear innovation and
common sense ideas in our health-care system have been stifled too
often by Federal regulations. For example, CMS permanently added
certain new services (including mental health and care planning
services) that it had temporarily added to the approved list of
Medicare telehealth services during the pandemic. Some regulations play
an important role in protecting safety and maintaining program
integrity but others may stifle good ideas.
Is health care too regulated that it's stifling good ideas?
Should executive agencies sunset regulations in the future to
enable more innovation in health care?
Answer. CMS issued hundreds of waivers in the Medicare and Medicaid
programs to ensure beneficiary access to services during the pandemic.
We reported in our testimony that telehealth waivers in particular were
instrumental in providing safe access to services that beneficiaries
would otherwise not have had. In addition to implementing rapid
innovations through waivers and flexibilities, as we reported in March
2018, CMS is also testing new approaches to health-care delivery and
payment in both programs through its Center for Medicare and Medicaid
Innovation Center, and, as of March 1, 2018, had implemented 37 models
to reduce spending and improve the quality of care.\7\
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\7\ GAO, CMS Innovation Center: Model Implementation and Center
Performance, GAO-18-302 (Washington, DC: March 26, 2018).
Our prior work examining States' views on the impact of Federal
Medicaid policies on their programs also highlights key considerations
with respect to any potential changes to program oversight. In this
work, States identified a range of Federal laws, regulations, and
procedures that affected their ability to efficiently administer their
Medicaid programs. In considering potential Federal actions to address
these challenges, we identified a series of tradeoffs and
considerations, including (1) targeting Federal oversight to critical
areas, such as to reduce improper payments or to manage other program
risks; (2) having accurate and complete data on key measures, such as
beneficiary access, service use, and related costs, to inform any
potential change; and (3) balancing States' ongoing efforts to waive
statutory requirements with an appropriate level of oversight, as
historically we have identified multiple instances where improved
oversight of such efforts was warranted.\8\
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\8\ GAO, Medicaid: State Views on Program Administration
Challenges, GAO-20-407 (Washington, DC: April 30, 2020).
Question. At the beginning of the public health emergency (PHE),
Congress provided the Health and Human Services (HHS) Secretary with
authority to waive Medicare requirements for telehealth payment during
the PHE. This allowed more than 140 telehealth services to be provided
that previously were not allowed or were limited. Some limitations
included a lack of payment parity, geographic limitations on where
services are provided, and restrictions on audio-only telehealth
services. Similar flexibilities were granted to States under Medicaid.
Most of these flexibilities will be go away once the PHE ends. MedPAC
reports ``there is not yet evidence on how the combination of
telehealth and in-person care affects quality and costs in the Medicare
---------------------------------------------------------------------------
program.''
Your written testimony mentioned that the ``Medicare and Medicaid
programs are on GAO's high-risk list'' when it comes to telehealth ``in
part due to concerns about fraud, waste, and abuse.'' While the public
health emergency is still in place, what program integrity measures
should CMS put in place to stop these high-risk activities?
Answer. As reported in our testimony, telehealth services can pose
heightened program integrity risks to the Medicare and Medicaid
programs stemming from increased program spending, the lack of complete
data, and suspens1dns of some program safeguards. Our ongoing work on
Medicare telehealth services, which we expect to issue in late 2021,
will examine the telehealth-related vulnerabilities CMS has identified
and control activities the agency has put in place to address them.
We also reported in our testimony that CMS is conducting and
updating program integrity risk assessments for all Medicaid waivers
and flexibilities issued as a result of the pandemic. According to CMS
officials, the risk assessments He an ongoing process and may be
updated, for example, when certain risk mitigation strategies are
implemented. In April 2021, CMS officials said that the agency was
developing a webinar and toolkit for States to conduct risk
assessments. We will continue to monitor these actions as part of our
ongoing work examining telehealth in Medicaid during COVID-19, which we
expect to issue in early 2022.
Question. Your written testimony mentioned that the ``quality of
telehealth services has not been fully analyzed.'' What quality metrics
should GAO and Congress be using?
Answer. We will report on CMS's progress on this topic in our
ongoing work on Medicare and Medicaid telehealth services. CMS has
tasked the National Quality Forum with updating its framework for
assessing the quality of telehealth services, and in February 2021, CMS
officials told us that they are still exploring these measures.
Question. Is GAO looking at the Medicare Advantage telehealth
experience pre-pandemic and throughout the pandemic to inform its
recommendations? If so, what kind of data does GAO have and how is it
using that data to inform recommendations?
Answer. Our ongoing work on Medicare telehealth services focuses on
the fee-for-service program through data analysis and interviews with
selected payer and other stakeholders. To the extent these interviews
provide insights into telehealth services in the Medicare Advantage
program, we will discuss these in our ongoing work.
Question. Expanding Medicare FFS telehealth after the PHE ends
should consider implications of federalism including scope-of-practice,
medical malpractice, and credentialing and licensing. What other
federalism considerations should Congress take into account when
determining telehealth expansion in Medicare FFS?
Answer. We have no plans at this time to explore these issues in
our ongoing work on Medicare telehealth services.
______
Questions Submitted by Hon. John Barrasso
Question. Before coming to the Senate, I had the privilege of
practicing medicine in Wyoming. Rural health care faced challenges
prior to the pandemic. In particular, we know since 2010 more than 135
rural hospitals have closed.
In the Senate, I am proud to help lead the bipartisan Rural Health
Caucus. This group is committed to ensuring patients in rural America
can get access to the care they need.
Can you specifically discuss the changes in Federal health-care
policy that you believe have helped rural providers the most during
this pandemic?
Can you please discuss any specific changes that Congress should
consider to better support rural health-care providers?
Answer. As we noted in our testimony, Medicare telehealth waivers
enabled beneficiaries in both rural and urban areas to receive care
from their home. A July 2020 Issue Brief from the Assistant Secretary
for Planning and Evaluation indicated that utilization of telehealth in
rural areas increased significantly between March and April 2020.\9\
However, as we also noted in our testimony, disparate effects from
COVID-19 extend to beneficiaries' receipt of services. Beneficiaries in
urban areas received more telehealth services or were more likely to
use telehealth services than beneficiaries in rural areas both in
Medicare and in one State's Medicaid program. Additionally, providers
face challenges offering telehealth services due in part to limited
patient access to broadband Internet. Specifically, in March 2021, we
reported that as of February 18, 2021, the Federal Communication
Commission's COVID-19 Telehealth Program had disbursed $143.2 million
in awards to eligible providers, including funding targeted towards
patient care in rural populations.\10\ While we have not assessed the
changes that helped rural providers the most during the pandemic, we
have reported on rural health care in our ongoing COVID-19 reporting,
for example, on Provider Relief Fund allocations and disbursements to
rural health-care facilities and Veterans Health Administration
outreach to rural veterans.\11\ We will continue to monitor
beneficiaries' receipt of services in urban and rural areas as part of
our ongoing work examining telehealth in both programs during COVID-19,
which we expect to issue in late 2021 and early 2022, respectively.
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\9\ Department of Health and Human Services, Assistant Secretary
for Planning and Evaluation (ASPE), Medicare Beneficiary Use of
Telehealth Visits: Early Data from the Start of COVID-19 Pandemic
(Washington, DC: July 28, 2020). ASPE reported that the proportion of
weekly rural primary care visits delivered via telehealth increased
from virtually none prior to the pandemic to about 25 percent mid-April
before gradually decreasing to about 10 percent by May.
\10\ GAO, COVID-19: Sustained Federal Action Is Crucial as Pandemic
Enters Its Second Year, GAO-21-387 (Washington, DC: March 31, 2021).
\11\ For example, see GAO, COVID-19: Opportunities to Improve
Federal Response and Recovery Efforts, GAO-20-625 (Washington, DC: June
25, 2020); GAO, COVID-19: Urgent Actions Needed to Better Ensure an
Effective Federal Response, GAO-21-191 (Washington, DC: November 30,
2020); and GAO-21-387.
Question. Prior to the pandemic, I introduced bipartisan
legislation with Senator Tina Smith, which among other things, would
---------------------------------------------------------------------------
allow Rural Health Clinics (RHCs) to provide more telehealth services.
I was pleased that Congress through the CARES Act authorized both
Rural Health Clinics and Federally Qualified Health Centers to furnish
telehealth services to Medicare beneficiaries during the public health
emergency.
Can you discuss the importance of Rural Health Clinics and
Federally Qualified Health Centers continuing to provide telehealth
services after the public health emergency has ended?
Answer. As we noted in our testimony, CMS waived or modified
certain telehealth provisions to increase access to care and give
providers more flexibilities in treating beneficiaries. We also noted
in our testimony that telehealth has been a major part of efforts to
provide services while limiting beneficiary exposure to COVID-19, and
that extending or ending waivers and flexibilities may affect
beneficiary health and safety in unknown ways. We will continue to
monitor utilization of telehealth services, including telehealth
services utilized by geographic location, as part of our ongoing work
examining Medicare telehealth waivers.
Question. My wife Bobbi and I are passionate about improving access
to mental health services. This pandemic has clearly impacted the
mental, as well as the physical health of our Nation.
For people living in rural America, getting help from a mental
health provider was challenging before the pandemic. This is why
Senator Stabenow and I have long supported professional counselors and
marriage and family therapists participating in Medicare. We believe
that increasing the number of mental health providers able to care for
our Nation's seniors is an important priority.
Please discuss how telehealth has impacted the ability of patients
to receive mental health services during the pandemic.
Can you please identify ways Congress can improve access to mental
health services, including expanding the number of providers that can
participate in Medicare?
Answer. Access to mental health services remains a growing concern
as the pandemic continues. As we noted in our testimony, in Medicaid,
preliminary data from CMS show outpatient mental health services for
adults age 19 to 64 declined starting in March and continuing through
July--despite CMS approving waivers and flexibilities to help ensure
the availability of care. In March 2021, we reported on longstanding
concerns about the availability of behavioral health treatment,
particularly for low-income individuals.\12\ Evidence collected during
the pandemic suggests the prevalence of behavioral health conditions
has increased, while access to in-
person behavioral health services has decreased. In our March 2021
report, we reiterated a 2019 recommendation that the Federal agencies
involved in the oversight of mental health parity requirements evaluate
the effectiveness of their oversight efforts. As of March 2021, the
agencies had not yet implemented this recommendation.
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\12\ GAO, Behavioral Health: Patient Access, Provider Claims
Payment, and the Effects of the COVID-19 Pandemic, GAO-21-437R
(Washington, DC: March 31, 2021).
Telehealth may help provide access to mental and behavioral health
services for beneficiaries. In our March 2021 report, we reported that
the increased use of and payment for telehealth has had a positive
effect during the pandemic, leading to improved access to behavioral
health services for some patients and resulting in fewer missed
appointments, according to most stakeholders. Further, CMS data show
that 60 percent of Medicare beneficiaries receiving mental health
services received them through telehealth between March 17th and June
13, 2020. We will continue to monitor utilization of telehealth
services, including mental and behavioral health services, as part of
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our ongoing work examining Medicare telehealth waivers.
______
Prepared Statement of Narayana Murali, M.D., Board Member,
America's Physician Groups; and Executive Director, Marshfield Clinic
Good morning, Chairman Wyden, Ranking Member Crapo, and members of
the committee. My name is Dr. Narayana Murali, and I serve as the
executive vice president of care delivery and chief strategy officer of
the Marshfield Clinic Health System. I also serve as the executive
director of Marshfield Clinic, headquartered in Marshfield, WI. It is
my honor to be here today to discuss this important topic.
It is my privilege to testify on behalf of America's Physician
Groups and myself. APG is a national professional association
representing over 300 physician groups that employ or contract with
approximately 195,000 physicians that provide care to nearly 45 million
patients. It is the vision of APG's member organizations to transition
from the fee-for-service (FFS) reimbursement system to a value-based
system where physician groups are held accountable for the cost and
quality of care they provide to their patients. APG's preferred model
of capitated, delegated, and coordinated care, eliminates incentives
for waste associated with Fee for Service reimbursement. I am here to
make the case for permanently supporting the telehealth flexibilities
created in during the PHE, with some refinements.
Since the outset of the pandemic, APG members in all 50 States have
risen to the challenge presented by COVID-19. Our members have been at
the forefront of caring for patients, as well as the communities we
serve from coast to coast. The challenges have been immense, and the
risks associated with COVID-19 remain serious today. However, the
lessons and experiences we have gained--as difficult as it has been at
times--can serve as opportunities to embrace changes, so we can
continually improve services we provide to our patients and
communities. This is especially true when it comes to the waivers and
flexibilities made available to address the Nation's current public
health emergency (PHE). The widespread adoption and utilization of
telehealth services in a variety of health-care settings have been
lifelines to patients, ensuring access and continuity of care during
some of the darkest days of the pandemic when alternatives were non-
existent. This is particularly true for those physician groups that
have moved away from FFS (where earnings are tied to volume of services
rendered) and are participating in models of care where the provider
takes partial or full financial risk for quality, outcomes and total
cost of care (degree of risk may be shared with a health plan or fully
absorbed by the provider--globally capitated contracts).
I joined the Marshfield Clinic in 2006 as a nephrologist, having
practiced and furthered my education in India, Australia, and the
United States. I did an internal medicine residency at Mayo School of
Graduate Medical Education, a National Institutes of Health-sponsored
Clinician Investigator Training Program and fellowship in kidney
disease at the Mayo Clinic College of Medicine, Rochester, MN. I serve
as the prime site principal investigator of the Wisconsin Consortium
for the All of Us Research Program, a historic effort to gather data
from one million or more people living in the United States to
accelerate research, improve health, and deliver precision medicine. In
addition, I serve as the secretary of American Physicians Group, the
vice chair of the governing council of the Integrated Physician and
Practice Section of the American Medical Association, and on several
other not-for-profit boards. As a physician with decades of experience
treating patients and navigating the health-care system, I would like
to especially commend Congress and the various relevant Federal
agencies for their efforts to address the struggles health-care
providers and organizations have alike faced during the COVID-19
pandemic. Yes, we have all come a long way and yet much work remains to
be done.
Marshfield Clinic Health System (MCHS), which Marshfield Clinic is
a part of, is an integrated health system serving northern, central,
and western Wisconsin. We are one of the Nation's largest fully
integrated systems serving a predominantly rural population. Our 1,400
physicians and providers accommodate 3.5 million patient encounters
each year across our 10 hospitals and over 60 ambulatory clinical
sites. Our primary service area encompasses over 80 percent of the
rural population of the State of Wisconsin. In fact, over half of our
60+ facilities are located in communities of less than 2,000 people. We
are the largest provider of primary and specialty care in our region.
As stewards of our communities and to what we call home along with our
patients, we have been committed to community engagement activities
that support the rural and underserved communities. We are a teaching
health system, providing over 1,300 students with over 2,300
educational experiences throughout our system. The Marshfield Clinic
Research Institute is the largest not for profit, private medical
research institute in Wisconsin with more than 30 Ph.D. and M.D.
scientists and 150 physicians engaged in medical research.
As a fully integrated health system, MCHS has a rich legacy of over
104 years and a long history of providing accessible, affordable and
high quality, compassionate health care. A third of the counties we
serve have less than two workers per Medicare beneficiary, and our
patients are older, sicker and poorer than average in the State of
Wisconsin and the Nation. Forty-two percent of the children in our
primary service area are eligible for reduced or free school lunches.
Telehealth at MCHS did not have its genesis in the pandemic. It has
been a foundational element in our clinical delivery of care for rural
Wisconsin. In fact, we have used telehealth services since 1997, and it
has become an important resource to care for patients in often remote
and distant locations throughout our service area, which is
approximately 45,000 square miles, just bigger than the State of Maine.
In 2019, by our estimates use of telehealth saved our patients over 1.2
million driving miles. For older and sicker patients who cannot
transport themselves, this is very impactful. To this, add the
inclement weather and the challenges of harsh and cold winters.
Additionally, in rural areas few, if any, public transportation systems
serve as safety net for our patients. A critical lever we have
leveraged to manage the cost of care for our patients and communities
is our full risk, globally capitated arrangements with our not for
profit Security Health Plan, and other models of risk based
arrangements with payers in the private and governmental markets.
Capitated arrangements have allowed us to innovate, invest and
implement effective systems of care for our patients while also passing
on the benefits in terms of lower premiums and additional benefits such
as hearing aids and spectacles. These programs have improved outcomes,
reduced costs and waste, and ensured high-quality and accessible health
care. Presently, Marshfield serves 68,224 patients in a globally
capitated, full risk arrangement. We also serve another 51,131 patients
on value-based contracts.
Relying on the knowledge gleaned from our several decades' long
history of utilizing telehealth services in our clinical care models,
and our present experience of responding to COVID-19, I would like to
share the following perspectives and substantiate why these are
relevant for your consideration.
1. Telehealth adoption has increased exponentially. With the
Federal waivers and commercial insurance coverage expansion during the
PHE, almost 20 percent of ambulatory care can be safely provided
through telehealth.
2. Expanded utilization of telehealth by baby boomers and senior
citizens has resulted in improved patient access, increased
convenience, and appropriate care albeit with less than robust,
integrated platforms. Creating such platforms within the framework of
existing health care and EHR systems can reduce overall cost of health
care.
3. Blanket telehealth waivers issued in response to the pandemic
have enabled the industry to continue its population health and health
promotion initiatives and provide innovative programs such as Hospital
Without Walls.
As we look forward to the next phases of the pandemic response and
the return to whatever our new paradigm will be, embracing telehealth
and stopping its backslide is critical. I urge you and your colleagues
to fully support and implement effective and responsible policy that
ensures continued accessibility to high-quality telehealth services
that benefits patients, and their overall health.
patient behavior and preferences, an mchs snapshot, and an apg view
Since COVID 19, patient preferences on how they choose to engage
with physicians and Health systems has forever changed. In MCHS, we
serve around 100,000 outpatients a month with some cyclical drop in
Wisconsin winters. Those appointments have declined to about 90,000
outpatients a month during the PHE. In entire year of 2019, we
registered about 12,500 telehealth encounters, with about 200
clinicians providing telehealth services in any given month.
In 2020, across all demographies, telehealth visits skyrocketed
from a pre-pandemic average of about 2 percent of visits a month, by
21-fold in April 2020. Within 4 weeks of the pandemic, MCHS was
averaging 3,000 telehealth visits per week, and by week 8, we were
delivering over 6,500 telehealth and phone care visits per week. During
the time our centers were closed, telehealth and phone care services
were able to provide access to 22 percent of our normally expected
patient volume. Overall, in 2020, MCHS provided 240,000 telehealth and
telephone encounters. All 1,400 physicians have been trained to provide
this service.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
In the last 4 months, telehealth visits have plateaued to an
average of 15.5 percent. In certain specialties, such as Behavioral
health, 30 to 32 percent of our patients use telehealth or ``phone
only'' visits.
In discussions with my APG colleagues and several health system
leaders across the nations, we all agree there has been a decline in
telehealth numbers. Observational evidence suggests this 15-16 percent
fraction of ``telehealth and phone visits'' over all appointments per
month are a reflection of a new steady state for consumer behavior
across the Nation. Baby boomers have increasingly adopted telehealth
visits, as have many of our octogenarian parents.
patient experience, loyalty, and direct-to-consumer models
Patients seem to be willing to switch to telehealth as tolerance to
waiting for appointments decreases. With increased access to convenient
care, patient satisfaction in the care they receive from their
physicians has also increased. In a survey of our patient population,
Marshfield Clinic found that 68 percent of respondents reported being
``highly satisfied'' or ``satisfied'' with their virtual visit. The
most common reason given by patients for frustration with their
telehealth visit was poor quality of Internet connection.
Removal of geographic site origination and other burdensome
regulatory burden would improve access to care. Our child psychologist
in Lake Hallie, WI had to move to Colorado because of family
commitments. With the low availability of skilled providers to cover
these patients we worked with the State of Wisconsin for approval of
telehealth services and invested in a telehealth room in Lake Hallie.
Patients were offered the option to continue or switch to new provider.
In two years, only one patient opted for a different provider. He sees
about 1,200 encounters annually.
digital divide (lack of broadband access)
Phone-only telehealth services have been critical to delivering
health care to the underserved, rural, and racial minorities. Even a
year into the pandemic, meeting the regulatory expectations of audio-
video visits for risk adjustment in rural Wisconsin has been
challenging. In April 2021, 57.6 percent of the 12,299 telehealth/phone
patient appointments used ``phone only'' care. Our patients, who are
old, have chronic illness sit in the parking lots of our schools and
clinics to access broadband Wi-Fi that they lack at home for telehealth
services. It is sad how little we, as one of the most developed nations
in the world, are able to support our old, poor, needy and sick.
According to the Federal Communications Commission, 19 million
Americans lack access to fixed broadband service at threshold speeds--
and 14.5 million of those residents are reside in rural settings.\1\
According to one study, during the pandemic, Federally Qualified Health
Center audio-only (``phone'') visits accounted for 65.4 percent for all
primary care visits and 71.6 percent of behavior health visits.\2\
Centers for Medicare and Medicaid Services (CMS) estimates up to 30
percent of visits during the pandemic have been audio-only.\3\ Rural
residents should not be disadvantaged in accessing telehealth just
because of where they live.
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\1\ https://www.fcc.gov/reports-research/reports/broadband-
progress-reports/eighth-broadband-progress-report.
\2\ Uscher-Pines L, et al. ``Telehealth Use Among Safety-Net
Organizations in California During the COVID-19 Pandemic.'' JAMA.
2021;325(11):1106-1107.
\3\ Verma, S. ``Early Impact of CMS Expansion of Medicare
Telehealth During COVID-19.'' Health Affairs Blog 2020. https://
www.healthaffairs.org/do/10.1377/hblog20200715.454789/full/.
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travel for health care and its economic impact
The economic impact on patient families of saved miles and time
cannot be lost upon us. Our three pediatric neurologists are the only
physicians with the subspecialty skills to see complicated neurological
patients across a 45,000 square mile service area. In order for a child
with well controlled epilepsy, the parent or parents are compelled to
take time off from work, often for a whole day, all for a 30-minute
physician visit that can be done over telehealth or telephone. This is
a wasteful exercise of time, money, and resources. This child is an
example of the 20 percent of medical care that is well suited for
virtual care.
Other such visits that are well suited for telehealth include
follow-up visits, tele-dermatology, provider-to-provider consulting in
subspecialty care, second opinions for highly specialized counseling,
and radiology opinions. The benefits of reducing unnecessary travel,
lost days of production for the family, and improved access to care
along with downstream reduction in urgent and emergency care
utilization are all important drivers of reducing cost of care and
improving patient experience.
geographic limitation and improving access to appropriate
healthcare in rural america
Overcoming geographic isolation through telehealth in rural America
has critical relevance. There is limited access to public
transportation, and long drive times to avail medical care. This is
further compounded in winter when the roads are treacherous with black
ice or travel is blinded by blowing winds and snow.
A story that tugs at my heart is that of a 67-year-old diabetic
woman who traveled 200 miles to see me, four times a year to titrate
medications and optimize her health. In 2007, MCHS provided me the
ability to provide virtual care, do a heart and lung and physical exam
over video, review her vital signs with the assistance of a nurse,
review her lab tests and arrange for diuretic infusions when her heart
failure worsened. For 13 years, every year she has sent me a Christmas
card and even now, when I no longer see her.
incent investments for increased physician adoption
In the wake of the pandemic, physicians have rapidly adapted to the
new paradigm of care. The additional waivers and regulatory changes
surrounding telehealth services have been vital in creating pathways
for organizations facing financial peril to be creative and expand
access to care.
The present state involves working simultaneously with an
electronic health record (EHR), a video platform, and a chat function
with their medical teams to coordinate scheduling, lab tests and
diagnostics, educating patients how to switch on their cameras,
educating themselves in performing a good virtual physical exam and
good ``web-side'' manners.
Substantial investments in infrastructure are needed to ensure
physicians can provide high quality, cost-effective, increased access
to care through telehealth services. As patients become increasingly
adroit with technology and physicians with telehealth workflows, access
to critically needed services such as behavioral health, primary, and
specialty care would also increase.
acute care without walls
Since 2016, MCHS has provided, hospital-level care in patients'
homes through use of telehealth, in-home nursing visits, and virtual
visits by hospitalists. We treat over 100 acute care conditions such as
asthma, congestive heart failure, pneumonia and chronic obstructive
pulmonary disease (COPD) safely at home with proper monitoring and
treatment protocols.\4\
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\4\ Centers for Medicare and Medicaid Services. (2020, November
25). CMS Announces Comprehensive Strategy to Enhance Hospital Capacity
Amid COVID-19 Surge [press release]. Retrieved from: https://
www.cms.gov/newsroom/press-releases/cms-announces-comprehensive-
strategy-enhance-hospital-capacity-amid-covid-19-surge.
Our research highlighted in the August 15, 2019, New England
Journal of Medicine Catalyst \5\ and those of others have demonstrated
high rates of patient satisfaction and improved outcomes, and
meaningful reductions in costs. As an author of this study, I will be
the first to admit that the best place for a patient to recover is
where they are most comfortable--and that is not in a hospital room in
many instances.
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\5\ NEJM Catalyst, ``No Place Like Home: Bringing Inpatient Care to
the Patient,'' Narayana Murali and Travis Messina. https://
catalyst.nejm.org/no-place-home-recovery-care.
Our patients had 44 percent fewer 30-day readmissions, and a
50-percent reduction in emergency department visits than Security
Health Plan members within the same group of DRGs who were treated in
the hospital.
HRC patients had 37 percent shorter length of stay, compared
with historical data from SHP members within our diagnosis-related
groups. (Length of stay for HRC patients was measured as number of days
in the ``acute'' phase.)
Patient satisfaction was greater than 90 percent, based on the
number of top-box responses for all questions administered via the HRC
program patient satisfaction survey.
The health plan saved approximately 15-30 percent per episode,
when compared to our historical baseline costs.
In late 2020, MCHS with bipartisan support from the congressional
delegation that represents our service territory was granted a Section
1135 waiver from CMS to more broadly implement the Acute Hospital Care
at Home program. MCHS, was one of the first nine, health-care
institutions in the country granted this waiver by CMS. MCHS was
approved four hospital sites by CMS for Acute Care at Home, during the
COVID pandemic. This waiver allowed us to expand our Hospital at Home,
and has increased our capacity for the care of patients during the
COVID-19 pandemic, providing greater flexibility and reducing the
burden on providers caring for the most acutely sick patients.
recommendations
In response to the committee's request, below are our
recommendations.
I. Allow Acute Care Without Walls flexibilities to extend beyond the
PHE waiver
Even in rural areas, this model has successfully improved access
and outcomes. While the CMS allowed a blanket waiver to permit the
expanded use of this program for the duration of the PHE, we continue
to gain data and experience to improve the program. We hope and
strongly urge that Congress recognize the success of these programs,
and ensure these programs can continue to grow and increase access
beyond the PHE.
II. Eliminate origination site and geographic limitations
a. These limitations are outdated based on our experience with the
present waivers and can no longer be justified as guard rails to
protect against fraud, waste, and abuse.
b. By creating certainty that telehealth will continue to be
reimbursed by Federal health-care programs, Congress will give
providers the certainty they need, to invest in the technology
infrastructure, software and practice redesigns necessary to make
telehealth part of their standard business operations. A lack of
certainty could create new disparities among providers, and result in
uneven access for patients.
III. Support and ensure access to reliable broadband
It is imperative to invest in broadband technology to close the
digital divide and ensure living in rural communities is not a barrier
to accessing telehealth.
IV. Allow phone-only telehealth services for Medicare Advantage risk
adjustment until we overcome the challenges of Internet access
The disparities in broadband access are exacerbated in rural,
underserved and minorities. In fact, over half of our telehealth visits
with our patients have been phone-only because of limited access to
broadband, smart phones, or tablets. Medicare Advantage has allowed
both audio and audio/video telehealth services. Audio-only (phone) has
not been allowed for risk adjustment, which impairs appropriate funding
for health-care delivery to the most vulnerable--an impact that will
ultimately affect future Medicare member benefits and premium, given
restrictions to formally document real risks is not true reflection of
no risk. Our APG members agree that barriers that discourage patient
participation through phone, when access to broadband is unavailable,
prevent patients from receiving necessary care, and ultimately expose
organizations that are in the capitated, value-based models to greater
financial peril.
V. Ensure payment parity
In order to guarantee that clinicians and systems have the
appropriate incentives to invest in telehealth services and
capabilities, Congress must ensure payment parity between in-person and
virtual visits. Allowing for expanded telehealth without the guarantee
of payment parity will create another barrier to adoption, limit
overall uptake by providers, and stagnate access to this important
treatment mechanism for patients. Congressional action on this front
will also send an important message to commercial payers to guarantee
parity across insurance markets.
VI. Reduce administrative burden on providers
First off, every effort possible should be made to harmonize
statutes and regulations at the Federal, State, and local levels to
promote the continued adoption and utilization of telehealth. For
example, Congress should explore the establishment of a form of blanket
patient consent to facilitate the provider connecting with them via the
2-way video method that the patient is most comfortable with. Congress
must also work in concert with the Department of Health and Human
Services and the Centers for Medicare and Medicaid Services to reduce
burdensome regulations that inhibit the expansion of telehealth to
smaller physician practices that reduce the ability of clinicians to
focus on their most important task: serving their patients.
VII. Protect patient data while fostering innovation and access
As patient satisfaction rises with the increased usage of
telehealth services, creating a care environment that best serves
patients and their needs is paramount. HIPAA waivers have been helpful
in providing care and allowing patients (senior patients especially) to
use compliant platforms they are familiar with. However, I am aware
that some of these non-HIPAA compliant applications and platforms may
compromise security and thus, it will be important to weigh the
benefits of expanding access via the use of consumer-based technology
versus potential privacy and security risks. All payers should be
encouraged to align payment policies and coding requirements in order
to ensure a seamless system of care that works in a coordinated manner
across all providers and organizations.
VIII. Support integrating telehealth in EHR platforms
Congress should consider supporting regulations and incentives for
integrating telehealth in Electronic Health Record Platforms.
I would again like to thank Chairman Wyden, Ranking Member Crapo,
and the rest of the committee for granting me this opportunity to share
these observations and recommendations with you during this hearing. We
look forward to continuing to work with you on this very important
issue and advancing America's health-care system.
______
Questions Submitted for the Record to Narayana Murali, M.D.
Questions Submitted by Hon. Thomas R. Carper
Question. During the pandemic, telehealth has been an essential
tool to get children the care that they need while minimizing risk.
Although telehealth under Medicare has been a focus, close to 40
million children are enrolled in Medicaid.
What are the main policy changes we need to ensure this broader use
of telehealth can be continued beyond the pandemic for children?
Answer. Thank you for your question. You are right that while the
focus of much our discussion centers around issues related to Medicare,
we must focus on ensuring patients' access to telehealth services no
matter what type of insurance coverage they use. When it comes to
Medicaid, there are particular rules pertaining to what services can be
provided, and by what type of provider. As telehealth becomes more
ubiquitous in the delivery of care, Medicaid coverage of telehealth
services should grow as well. A patient's access to telehealth should
not be based on what type of insurance coverage they have. This
includes the expansion of the CPT codes where telehealth is an option
for Medicaid enrollees, both in managed care and traditional fee-for-
service reimbursement arrangements.
There are also a number of State-level issues that will have to be
addressed on a case-by-case basis. A good example of this was the
passage of Wisconsin 2019 Act 56, which mandated parity in coverage for
telehealth services for Medicaid enrollees.
Additionally, patients must not be precluded from accessing
telehealth due to lack of access to technology. This includes providing
supports to ensure that individuals can use technology that allows for
video visits, and that they have access to reliable Internet service.
The truth of the matter is that while we take access to broadband
coverage and smart phones for granted, many Americans, and especially
those who rely on Medicaid, do not actually have access to these
conveniences of every day life. Nineteen million Americans lack access
to fixed broadband service at threshold speeds--and 14.5 million of
those residents are reside in rural settings. And, many of our Medicaid
patients cannot afford smart phones, or the service to use them. As a
result, CMS should consider creating technology vouchers and reduced-
cost broadband as part of coverage, especially for chronic conditions.
Question. During COVID-19, many States adopted temporary changes to
their telehealth policies, such as expanding the scope of services and
providers able to furnish telehealth, relaxing of licensure
requirements and modifying reimbursement policies. Many States
legislatures have also begun the work to adopt more permanent
telehealth policy changes.
How can the Federal Government best support State Medicaid programs
in their efforts to expand telehealth?
Answer. First and foremost, the Federal Government should continue
to support the flexibilities to Medicaid programs that have been
granted throughout the pandemic. While vaccinations are readily
available and we are all trying to find ways to return to normal, we
must realize that we are going to be dealing with the fallout of this
pandemic for a very long time. As a result, States and Medicaid
providers need time to recover from the pandemic and adequately prepare
for the move away from the current flexibilities.
CMS needs to develop and implement effective lines of
communications with State Medicaid programs about future changes in the
program. Furthermore, State Medicaid programs must undertake
initiatives now to ensure that when the pandemic flexibilities expire
that Medicaid enrollees are not all of a sudden unable to access
telehealth services. This is an issue of equity and access.
Further, providers need clarity about the scope and parameters of
what is allowed under Medicaid when it comes to telehealth services so
they can adequately plan and implement changes to their service models.
Unnecessary and arbitrary obstacles to telehealth will serve as a
disincentive to providers and patients, and result in missed
opportunities to provide high-quality accessible health care, no matter
the patient's coverage.
Question. Are there Medicaid supports, incentives, and learnings
that Federal policymakers could provide?
Answer. Honestly, the ability to develop Medicaid programs that
meet the unique needs of the patients we care for is the most important
tool Federal lawmakers could provide. It is just a fact that the needs
of patients in north central Wisconsin will be different than those of
residents in Texas, Florida, or even Iowa for that matter. However,
everything possible should be done to prevent arbitrary obstacles from
getting in the way, like access to broadband and flexibility in how
patients access care.
Question. COVID-19 has introduced additional stress and trauma for
children and families. Telehealth, and particularly audio-only
telehealth has been a crucial tool to connect children and adolescents
to needed mental health-care services.
How can telehealth be best utilized to meet kids' mental health-
care needs, and can you speak to the use of audio-only telehealth
specifically?
Answer. Telehealth has the great potential to increase access and
utilization of mental health services for children enrolled in
Medicaid. This is something we must embrace. The pandemic has been
catastrophic in terms of mental health for large segments of society,
but especially children. Children in Medicaid have long been challenged
to access mental/behavioral health services. For children in rural
settings like Marshfield Clinic' service area, access is even more
challenging because a lack of providers. However, throughout the
pandemic we have been able to access care through video visits, and
many instances through audio-only visits when they cannot take
advantage of video visits. This has been an important tool to ensure
access to vital mental health services, especially when children face
serious mental health challenges resulting from the disruptions of the
pandemic. Congress should ensure that CMS maintains the telehealth
flexibilities that allow Medicaid enrollees, especially children the
ability to access mental health services even after the end of the
public health emergency.
An important component to the delivery of this care is the use of
audio-only visits. These visits routinely are the only way children can
access mental health services in some rural areas that lack access to
reliable broadband, or the patients and their families may not have
access to video-enabled phones/computers. Additionally, audio-only
visits help maintain regular and consistent engagement between patient
and provider. And, phone-only visits are also great tools for check-ups
in between regular appointments, especially in acute situations.
Question. As State Medicaid programs look at expanding their use of
telehealth, it is particularly important that vulnerable populations
like children are not negatively impacted. Policies must be looked at
through a health equity lens, considering access to reliable and
affordable broadband services, access to devices that support HIPAA-
compliant telehealth platforms and coverage policies.
How can Medicaid programs work to ensure telehealth policies are
equitable for children and mitigate potential inequities that may
arise?
Answer. You concern about the expansion of telehealth services
exacerbating health disparities is certainly valid. First and foremost,
we must remember that telehealth is best integrated into a full
spectrum of services available to all patients, based on their needs
and unique circumstances in consultation with their medical provider.
An individual should not be precluded from a particular care because of
their type of insurance coverage.
Medicaid programs must make efforts to ensure that access to
reliable broadband is not an obstacle to accessing telehealth services.
This is not just the issue of having broadband available. It also means
being able to afford broadband. Broadband services, no matter whether a
patient lives in a rural, urban or even suburban setting can be
expensive. Affordability must be taken into account. Medicaid could
consider providing broadband subsidies for enrollees, especially
children because of the added value of supporting their educational
pursuits, just like transportation subsidies.
And, continuing to allow for phone-only will be an important bridge
to ensure care is accessible, no matter the circumstances of the
patient. In the end, it will always be necessary for a provider to make
the final decision on the best way to treat their patient, but they
should not be precluded because of arbitrary obstacles like access to
smart technology like phones or tablets, or broadband access.
______
Questions Submitted by Hon. Benjamin L. Cardin
Question. We have seen licensure limits substantially restrict
access to cross-State medical care during this unprecedented COVID-19
emergency period. To maximize the utility of telehealth options and
ensure provider accountability, some experts have suggested that States
should do more to ensure mutual licensing reciprocity in the post-
pandemic environment.
I am a cosponsor of Senator Murphy's Temporary Reciprocity to
Ensure Access to Treatment Act (TREAT Act, S. 168/H.R. 708)--a narrowly
tailored bill to enable providers licensed in good standing in one
State to treat patients in any State for the duration of the COVID-19
Public Health Emergency.
How have health systems and patients benefited from State licensing
reciprocity during the COVID19 public health emergency?
Answer. You are certainly correct that State licensing reciprocity
was an important tool to ensure access during the height of the
pandemic. The greatest benefit was in patients being able to access
high-quality care without unnecessary delays or obstacles.
This reciprocity was especially important for rural providers such
as Marshfield Clinic Health System. Our model is to bring as much care
as close to home as possible for our patients. However, as a rural
provider, recruiting and retaining talent can be difficult. According
to a recent study, less than 5 percent of current medical students want
to practice care in a town smaller than 50,000 people.
During the pandemic, we were able to use licensing reciprocity to
engage physicians in high-demand/need areas more quickly via
telehealth, and to bring in necessary staff to bridge gaps in coverage.
A perfect example of this is during a significant surge of COVID-19
patients in the Midwest, we were able to secure staffing support from
the Federal Emergency Management Administration and the U.S. Department
of Defense. The staff that was assigned to our facilities were able to
expedite their licensure through reciprocity flexibility. This meant
they were not delayed in getting into clinical settings where they
could provide much need support and relief to our permanent staff.
Workforce is a major issue at all levels for rural medical
providers, and reciprocity was an important tool we could use to take
care of our patients. And to be frank with you all, after the harrowing
last year and a half, I suspect that the health-care sector is going to
be dealing with long-term staffing challenges. This will necessitate us
to be creative and nimble in developing solutions that are not always
easy, or quick. Continued reciprocity flexibility will help us recruit
and on-board staff at multiple levels that could lead to delays in
patient care.
Question. I recently reintroduced the Home Health Emergency Access
to Telehealth (HEAT) Act with Senators Collins and Shaheen. This bill
would allow Medicare home health providers to be reimbursed for the
telehealth services during a public health emergency. I also have heard
from other home-based care providers, like hospice and palliative care
as well as home-based primary care about the importance of telehealth
during the emergency and into the future as services in the home and
community continue to grow.
Could you talk about your experiences using telehealth to
supplement care for the populations you take care of?
Answer. Telehealth at MCHS did not have its genesis in the
pandemic. It has been a foundational element in our clinical delivery
of care for rural Wisconsin. In fact, we have used telehealth services
since 1997, and it has become an important resource to care for
patients in often remote and distant locations throughout our service
area, which is approximately 45,000 square miles, just bigger than the
State of Maine. In 2019, by our estimates use of telehealth saved our
patients over 1.2 million driving miles. For older and sicker patients
who cannot transport themselves, this is very impactful. To this, add
the inclement weather and the challenges of harsh and cold winters.
Additionally, in rural areas few, if any, public transportation systems
serve as safety net for our patients.
During the peak of COVID, we converted about 35 percent of our out-
patient visits to telehealth visits, about 6,000 visits per week. And
we leveraged the flexibilities granted by CMS to provide as much care
as possible remotely, including inpatient level care of patients at
home, mental and behavioral health services, rehabilitation and
physical therapy services and even chronic care management to just to
name some of the categories of care we transition to virtual platforms.
Anecdotally, patients have had positive experiences and come to realize
that the best place to heal or recuperate is their own home, not in a
hospital bed. It has also been a chance for us as a system to
reevaluate some of the services we provide and think more creatively.
And, as a physician myself, I will admit that the pandemic forced many
providers to reevaluate their preconceptions about what they could do
via telehealth and what they have to do as part of an in-person
clinical visit. It will take time to fully adjust our clinical approach
and our operations as a health-care system. But telehealth is here to
stay and has the chance to make a huge positive difference in the lives
of our patients.
Palliative care and hospice care are some of our most sacred duties
as physicians to our patients and their loved ones. Even before the
COVID-19 pandemic, MCHS was committed to using new models of care to
provide comfort and support to patients throughout their care journey.
Our model of home-based care, Home Recovery, has been deployed to
assist patients in these circumstances. This is especially important in
rural areas where palliative care and hospice facilities are less
common. Additionally, because of longer distances between home and
facility, virtual care cuts down on the stress to the patient, as well
as burdens to their families/caregivers. And virtual care in these
settings routinely allows for more fulsome discussion with families and
the patients about their wishes, and gives greater peace to all
involved.
Continuing to allow for these types of services through telehealth
and other virtual platforms will go a long way to ensuring all patients
can go through this type of care with dignity. For the last 3 years
MCHS has been at the forefront of delivering a large spectrum of
services that are traditionally only offered as inpatient services to
our patients in the comfort of their home. This experience has
demonstrated that patients routinely prefer to be at home, and that
outcomes at home are usually much better than in a hospital setting.
That is because patients are most comfortable where they live. We
should continue to expand on the opportunity to bring care to the homes
of patients leveraging technology and telehealth, and when that is not
possible to deliver it close to home at the best facility for the
patient and their families. That will make a difference in the
experience for all involved, the patient, their family and the
provider.It is an exciting potential, and one that we should all work
together to realize in the coming months and years.
The number one barrier during this time was lack of technology in
people homes and lack of sufficient broadband. About 65 percent of our
telehealth visits during COVID were audio-only, underscoring both the
importance of phone care continuing to maintain access to patients as
well as the need to continue advancing broadband expansion. Congress
must also do everything to ensure that a person's health-care coverage
does not dictate the type of care they receive. There must be parity
when it comes to access to telehealth services.
Question. What lessons from the pandemic would you like to see
brought forward into the future of care for home health, hospice,
palliative, and other home-based care providers?
Answer. Telehealth has the ability to improve outcomes, increase
access and satisfaction for patients in all settings, and reduce
health-care disparities. Some of the most important lessons gleaned
confirmed long-held ideas about the potential of telehealth to improve
the care we provide our patients.
Telehealth can increase access, improve outcomes and patient
satisfaction. Keep in mind, the cost of health care is not limited to
the bill from a doctors' office. Patients often take time off of work,
often unpaid, to drive up to 3 hours to receive care. Telehealth can
increase access by allowing patient to present closer to home and this
reduces their cost of accessing care.
Telehealth has an important role to play in a comprehensive
approach to care delivery, especially as we promote the move from
volume to value. More frequent low-acuity contact with your provider is
better than less frequent high-acuity contact. And, telehealth can be
integrated to comprehensive care that includes auxiliary services like
case management, physical or occupational therapy and even palliative
care.
Telehealth should continue to be an option for all patients,
regardless of their location or the type of insurance they have. The
site of service and geographic limitations that have been the hallmark
of telehealth reimbursement policy in Medicare are outdated. They do
not serve the best interests of the patients or the programs. While it
is important to come up with a comprehensive system to monitor and
track utilization of telehealth services, arbitrary limits will cause
us to regress from the progress we have made. The ones that will
ultimately pay the price for that lack of foresight will not be
decision-makers, but instead patients and their loved ones.
______
Questions Submitted by Hon. Chuck Grassley
Question. Throughout the public health emergency, the Centers for
Medicare and Medicaid Services (CMS) issued over 200 waivers under
Medicare and approved more than 600 waivers and other flexibilities
under Medicaid. While some of the regulations waived are specifically
for responding to a pandemic, ensuring patient safety, controlling
costs, and maintaining program integrity its clear innovation and
common sense ideas in our health-care system have been stifled too
often by Federal regulations. For example, CMS permanently added
certain new services (including mental health and care planning
services) that it had temporarily added to the approved list of
Medicare telehealth services during the pandemic. Some regulations play
an important role in protecting safety and maintaining program
integrity but others may stifle good ideas.
Is health care too regulated that it's stifling good ideas?
Answer. Health-care regulation is not keeping up with technology
and science. As a result, patients and providers are stuck in a system
that is behind the times and not adequately harnessing all the
innovation that is occurring throughout health care. And we are missing
out on taking advantage of the potential fields like artificial
intelligence and data analytics have to deliver new and improved care
to our patients and communities.
Good ideas are being brought to life each and every day. The real
challenge is implementing them in a way that can have a meaningful
impact on patients and their health-care providers, and the health
system in general in any timely and useful way. A perfect example of
this has been the long-time desire to promote a health-care system
where value is rewarded over pure volume. This catch-phrase has
seemingly been around for decades. But, it is hard to say we are much
further along our journey from volume to value than when we started.
For decades, American Physicians Group has been promoting capitated
care. This model has been demonstrated to be in the best interests of
providers, payers and patients. Experience during the pandemic has born
this out. As decreased volumes imperiled providers reliant on fee-for-
service revenues, while many providers in capitated arrangements were
able to manage the ups and downs more effectively.
Regulatory frameworks should not be focused on what is allowed or
not allowed. Instead, it should be focused on giving practitioners
guidelines to achieve a shared goal like promoting value-based care,
and then allow stakeholders (including providers, payers, technologists
and leaders) the ability to create systems that they think will work
best for their patients and communities.
It is hard to imagine creating a universal health-care model that
works as effectively in Marshfield, WI as it would in Laredo, TX, New
York City, or even Manhattan, KS. We should be focusing on creating a
regulatory system that lets providers tailor a system to the needs of
their patients and communities, and promotes utilizing the best
available technology and data to promote a culture of health and well-
being.
Question. Should executive agencies sunset regulations in the
future to enable more innovation in health care?
Answer. The current health-care regulatory framework is a hindrance
to the development and implementation of innovative models of care. We
should reorient our approach to the regulatory system. Instead of
overly prescriptive, or restrictive, regulations that do nothing to
advance a culture of health, we should create a framework that allows
providers, innovators and patients the power to create systems that are
functional and effective in delivering care for all patients.
When health-care leaders are conceptualizing new models of care and
implementing new technology for their patients, they look for
certainty. They need to know that what they are envisioning will be
permitted well into the future. Potentially sunsetting, or requiring
regulations to be renewed, could actually have the unintended
consequence of creating uncertainty and cool the embrace of new
technology and methods. Of the 18,000 or so regulations defined in the
Code of Federal Regulations, sunsetting all regulations (SUNSET rule
published in the Federal Register on November 4, 2020, 85 Fed. Reg.
70096) without adequate review by the impacted stakeholders would
likely have far-reaching economic impact and even greater impact on the
ability to provide care due to regulatory uncertainty it will create
for insurance providers and patients. During the pandemic, it would
divert vital resources from HHS, away from providing needed support at
the worst of times. Therefore while there are regulations that need
change, the how, what, and when matters so as not to throw out the baby
with the bath water. Instead of automatically sunsetting regulations,
agency leadership should reframe how they construct proposed
regulations and regulatory guidance to foster innovation.
Unnecessary or overly burdensome regulations certainly need to be
addressed. The experience we have had during the pandemic when
regulatory flexibility was exercised appropriately is a great
illustration. The quality of care a patient received did change from
all indications, and these flexibilities allowed providers to think of
new approaches to new and old problems. Creating an environment that
fosters growth and innovation is imperative to improve the health and
well-being of our patients and communities.
______
Questions Submitted by Hon. John Barrasso
Question. Before coming to the Senate, I had the privilege of
practicing medicine in Wyoming. Rural health care faced challenges
prior to the pandemic. In particular, we know since 2010 more than 135
rural hospitals have closed.
In the Senate, I am proud to help lead the bipartisan Rural Health
Caucus. This group is committed to ensuring patients in rural America
can get access to the care they need.
Can you specifically discuss the changes in Federal health-care
policy that you believe have helped rural providers the most during
this pandemic?
Answer. Thank you, Senator, for your focus on the important topic
of how to support rural health-care providers. Even before the onset of
the pandemic, rural health-care providers were struggling financially.
This is the result of the unique challenges associated with delivering
medical care to rural communities.
By far, the expansion of telehealth services has made a huge
difference for rural health-care providers. The suspension of
geographic restrictions and site of service rules were a lifeline to
patients during the darkest periods of the pandemic. When we had to
curtail in-person care, telehealth became an important lifeline for our
providers, and more importantly for our patients. For example, we went
from doing about 200 telehealth visits per month before the beginning
of the pandemic, to about 6000 visits per week in the spring of last
year.
And one of the most important lessons for providers and patients
from the pandemic is the breadth and depth of services that can be
provided via telehealth services. It is not just routine clinical
visits, but behavior health and substance abuse support, physical
therapy, pre-operative and post-operative appointments, and so much
more. The expansion of the types of services allowed to be done through
telehealth was vital to its broad acceptance at the outset of the
pandemic, and even now.
Furthermore, allowing audio-only telehealth visits was vital for a
number of our patients, especially those in rural areas that do not
have access to reliable broadband, or may not be comfortable with
technology because of their age.
Question. Can you please discuss any specific changes that Congress
should consider to better support rural health-care providers?
Answer. First and foremost, Congress must understand that the model
to deliver care in rural areas is just plain different than those in
more urban settings. As a result, as changes are made to the way
reimbursement occurs, or rules about operations of facilities, the
unique impacts on rural operations must be considered. And, it has to
be acknowledged that the finances of rural health-care providers are
routinely much more precarious than more populated areas. And, we have
to understand that the population we serve is different as well. Rural
residents on average are older, sicker, and poorer than their more
urban counterparts. In some of the counties we serve, there are less
than two workers per every Medicare beneficiary, so our payer mix is
very different than a health system in suburban Washington, DC. Lastly,
it should be remembered that access to care is an equity issue for
rural residents as well. A person should not be limited in their
medical options just because of where they choose to live.
Achieving a high-functioning rural health-care ecosystem requires
supporting and strengthening the programs that work well for rural
residents. One such program is Rural Health Clinics. This program can
help ensure access to care when otherwise it would not be economically
feasible. However, recent changes to reimbursement at RHCs could
restrict their growth moving forward, which is dangerous for rural
communities. A new provision passed in December would cap reimbursement
rates at newly created RHCs. This significant change came as a surprise
to many in the rural health community, and has imperiled plans across
the country to create RHCs in areas of significant medical need,
including some of the areas we serve at MCHS.
In the context of RHCs and telehealth, the long-standing limitation
of providing telehealth services external to the RHC is overly
burdensome and creates an unfair obstacle to accessing care. Before the
waivers for COVID-19, a provider in an RHC could not connect to a
facility outside of the RHC to render service. Clinicians would be
required to use space specifically carved out of the RHC to have
telehealth visits with outside clinicians. Further, restrictions on
telehealth services at Federally Qualified Health Centers are
unnecessary and again create an unjustifiable barrier to accessing care
for those patients who rely on FQHCs for their care.
Beyond these concrete examples, the issue of workforce is one of
the most pressing for our system, and providers across the country. In
the last 16 months, our front-line staff have truly embodied the
moniker they were given as Healthcare Heroes. However, we are not
facing challenges from burnout. And, this has to do with every level of
employee, from frontline staff in the ICUs, to technologists and
administrative staff who have been doing more than their fair share at
work, while at the same time having to change their lives at home. This
is a burgeoning problem that has no quick solution. Recruitment and
retention in rural areas is always more difficult because of the unique
circumstances of living in smaller communities, and the overall lack of
a ready labor pool.
Question. Prior to the pandemic, I introduced bipartisan
legislation with Senator Tina Smith, which among other things, would
allow Rural Health Clinics (RHCs) to provide more telehealth services.
I was pleased that Congress through the CARES Act authorized both
Rural Health Clinics and Federally Qualified Health Centers to furnish
telehealth services to Medicare beneficiaries during the public health
emergency.
Can you discuss the importance of Rural Health Clinics and
Federally Qualified Health Centers continuing to provide telehealth
services after the public health emergency has ended?
Answer. You are absolutely right to highlight the importance of
RHCs and FQHCs in rural health care. For many rural communities that do
not have a full hospital, RHCs and FQHCs are patients' only consistent
connection to care. Every effort should be made to ensure that the
restrictions to telehealth services at RHCs and FQHCs that were in
place before the pandemic are not reinstated when the public health
emergency ends. Otherwise, there will be an unfair difference in access
based on where individuals access their care. This is wrong and
unnecessary. Patients should be able to get the best care possible, no
matter where they get their care, in consultation with their clinician.
Question. My wife Bobbi and I are passionate about improving access
to mental health services. This pandemic has clearly impacted the
mental, as well as the physical health of our Nation.
For people living in rural America, getting help from a mental
health provider was challenging before the pandemic. This is why
Senator Stabenow and I have long supported professional counselors and
marriage and family therapists participating in Medicare. We believe
that increasing the number of mental health providers able to care for
our Nation's seniors is an important priority.
Please discuss how telehealth has impacted the ability of patients
to receive mental health services during the pandemic.
Answer. The COVID-19 pandemic has demonstrated the importance of
access to mental health services for all Americans, and the challenges
that occur when we cannot meet those needs.
A vast majority of behavioral health services are uniquely suited
for telehealth. In fact, at MCHS, the behavioral health service line
was the only group to experience an increase in volume in 2020. We saw
an increase of approximately 20 percent in utilization and
appointments. Further, we saw a decrease in no-show appointments, and
greater adherence to a course of treatment. This is accentuated in
rural areas where access to mental health services is more limited due
to a dearth of providers, and because of the usually extra-long
distances patients are sometimes required to travel to seek care.
Telehealth has served as an important bridge to ensure patients
have access to care, and as a way to address a chronic shortage of
access to mental health services in rural areas. A case in point is
research we have done about mental health and farmers. MCHS in
partnership with the National Farm Medicine Center published an article
in the Journal of Agromedicine in September 2020 after recognizing that
we were seeing an increase in farmers receiving behavioral health
services, a notoriously difficult population to engage in BH services,
largely due to stigma. Farmers reported that not having to present in a
facility where others were waiting in a waiting room was a significant
reason they didn't previously request care.
And I agree with you that we have to expand the types of providers
eligible to provide mental health services in Medicare. Doing so will
not only address access issues, but also ensure that patients can get
the right type of care.
Question. Can you please identify ways Congress can improve access
to mental health services, including expanding the number of providers
that can participate in Medicare?
Answer. First and foremost, Congress must recognize that telehealth
will continue to play a vital role to ensuring access to mental health
services. It pales in comparison to the suffering many people have
dealt with through this pandemic, but the emergence of telehealth as an
important part of the continuum of care, especially in behavioral
health, must be embraced and supported with the appropriate policy
changes moving forward.
Geographic restrictions and site of service regulations for
behavioral health services in Medicare must be rescinded. The pandemic
has shown that care can be effective care through telehealth and it
should be available to all patients, no matter where they live and
where they get their care.
Furthermore, Congress can move forward with incentives for States
to implement responsible and effective licensing rules that allow for
delivery of telehealth services across State lines in selected fields,
like mental health. This will mean that patients would have access to
these important services no matter where they live. And, it would also
fill in coverage gaps, especially in rural areas, where it is hard to
recruit and retain trained mental health professionals. Lastly, it is
important to ensure that there are a variety of providers eligible to
provide services in the Medicare program, including licensed clinical
social workers, family counselors and other non-physician providers.
Question. I was interested in your testimony where you discussed
the need to reduce the administrative burdens on health-care providers.
I agree telehealth is transforming the way we are providing care.
However, in Wyoming, most of our providers are part of smaller
hospitals and practices. We need to make sure government regulation is
not making it more difficult for these providers to serve their
patients.
Can you discuss specific ways Congress can reduce the
administrative burden in providing care through telehealth?
Answer. We must create an environment that supports delivery of
high-quality care and does not unnecessarily burden patients or
providers. As the use of telehealth continues to expand, CMS must
simplify the process for coding and billing of telehealth services.
Complexity will serve as a deterrent for providers and their offices to
wholly embrace telehealth. Also, CMS should approach telehealth through
the lens of maximizing the categories of providers eligible to provide
care through telehealth services. This includes advanced practice
clinicians, as well as medical students with appropriate supervision.
The future of health care will include telehealth, and we are doing a
disservice to patients and future clinicians if we fail to provide
appropriate training in how to provide care in this medium.
Further, CMS should ensure that there is parity for Medicaid
enrollees when it comes to telehealth services. Providers and their
staff should not have to sift through different regulations to
understand what services a patient is eligible for based on their
insurance coverage. We cannot allow a tiered system to emerge. And, we
must figure out a framework that allows for appropriate care across
borders, especially in high priority fields like behavioral health.
Question. Wyoming has many passionate advocates supporting both
hospice and palliative care. These folks are committed to ensuring
patients have the highest quality of life and are able stay out of the
hospital and with their families. This is why I help lead the
bipartisan Comprehensive Care Caucus. Our mission is to improve both
palliative and hospice care for patients.
Answer. Palliative care and hospice care are some of our most
sacred duties we have as physicians to our patients, and their loved
ones. Even before the COVID-19 pandemic, MCHS was committed to using
new models of care to provide comfort and support to patients
throughout their care journey. Our model of home-based care, Home
Recovery, has been deployed to assist patients in these circumstances.
This is especially important in rural areas where palliative care and
hospice facilities are less common. Additionally, because of longer
distances between home and facility, virtual care cuts down on the
stress to the patient, as well as burdens to their families/caregivers.
And virtual care in these settings routinely allows for more fulsome
discussion with families and the patients about their wishes, and gives
greater peace to all involved.
Continuing to allow for these types of services through telehealth
and other virtual platforms will go a long way to ensuring all patients
can go through this type of care with dignity. For the last 3 years
MCHS has been at the forefront of delivering a large spectrum of
services that are traditionally only offered as inpatient services to
our patients in the comfort of their home. This experience has
demonstrated that patients routinely prefer to be at home, and that
outcomes at home are usually much better than in a hospital setting.
That is because patients are most comfortable where they live.
We should continue to expand on the opportunity to bring care to
the homes of patients leveraging technology and telehealth, and when
that is not possible to deliver it close to home at the best facility
for the patient and their families. That will make a difference in the
experience for all involved, the patient, their family and the
provider. It is an exciting potential, and one that we should all work
together to realize in the coming months and years. To achieve this
grand goal, we must allow programs like the Hospital Without Walls and
other flexibilities to remain intact and to establish new policies that
promote home- based care. It will also be necessary to educate
providers, payers, and patients about the best practices in delivering
care this way, and how it benefits all parties involved.
______
Prepared Statement of Hon. Ron Wyden,
a U.S. Senator From Oregon
When COVID-19 hit, it was no longer safe to meet face to face, take
a bus to the doctor's office, or even walk into the hospital for care.
Congress, Federal agencies, and health-care providers had to act fast
with bold changes to prevent a dramatic disruption of health care in
America.
This morning's hearing is an opportunity to talk about the changes
that ought to stick around post-pandemic, and there's no better example
than telehealth. Right at the top, I want to thank Senator Crapo for
proposing a hearing on this vital topic, where there's a big
opportunity for the two sides to work together.
The telehealth challenge has always been about balancing the speed
and efficiency of new technologies with the need for health-care
quality and accountability. During the pandemic, some patients have
felt like they had to jump through too many hoops to get access to
telehealth. My view is, as a general proposition, patients ought to
have telehealth available as an option after seeing a provider for the
first time.
In some cases, the right approach might be to give the green light
for telehealth from the beginning. I hope today the committee is able
to discuss how to go about striking that balance after a year of
telehealth experience during the pandemic.
Last year, in the CARES Act, Congress allowed health-care providers
in Medicare to offer telehealth services to all seniors, regardless of
whether they lived in the biggest city or the smallest rural town. That
brought badly needed health-care safely into the homes of tens of
millions of seniors nationwide.
The CARES Act also allowed Federally Qualified Health Centers,
including community health centers and Rural Health Clinics, to receive
Medicare payment for telehealth services, allowing more health-care
providers to help meet the overwhelming demand for remote health
services.
Fortunately, the Finance Committee had already paved the way for a
lot of these changes, which means they were a lot easier to adopt.
Telehealth has been a Finance Committee priority for years,
particularly when it's part of the effort to update the Medicare
guarantee.
For many years, the Congress fell behind in terms of recognizing
the transformation of this flagship health-care program. When the
Medicare program was designed, it was built to cover acute conditions--
broken ankles under Medicare Part A, bouts of the flu under Part B.
Modern-day Medicare is about cancer, diabetes, heart disease, and more
of the chronic health conditions that are a lot more complicated and
more expensive to treat. Telehealth is going to be a bigger part of
that transformation going forward.
The CHRONIC Care Act, passed by this committee in 2017, marked the
very first time seniors could get telehealth at home for kidney
disease. The law also made it easier to use telehealth to diagnose and
treat strokes. It allowed more flexibility for Medicare Advantage plans
and Accountable Care Organizations. When the pandemic hit, CMS already
had a head start for telehealth.
Federal agencies also took advantage of existing law to allow
providers to care for their patients in fresh ways. For example,
certain hospital doctors and nurses were able to travel out into their
communities and provide services at home that would typically be
reserved for inpatient care.
Others were able to set up temporary spaces like tents near
hospitals themselves. That wasn't allowed in ordinary times pre-
pandemic. These steps have increased capacity, kept patients safe, and
helped maintain care.
Today the committee will hear from physicians and hospitals who
have been on the front lines, as well as health policy experts. They
have seen how these fresh approaches transformed care. In my view,
there is bipartisan interest in building on the changes that worked
well for both seniors and providers.
That bipartisan work has already begun. At the end of last year,
Congress passed legislation that allowed all seniors in Medicare to
receive mental health services via telehealth, including at home. My
view is, mental health services ought to be available via telehealth
for all Americans. That provision was part of a bill I authored that
would also permanently allow telehealth for routine health-care visits
in Medicare, known as evaluation and management services. I'm going to
keep working to make that a reality.
So there's a lot for the committee to discuss today. I'd like to
welcome the witnesses, and again I want to thank Ranking Member Crapo
for his partnership on this bipartisan issue.
______
Medicare Payment Advisory Commission (MedPAC)
425 I Street, NW, Suite 701
Washington, DC 20001
202-220-3700
https://www.medpac.gov/
Michael E. Chernew, Ph.D., Chair Paul B. Ginsburg, Ph.D., Vice Chair
James E. Mathews, Ph.D., Executive Director
Statement of Michael E. Chernew, Ph.D., Chair
The Medicare Payment Advisory Commission (MedPAC) is a small
congressional support agency established by the Balanced Budget Act of
1997 (Pub. L. 105-33) to provide independent, nonpartisan policy and
technical advice to the Congress on issues affecting the Medicare
program. The Commission's goal is to achieve a Medicare program that
ensures beneficiary access to high-quality care, pays health-care
providers and plans fairly by rewarding efficiency and quality, and
spends tax dollars responsibly. The Commission would like to thank
Chair Wyden and Ranking Member Crapo for the opportunity to submit a
statement for the record today.
The Congress and the administration granted temporary modifications to
Medicare policies to enable providers, health plans, and others to
effectively respond to the coronavirus pandemic. While many of these
actions have been helpful in addressing the short-term issues presented
by the pandemic, continuing those changes indefinitely would have
drawbacks. Therefore, policymakers should be cautious about extending
them beyond the duration of the public health emergency (PHE) or other
scheduled expiration date.
Introduction
The Commission acknowledges the catastrophic consequences the
coronavirus pandemic has had on all Americans and the health-care
delivery system. Medicare beneficiaries are at particular risk of
developing COVID-19, and those over 65 years old are more likely to
suffer complications and die compared to those who are younger and have
fewer comorbidities. Non White beneficiaries have faced
disproportionately high rates of mortality due to COVID-19, reflecting,
in part, longstanding inequities in the health-care system. The
Commission also recognizes the heroic work performed by the nation's
health-care workers, who have been on the front lines of this health
crisis for more than a year, and thanks them for their tireless
dedication and service.
The coronavirus pandemic has put our nation's health-care system under
enormous strain. Starting in March of last year, cases of patients
infected with the coronavirus began to rise sharply at institutional
settings, like hospitals and nursing homes. Hospital emergency rooms
and intensive care units were regularly filled with patients affected
by the pandemic, and beneficiaries in nursing homes have accounted for
a disproportionate share of fatalities from COVID-19.
Meanwhile, the volume of ambulatory care services furnished to Medicare
beneficiaries dropped sharply last spring as patients delayed or
avoided care, and access to some services was curtailed to avoid
spreading the disease. The number of ambulatory care services furnished
to Medicare beneficiaries in the spring of 2020 was about half of the
volume of the same services furnished during the same period the year
before. The sudden decline in service volume during this period placed
many providers under financial stress and may have put patient health
and well-being at risk.
Actions Taken to Modify Medicare Policies in Response to the Public
Health Emergency
As the coronavirus emerged in the U.S. and our health-care system
confronted extraordinary challenges, the Secretary of Health and Human
Services first declared the public health emergency in January 2020.\1\
Starting in March 2020, CMS and the Congress made numerous changes to
Medicare policies and granted regulatory flexibilities aimed at helping
health-care providers respond to the pandemic. We applaud CMS and
policymakers for acting rapidly to provide a comprehensive array of
policy modifications and flexibilities during an unprecedented time.
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\1\ Under section 319 of the Public Health Services Act, the
Secretary of Health and Human Services may determine that a disease or
disorder presents a public health emergency (PHE) or that a PHE,
including significant outbreaks of infectious disease or bioterrorist
attacks, otherwise exists. On January 31, 2020, the Secretary first
determined the existence of a coronavirus PHE since January 27, 2020,
based on confirmed cases of COVID-19 in the U.S. Since then, the
coronavirus PHE has been renewed five times, most recently on April 15,
2021, and is scheduled to expire on July 20, 2021 (Office of the
Assistant Secretary for Preparedness and Response 2021).
According to a report from the Commonwealth Fund, the administration
and Congress modified more than 200 Medicare program policies and
requirements between January and July 2020 (Podulka and Blum 2020). In
addition, CMS has been issuing subregulatory flexibilities to providers
and plans since the PHE began. Some of these measures have been phased
out, but many of these temporary policy changes are scheduled to remain
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in effect for the duration of the PHE.
In general, the steps taken by CMS and the Congress are time limited
and intended to support providers in diagnosing and treating COVID-19
patients by reducing or eliminating certain regulatory requirements and
enabling providers to treat Medicare beneficiaries under social
distancing protocols. The regulatory and legislative changes fall into
nine broad categories (Podulka and Blum 2020):
Alternative care sites.
Benefits and care management.
Conditions of participation.
Expanded testing.
Payment systems and quality programs.
Provider capacity and workforce.
Reporting and audit requirements.
Safety requirements.
Telehealth.
A plurality of the regulatory changes eased some provider eligibility
requirements. Regulatory waivers allowed providers to furnish services
outside the state where they are enrolled and permitted beneficiaries
to receive care in settings other than acute care hospitals (e.g.,
homes and skilled nursing facilities) to allow for surge capacity in
those hospitals. Some of the changes suspended audits and quality
reporting requirements or granted more flexibility over which measures
to report. CMS has also expanded access to telehealth services in a
variety of ways, including temporarily eliminating geographic
restrictions on where such services can be provided and expanding the
types of services that can be furnished remotely.
Although the pandemic-related policy changes and flexibilities have
touched almost every part of the Medicare program, I want to focus on
two areas where the changes are especially important: telehealth and
post-acute care.
Telehealth: The changes made to Medicare's telehealth coverage and
payment policies enabled more types of services to be furnished
remotely to more Medicare beneficiaries. These changes contributed to a
substantial increase in the number of Medicare-covered services
furnished via remote technologies, which helped to offset the decrease
in in-person clinician visits.
Post-acute care: CMS modified numerous post-acute care (PAC) policies
and requirements to preserve hospital capacity for beneficiaries with
COVID-19. These actions enabled inpatient rehabilitation facilities and
long-term care hospitals to treat certain hospital-level patients that
do not meet certain requirements for these PAC settings and, in some
cases, be paid the higher PAC-level payments. These waivers also
extended skilled nursing facility coverage to beneficiaries who
normally would not qualify.
The temporary waivers and other policy changes gave providers the
flexibility to maintain access to care under social distancing
guidelines and helped providers to respond to surges in COVID-19 cases
by providing capacity beyond the acute care setting. These have been
important tools for providers during the pandemic, but policymakers
would be remiss in thinking that the extending these measures has only
the potential for good. The underlying policies and regulations that
have been waived or altered are designed to protect beneficiaries,
support program integrity, and minimize potential overuse and misuse
based on the incentives of the payment systems. As decisions are made
about which pandemic-related measures should be continued, policymakers
need to account for the fact that not all actors in the health-care
system are well-intentioned, and remain vigilant in protecting the
Medicare program, beneficiaries, and taxpayers.
Telehealth
Medicare coverage of telehealth services before the PHE was limited by
statute under the physician fee schedule (PFS). Before the PHE,
Medicare covered telehealth services if they were provided to
beneficiaries who received the service at a clinician's office or
certain health-care facilities (known as ``originating sites'') located
in a rural area, with some exceptions.\2\ Medicare has historically
been cautious about covering telehealth services because of
uncertainties about the impact of telehealth on total spending,
quality, and program integrity.
---------------------------------------------------------------------------
\2\ Medicare pays for some telehealth services outside of rural
areas and in any location, including a patient's home, including
telehealth services for substance use disorders, for end-stage renal
disease patients receiving home dialysis, and for mental health
conditions (if the physician or practitioner has furnished an in-person
service to the individual within the 6 months prior to the first time
they furnish the telehealth service, and during subsequent periods that
the Secretary would determine). Medicare also covers telehealth
services to treat patients with a stroke in hospitals in urban and
rural areas.
Prior to the PHE, the Commission evaluated the use of telehealth in the
Medicare program and whether telehealth services covered under
commercial plans should be incorporated into the Medicare fee-for-
service (FFS) program (Medicare Payment Advisory Commission 2018). Our
analysis of a sample of commercial insurers found a lack of uniformity
in how these insurers covered telehealth services. Consequently, we did
not make recommendations about covering specific telehealth services in
Medicare. Instead, the Commission recommended that policymakers should
use a set of principles (access, quality, and cost) to evaluate
---------------------------------------------------------------------------
individual telehealth services before covering them in Medicare.
To increase access to care and help limit community spread of COVID-19
during the PHE, Medicare temporarily expanded coverage of telehealth
under the PFS to all Medicare beneficiaries, including telehealth
visits provided to patients at home (Table 1).
Table 1. Selected Temporary Telehealth Expansions to the Physician Fee
Schedule During the Public Health Emergency
------------------------------------------------------------------------
Pre-PHE During the PHE
------------------------------------------------------------------------
Who can receive Clinicians can provide Clinicians may provide
telehealth services? telehealth services to telehealth services to
Medicare beneficiaries Medicare beneficiaries
in certain originating outside of rural areas
sites in rural areas and in the patient's
(e.g., a clinician's home.
office or hospital but
not the beneficiary's
home).
------------------------------------------------------------------------
Which types of Limited set of services CMS pays for over 140
telehealth services (does not include audio- additional services
does Medicare pay only E&M visits). (e.g., emergency
for? department visits,
radiation treatment
management). CMS
allows audio-only
interaction for some
of the telehealth
services and covers
audio-only E&M codes.
------------------------------------------------------------------------
How much does PFS rate for facility- PFS rate is the same as
Medicare pay for based services (less if the service were
telehealth services? than the nonfacility furnished in person
rate). (facility or
nonfacility rate,
depending on the
clinician's location).
Same for audio-only
visits.
------------------------------------------------------------------------
What are the costs to Standard cost sharing. Clinicians are
beneficiaries? permitted to reduce or
waive cost sharing.
------------------------------------------------------------------------
Note: PHE (public health emergency), E&M (evaluation and management),
PFS (physician fee schedule). Under the PFS, clinicians who provide
services in facilities such as hospitals receive a lower payment rate
(the facility rate) than clinicians who provide services in offices
(the nonfacility rate).
During the PHE, demand for telehealth services soared as providers and
beneficiaries sought to reduce the risk and spread of infection by
avoiding in-person visits. According to an analysis of FFS Medicare
claims data from the first 6 months of 2020 and the first 6 months of
2019, there were 8.4 million telehealth services paid under the PFS in
April 2020, compared with 102,000 in February 2020 (Medicare Payment
Advisory Commission 2021). The number of telehealth services declined
to 5.6 million in June 2020, as the number of in-person services began
to rebound. During the first 6 months of 2020, 10.3 million
beneficiaries in FFS Medicare (32 percent of the total) received at
least one telehealth service, compared with 134,000 beneficiaries
during the first 6 months of 2019. The share of all primary care
services conducted by telehealth rose dramatically from less than 1
percent in January 2020 to 47 percent in April.\3\ The share declined
to 31 percent in May and 18 percent in June as in-person primary care
services rebounded. The Commission will analyze more recent claims data
over the next year.
---------------------------------------------------------------------------
\3\ Primary care services include the following PFS services:
office/outpatient evaluation and management (E&M) visits, home E&M
visits, E&M visits to patients in certain non-inpatient hospital
settings (nursing facility, domiciliary, rest home, and custodial
care), audio-only E&M visits, chronic care management, transitional
care management, Welcome to Medicare visits, annual wellness visits, e-
visits, and advance care planning services.
---------------------------------------------------------------------------
Rationale for Telehealth Expansion and Potential Safeguards
During the past year, the Commission discussed whether the temporary
telehealth expansions should continue in Medicare after the PHE. Many
providers and beneficiaries have described the benefits of increased
access and convenience from telehealth during the PHE. Advocates of
telehealth services support making the temporary expansion of
telehealth in Medicare permanent after the PHE. They assert that these
services can expand access to care, increase convenience to patients,
improve quality, and reduce costs relative to in-person care. However,
there is a risk that under FFS Medicare, telehealth services could
supplement--rather than substitute for--in-person services, thereby
increasing spending for Medicare and patients (Ashwood et al. 2017,
Mehrotra et al. 2020). Telehealth could lead to higher volume if
telehealth providers induce demand for their services, if the greater
convenience of telehealth leads beneficiaries to use telehealth
services more frequently than in-person services, or if additional in-
person follow-up visits are required. Although there are some clinical
trials comparing telehealth and in-person care, there is not yet
evidence on how the combination of telehealth and in-person care
affects quality of care and outcomes.
Expanding telehealth services also raises program integrity concerns.
Telehealth companies have been involved in several large fraud cases,
resulting in billions of dollars in losses for Medicare. For example,
the Department of Justice (DOJ) recently charged defendants--including
telemedicine companies--with submitting false and fraudulent claims
worth more than $4.5 billion to federal health programs and private
insurers (Department of Justice 2020). Telehealth technology makes it
easier to carry out fraud on a large scale because clinicians employed
by fraudulent telehealth companies can interact with many beneficiaries
from different parts of the country in a short amount of time. In
addition, if beneficiaries become more comfortable receiving care by
telehealth, they might become more vulnerable to being exploited by
companies that pretend to be legitimate telehealth providers.
In considering a permanent expansion of telehealth, it is important to
balance the potential of telehealth to improve beneficiaries' access to
care with the risk of higher spending due to overuse, while ensuring
that beneficiaries receive high-quality care. In our March 2021 report
to the Congress, we present a policy option for expanding FFS
Medicare's coverage of telehealth services after the PHE (Medicare
Payment Advisory Commission 2021). In developing this policy option, we
maintain our previous recommendation that policymakers should use the
principles of access, cost, and quality to evaluate individual
telehealth services before covering them under Medicare.
Under this policy option, policymakers should continue some telehealth
expansions for a limited duration following the end of the PHE (e.g.,
one to two years) to gather more evidence about the impact of the
telehealth expansions on total spending, access, patient experience,
and outcomes of care. Policymakers should use this evidence to inform
any permanent changes. First, Medicare should temporarily pay for
specified telehealth services provided to all beneficiaries regardless
of their location. Second, Medicare should temporarily cover selected
telehealth services in addition to services covered before the PHE if
there is potential for clinical benefit. Third, to improve access to
those without the capability to engage in a video visit from their
home, Medicare should temporarily cover certain telehealth services
when they are provided through an audio only interaction if there is
potential for clinical benefit.
Other telehealth policies that were adopted during the PHE should end
when the PHE ends. First, Medicare should return to paying the fee
schedule's facility rate for telehealth services instead of paying
either the facility or nonfacility rate, as it does during the PHE. CMS
should also collect data from practices and other entities on the costs
they incur to provide telehealth services and make any future changes
to telehealth payment rates based on those costs. We expect the rates
for telehealth services to be lower than rates for in-person services
because services delivered via telehealth likely do not require the
same practice costs as services provided in a physical office. Although
telehealth may require upfront investments in technology and training,
in the long run the marginal cost of a telehealth service should be
lower than that of an in-person service (Mehrotra et al. 2020).
In addition, Medicare should require the same share of beneficiary cost
sharing for telehealth as it does for in-person service after the PHE.
Because telehealth services are more convenient for beneficiaries to
access, they have a higher risk of overuse than in-person services,
particularly in the context of a fee-for-service payment system in
which providers have a financial incentive to bill for more services.
Requiring beneficiaries to pay a portion of the cost of telehealth
services would help reduce the possibility of overuse.
After the PHE, CMS should implement other safeguards to protect the
Medicare program and its beneficiaries from unnecessary spending and
potential fraud related to telehealth, including:
Applying additional scrutiny to outlier clinicians who bill many
more telehealth services per beneficiary than other clinicians;
Requiring clinicians to provide an in-person, face-to-face visit
before they order high-cost durable medical equipment or high-cost
clinical laboratory tests; and
Prohibiting ``incident to'' billing for telehealth services
provided by any clinician who can bill Medicare directly.
In future work, we will continue to monitor beneficiaries' and
providers' experiences with telehealth in Medicare and the use of
telehealth during the PHE. We plan to continue exploring trends in
telehealth use and spending using more recent Medicare claims data.
This summer, we will ask clinicians and Medicare beneficiaries about
their use of telehealth during focus groups, and we will ask
beneficiaries and privately insured individuals about their use of
telehealth during our annual telephone survey. In addition, we continue
to meet with telehealth companies and other stakeholders and will
regularly inform the Congress of our work.
Post-Acute Care
Institutional post-acute care (PAC) settings-skilled nursing facilities
(SNFs), inpatient rehabilitation facilities (IRFs), and long-term care
hospitals (LTCHs)-provide care to patients who need skilled
institutional care to recuperate and regain function, typically
following an acute care hospital stay. The Medicare program maintains
separate conditions/requirements of participation and coverage rules
and uses setting-specific prospective payment systems (PPSs) to pay for
stays in each setting. Distinct facility and patient requirements help
ensure that care provided in each setting is consistent with Medicare
coverage rules and help control unnecessary spending for care in high-
cost settings when patients' conditions do not warrant this level of
care.
During the PHE, CMS used its emergency and other waiver authority to
modify numerous policies and requirements intended to preserve hospital
capacity for beneficiaries with COVID-19 (Centers for Medicare and
Medicaid Services 2021b). Waivers allowed IRFs and LTCHs to be paid the
higher-level payments for some cases that do not qualify as IRF or LTCH
stays, and they extended SNF coverage to beneficiaries who normally
would not qualify for SNF stays. The SNF, IRF, and LTCH facility and
patient requirements and PHE-related waivers are summarized below.
Skilled nursing facility requirement. Beneficiaries who need daily,
short-term skilled nursing or rehabilitation care on an inpatient basis
following a hospital stay of at least three days are eligible to
receive covered services in SNFs. By limiting coverage to post-hospital
``skilled'' services, the program extends coverage for services similar
to those provided to hospital inpatients, but at a lower level of care,
and effectively excludes long-term care, which is not a covered
Medicare benefit.
Skilled nursing facility waiver. During the PHE, CMS is waiving the
requirement for a three-day prior hospitalization for coverage of a SNF
stay for beneficiaries who experience dislocations or were otherwise
affected by COVID-19. In addition, for certain beneficiaries who
recently exhausted their SNF benefits, CMS authorizes renewed SNF
coverage without first having to start a new benefit period. These
waivers allowed facilities to ``skill in place'' beneficiaries who
required skilled care without having to transfer them to a hospital for
a three-day hospital stay and helped retain hospital capacity for
COVID-19 patients. CMS estimated that about 16 percent of SNF
admissions in fiscal year 2020 used a waiver, and the majority of those
were attributed to the waived prior hospital stay requirement (Centers
for Medicare and Medicaid Services 2021b).
Inpatient rehabilitation facility requirements. After an illness,
injury, or surgery, some beneficiaries need intensive inpatient
rehabilitation services, such as physical, occupational, or speech
therapy. For a facility to receive payment as an IRF, 60 percent of its
admissions must be for one of 13 conditions that typically require
intensive rehabilitation therapy (referred to as the ``60-percent
rule''). To qualify for admission to an IRF, a beneficiary must be able
to tolerate and benefit from intensive therapy, typically defined as
three hours of therapy a day at least five days a week (referred to as
the ``3-hour rule''). These Medicare requirements help ensure that only
the most appropriate patients are eligible to receive care at this
relatively costly setting, given that many beneficiaries are able to
receive care at lower-cost settings.
Inpatient rehabilitation facility waiver. CMS is allowing IRFs to
exclude from the calculation of their compliance with the 60-percent
rule those patients who were admitted in response to the PHE. CMS is
also waiving the three-hour therapy rule, as required by Section
3711(a) of the Coronavirus Aid, Relief, and Economic Security (CARES)
Act. These waivers effectively allow IRFs to admit patients who would
not normally qualify for IRF care and provide additional hospital beds
for surge capacity in communities that need it. These cases may be paid
the IRF PPS rates in freestanding IRFs in areas experiencing a surge
during the PHE.\4\
---------------------------------------------------------------------------
\4\ A state (or region, as applicable) that is experiencing a surge
means a state (or region, as applicable) that satisfies all of the
following, as determined by applicable state and local officials: (1)
all vulnerable individuals continue to shelter in place, (2)
individuals continue social distancing, (3) individuals avoid
socializing in groups of more than 10, (4) non-essential travel is
minimized, (5) visits to senior living facilities and hospitals are
prohibited, and (6) schools and organized youth activities remain
closed (Centers for Medicare and Medicaid Services 2021a).
Long-term care hospital requirements. Some patients with profound
debilitation of multiple systems, frequently with ongoing respiratory
failure, receive care in an LTCH. To be paid at the higher standard
Medicare LTCH payment rate, a case must immediately follow an acute
care hospital stay, not be a psychiatric or rehabilitation case, and
the preceding hospital stay must include three or more days in an
intensive care unit or the LTCH case must include mechanical
ventilation services for at least 96 hours. If these requirements are
not met, cases are paid at a lower ``site-neutral'' rate. In addition,
to qualify for Medicare payment as an LTCH, a facility must have an
average length of stay greater than 25 days for Medicare cases paid the
LTCH PPS standard payment rate. Finally, if less than 50 percent of
Medicare discharges qualify for the standard LTCH PPS rate, the
facility is to be paid under the acute care hospital PPS until that
share reaches 50 percent or higher. As with Medicare's IRF
requirements, LTCH criteria were implemented to ensure that Medicare
does not pay the high LTCH rates for lower-acuity cases that can be
---------------------------------------------------------------------------
cared for in other, lower-resource intensive settings.
Long-term care hospital waiver. Consistent with section 3711(b) of the
CARES Act, all cases admitted are being paid the LTCH payment rate,
even those that normally would not qualify for the higher LTCH rate,
for the duration of the PHE. In addition, all cases will be counted as
discharges paid the LTCH PPS rate for purposes of calculating an LTCH's
share of Medicare discharges that qualify for the standard LTCH PPS
rate. In addition, CMS waived the 25-day average length-of-stay
requirement to participate in the LTCH PPS when an LTCH admits or
discharges patients to meet the demands of the PHE. These waivers
enable LTCHs to treat a broad mix of patients, including overflow
short-term acute care hospital patients, and be paid LTCH payment
rates.
Waived PAC Criteria Should Be Reinstated When the Public Health
Emergency Ends
The waivers of facility and patient requirements for SNFs, IRFs, and
LTCHs are examples of policy changes that provide flexibility to expand
capacity and reduce patient transfers for the duration of the PHE. The
waivers allowed providers to be paid for Medicare patients that would
not ordinarily qualify for payment in those settings or to be paid
higher rates for those patients during the PHE, but there are
compelling reasons to reinstate these waived requirements after the PHE
is over. Making these changes permanent would roll back gains in
defining appropriate use of costly settings and expose the Medicare
program to increased spending. For example, until 2016, the lack of
meaningful criteria for LTCH use resulted in admissions of less-complex
patients who could be cared for appropriately in lower-cost settings.
The Commission and CMS had long been concerned that caring for lower-
acuity patients in LTCHs increased spending without demonstrable
improvements in quality or outcomes (Medicare Payment Advisory
Commission 2020). When ``site-neutral'' payments for less-complex
patients were implemented starting in 2016 and LTCHs received lower
acute hospital rates for these cases, providers responded by reducing
the number of site-neutral cases treated in LTCHs (Medicare Payment
Advisory Commission 2021).
Studies of the impact of eliminating the SNF prior-hospitalization
requirement (along with other changes) under the Medicare Catastrophic
Coverage Act suggest that spending would increase substantially without
the three-day rule to act as a guardrail for program spending (Aaronson
et al. 1994, Laliberte et al. 1997, Office of Inspector General 1991).
To balance the objectives of updating the policy to reflect current
hospital practices yet protect the Hospital Insurance Trust Fund, in
2015 the Commission recommended that the three-day policy be revised to
allow up to two days spent in outpatient observation status to count
toward the three-day prior hospitalization requirement (Medicare
Payment Advisory Commission 2015). When the three day hospital stay
waiver is lifted, the Congress should revise it to allow two of the
days in observation status to count towards meeting the required three-
day stay.
While Medicare permitted the SNF three-day stay requirement to be
waived for entities participating in bundled payment demonstrations,
some entities did not take advantage of this flexibility (Dummit et al.
2018, Lewin Group 2019, The Lewin Group 2020). Similarly, not all Next
Generation ACOs elected to waive the three-day stay requirement (NORC
at the University of Chicago 2020). However, since these bundled
payment entities and ACOs are at full risk, this experience may not be
relevant to entities operating under traditional FFS Medicare. This is
because they already have a financial incentive to control the total
cost of care to Medicare, unlike providers not at financial risk under
traditional Medicare.
In 2016, the Commission recommended design features of a unified
payment system for post-acute care that would pay for PAC services
based on patient characteristics and needs, rather than setting
(Medicare Payment Advisory Commission 2016). Later, it outlined a
patient centered approach to align regulatory requirements so that
providers would face similar regulatory requirements for treating
similar patients (Medicare Payment Advisory Commission 2019). Until a
uniform payment system is implemented and regulatory requirements are
aligned, institutional PAC settings' patient and facility criteria
provide important program safeguards against paying for unnecessary
care and help ensure that care provided in costly, intensive settings
is targeted to patients who can benefit from that level of care.
Policymakers Should Be Cautious About Making Current Flexibilities and
Policy Modifications Permanent
It is important to keep in mind the reasons that policies and rules in
place prior to the pandemic exist. Many of the Medicare policy changes
made in response to PHE affect important beneficiary protections, as
well as measures designed to deter fraud, overuse, or inappropriate
spending. The intended effects of the regulatory flexibilities and
other changes to Medicare's policies are to maintain beneficiary access
to needed services and help the health-care system to respond to the
pandemic, but these flexibilities can also have negative effects. For
example, waiving conditions of participation can expand access and
minimize provider burden, but looser regulations may also negatively
affect quality of care and quality of life for patients and put
Medicare at higher risk for waste and fraud by creating opportunities
for those who wish to exploit the program to do so.
If it is determined that any temporary policy changes are leading to
poor health outcomes, patient harm, or increases in fraud and abuse,
policymakers should take immediate action to curtail those
flexibilities prior to the end of the PHE. Likewise, some of the
temporary policy changes that were viewed as necessary during the worst
days of the PHE--such as increased payment rates for certain services--
may no longer be needed as the effects of the pandemic wind down.
In other cases, decisions about whether to extend or make permanent
policy modifications after they are scheduled to expire should be made
based on evaluation of data collected not only during the pandemic, but
also during more typical circumstances. That being said, we do not yet
have reliable information about how policy modifications and
flexibilities granted during the PHE have affected health status,
access, spending, program integrity, and other important
considerations. Furthermore, findings on the effects of policy changes
based on data collected during a pandemic may not be generalizable to
the post-pandemic environment. For instance, the impact of the
modifications that increased use of telehealth on quality and cost of
care are largely unknown and will take time to fully analyze, and
findings from 2020 could be shaped by factors that may not be
applicable after the pandemic.
Conclusion
MedPAC recognizes the tremendous challenges the coronavirus pandemic
has imposed on beneficiaries, providers, and the rest of the health-
care system. We applaud the quick and decisive actions taken by the
Congress and CMS aimed at maintaining access to care and enabling an
effective response to the public health emergency. In general, the
Commission has been supportive of the temporary waivers, flexibilities,
and other changes to Medicare policies implemented during the PHE. We
are supportive of continuing some of the telehealth expansions for a
limited time, beyond the PHE, provided that adequate oversight and
protections are in place to protect the Medicare program and
beneficiaries. We would not advise extending the PAC waivers beyond the
PHE.
The Commission is also supportive of efforts by this Committee and
others to review the changes and make determinations about which, if
any, flexibilities and policy changes should be continued, and which
should be reinstated once the PHE ends. We realize many stakeholders
see the benefits of less regulatory oversight and expanded coverage of
services like telehealth, along with other pandemic-related policy
changes, and wish to see them made permanent. But the Commission is
concerned about the implications of indefinitely continuing Medicare
policy modifications and flexibilities that were granted in direct
response to the unique circumstances of the coronavirus pandemic. There
are trade-offs to extending PHE-related modifications, and the benefits
of continuing these changes must be weighed against the potential
drawbacks, including substantial spending and program integrity
implications.
Although we are concerned about the potential for some of the waivers
and coverage expansions to lead to overuse of services and reductions
in quality of care, these modifications may not have the same drawbacks
when implemented in alternative payment arrangements to traditional FFS
where an entity is at financial risk for the cost and quality of care.
In fact, many existing Medicare alternative payment models (APMs)
contain waivers and flexibilities similar to those granted during the
PHE. As noted earlier, many APMs permit beneficiaries to receive care
in a SNF without a preceding three-day inpatient hospital stay, and
there are fewer restrictions on telehealth compared to traditional FFS.
The Commission is hopeful that the continued development of such models
can help facilitate more flexibility for providers and expanded
coverage of technologies such as telehealth, while minimizing the
negative behaviors.
In closing, MedPAC urges the administration and the Congress to
carefully consider how making waivers permanent will affect the quality
of care beneficiaries receive, the willingness of providers to continue
to participate in the Medicare program, and the already challenging
issues of fiscal solvency and Medicare program integrity. The
Commission plans to continue to follow the status of the temporary
policy changes and waivers granted during the PHE and will be closely
monitoring their impact on the program. Ultimately, all decisions about
whether to continue these measures beyond the PHE should balance the
benefits of expanding access to care and reducing administrative burden
with the need to minimize the potentially negative effects that the
rules and policies were originally designed to prevent.
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of the Medicare Catastrophic Coverage Act: A paradoxical lesson for
health-care reform. Journal of Health Politics, Policy and Law 19, no.
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______
Communications
----------
Adventist Health
May 26, 2021
Senator Ron Wyden
Chairman
U.S. Senate
Committee on Finance
Washington, DC 20510
Senator Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
Washington, DC 20510
RE: Mayo Clinic Statement for the Record for the Committee hearing
entitled: ``COVID-19 Health Care Flexibilities: Perspectives,
Experiences, and Lessons Learned,'' May 19, 2021
Dear Chairman Wyden and Ranking Member Crapo:
On behalf of Adventist Health and the patients we serve, thank you for
holding the May 19, 2021 hearing on ``COVID-19 Health Care
Flexibilities: Perspectives, Experiences, and Lessons Learned.'' We
commend the committee for addressing this important issue and analyzing
critical lessons learned from the hospital and patient perspectives. We
look forward to supporting the evolution and advancement of health-care
flexibilities today and post-pandemic.
Adventist Health is a faith-based, nonprofit integrated health system
serving more than 80 communities in California, Hawaii, and Oregon.
Adventist Health provides compassionate care in 23 rural and urban
safety net hospitals. We operate the largest network of rural health
clinics in California, with more than 20 percent of California's Rural
Health Clinics as a part of the system. Our rural Health Clinics (RHCs)
provide care to about 315,000 individuals who mostly live in medically
underserved communities.
Adventist Health is transforming the health-care experience, shifting
from providing care to focusing on the overall health of the
communities it serves. This includes embracing technology that makes
care more convenient and accessible. The beginning of 2020 introduced a
disruption that has created more opportunities for virtual visits,
which are an essential component of health-care innovation that have
proven to be a lifeline during the COVID-19 pandemic. This innovative
approach also offers insights on the virtual hospital of the future. In
May of 2020, Adventist Health created a new care model that is
reshaping the way acute care is delivered to the system's communities.
Hospital@Home, in collaboration with Medically Home Group, Inc. and
Huron, is a virtual hospital that harnesses virtual and telemedicine
technologies proven successful in hospitals for the last decade, to
provide care in a patient's home.
Telehealth services, like those provided by Hospital@Home, are more
convenient and accessible than traditional office visits and can
greatly benefit populations who find it difficult to manage their
health-care needs in person. Our virtual visits provide crucial access
to care for high-risk patients who need to stay home to protect
themselves, both during public health crises and in normal times. Our
telehealth services also provide vital access for patients in rural
communities, where in-person clinic visits may require extraneous time
and effort to schedule and attend. Virtual visits are also an essential
way for patients to receive mental and behavioral health-care services
that are increasingly necessary for whole-person care, but often
difficult to access. Telehealth services are an important way for
traditionally disadvantaged patient populations to easily connect to
primary as well as specialty care providers that may not be accessible
in person. It has been a critical lifeline for the patients and
communities we proudly serve.
The past year has demonstrated the undeniable value of virtual care.
However, much work remains to be done to ensure the continued growth of
telehealth and preserving beneficiary choice in how care is furnished.
Expedient action from Congress is essential to permanently establish
the flexibilities granted to CMS during the COVID-19 pandemic and to
subsequently authorize CMS to build out an accompanying regulatory
framework.
Virtual Care at Adventist Health
During the pandemic, Adventist Health's clinical and digital teams
provided essential remote care through 300,000 telephone and video
visits. Through our virtual care we have seen a decrease in missed
visits, our patient satisfaction rates have increased and we are able
to create access points to our most vulnerable populations where we
otherwise would not have.
Hospital@Home
In one of the most significant developments in remote care, in May of
2020, Adventist Health launched its Hospital@Home program to furnish
acute-level services to patients in their home. Adventist Health's
Hospital@Home serves patients in 7 locations throughout California and
Oregon. The program has served hundreds of patients, delivering complex
comprehensive acute care to qualifying patients in their homes. These
services, provided in person and virtually, include infusions, nursing
care, medications, laboratory and imaging services, and rehabilitation
services from a network of registered nurses, community paramedics, and
an ecosystem of support team members--all under the clinical direction
of credentialed board certified hospitalists in Adventist Health
command centers.
The availability of an acute care option at home was a critical tool in
the pandemic response and Adventist Health's hospitals are approved
participants under the CMS Acute Care at Home (CMS ACH) program
announced in November 2020.
Our model counters isolation created by the COVID-19 pandemic and
allows family members to be at a patient's bedside in their home, while
helping hospitals balance the increased demand for hospital beds. The
Adventist Health Hospital@Home care model is applied in emergency
medicine, acute level COVID-19 care, and for patients with infections
and chronic disease exacerbation (e.g., CHF, COPD). This broad spectrum
of applications unlocks patients' homes as a meaningful addition to
flexible medical care capacity and supports greater health system
resiliency, while meeting the needs and wants of patients who prefer to
be cared for at home or in a home-like setting. The CMS ACH waiver
expires at the end of the PHE, and it is essential that Congress act to
extend the current waivers to enable Medicare beneficiaries to continue
to access safe and effective acute-level care in the comfort of their
home.
Since launching Hospital@Home in May 2020, Adventist Health has been
collecting and analyzing data on Hospital@Home's impact on patient
care, experience, acuity, readmission rates, and mortality. To date,
Adventist Health has cared for over 500 patients and has had over 3,000
patient days, with promising data. For Adventist Health patients
receiving care in the Hospital@Home program, the 30-day hospital
readmission rate is 43.4% lower than the comparable population in the
same timeframe within Adventist Health's traditional (brick and mortar)
hospital practice.
To assess 2020 patient satisfaction, data collected using inpatient
HCAHPS surveys have been generated for Hospital@Home patients,
resulting in top decile scores for overall rating - 89.4% (n=53) - and
would recommend - 87% (n=46).
Recommendations for Health Care Flexibilities
Adventist Health supports keeping these important flexibilities in
place so that we can ensure that our forward momentum is built upon and
that the significant investments in telehealth infrastructure and
accessible patient care are maintained.
Geographic and originating site restrictions. Before the
pandemic, Medicare required that a patient either live in a rural or
certain health professional shortage area or only use telehealth at an
approved originating site, such as a hospital or physician's office.
Together, these restrictions functionally prevented beneficiaries from
accessing telehealth at home. Only about 2 percent of beneficiaries
reside in zip codes that meet the traditional geographic and
originating site criteria.
FQHC and RHC expansion. Without making permanent the COVID-19
regulatory flexibility, Rural Health Clinics (RHCs) and Federally
Qualified Health Centers (FQHCs) will not be allowed to serve as
distant site telehealth providers. This prevents low-income and
geographically isolated individuals from utilizing accessible points of
care for telehealth visits, creating barriers to affordable treatment
for the populations who often need it most.
Qualifying providers. When the PHE ends, CMS would currently
have to revert to policies that restrict the types of providers that
can deliver reimbursable virtual care to Medicare beneficiaries.
Commonly accessed providers like physical therapists, occupational
therapists and speech language pathologists would no longer be able to
bill for telehealth services.
Audio-Only Services. Audio-only services are critically
important for many populations. Technology challenges, such as access
to Internet/broadband and low digital literacy, is a telehealth barrier
for 64% of patients. These patients require audio-only services to meet
their unique needs.
Hospital Without Walls. Acute Hospital Care at Home waivers
mitigate the residual impacts of COVID-19 on public health and
encourage broader adoption of providing patient centered health-care
services in the home.
Thank you again for holding this important hearing. We look forward to
continuing to work with Congress and HHS to ensure that access and
quality care are available to our patients and our communities during
and beyond the PHE, as well as to further provide groundwork for
greater innovations in health-care delivery for the future.
Sincerely,
Scott Reiner, CEO
______
Advocate Aurora Health
June 2, 2021
Hon. Ron Wyden Hon. Mike Crapo
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
219 Dirksen Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Re: Written Testimony Submitted to the Senate Committee on Finance for
the May 19, 2021 Hearing Record, ``COVID-19 Health Care Flexibilities:
Perspectives, Experiences, and Lessons Learned''
Dear Chairman Wyden and Ranking Member Crapo:
On behalf of Advocate Aurora Health (Advocate Aurora), thank you for
holding a hearing on May 19, 2021 titled, ``COVID-19 Health Care
Flexibilities: Perspectives, Experiences, and Lessons Learned.'' We are
grateful for your leadership on--and attention to--this important
topic. We appreciate the opportunity to submit this statement for the
hearing record and thank you in advance for your consideration of our
recommendations for how to sustain the gains made in telehealth
deployment during the Public Health Emergency (PHE), fully harness the
potential telehealth holds for tackling many of the challenging health-
care issues facing our nation, including how to increase access to
quality care, lower costs, eliminate health-care disparities, and
address socioeconomic determinants of health (SDOH), such as lack of
safe, reliable transportation.
Our clinicians feel strongly that telehealth, remote patient
monitoring, and other health technology together are a powerful set of
tools that can help expand access to care for rural and underserved
communities, such as South Chicago and inner-city Milwaukee. For many
patients, having the option to engage with a clinician via telehealth
offers them a convenient clinical option as it eliminates the need for
transportation, parking, and childcare and reduces absences from school
or work. Further, for some patients with mobility challenges,
disabilities, or other special needs, such as autism, telehealth and
remote care can provide a more effective, less burdensome, and less
stressful clinical care experience.
As enumerated further below, Advocate Aurora has appreciated the
waivers and flexibilities afforded to clinicians during the PHE, and in
particular, the waivers associated with telehealth have supported our
ability to maintain continuity of care for a significant number of our
patients and to expand access to care to traditionally underserved
individuals and communities. As we begin to emerge from the PHE, it
will be imperative that we retain the advances in telehealth. We thank
you in advance for your consideration of our recommendations and
requests with respect to making the PHE telehealth and related changes
permanent.
Overview of Advocate Aurora
Advocate Aurora is a leading employer in the Midwest with more than
75,000 team members, including more than 22,000 nurses and the region's
largest employed medical staff and home health organization. The system
serves nearly 3 million patients annually; across both Illinois and
Wisconsin, in particular, we serve an estimated 695,000 Medicare
beneficiaries and more than 485,000 individuals with Medicaid coverage.
With more than 500 sites of care, Advocate Aurora is engaged in
hundreds of clinical trials and research studies, and is nationally
recognized for its expertise in cardiology, neurosciences, oncology,
and pediatrics. The organization contributed $2.2 billion in charitable
care and services to its communities in 2019. Advocate Aurora brings
its strengths, assets, and commitment to delivering value and outcomes
to individuals, families, and communities throughout Illinois and
Wisconsin.
Advocate Aurora also serves as a transformative leader and strong
partner with the federal government in the journey from volume to
value. The Centers for Medicare & Medicaid Services in 2020 announced
that Advocate Aurora Health's three affiliated Accountable Care
Organizations (ACOs) combined saved taxpayers $87.5 million through the
Medicare Shared Savings Program, the most of any integrated system in
the country.
Advocate Aurora and Telehealth
Advocate Aurora has long been engaged in the provision of care through
telehealth, as it is an important tool in reaching rural and
underserved communities, including individuals with special needs, such
as people who are deaf and hard-of-hearing. For example, we are proud
that more than 15 years ago we were the only Chicago area provider to
offer tele-psychiatry visits using videoconferencing and clinicians who
speak American Sign Language (ASL) to deaf and hard-of-hearing patients
who were living in southern Illinois. These patients had unmet mental
health needs but there were no providers in the community who spoke ASL
and an audio-only visit is ineffective and inappropriate. By offering
video-tele-psychiatry with ASL speakers, patients could access the
specialty care they needed without the burden of having to travel.
Since that time, we have significantly expanded our telehealth and
digital medicine offerings in Illinois and Wisconsin.
We connect to our patients through videoconferencing, remote
monitoring, electronic consults, and wireless communications and we
deploy these technologies to provide primary, urgent care, and
specialty services. The strategic utilization of telehealth--both prior
to and during the PHE--allows us to offer patients an important, safe,
and convenient care option.
Advocate Aurora Telemedicine ED Triage
For example, prior to the PHE, we successfully implemented remote video
monitoring technology to help reduce overcrowding at Aurora Sinai
Medical Center's Emergency Department (ED) in Milwaukee, Wisconsin, one
of our busiest EDs. This telemedicine program allows patients to be
seen initially by an Advocate Aurora clinician via video when they
arrive, with a nurse at the patient's side. By having additional
clinicians available via telemedicine--with triage assistance and on-
site clinician support--patients are seen by a clinician faster and, in
turn, they experience a reduced time to diagnoses and quicker
initiation of treatment.
The program has helped to reduce door-to-provider times from 60
minutes to about 10 minutes, on average.
The average length of stay has declined by 40 minutes.
The leave-without-being-seen rate has plummeted from 8% to 2%.
Overcrowding in the ED has decreased significantly.
Advocate Aurora's Experience with Telehealth During the PHE
We are eager to sustain the recent advances made in the utilization and
adoption of telehealth; while the advantages and power of telehealth
have been known for decades, the importance of virtual care has become
profoundly clear in the past year during the PHE. Starting in March
2020, providers and patients alike sought ways to interact that reduced
their risk of exposure to COVID-19. Many physicians and Advance
Practice Clinicians (APCs) could not be in the office or at the
hospital due to COVID-19 restrictions but could still see patients
through virtual care. Telehealth helped reduce unnecessary patient and
provider exposure to COVID-19 and allowed us to preserve scarce PPE
during shortages.
Moreover, many patients, including home care patients, were fearful of
seeing their care providers in person but were eager to engage in a
visit through audio or video means. Further, as noted earlier, many
patients have mobility issues, disabilities, transportation challenges,
or home, work, or school obligations that make traveling to an office,
clinic, or hospital campus extremely burdensome even in non-pandemic
times. With vast disruption with public transportation systems and
patients experiencing greater stress overall, telehealth allowed us to
provide convenient, continuity of care for our patients across the care
spectrum--primary, specialty, post-acute, chronic disease management,
etc.
Advocate Aurora's behavioral health-care physicians and APCs in
particular have noticed a significant reduction in canceled or missed
appointments and high patient satisfaction levels among patients using
tele-behavioral health services. Our behavioral health patients
consistently gave high daily ratings to virtual treatment with an
average rating of 8.7 out of 10. When questioned about future
preferences, 72% of patients either preferred virtual to in-person
treatment or were neutral. Across the Advocate Aurora system, 90% of
patients were satisfied after virtual visits and likely to use virtual
visits again. Further, 91-93% found it either easy or very easy to
interact with their provider via video.
In 2019 and before the pandemic, an estimated 300 Advocate Aurora
physicians and APCs performed 13,026 virtual health visits. By the end
of 2020, Advocate Aurora's virtual care program:\1\
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\1\ Advocate Aurora's virtual care services are comprised of Quick
Care, E-Visits, telephonic, and virtual clinic visits.
Provided a total of 876,000 virtual visits to 507,375 unique
patients;
Reached a diverse patient population: 17% Black/African
American, 10% Hispanic or Latino; and 3% Asian;
Experienced most demand (45%) within primary care with Family
Practice providers accounting for 27% of visits and Internal Medicine
providers comprising 18% of visits, while Behavioral Health services
were 14% of visits, followed by Cardiology at 6%;
Delivered care to patients in 15 states; and
Had a payer mix of 32% Medicare, 12% Medicaid, 51% commercial
insurance, and 5% self-paying patients or another payer source.
Advocate Aurora Supports Making Permanent the PHE-Related Telehealth
Policy Changes
Advocate Aurora very much appreciates the changes that both the Centers
for Medicare and Medicaid Services (CMS) and Congress have made since
the start of the PHE to ensure that patients can receive care via
telehealth, should they so choose. We enumerate below a number of the
flexibilities and waivers currently available that we respectfully
request be made permanent. We understand that some of the waivers and
flexibilities can be made permanent under existing CMS authority, while
others require Congressional action. We urge you and your colleagues to
work with CMS to ensure all of these policies are made permanent so
patients can continue to benefit from what telehealth offers them.
Specifically, we ask that you continue to allow:
All patients, irrespective of their geography (e.g., rural) and
physical location (e.g., home), to receive telehealth services in the
location of their choosing.
Medicare to pay for telehealth services at the same rate as in-
office visits for all diagnoses.
Practitioners to provide telehealth services to both new and
established Medicare patients.
We appreciate that audio-only telehealth was an important focus during
the hearing. Audio-only telehealth flexibilities have allowed our
clinicians a convenient and effective way to maintain and expand access
to care during the pandemic. Currently these audio-only visits
represent approximately 35% of our total virtual health consults,
providing care to 285,601 unique patients. Audio-only visits
experienced most demand from our Family Practice providers (18%) and
Internal Medicine providers (18%) followed by our Behavioral Health,
Oncology and Cardiology specialists. 45% of our patients receiving
audio-only virtual visits are covered by Medicare, 12% by Medicaid
while 36% are covered by commercial insurance with the remainder
receiving coverage from self-pay or some other source. We strongly
support policymakers continuing to allow:
Practitioners to provide audio-only telephone evaluation and
management visits for new and established patients; this is especially
important for patients who may not have Internet access or a smart
phone.
Practitioners licensed in one state to be reimbursed for
services provided to Medicare beneficiaries in another state and
reduction of burdens preventing reciprocity in state licensures.
Practitioners such as licensed clinical social workers, clinical
psychologists, physical therapists, occupational therapists, and
speech-language pathologists to provide--and be reimbursed for--
telehealth, virtual check-ins, e-visits, and telephone calls to
patients.
Practitioners to provide a greater range of services to
beneficiaries via telehealth, including ED visits.
Medical screening exams (MSEs), a requirement under Emergency
Medical Treatment and Labor Act (EMTALA), to be performed via
telehealth.
Further, we very much appreciate that CMS and the Office of Inspector
General at the Department of Health and Human Services (HHS) have
offered relief from enforcement of Stark Self-Referral and Anti-
Kickback laws during the PHE. As you know, while well intended when
they were designed, the nature of health-care delivery has changed
significantly in the decades since these laws were passed and their
implementing regulations promulgated. We urge that many of these
flexibilities be made permanent so that patients can have access to the
technologies they need to benefit from advances in virtual care. We are
concerned that underserved and vulnerable patient populations may not
have access to the needed technologies primarily used for telemedicine,
including broadband Internet access and smartphones, yet providers
cannot provide financial help so patients can secure these needed
tools.
Without a permanent change, hospitals face significant legal risk if
they want to provide a subsidy to their physicians to purchase
telehealth technologies, like specialized tablets to perform remote
patient monitoring, or if they want to give patients, free of cost or
at reduced prices, devices such as wearable ``stethoscopes,'' blue-
tooth enabled-digital blood pressure cuffs, or a virtual care kit for a
home examination. Patients who cannot afford the out-of-pocket costs
for these devices, apps, etc. will be unable to benefit from
innovative, patient-centered virtual care. This further exacerbates
inequities and health disparities, and prevents physicians and APCs
from being able to address many SDOH. We appreciate the recent changes
CMS and HHS have made to the Stark and Anti-Kickback regulations but we
urge federal policymakers to further modernize these outdated laws and
regulations so that underserved and vulnerable patients can have access
to the care and tools they need and deserve.
Summary
Again, we thank you for the opportunity to submit this statement for
the hearing record and we stand ready to work with you to ensure that
the advances made in leveraging telehealth are maintained so we can
continue to improve and transform health care in America, particularly
for our most vulnerable patient populations. To that end, we urge you
and your colleagues to make permanent the PHE-related telehealth
waivers and flexibilities.
On behalf of Advocate Aurora's physicians, nurses, other health
professionals and associates, and the patients, families, and
communities we serve, thank you for your leadership and commitment to
ensuring that we as a nation sustain the gains made in expanding access
to care via telehealth and other virtual care offerings. We look
forward to working with you throughout the 117th Congress to improve
the health and well-being of the communities we serve.
Sincerely,
Meghan Woltman
Chief Government Affairs Officer
______
Alliance for Connected Care
1100 H Street, NW, Suite 740
Washington, DC 20005
https://connectwithcare.org/
The Alliance for Connected Care appreciates the opportunity to submit
testimony for this hearing examining COVID-19 health-care
flexibilities. The Alliance for Connected Care (the Alliance) is an
advocacy organization dedicated to facilitating the delivery of high-
quality care using connected care technology. Our members are leading
health care and technology companies from across the health-care
spectrum, representing insurers, health systems, and technology
innovators. Our Advisory Board includes more than 30 patient and
provider groups, including many types of clinician specialty and
patient advocacy groups who wish to better utilize the opportunities
created by telehealth.
The Alliance will focus comments on (1) Research and evidence we have
gathered thus far; (2) recommendations for future telehealth expansion
that Congress should consider--including steps to ensure equitable
access; and (3) Recommendations for telehealth ``guardrail'' provisions
that Congress should consider to prevent fraud, waste and abuse in the
health-care system.
While we prefer the implementation of permanent policies described in
our recommendations below, the Alliance supports a two-year clean
extension of telehealth flexibilities exercised during the COVID-19
pandemic, including 1834(m) Medicare telehealth waivers, a safe harbor
for employer-subsidized telehealth for people with Health Savings
Account eligible High-Deductible Health Plans, and the flexibility for
Critical Access Hospitals to continue to bill telehealth as they have
during the pandemic. We want policymakers to feel comfortable that
access to telehealth services in Medicare will not negatively impact
health-care quality, or the federal budget. Therefore, we recommend
Congress wait to make permanent policy until more peer-reviewed
research has been published, government studies--such as the study
underway by AHRQ--have been completed, the Office of the Inspector
General has examined the level of fraud in telehealth during the Public
Health Emergency, and when we have observed what the use of telehealth
during ``normal times.''
Telehealth Research and Evidence
We have a unique opportunity afforded by the PHE to understand the
effects of telehealth on clinical practice--and to make direct apples-
to-apples comparisons across service modality. The sudden shift to
virtual services generated fee-for-service (FFS) data and empirical
provider and patient experience that didn't exist prior to the
pandemic. This data is just now being understood, and peer-reviewed
studies and reports are forthcoming. We believe it is essential to take
this new evidence into account when writing permanent laws especially
given that pre-pandemic telehealth studies were either narrowly-focused
or relied on inferences on the impact of Medicare using commercial or
Veterans Affairs data.
The COVID-19 pandemic has resulted in drastic increases in telemedicine
utilization, introducing millions of Americans to a new way to access
health-care. Data from the Centers for Disease Control and Prevention
(CDC) finds that during the period of June 26--November 6, 2020, 30.2
percent of weekly health center visits occurred via telehealth. In
addition, preliminary data \1\ from the Centers for Medicare and
Medicaid Services (CMS) show that between mid-March and mid-October
2020, over 24.5 million out of 63 million beneficiaries and enrollees
have received a Medicare telemedicine service during the PHE. Finally,
an HHS Office of the Assistant Secretary for Planning and Evaluation
(ASPE) Medicare fee-for-service (FFS) telehealth report \2\ found that
from mid-March through early July more than 10.1 million traditional
Medicare beneficiaries used telehealth, including nearly 50 percent of
primary care visits conducted via telehealth in April vs. less than 1
percent before the COVID-19 pandemic. In addition to providing a
lifeline to continuity of care, it is important to note that the net
number of Medicare FFS primary care in-person and telehealth visits
combined remained below pre-pandemic levels. As in-person care began to
resume in May, telehealth visits dropped to 30 percent but there was
still no net visit increase. We infer this and other data showing that
as in-person visits increased, telehealth visits decreased, that there
was a substitution effect. A claims-based analysis \3\ suggests that
approximately $250 billion in health care spend could be shifted to
virtual care in the long term--roughly 20 percent of all Medicare,
Medicaid and commercial outpatient, office and home health spend. The
effects of the COVID- 19 pandemic on patients seeking or avoiding care
still need further analysis, but these data suggest that telehealth
substituted for in-person care without increasing utilization.
---------------------------------------------------------------------------
\1\ https://www.cms.gov/newsroom/press-releases/trump-
administration-finalizes-permanent-expansion-medicare-telehealth-
services-and-improved-payment.
\2\ https://aspe.hhs.gov/sites/default/files/private/pdf/263866/hp-
issue-brief-medicare-telehealth.pdf.
\3\ https://www.mckinsey.com/industries/healthcare-systems-and-
services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-
19-reality?_lrsc=a92397a2-f826-4e32-863b-4f1f467784d
1&cid=other-soc-lke.
In addition to telehealth largely substituting for in-person care,
policymakers should consider telehealth's ability to increase
efficiencies and improve access where barriers to care exist. COVID-19
has dramatically heightened awareness of existing health disparities
and made the call to address these longstanding issues more urgent.
Transportation is just one example of a barrier to care that telehealth
can alleviate. Transportation barriers are regularly cited \4\ as
barriers to access, particularly for low-incomes or under/uninsured
populations--leading to missed appointments, delayed care, and poor
health outcomes. In a 2018 proposed rule,\5\ CMS estimated that
telemedicine is saving Medicare patients $60 million in travel time,
with a projected estimate of $100 million by 2024 and $170 million by
2029. CMS also noted that these estimates tend to underestimate the
impacts of telemedicine. Higher projections estimate $540 million in
savings by 2029.
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\4\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4265215/
#:%7E:text=Transportation%20
barriers%20are%20often%20cited,and%20thus%20poorer%20health%20outcomes.
\5\ https://www.govinfo.gov/content/pkg/FR-2018-11-01/pdf/2018-
23599.pdf.
The experience during COVID-19 has pushed forward a revolution in
consumer attitudes toward virtual care. Polling data from the
University of Michigan \6\ showed that one in four older adults had
used telemedicine during the first three months of the pandemic,
compared to just 4% in 2019. The same poll showed that 64% of those
surveyed in June 2020 were comfortable with using videoconferencing
technology for any purpose, up from 53% in May 2019.
---------------------------------------------------------------------------
\6\ https://labblog.uofmhealth.org/rounds/telehealth-visits-
skyrocket-for-older-adults-but-concerns-and-barriers-remain.
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Top Telehealth Priorities
Remove geographic and originating site restrictions on
telehealth in Medicare. The COVID-19 pandemic has clearly demonstrated
the need for telehealth in rural areas, in urban areas, at work, at
school, at home and many other locations. These provisions are obsolete
and outdated and should be removed from statute entirely. The location
of the patient should not matter for telehealth--only the quality of
the care being delivered.
Please note that the removal of the originating
site construct, a relic from an era in which telehealth was an office-
to-office interaction, is better policy that the addition of the home
as a site for telehealth services or a waiver of these restrictions.\7\
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\7\ The Alliance strongly supports the Telehealth Modernization Act
(H.R. 1332), introduced by Senators Tim Scott and Brian Schatz, which
would eliminate the originating site construct completely.
Remove distant site provider list restrictions to allow all
Medicare providers who deliver telehealth-appropriate services to
provide those services to beneficiaries through telehealth when
clinically appropriate and covered by Medicare--including physical
therapists, occupational therapists, speech-language pathologists,
social workers, and others. Additionally, work to ensure that in-person
payment models, such as those in which a facility/provider organization
bills on behalf of a care-team can be fully compatible with virtual
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care environment.
Ensure Federally Qualified Health Centers, Critical Access
Hospitals, and Rural Health Clinics can furnish telehealth in Medicare
and be reimbursed fairly for those services, despite unique payment
characteristics and challenges for each. Please note that Critical
Access Hospitals (CAHs) are sometimes omitted from this list, but are a
crucial component of a health-care system able to reach all Medicare
beneficiaries and must be able to directly bill for telehealth services
as a distant site provider.
Make permanent the Health and Human Services (HHS) emergency
waiver authority for virtual care so that it can be quickly leveraged
during future emergencies. Telehealth has maintained critical
connections between patients and health-care practitioners during the
pandemic, and should be enabled for a future wildfire, flood,
hurricane, or other emergency.
Make permanent the HDHP/HSA Telehealth Safe Harbor created in
Section 3701 of the CARES Act. This provision allows Americans with
health savings account (HSA) eligible high deductible health plans
(HDHP) to receive cost-free or discounted telehealth and remote care
services prior to the patient reaching their deductible. According to
the Bureau of Labor Statistics (BLS), only 15 percent of workers
employed in the private sector participated in an HDHP in 2010. By
2018, that number had risen to 45 percent. With significant numbers of
American workers now relying on coverage through account-based plans,
policymakers can meaningfully expand access to care by permanently
allowing first-dollar coverage of virtual care under HDHPs.
Allow employers to offer telehealth benefits for seasonal and
part-time workers. Congress should designate standalone telehealth as
an excepted benefit so that this service can be offered to part-time
employees, seasonal workers, interns, new employees in a waiting
period, etc. Currently, standalone telehealth benefits are considered a
``health plan'' under Affordable Care Act (ACA) rules. That means they
must be paired with a full medical benefit that meets all of the
different ACA requirements. In June 2020, the Department of Labor
created flexibility \8\ for large employers to offer telehealth to non-
eligible employees but this access will end with the PHE.
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\8\ https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-
activities/resource-center/faqs/aca-part-43.pdf.
Enable the Centers for Medicare and Medicaid Services (CMS) to
investigate and retain some ``Hospital Without Walls'' authorities
after the end of the public health emergency and encourage that these
authorities be used to maintain site of care flexibility whenever the
services provided are clinically appropriate for virtual delivery. We
believe that expanded capability for hospitals to remotely monitor and
care for patients could lead to shorter or avoided hospital stays and
lower costs--a potential benefit for both seniors and the Medicare
---------------------------------------------------------------------------
program.
Fund a comprehensive study of telehealth during the COVID-19
pandemic using claims data and qualitative interviews with providers
and patients who used telehealth during the pandemic. The study should
to answer specific questions critical to future telehealth decision-
making by Congress and regulators at CMS. Suggested priorities include:
1. Is telehealth being adequately leveraged to address health
disparities, and what policies could Congress or HHS enact to ensure
telehealth is a tool to increase access to those most in need of health
care?
2. To what extent are Medicare telehealth services during the
PHE replacing in-person care?
How often to telehealth services require a follow-up in
person visit and how often are they fulfilling patient needs?
Is the availability of telehealth increasing
utilization, and if so, are they primary care or preventative services
with the potential to prevent a more costly encounter downstream?
3. Are there specific, high-cost areas of the Medicare program
that might lower long-term costs through telehealth utilization?
Are care coordination codes that have been shown to
improve care such as 99495 and 99496 being used more frequently during
virtual care?
Has the shift to using telehealth to manage lower acuity
conditions in skilled nursing facilities prevented unnecessary
transfers to hospitals?
4. To what extent have CMS permissions for virtual/remote
supervision of health-care professionals been utilized during the
COVID-19 pandemic? Have these permissions resulted in patient harm? How
have health-care providers expanded their capability and capacity using
this tool during the PHE.
5. In addition to HHS investigations of fraud and abuse, what
has been the health-care provider, patient, and health plan experience
with fraud perpetrated through virtual tools during the PHE?
Facilitate the removal of remaining telehealth restrictions on
alternative payment models
Accountable Care Organization's (ACO) telehealth
flexibility is limited a narrow set of ACOs with downside risk and
prospective assignment--even though other tools apply to all ACOs.
Since all participants in the Medicare Shared Savings Program are being
held accountable for quality, cost, and patient experience, all of them
should have flexibility to use telehealth tools to deliver care. We
recommend eliminating Sec. 1899. [42 U.S.C. 1395jjj] (I)(2)
requirements limiting participation to a select set of ACOs. (We
believe CMS may already have the statutory authority to make these
changes under 42 U.S.C. 1315a(d)(1) and 42 U.S.C. 1395jjj(f) if
directing the use of authority instead would keep the score down)
Allow the Centers for Medicare and Medicaid Services to cover
audio-only telehealth services where necessary to bridge gaps in access
to care. This would include, at a minimum, flexibility for areas with
limited broadband service, for populations without telehealth-capable
devices, or in necessary situations such as a future public health
emergency. We anticipate that CMS would also maintain a list of
services that were appropriate for this emergency audio-only care, as
it has done during the PHE, and that the clinician would document the
reason.
Expand virtual chronic disease interventions with the potential
to prevent downstream costs to the Medicare program. The most obvious
example are virtual diabetes prevention programs (DPP), which can
produce transformative weight loss reducing the prevalence of obesity
and comorbidities including prediabetes and type 2 diabetes. These
programs can produce better outcomes for patients and would likely
reduce downstream costs to the Medicare program, not only by expanding
access to a broader set of beneficiaries but by keeping patients
engaged and creating more sustainable lifestyle changes. During the
COVID-19 PHE, CMS has allowed DPP providers to practice virtually, but
it has not created a long-term pathway for virtual DPP programs. As
much of the commercial market has already moved to virtual care and
app-driven interventions, the DPP program must be able to adapt to meet
patients where they are and expand access to services for individuals
not near a physical DPP provider.
Expand the mandate of the Office for the Advancement of
Telehealth at HRSA and require it to develop tools and resources on
telehealth services that can be distributed to small health-care
practices, patients, and consumer organizations. Additionally, explore
partnerships with leading consumer and patient organizations to educate
seniors about telehealth services, including the use of technology and
how to verify the identity of a health-care provider.
Encourage CMS to continue facilitating greater use of remote
patient monitoring (RPM) technology through policy, including ongoing
flexibility for allowing acceptance of patient-reported data for scales
up to meet connected device requirements.
Recommendations for Fraud, Waste, and Abuse
The Alliance understands that with change sometimes comes risk, and
that Congress holds ultimate authority for protecting the Medicare
program. We understand and respect this responsibility. We also believe
that, using the data we are collecting about the provision of
telehealth services during the PHE, the Medicare program and the Office
of the Inspector General at HHS will be able to target and
differentiate nearly all fraudulent behavior. Congress must trust this
capability and authority, rather than creating barriers to access
between Medicare beneficiaries and critical health services.
The Alliance and its members strongly believe that an in-person
requirement, as Congress created in the Consolidated Appropriations
Act, 2021 (Pub. L. 116-260) is never the right guardrail for a
telehealth service. Requiring an in-person visit constrains telehealth
from helping individuals that are homebound, have transportation
challenges, live in underserved areas, etc. It does not constrain those
using telehealth for convenience. This creates a perversion of the
Medicare payment system by reducing access for those who need it most,
while allowing access for others. We cannot create a guardrail that is
an access barrier between patients and their clinicians--it will lead
to harm the most vulnerable and access-constrained Medicare
beneficiaries.
We also believe it is important to note that nearly all of the fraud
Congress may seek to prevent is fraud that mirrors activities currently
occurring during in-person care. These concerns include fraudulent
Medicare enrollment, false claims, fake patients, and durable medical
equipment (DME) prescribing. All of these issues are problems for the
Medicare program--and should be addressed as Medicare fraud problems.
They are not new problems for telehealth services. Therefore, an in-
person requirement would hinder legitimate telehealth providers while
doing very little to stop fraudulent actors. Instead of creating
barriers to services for Medicare beneficiaries, Congress must empower
CMS to address fraudulent actors.
We are pleased to note that on February 26, 2021, OIG Principal Deputy
Inspector General Grimm issued a statement \9\ to this effect--
differentiating between fraud perpetrated through virtual tools and
telehealth fraud.
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\9\ https://oig.hhs.gov/coronavirus/letter-grimm-
02262021.asp?utm_source=oig-home&utm_
medium=oig-hero&utm_campaign=oig-grimm-letter-02262021.
We are aware of concerns raised regarding enforcement actions
related to ``telefraud'' schemes, and it is important to
distinguish those schemes from telehealth fraud. In the last
few years, OIG has conducted several large investigations of
fraud schemes that inappropriately leveraged the reach of
telemarketing schemes in combination with unscrupulous doctors
conducting sham remote visits to increase the size and scale of
the perpetrator's criminal operations. In many cases, the
criminals did not bill for the sham telehealth visit. Instead,
the perpetrators billed fraudulently for other items or
services, like durable medical equipment or genetic tests. We
will continue to vigilantly pursue these ``telefraud'' schemes
and monitor the evolution of scams that may relate to
telehealth.
Recommendations
With the understanding the Congress may still want to pursue additional
guardrails against fraud, waste, and abuse as part of telehealth
legislation, we offer the following alternatives. Please note that many
of these are simple regulatory changes, and could be issued as
recommendations to CMS.
Enhance the ability of HHS to fight fraud in Medicare through
new resources and capacity
Provide additional funding for OIG to strengthen
existing fraud, waste, and abuse mechanisms that have already been
proven successful in fighting fraud perpetrated through virtual tools.
The House Ways and Means minority staff has proposed workable text to
this effect that we support.
We also support the development of OIG telehealth
compliance guidance to health-care organizations to help prevent and
mitigate unintentional mistakes related to Medicare telehealth billing.
Strengthen the Public-Private Partnership for
Health Care Waste, Fraud and Abuse Detection created by the
Consolidated Appropriations Act of 2021 (Section 1128C(a) of the Social
Security Act (42 U.S.C. 1320a-7c(a))). This public-private partnership
must be empowered with experts with experience in virtual care delivery
and payment.
After--(6)(E)(i)(II) add ``(III) The executive board
shall include no less than 3 individuals with significant expertise
delivering and managing the delivery of virtual care, including
practitioners, medical directors and individuals with oversight of
telehealth programs, and virtual care experts with experience in
corporate fraud prevention.
Work with CMS to develop restrictions on the solicitation of
Medicare Fee-For-Service telehealth services. It is our understanding
that one of the primary ways in which fraudulent actors exploit virtual
services is by calling Medicare beneficiaries to solicit their
interested in high-value DME products. We believe a restriction on
marketing, as currently exists for DME, would significantly hinder
situations in which DME fraud actors exploit telehealth services to
drive DME sales. As long as there was a significant allowance for
legitimate marketing practices, we do not believe this restriction
would hinder legitimate telehealth providers.
Work with CMS to strengthen the Medicare provider enrollment
process. The provider enrollment process is the best tool to prevent
fraudulent actors from billing the Medicare program. Rather
strengthened to identify and screen higher risk entrants.
Encourage CMS to advantage of the enhanced data capabilities
present in most telehealth platforms. Technology platforms that provide
telehealth are often capable of automatically recording times, dates,
patient information, prescribing, and other details which can be used
to enhance compliance. These technologies should allow for the greater
use of audits and other forms of retroactive monitoring approaches on
providers. As long as data capture requirements are very clear, and
that compliance with any requirements do not impose a significant
regulatory burden they could be a compliance tool. (Please note that
very small- providers should likely be exempted from these burdens.)
Work with CMS to develop targeted restrictions on high-value,
high-risk DME prescribing through telehealth. While we continue to
believe that there are some appropriate circumstances for this
prescribing, a step like this could significantly lower risk to the
Medicare program.
Thank you for your consideration of these recommendations. Some
combination of these recommendations could protect the Medicare program
while aligning with the recommendations of the Task Force on Telehealth
Policy,\10\ which stated ``we should not hold telehealth to higher
standards than other care sites, and we should trust clinicians
providing telehealth services to triage patients needing a higher level
or care or in-patient care, as we do in other care settings. As is done
in other care settings, patients' preference for obtaining care in-
person or via telehealth should be respected.''
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\10\ https://www.ncqa.org/programs/data-and-information-technology/
telehealth/taskforce-on-telehealth-policy/taskforce-on-telehealth-
policy-findings-and-recommendations-overarching-issues/.
Thank you for your consideration--we look forward to working with you
on this important effort. Please contact Chris Adamec at
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[email protected] with any questions.
Sincerely,
Krista Drobac
Executive Director
______
America's Health Insurance Plans
601 Pennsylvania Avenue, NW
South Building, Suite 500
Washington, DC 20004
Everyone deserves access to affordable, high-quality care and coverage.
This is a core principle for health insurance providers and our
industry. America's Health Insurance Plans (AHIP) greatly appreciates
the Committee holding this hearing on COVID-19 health-care
flexibilities.\1\
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\1\ America's Health Insurance Plans (AHIP) is the national
association whose members provide coverage for health care and related
services to millions of Americans every day. Through these offerings,
we improve and protect the health and financial security of consumers,
families, businesses, communities, and the nation. We are committed to
market-based solutions and public-private partnerships that improve
affordability, value, access, and well-being for consumers.
Through temporary flexibilities enacted during the national emergency
period, health insurance providers have expanded access to virtual care
via telehealth so that Americans can get the care they need when and
where they need it. Health insurance providers have also innovated the
way care can be delivered, especially for individuals who are homebound
to ensure the safety and well-being of their members during the COVID-
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19 pandemic.
AHIP looks forward to working with the Committee to ensure that many of
the flexibilities enacted during the pandemic will endure beyond COVID-
19 in order to continue to provide Americans with affordable,
convenient, high quality care.
Telehealth Growth During COVID-19
The COVID-19 crisis led to an exponential increase in telehealth use as
a safe and convenient way for people to access needed care. Telehealth
claims increased over 8,000 percent in April 2020 compared to April
2019.\2\ Several health insurance providers have seen 50 times the
number of telehealth claims as in years past, with telehealth claims in
some cases comprising roughly 25 percent of all claims in 2020.\3\
Among those experiencing significant growth are Blue Cross of Idaho,
which processed more than 90,500 telehealth claims between March and
June of 2020, with telehealth representing more than one-quarter of all
claims.\4\
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\2\ https://www.fairhealth.org/states-by-the-numbers/telehealth.
\3\ https://www.ahip.org/telehealth-growth-during-covid-19/.
\4\ https://www.ahip.org/telehealth-growth-during-covid-19/.
Patients and providers understand and experience the value of
telehealth. They accept--and often prefer--digital technologies as an
essential part of health-care delivery. Telehealth delivers convenient
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access to affordable, high-quality care.
Patients have taken advantage of telehealth from wherever they are,
making it a vital tool to bridge health-care gaps nationwide. For
patients in rural communities or underserved areas with a shortage of
practicing clinicians, telehealth programs and remote patient
monitoring can make care more accessible, efficient, and sustainable
than it otherwise would be. Patients can connect with a doctor within
seconds rather than driving long distances for an office visit.
Patients who can access care remotely can also avoid challenges
associated with taking time off work or finding childcare. Those
accessing behavioral health services can do so from the privacy of
their own homes and free from stigma. Telehealth is a tool that can
connect patients with care in the most convenient, comfortable
settings--without the challenges of finding in-person care.
Additionally, telehealth costs less. Even before the pandemic, 93
percent of consumers who used telehealth said that it has lowered their
health-care costs.\5\ Furthermore, studies have shown that a virtual
visit can save up to $100 compared to a visit in other care settings
(e.g., urgent care, primary care, emergency room) when accounting for
cost of services, cost of travel to a physical care setting, and lost
earnings associated with travel and wait times.\6\
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\5\ https://www.prnewswire.com/news-releases/39-of-tech-savvy-
consumers-have-not-heard-of-telemedicine-healthmine-survey-
300241737.html.
\6\ https://news.regence.com/releases/regence-data-measures-real-
world-savings-for-telehealth-users.
By connecting patients with convenient care, providers are also
reporting lower no-show rates with telehealth.\7\ Telehealth can lead
to better management of chronic diseases, reduced travel times, reduced
emergency department visits, and fewer or shorter hospital stays.\8\
Patients are healthier and have better peace of mind by getting the
right care at the right time and in the right setting.
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\7\ https://www.healthcareitnews.com/news/telehealth-linked-ehr-
drastically-reduces-no-show
-rate-garfield-health-
center#::text=Data%20for%20October%202020%20shows,the%20office%20
for%20an%20appointment.
\8\ https://www.ahip.org/wp-content/uploads/FactSheet_Telehealth-
030719.pdf.
Faster expansion of telehealth has been made possible through
flexibilities implemented during the COVID-19 crisis. For instance, the
Coronavirus Preparedness and Response Supplemental Appropriations Act
(CARES Act) temporarily authorized the Secretary of Health and Human
Services (HHS) to waive originating site requirements for telehealth
services under Medicare, as well as allowing reimbursement of more
video-enabled telehealth and audio-only telehealth services for the
duration of the COVID-19 public health emergency (PHE). HHS also
expanded the number and types of providers who are eligible and
licensed to deliver care via telehealth and allowed providers to waive
telehealth visit cost-sharing for Federal health-care programs.\9\
Medicare Advantage (MA) plans were also allowed to waive or reduce
enrollee cost-sharing for telehealth benefits and expand coverage of
telehealth services beyond those approved in the plan's benefit
package.\10\ These measures allowed for greater flexibility in
telehealth use for both patients and providers, leading to exponential
growth in use.
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\9\ 45 CFR Sec. Sec. 160, 164 (2020). See www.govinfo.gov/content/
pkg/FR-2020-04-21/pdf/2020-08416.pdf (accessed February 23, 2021).
\10\ https://www.cms.gov/files/document/updated-guidance-ma-and-
part-d-plan-sponsors-42120.pdf.
The Centers for Medicare and Medicaid Services (CMS) issued guidance
allowing health insurance providers in the individual and group market
to amend plan benefits during the 2020 plan year to expand coverage for
telehealth services.\11\ Many health insurance providers have since
reduced or eliminated cost-sharing for telehealth during the PHE, and
broadened coverage of telehealth benefits by expanding coverage options
and increasing telehealth provider networks. CMS issued guidance on
remote supervision of nurse practitioners and physician assistants,
expanding the capacity to treat patients without requiring every
element of care to be in-
person. These policies helped many patients remain safe from possible
and unnecessary exposure to COVID-19 in waiting rooms or other in-
person care settings while still ensuring that patients received high-
quality care.
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\11\ www.cms.gov/files/document/faqs-telehealth-covid-19.pdf.
Many states provided similar flexibilities in state Medicaid and CHIP
programs and facilitated the delivery of telehealth by modifying
provider licensure restrictions that have long served as a barrier to
the effective delivery of telehealth.\12\ However, most of the actions
on both the state and federal levels are limited in scope and temporary
for the public health emergency. Long-term telehealth policy changes
are necessary to drive innovation, promote investment, and address
patient needs during periods of stability and crisis.
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\12\ Spring2021_SummaryChartFINAL.pdf (digitaloceanspaces.com).
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Homebound Care During COVID-19
As the COVID-19 crisis disrupted lives and livelihoods, it also
worsened health disparities and access to care for vulnerable
populations, including homebound populations and seniors. Additionally,
many home health and home and community-based services (HCBS) providers
lacked sufficient supplies of personal protective equipment (PPE),
creating significant risk for providers and patients, and exacerbating
the challenges in reaching patients who were afraid to receive care out
of concern over potential exposure to COVID-19.
Nationally, between 2 million and 4.4 million older adults are
homebound with the vast majority receiving services from Medicare,
Medicaid, or both.\13\ More than 600,000 people receive Medicaid funded
home health services, 1.2 million people receive Medicaid funded
personal care services, and total enrollment in Medicaid HCBS waivers
exceed 2.5 million people. According to a 2019 MedPAC report, about 3.4
million Medicare beneficiaries received home health care in 2017.\14\
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\13\ https://www.washingtonpost.com/health/vaccinating-homebound-
seniors/2021/03/26/a06c71f8-7620-11eb-9537-496158cc5fd9_story.html.
\14\ http://www.medpac.gov/docs/default-source/reports/
mar19_medpac_ch9_sec.pdf?sfvrsn=0#
::text=In%202017%2C%20about%203.4%20million%20Medicare%20beneficiaries%
20received%20
home%20care,billion%20on%20home%20health%20services.
Medicare requires that individuals be homebound to receive home health
care. Given limits on the use of Medicare's home health benefit, there
are significant numbers of Medicare beneficiaries who are in fact
homebound but not receiving home health services. In 2011, the
prevalence of homebound Medicare beneficiaries was estimated to be 5.6
percent, or about 2 million people.\15\ Applying the same percentage to
today's Medicare population, an estimated 3.5 million Medicare
beneficiaries are homebound. During the public health emergency (PHE),
CMS expanded the Medicare definition of homebound to allow patients to
be considered such if it is medically contraindicated for the patient
to leave the home. This includes patients with a confirmed or suspected
COVID-19 diagnosis or patients with conditions making them more
susceptible to contract COVID-19.
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\15\ https://www.researchgate.net/publication/
277251465_Epidemiology_of_the_Homebound_
Population_in_the_United_States.
The Biden Administration proposed to increase funding for HCBS by $400
billion in the American Jobs Plans and recently outlined $1.4 billion
in funding from the American Rescue Plan for Older Americans Act
programs, including programs to support vaccine outreach and
coordination, address social isolation, provide family caregiver
support, and offer nutrition support.\16\ As part of the American
Rescue Plan Act, states can also receive a temporary 10 percentage
point increase to the federal medical assistance percentage (FMAP) for
certain Medicaid HCBS from April 1, 2021, through March 31, 2022.
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\16\ https://www.whitehouse.gov/briefing-room/statements-releases/
2021/05/03/fact-sheet-biden-harris-administration-delivers-funds-to-
support-the-health-of-older-americans/.
Health insurance providers know that many Americans are homebound or
rely on caregivers and family members to manage their health even under
normal conditions. Plans are playing a leadership role in meeting the
medical and social needs of their members and helping to provide
emotional support to members, their families, and caregivers, and
making sure individuals and caregivers have access to peer coaches and
support specialists with information on social services.
Health Insurance Providers Are Committed to Delivering Affordable and
Convenient Care Through Telehealth and Homebound
Care
During the COVID-19 crisis, health insurance providers have expanded
and innovated in the way care is delivered. Many of AHIP's member
companies significantly expanded telehealth accessibility and benefits,
effectively encouraging people to continue to receive care they need
despite the public health crisis.
Those who are older, live in rural areas, are a racial or ethnic
minority, have a lower socioeconomic status, or represent other
vulnerable populations may have less access to broadband and other
technologies and resources necessary to fully leverage the promise of
telehealth.\17\ These same populations often face disparities in access
to in-person services.
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\17\ https://www.pewresearch.org/fact-tank/2019/05/07/digital-
divide-persists-even-as-lower-income-americans-make-gains-in-tech-
adoption/; https://www.pewresearch.org/fact-tank/2019/08/20/
smartphones-help-blacks-hispanics-bridge-some-but-not-all-digital-gaps-
with-whites/.
America's health insurance providers embrace digital solutions that
help increase access to care and want to ensure that the people they
serve, regardless of where they live or their economic situation, can
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access safe and convenient care. For instance:
Centene has worked with Samsung Electronics America to supply
providers with 13,000 Samsung Galaxy A10e smartphones to disseminate to
patients who would not otherwise be able to receive their health care
virtually.
CareOregon is working with providers to supply flip phones and
basic smartphones along with data plans for their members.
Blue Shield Promise (the Medicaid Managed Care Organization of
Blue Shield of California) and LA Care partnered to establish resource
centers for local communities to provide members with wellness programs
and to connect them with local resources to address socioeconomic
needs. As their services and programs moved online due to COVID-19,
Blue Shield Promise and LA Care offered technology and Wi-Fi to help
their members access virtual programs, services, and telehealth.
Health insurance providers are encouraging their vulnerable members,
particularly older people and others who may have delayed care, to get
their preventive screenings, routine care, and chronic condition
management despite the COVID-19 pandemic.
Bright Health makes non-emergency transportation available for
all members, and ride limits are being waived for non-emergency visits
to and from their doctor.
Priority Health has partnered with technology company Papa to
connect college students with Medicare members with specific chronic
conditions who need assistance with transportation, house chores,
technology lessons, companionship, and other senior services.
Humana mailed more than 1 million in-home preventive screening
kits to members in 2020, helping increase access to routine screenings
that many members have put off during the COVID-19 crisis.
Health insurance providers have also taken proactive actions to provide
COVID vaccines for vulnerable seniors, individuals who are homebound,
and other vulnerable populations.
Given the vast majority of Medicare beneficiaries are enrolled in
Medicare Advantage or Medicare Part D (50.8 million)\18\ and 40 \19\
states leverage Medicaid Managed Care as their delivery system
(including 25 \20\ who use health plans to deliver managed long-term
services and supports), health insurance providers are uniquely
situated to help get the homebound population vaccinated quickly,
effectively, and equitably.
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\18\ https://www.cms.gov/research-statistics-data-and-
systemsstatistics-trends-and-reportsmcra
dvpartdenroldatamonthly/contract-summary-2021-05.
\19\ https://www.kff.org/medicaid/issue-brief/10-things-to-know-
about-medicaid-managed-care
/
#::text=As%20of%20July%202019%2C%2040,Medicaid%20beneficiaries%20(Figur
e%201).
\20\ https://www.macpac.gov/subtopic/managed-long-term-services-
and-supports/.
On March 3, 2021, the White House, America's Health Insurance Plans
(AHIP) and the Blue Cross Blue Shield Association announced the Vaccine
Community Connectors (VCC) pilot initiative. As vaccine supplies expand
and appointments become more available, health insurance providers have
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committed to use their combined expertise, data, and insights to:
Identify seniors who are vulnerable to COVID-19 and who live in
areas where vaccination rates are most inequitable;
Work with partners in the community to educate seniors on the
safety, efficacy, and value of COVID-19 vaccines;
Contact those seniors who are eligible to get a vaccine through
multiple channels to facilitate vaccine appointment scheduling;
Coordinate services to help overcome barriers that may stand
between them and getting vaccinated; and
Track and report progress to ensure those who need vaccinations
most are receiving them.
The VCC has since expanded to include the Medicaid population, many of
whom are members of the at-risk and underserved communities this
program aims to reach.\21\
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\21\ https://www.communityplans.net/acap-joins-ahip-bcbsa-in-
advancing-vaccine-accessibility-and-equity-initiative/.
As part of these broader vaccination efforts, health insurance
providers are helping vulnerable, homebound individuals to receive the
COVID-19 vaccine. Examples of health plans partnering to address the
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needs of homebound individuals are growing across the country include:
Commonwealth Care Alliance (CCA) has partnered with the
Commonwealth of Massachusetts to lead the state's effort to vaccinate
homebound individuals. In this partnership, CCA serves as the vaccine
coordinator for the Massachusetts homebound population. CCA manages a
technological, logistical, and provider infrastructure to receive
referrals of state-screened homebound residents for outreach and
appointment scheduling, vaccine distribution, delivery of vaccines to
people's homes, and reporting on their performance. CCA has expanded
the program to all homebound individuals in Massachusetts, regardless
of health plan.\22\
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\22\ https://www.commonwealthcarealliance.org/news/2021/march/
commonwealth-care-alliance-to-lead-massachusetts-h.
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SCAN Health Plan provides in-home COVID-19 vaccinations to
homebound plan members and their families in Los Angeles County. The
vaccination program is made possible through a unique partnership
between SCAN and MedArrive, a logistics platform that enables health-
care payers and providers to seamlessly extend care services into the
home, unlocking access to highly qualified, trusted EMTs and
Paramedics. The vaccines are being administered by trained EMTs at no
cost to the members. Caregivers and other eligible household members
are also receiving the vaccine at no cost.\23\
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\23\ https://www.businesswire.com/news/home/20210426005231/en/.
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HealthPartners has collaborated with 10 health systems across
Minnesota to coordinate efforts to distribute and administer vaccines,
leveraging HealthPartners' home health subsidiary to offer vaccines in
people's homes.
Blue Cross Blue Shield of Tennessee is bringing vaccines to
their homebound members by working with local health departments,
provider partners, and local emergency services to identify, educate,
and deliver vaccines to those with mobility issues.
Policy Recommendations to Strengthen Health Care Flexibilities,
Telehealth and Homebound Care
AHIP is ready to work with Congress and the Administration to
strengthen telehealth and homebound care and establish policies that
ensure the programs' long-term sustainability. Policymakers can further
advance this work by embracing comprehensive, multi-stakeholder
approaches:
(1) Make permanent the flexibilities in benefit design implemented
during the PHE. The Coronavirus Preparedness and Response Supplemental
Appropriations Act allowed the HHS Secretary to waive certain Medicare
telehealth payment requirements and the CARES Act enacted flexibility
for commercial health insurance providers to cover telemedicine.
Congress should pass legislation to make these provisions permanent and
redefine how Medicare and commercial (e.g., employer-sponsored
coverage) and individual market enrollees can access telehealth. To
solidify several regulations implemented by CMS and HHS during the
COVID-19 crisis, Congress should revise section 1834(m) of the Social
Security Act to allow for flexibility in benefit design for originating
sites, eligible geographies, eligible services, and eligible providers.
In reviewing this law, we encourage Congress is to leave room for
flexibility and innovation--the speed at which telehealth and virtual
care evolved during the COVID-19 crisis alone shows how quickly the
care delivery landscape can change. We recommend against lawmakers
attempting to strictly define the future of virtual care and instead
allowing health insurance providers and other innovators the
opportunities to connect patients with the most convenient, affordable,
and high-quality care available.
Additionally, while telehealth may be no more subject to fraud and
abuse than other modalities, it will be essential to monitor the impact
of telehealth on health outcomes, including quality and costs.
(2) Pass S. 150, the Ensuring Parity in MA for Audio-Only Telehealth
Act of 2021. This bipartisan bill would reduce health disparities that
result from unequal access to health technology, broadband service, and
video telehealth platforms. It would also ensure that the more than
26.5 million seniors and people with disabilities who receive their
Medicare benefits through Medicare Advantage (MA) and PACE continue to
receive the high-quality care on which they rely.
Rural patients may have trouble accessing technology or broadband
services necessary to support video-enabled telehealth. Additionally,
seniors or frail populations may have physical limitations that prevent
them from using video-enabled telehealth platforms. An audio-only
telehealth visit may be the only option for these patients to safely
and conveniently access needed care. MA plans have taken decisive steps
to support these patients by expanding telehealth services, including
providing coverage for telephonic (also known as ``audio-only'')
telehealth at the onset of the COVID-19 pandemic despite CMS's decision
to exclude diagnoses identified during the delivery of this care in
determining the severity of those patients' health conditions.
In addition, allowing diagnoses from audio-only telehealth services to
count for MA and PACE risk adjustment will help ensure patient health
costs are adequately accounted for and reimbursed. Without the accurate
documentation of diagnoses for MA and PACE risk adjustment, the
programs will effectively experience cuts, leaving MA and PACE
organizations and providers with fewer resources necessary to care for
patients. This could lead to unequal access, fewer choices, higher
premiums, or reduced benefits for beneficiaries in the long run. Given
that MA and PACE plan rates are benchmarked at the county level, this
impact could be particularly acute in areas where accessing video-
enabled telehealth posed more significant challenges for many
enrollees, enhancing disparities between communities on either side of
the digital divide.
That is why AHIP strongly supports S. 150, the Ensuring Parity in MA
for Audio-Only Telehealth Act of 2021, introduced by Senators Catherine
Cortez Masto and Tim Scott. This bipartisan legislation would reduce
health disparities due to unequal access to health technology while
supporting the more than 26.5 million Americans enrolled in MA and PACE
and the providers who have cared for them throughout the COVID-19
crisis.
AHIP recently joined with 17 other health-care organizations in support
of the bill.\24\ We appreciate the Committee's focus on the importance
of telehealth and the recognition that for many Medicare beneficiaries,
a phone call is their best or only option for immediately accessing
health care. We look forward to working with the lead sponsors of S.
150 and the Senate Finance Committee to support the MA and PACE
programs, their provider partners, and the 43 percent of Medicare
beneficiaries choosing these programs for their care.
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\24\ https://www.ahip.org/wp-content/uploads/04.28.21-Stakeholder-
LoS-HR-2166-and-S-150.
pdf.
(3) Improve Workforce Opportunity and Support for Caregivers and Home
Health Care Providers. Lack of training, lack of opportunity, and low
wages lead to low job satisfaction, high rates of caregiver burnout,
and high rates of turnover. Many in the workforce cite lack of
professional development and growth as a reason for exiting the direct
care workforce. Studies have shown a decrease in departures among
workers who are offered training and a career ladder.\25\ Policymakers
and health insurance providers must champion efforts to create training
opportunities and develop pathways to promotion.
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\25\ https://www.leadingage.org/sites/default/files/
Direct%20Care%20Workers%20Report%20%
20FINAL%20%282%29.pdf.
(4) Sustain Funding for HCBS. We support enacting measures that
incentivize adoption and expansion of HCBS as an alternative to
institutional care in state Medicaid programs. Policies such as
sustained enhanced federal financial participation and flexibilities
for states in developing HCBS infrastructure are key elements in making
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home-based care available to everyone who needs it.
(5) Extend Telehealth Safe Harbor for High Deductible Health Plans. The
CARES Act created a temporary safe harbor for High Deductible Health
Plans (HDHPs) that may be paired with tax-advantaged Health Savings
Accounts (HSAs) to allow health insurance providers offering those
plans to pay for telehealth services without applying a deductible.
This safe harbor has allowed plans to offer benefits that better serve
the needs of the more than 32 million Americans enrolled in these
plans, particularly during the pandemic. This flexibility is both cost-
effective and, as with access to virtual care in other plan types,
highly responsive to patient needs. The safe harbor applies only to
commercial health plans that begin prior to December 31, 2021, and many
health insurance providers and their employer clients would like to see
this safe harbor extended. There continues to be strong bipartisan
support for extending the safe harbor and promoting greater utilization
of telehealth among commercial plans while helping working families
access care when it is convenient to them without imposing undue costs.
We urge Congress to take bipartisan action to extend this highly
popular change to HDHPs.
Conclusion
Everyone deserves access to affordable, high-quality care, whether
delivered directly to a person in their home or virtually. Together
with the Administration, Congress, and our provider partners, health
insurance providers are working to ensure that patients continue to
have access to health care when they need it so that no community is
left behind. AHIP thanks the Committee for focusing on this important
issue, and we look forward to working together on more initiatives to
improve health care in every community.
______
American Association of Nurse Practitioners
On behalf of the more than 118,000 individual members of the American
Association of Nurse Practitioners (AANP), and the over 325,000 nurse
practitioners (NPs) across the nation, we appreciate the opportunity to
provide the following statement for the record to the United States
Senate Committee on Finance (the Committee). We commend Chairman Wyden,
Ranking Member Crapo and the members of the Committee for holding this
hearing on the experiences and lessons learned regarding COVID-19
flexibilities. NPs have been on the front lines providing care to
patients since the onset of this pandemic, and many of these
flexibilities, specifically those related to telehealth and workforce
expansion, have been integral in their ability to provide high-quality
and timely care to patients. Making these waivers permanent will
increase patient access to health care, particularly in rural and
underserved communities, and help alleviate the health-care disparities
that were exacerbated by this pandemic.
As you are aware, NPs are advanced practice registered nurses who are
prepared at the masters or doctoral level to provide primary, acute,
chronic and specialty care to patients of all ages and walks of life.
Daily practice includes: assessment; ordering, performing, supervising
and interpreting diagnostic and laboratory tests; making diagnoses;
initiating and managing treatment including prescribing medication and
non-pharmacologic treatments; coordinating care; counseling; and
educating patients and their families and communities. NPs practice in
nearly every health-care setting including clinics, hospitals, Veterans
Health Administration and Indian Health Services facilities, emergency
rooms, urgent care sites, private physician or NP practices (both
managed and owned by NPs), skilled nursing facilities (SNFs), nursing
facilities (NFs), schools, colleges and universities, retail clinics,
public health departments, nurse managed clinics, homeless clinics, and
home health. NPs hold prescriptive authority in all 50 states and the
District of Columbia and complete more than one billion patient visits
annually.
NPs have a particularly large impact on primary care as approximately
70% of all NP graduates deliver primary care.\1\ NPs comprise
approximately one quarter of the primary care workforce, with that
percentage growing annually.\2\ They provide a substantial portion of
health care in rural areas and areas of lower socioeconomic and health
status. As such, they understand the barriers to care that face
vulnerable populations on a daily basis.\3\, \4\,
\5\ NPs are the second largest provider group in the National Health
Services Corps \6\ and the number of NPs practicing in community health
centers has grown significantly over the past decade.\7\
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\1\ https://www.aanp.org/about/all-about-nps/np-fact-sheet.
\2\ ``Rural and Nonrural Primary Care Physician Practices
Increasingly Rely on Nurse Practitioners,'' Hilary Barnes, Michael R.
Richards, Matthew D. McHugh, and Grant Martsolf, Health Affairs 2018
37:6, 908-914.
\3\ Davis, M.A., Anthopolos, R., Tootoo, J., Titler, M., Bynum,
J.P.W., and Shipman, S.A. (2018). ``Supply of Healthcare Providers in
Relation to County Socioeconomic and Health Status.'' Journal of
General Internal Medicine, 4-6. https://doi.org/10.1007/s11606-017-
4287-4.
\4\ Xue, Y., Smith, J.A., and Spetz, J. (2019). ``Primary Care
Nurse Practitioners and Physicians in Low-Income and Rural Areas, 2010-
2016.'' Journal of the American Medical Association, 321(1), 102-105.
\5\ Andrilla, C.H.A., Patterson, D.G., Moore, T.E., Coulthard, C.,
and Larson, E.H. (2018). ``Projected Contributions of Nurse
Practitioners and Physicians Assistants to Buprenorphine Treatment
Services for Opioid Use Disorder in Rural Areas.'' Medical Care
Research and Review, Epub ahead. https://doi.org/10.1177/
1077558718793070.
\6\ https://www.hrsa.gov/sites/default/files/hrsa/about/budget/
budget-justification-fy2021.
pdf.
\7\ https://www.nachc.org/wp-content/uploads/2020/01/Chartbook-
2020-Final.pdf.
As noted in the testimony before the Committee provided by Jessica
Farb, Director of Health Care for the Government Accountability Office,
the Medicare waivers issued by the Centers for Medicare and Medicaid
Services (CMS) for the COVID-19 public health emergency (PHE) can
broadly be broken into three categories: expansion of hospital
services, workforce expansion and telehealth services. Our comments
will focus on workforce expansion and telehealth services. First, we
would like to highlight the impact that some of these flexibilities
have had for our members, their patients and communities. For instance,
AANP members have reported that the waiver authorizing NPs to perform
the initial assessment and all other mandatory assessments in skilled
nursing facilities has provided flexibility to meet the needs of
skilled nursing facility (SNF) patients while also meeting the other
demands that COVID-19 has placed on their communities. Additionally,
increased coverage of telehealth and remote technologies, particularly
coverage and increased reimbursement for audio-only services, has been
an essential lifeline for meeting the needs of their patients. Many of
our members have patients who lack access to audio-video technology,
and they would have had to make the difficult choice between delaying
care or risking exposure to COVID-19 if this authorization had not been
made.
Workforce Expansion
During the PHE, CMS waived multiple barriers to practice within the
Medicare program that have previously prevented nurse practitioners
from practicing to the full extent of their education, clinical
training and State scope of practice. Below are waivers that should be
made permanent before the end of the PHE. These recommendations are
consistent with the National Academies of Science, Engineering and
Medicine report The Future of Nursing 2020-2030: Charting a Path to
Achieve Health Equity which recommends that ``[b]y 2022, all changes in
policies and state and federal laws adopted in response to COVID-19
should be made permanent, including those that expanded scope of
practice, telehealth eligibility, insurance coverage, and payment
parity for services nurses provide.''\8\ The World Health
Organization's State of the World's Nursing 2020 report also recommends
modernizing regulations to authorize APRNs to practice to the full
extent of their education and clinical training, and noted the positive
impact this would have on addressing health-care disparities and
improving health-care access within vulnerable communities.\9\
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\8\ https://www.nap.edu/resource/25982/
FON%20One%20Pagers%20Lifting%20Barriers.pdf.
\9\ https://apps.who.int/iris/bitstream/handle/10665/331673/
9789240003293-eng.pdf.
Removing barriers to care for NPs and their patients has also garnered
widespread bipartisan support. In addition to bipartisan support in
Congress, reports issued by the American Enterprise Institute,\10\ the
Brookings Institution,\11\ the Federal Trade Commission \12\ and the
U.S. Department of Health and Human Services under the past two
administrations \13\, \14\, \15\ have all
highlighted the positive impact of removing barriers on NPs and their
patients.
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\10\ https://www.aei.org/wp-content/uploads/2018/09/Nurse-
practitioners.pdf.
\11\ https://www.brookings.edu/wp-content/uploads/2018/06/
AM_Web_20190122.pdf.
\12\ https://www.aanp.org/advocacy/advocacy-resource/ftc-advocacy.
\13\ https://www.hhs.gov/sites/default/files/Reforming-Americas-
Healthcare-System-Through-Choice-and-Competition.pdf.
\14\ https://aspe.hhs.gov/pdf-report/impact-state-scope-practice-
laws-and-other-factors-practice-and-supply-primary-care-nurse-
practitioners.
\15\ https://www.cms.gov/About-CMS/Agency-Information/OMH/
Downloads/Rural-Strategy-2018.pdf.
State experience has also shown that removing state restrictions on NP
practice improve access to care for patients in rural areas, reduce
unnecessary complications, lower costs and improve quality of life.
Currently, twenty-three states and DC are considered Full Practice
Authority (FPA) states because their licensure laws allow full and
direct access to NPs. No state has ever moved away from FPA once it has
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been enacted.
States that restrict the legal authorization of NPs to practice their
profession limit patient choice and decrease access to care, with
particularly acute effects in rural areas.\16\ Recent studies have
found that restrictive practice environments are associated with a
lower percentage of NPs obtaining medication-assisted treatment (MAT)
waivers.\17\ States that adopt FPA have found overall positive rural
health-care workforce trends. Arizona adopted FPA in 2001 and found
that ``the number of Arizona licensed NPs in the state increased 52%
from 2002 to 2007'', with the largest increase occurring in rural
areas.\18\ Other states that have reported similar workforce trends
include Nevada,\19\ Nebraska \20\ and North Dakota.\21\ South Dakota
also reported reduced administrative costs after adopting FPA.\22\
These results highlight the importance of removing barriers to practice
on NPs to increase access to care for patients.
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\16\ https://www.ftc.gov/system/files/documents/reports/policy-
perspectives-competition-regulation-advanced-practice-nurses/
140307aprnpolicypaper.pdf.
\17\ https://jamanetwork.com/journals/jama/fullarticle/
2730102?widget=personalizedcontent
&previousarticle=2737024.
\18\ http://azahec.uahs.arizona.edu/sites/default/files/u9/
azworkforcetrendanalysis02-06.pdf.
\19\ https://www.healthaffairs.org/do/10.1377/hblog20181211.872778/
full/.
\20\ Holmes, L.R., Assistant, F.C., and Waltman, N. (2019).
Increased access to nurse practitioner care in rural Nebraska after
removal of required integrated practice agreement, 31(5).
\21\ https://cnpd.und.edu/research/_files/docs/cnpd-
ndnpwfreport.pdf.
\22\ http://sdlegislature.gov/docs/legsession/2017/FiscalNotes/
fn61A.pdf.
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Authorizing NPs to perform all mandatory visits in SNFs.
As noted above, authorizing NPs to perform all mandatory visits in SNFs
has enabled practices and SNFs to maximize their workforce. This waiver
improves continuity of care and infection control by reducing
unnecessary contacts among patients and multiple providers. This is
also consistent with the permanent policy for Medicaid nursing
facilities,\23\ creating further alignment between these two programs
and improving care for dual-eligibles. Patients and health-care
providers in SNFs have been hardest hit by COVID-19. Making this waiver
permanent will provide them with the necessary flexibility to provide
the care that patients require for the duration of the PHE and beyond.
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\23\ 42 CFR 483.30(f).
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Authorizing NPs in rural health clinics (RHCs) and
federally qualified health centers (FQHCs) to
practice to the top of their license.
Waiving the requirement for physician supervision of NPs in RHCs and
FQHCs has provided much needed workforce flexibility in rural and
underserved communities where provider shortages are being exacerbated
by COVID-19. Our members reported that this waiver has helped the
entire health-care workforce because they are able to increase the
focus on patient care instead of unnecessary paperwork and more
expeditiously provide necessary treatments to their patients.
Authorizing NPs in critical access hospitals (CAHs) to
practice to the top of their license.
We support making the waiver of the CAH physician physical presence
requirement permanent. This will enable NPs in CAHs to practice to the
full extent of their education and clinical training. NPs who stated
that this waiver was implemented in their facilities have reported
positive impacts including: reduced regulatory burden for the clinical
workforce, allowing more time to be spent on direct patient care,
improved continuity of care, and more timely initiation of necessary
treatments. Making this waiver permanent would improve the ability of
CAHs to appropriately utilize their entire health-care workforce to
meet the needs of their patients following the PHE.
Authorizing Medicare hospital patients to be under the
care of an NP.
Waiving the requirement that every admitted hospital patient be placed
under the care of a physician enables NPs in hospitals to practice to
the top of their license and authorizes hospitals to optimize their
workforce strategies. Similar to the CAH waiver, NPs who stated that
this waiver was implemented in their facilities reported that this
waiver has streamlined the health care delivery process and improved
continuity of care. Facilities also increased the utilization of NPs in
leadership positions and participation in administrative planning for
emergency policies. While some of the changes that were reported were
allowed prior to the PHE, the removal of this barrier was noted to have
positive ancillary impacts on many additional hospital policies and
bylaws.
Telehealth Services
As mentioned previously, increased flexibility to provide telehealth to
patients has been an essential component of providing care during
COVID-19 and will continue to be integral to clinicians after the PHE.
Specific telehealth provisions that we support making permanent are
removing the geographic limitations, removing originating site
restrictions so that patients can receive telehealth in their homes and
increased coverage and reimbursement for audio-only telehealth
services. We also support the expansion of telehealth to previously
uncovered services and visits when the clinician determines that it is
clinically appropriate. These flexibilities have enabled NPs and other
clinicians to reach patients who otherwise may have been unable to
receive medically necessary health care, particularly in rural and
underserved communities.
Conclusion
AANP appreciates the Committee's examination of these flexibilities
granted under the PHE. These flexibilities are essential to building
back a robust health-care system after the pandemic and ensuring that
all providers are practicing to the full extent of their education and
clinical training. We look forward to working together to improve our
health-care system in the wake of the COVID-19 pandemic.
______
American Hospital Association
800 10th Street, NW
Two CityCenter, Suite 400
Washington, DC 20001-4956
(202) 638-1100
On behalf of our nearly 5,000 member hospitals, health systems and
other health-care organizations, our clinician partners--including more
than 270,000 affiliated physicians, 2 million nurses and other
caregivers--and the 43,000 health-care leaders who belong to our
professional membership groups, the American Hospital Association (AHA)
appreciates the opportunity to submit this statement for the record.
Since the first COVID-19 cases were diagnosed and the pandemic changed
the ways in which patients were able to access traditional health-care
settings, providers were required to navigate significant challenges to
ensure their services were still able to reach millions of patients. In
response, Congress and the Administration granted various flexibilities
intended to improve access and facilitate the delivery of safe, quality
care.
As health-care providers reflect on lessons learned and plan a post-
pandemic course for the future, it is evident that several of the
flexibilities have enhanced the patient experience and led to better
outcomes. The AHA believes that, if extended, these flexibilities can
continue to drive significant improvements in patient care long after
the public health emergency (PHE) ends. Given the beneficial impact of
those specific flexibilities, the AHA urges Congress and the
Administration to make them permanent. In addition, a second group of
flexibilities will remain critically important for some time following
the PHE and will require a carefully crafted phase-out plan to ensure
enough time is provided for a necessary transition. Without action from
Congress and the Administration prior to the termination of the PHE, we
are concerned that much of the progress made because of the
implementation of many of these flexibilities may be unnecessarily
halted or even lost. America's hospitals, health systems and post-acute
care providers have taken significant steps to improve the way care can
be delivered due to the pandemic, and failing to seize the opportunity
presented by the progress made would be a step back for the nation's
health-care infrastructure. Following are the AHA's recommendations for
each category of flexibilities.
Flexibilities That Should Be Made Permanent
Telehealth Provisions. The increased use of telehealth since the start
of the PHE is producing high-quality outcomes for patients, enhancing
patient experience, and protecting access for individuals susceptible
to infection. With the appropriate statutory and regulatory framework,
this beneficial shift in care delivery could continue to improve
patient experiences and outcomes and deliver health system efficiencies
beyond the pandemic. The AHA urges Congress and the Administration to
consider making these flexibilities permanent.
Telehealth policies should work together to maintain access for
patients by connecting them to vital health-care services and their
personal providers through videoconferencing, remote monitoring,
electronic consults and wireless communications. We support the
following: elimination of the 1834(m) geographic and originating site
restriction; coverage and reimbursement for audio-only services; an
expanded list of providers and facilities eligible to deliver and bill
for telehealth services, including rural health clinics and federally
qualified health centers; a national approach to licensure so that
providers can safely provide virtual care across state lines; and,
adequate reimbursement for the substantial costs of establishing and
maintaining a telehealth infrastructure, among others.
Payment Flexibility. In addition to the payment flexibilities needed to
continue effectively offering telehealth services beyond the PHE,
further payment flexibility is necessary to ensure access to care for
patients. Specifically, Congress and the Administration should consider
permanently increasing flexibility for site-neutral payment exceptions
for providers seeking to relocate hospital outpatient departments and
other off-campus provider-based departments. These steps would permit
hospitals and health systems to better and more effectively serve their
communities.
Hospital-at-Home Programs. The pandemic forced providers to rethink
ways to deliver care safely to all patients, while simultaneously
responding to surges in COVID-19 cases. To help providers make
necessary adaptations, the Centers for Medicare & Medicaid Services
(CMS) created new opportunities for providers to implement hospital-at-
home programs.
These flexibilities permit approved providers to offer safe hospital
care to eligible patients in their homes, and the results have proved
pivotal in caring for COVID-19 and non-COVID-19 patients during the
pandemic. While the initial aim of this flexibility was to increase
health-care capacity while keeping patients safe at home during the
PHE, promising outcomes are demonstrating the need for hospital-at-home
to be made permanent.
Hospitals and health systems are increasingly interested in standing up
hospital-at-home programs, yet many hesitate to do so without
assurances that their programs, which are very popular among patients
and their families, could continue to exist beyond the PHE. Extending
the hospital-at-home flexibilities permanently can engage providers who
may be hesitant to implement these programs now and will help transform
the way more providers deliver care, while enhancing the patient
experience. Given the benefits provided by this program, AHA
anticipates considerable additional provider interest and growth of
hospital-at-home programs should the flexibilities be made permanent.
Workforce Assistance. The COVID-19 pandemic has exacerbated the strain
on an already overworked and understaffed health-care workforce. To
help mitigate that strain, we support allowing health-care
professionals to practice at the top of their licenses and permanently
permitting out-of-state providers to perform certain services when they
are licensed in another state. We also support extensions of the five-
year cap-building period for new Graduate Medical Education (GME)
programs to account for COVID-19-related challenges and support long-
term sustainability of physician training. Permanently extending these
workforce flexibilities would help alleviate workforce shortages as the
PHE ends.
Review of Certain Conditions of Participation. The PHE has shed light
on several shortcomings and outdated practices across the national
health-care infrastructure; however, it also creates the unique
opportunity to reevaluate and improve upon processes based on the
lessons we have learned thus far. Conditions of participation (CoPs)
are a logical starting point for review and reevaluation, as they serve
as the foundation for ensuring high quality care and safety for
patients and set the baseline for hospital participation in the
Medicare and Medicaid programs. Compliance with the CoPs and the
potential for termination from the Medicare and Medicaid programs for
non-compliance serve as valuable tools ensuring hospitals are meeting
critical safety and quality requirements. However, the past year's
experiences demonstrated the need to modernize certain CoPs. For
example, reexamining and updating infection control and life safety
code requirements would allow hospitals and health systems to continue
to employ innovative approaches, such as allowing for separate facility
entrances for potentially infectious patients and minimizing personal
protective equipment (PPE) use and infection risk by placing IV tubes
outside patient rooms. The AHA has urged CMS to collaborate with
providers to determine how specific CoPs can be revamped to improve
quality and safety.
Rural Capacity. CMS should continue to support increased bed capacity
in rural areas when an emergency requires such action. Rural hospitals
should be held harmless for increasing bed capacity during any future
emergency, and those providers should be permitted to maintain pre-
emergency bed counts for applicable payment programs, designations and
other operational flexibilities.
Flexibilities Requiring a Transition Period
Emergency Use Authorization (EUA) Transition. The COVID-19 pandemic
placed significant strain on an already fragile medical supply chain
and highlighted several substantial flaws in the acquisition process.
Many of those impacts still exist today to varying degrees. In response
to supply chain disruptions, the Food and Drug Administration (FDA)
issued an unprecedented number of EUAs to help mitigate constant
disruption and continuous impact. The EUAs covered a broad range of
devices, from respirators and COVID-19 tests to ventilators and
decontamination systems. These EUAs saved lives by opening up new
supply lines to ensure providers have the items they need to safely and
effectively care for patients throughout the pandemic. However, the
EUAs are not a silver bullet, and additional disruptions will occur
post-pandemic. Congress should reassess how the supply chain operates
and consider modifications to mitigate further disruptions. To ensure
supply chain stability, the FDA should offer full approval to those
devices deemed necessary, and provide sufficient transition periods to
move away from devices that do not receive full approval.
Personal Protective Equipment. The COVID-19 pandemic illuminated
several supply chain shortcomings, not least of which was adequate
access to PPE necessary to keep both front-line health-care workers and
patients safe. In response to the massive PPE shortages, the FDA issued
EUAs for a number of items, such as respirators and facemasks. To
address the short- and long-term challenges associated with PPE, the
FDA should take steps to ensure a reasonable wind-down of PPE EUA
flexibilities to allow the supply chain to recalibrate and providers to
use supply on-hand. In addition, the FDA should examine the long-term
fragility of the PPE supply chain and consider offering certain non-
traditional medical PPE manufacturers the opportunity to receive full
medical supply authorization from the FDA. Finally, as this wind-down
occurs, the FDA and other federal agencies, including the Occupational
Safety and Health Administration (OSHA), the National Institute for
Occupational Safety and Health (NIOSH) and the Centers for Disease
Control and Prevention (CDC) should work together to ensure a
coordinated approach to the transition.
Health Information and Data Sharing. Robust health information and data
exchange capabilities among providers and with patients and government
agencies are foundational to improving care delivery, supporting better
health outcomes and facilitating emergency response. Data exchange
capabilities support decision-making at the point of care and the data
generated can provide insights into health disparities and inequities
at the patient and population health levels. Yet, to realize these
benefits, robust, secure infrastructure must be in place for all
entities, utilizing a common set of data definitions and standards.
Requirements around data collection and sharing also must be well
defined and well understood by health-care providers and have a clear
value proposition. Building this information technology infrastructure
requires significant resources, both capital and workforce, and
extensive efforts to redesign procedures and workflows and train
clinicians and staff across the organization. Until all of these core
building blocks are in place across the health information exchange
continuum, implementation of new requirements on health-care providers,
such as the Office of National Coordination for Health Information
Technology's information blocking rules and CMS' admit, discharge and
transfer notification CoP, should be delayed.
Quality Measurement Reporting. During the pandemic, CMS provided
hospitals relief from quality reporting requirements, including making
quality reporting optional in Q1 and Q2 of 2020, and allowing hospitals
to apply for reporting waivers using the pandemic as justification. We
note, however, that hospital performance on the measurement programs,
like readmissions, hospital-acquired conditions and value-based
purchasing, will be affected over multiple fiscal years to come, and it
is vital that performance be assessed reliably and fairly. For that
reason, CMS should use its statutory flexibilities to not apply payment
adjustments in program years where it determines that, as a result of
measure reporting exceptions, it has insufficient data to calculate
national performance in a reliable manner.
Federal Medical Assistance Percentages (FMAP) Increase. The temporary
FMAP increase in the COVID-19 relief laws has provided critical
financial support for states to ensure their Medicaid programs can
provide coverage for millions of their citizens during the COVID-19
pandemic. The temporary FMAP increase of 6.2 percentage points is set
to expire at the end of the quarter in which the PHE ends. To benefit
from the temporary FMAP increase, states must meet certain maintenance
of effort requirements, including continuous enrollment for those
enrolled in the program as of March 18, 2020. State governments,
advocates and stakeholders recommend that additional federal funding
will be needed for up to a year after the PHE ends. Extending FMAP will
provide a smooth process to reevaluate Medicaid COVID-19-related
coverage extensions.
Congress addressed a similar situation during the Great Recession of
2008-2009. Then, the FMAP was increased by 6.2 percentage points for 27
months (through the end of 2010) and then extended and tapered down
from 6.2 % to 3.2% and finally to 1.2% for another six months ending in
June 2011. Congress should consider a comparable approach for states at
the end of the PHE. Congress also should consider an enhanced FMAP for
states with high unemployment rates. During the Great Recession, states
with increases in unemployment rates of 3.5% received an enhanced FMAP
above the 6.2%.
Medicaid Coverage, Enrollment and Outreach. The PHE enabled states to
leverage Medicaid's emergency authorities to make temporary changes to
their programs that increased access to coverage and care. Most
policies adopted by states helped individuals qualify for and enroll in
Medicaid coverage. The two major pathways for states to change Medicaid
eligibility, coverage and enrollment during the PHE were: Medicaid
disaster relief state plan amendments that allow states to modify their
state Medicaid plans quickly to change eligibility, benefits, cost
sharing and payments; and disaster relief verification plan addenda
that allowed state agencies to verify eligibility and use electronic
data sources without prior approval from CMS.
The coverage needs facing states--and the policy changes needed to
respond adequately--will continue to exist beyond the PHE. To provide
continued flexibility, CMS should relax hospital-based presumptive
eligibility standards, maximize flexibility for income verification and
the use of self-attestation, and continue allowing qualified entities
like hospitals to make presumptive eligibility determinations for all
Medicaid eligibility groups.
Post-acute Care. Post-acute care (PAC) providers continue to play a key
role in the national COVID-19 response. In communities that faced or
are facing surges of the virus, they have treated many of the sickest
COVID-19 patients following hospital discharge, as well as provided
important relief to hospitals and other settings overwhelmed by
patients with and recovering from the virus. Concurrently, the
prospective payment systems (PPS) of three of the four PAC settings--
the long-term care hospital, inpatient rehabilitation hospital, and
skilled nursing facility PPSs--have been in the midst of major payment
transformations during the PHE. The collective magnitude of the PHE and
these PPS redesigns is extensive, and time is needed for policyholders
and stakeholders to disentangle and understand the longer-term
ramifications of each. Thus far, their combined impact includes, as
examples, material reductions in case volume and overall payments, the
rise of average levels of patient acuity, facility closures, personnel
shifts and revised clinical pathways. For example, AHA analysis shows
that, in comparison to prior patterns, case volume for these settings
dropped by 6% to 30% while the average case-mix index rose from between
2.5% and 6.9% over the prior year.i In recognition of this
complex dynamic, the recent FY 2022 PAC proposed rule calls upon
stakeholders to provide guidance on how to account for both of these
overlapping and powerful drivers of change. At this time, it remains
unclear which of these and other operational impacts will persist after
the PHE, but given their scope and duration, it seems possible that the
PAC field will not return to its pre-PHE profile. Given this level of
change and uncertainty, key PAC flexibilities should remain in effect
during a transition period that follows the official end of the PHE. In
particular, such extended flexibilities should include PHE-levels of
payment and coverage for highest acuity COVID-19 patients who remain in
the PAC setting following the PHE, including those ``long-haul COVID-19
patients'' for whom the virus has concluded but related symptoms
remain.
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i These data compare a 12-month period during the PHE,
January 27, 2020 through January 26, 2021, to a pre-PHE 12-month
period, January 26, 2019 through January 26, 2020. Data source:
Medicare fee-for-service claims, Centers for Medicare and Medicaid
Services, Chronic Conditions Data Warehouse, https://www2.ccwdata.org/
web/guest/home.
The AHA is gratified that the Committee is examining the many
flexibilities granted during the COVID-19 pandemic. We stand ready to
work with the Committee as you consider learnings from these
flexibilities and how to ensure that the nation's health-care system
can continue to evolve for the benefit of patients and the health of
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their communities.
______
American Medical Association
25 Massachusetts Avenue, NW, Suite 600
Washington, DC 20001
Division of Legislative Counsel
(202) 789-7426
The American Medical Association (AMA) appreciates the opportunity to
provide a statement for the record to the Senate Finance Committee as
part of the hearing on ``COVID-19 Health Care Flexibilities:
Perspectives, Experiences, and Lessons Learned.'' We welcome the
opportunity to support congressional efforts to ensure patients and
physicians continue to have access to valuable services that
flexibilities during the COVID-19 Public Health Emergency (PHE)
enabled. In particular, the AMA strongly supports congressional efforts
to ensure that Medicare beneficiaries have access to telehealth
services and to make permanent valuable flexibilities provided for the
treatment of substance abuse services, hospital at home services, and
the Medicare Diabetes Prevention Model.
Telehealth Flexibilities Should Remain in Place
Telehealth is a critical part of the future of effective, efficient,
and equitable delivery of health care in the United States. Efforts
must continue to build capacity and support access to care centered on
where the patient is located (to the greatest extent it is clinically
efficacious), and to ensure physicians and other health-care
professionals have the tools to optimize care delivery. The AMA has
been a leader in advocating for expanded access to telehealth services
for Americans because it has the capacity to improve access to care for
many underserved populations and improve outcomes for at-risk patients,
particularly those with chronic diseases and/or functional impairments.
In response to the COVID-19 PHE, Congress passed the CARES Act, which,
among other things, provided the Centers for Medicare and Medicaid
Services (CMS) the authority to waive the geographic and originating
site requirements for the duration of the COVID-19 PHE, which CMS
subsequently did.\1\ Following these policy actions, telehealth usage
among Medicare beneficiaries has expanded greatly as patients could,
for the first time, access telehealth services from wherever they are
located, including their home, regardless of where they reside in the
country. The AMA remains deeply grateful for these flexibilities, which
have allowed Medicare patients across the country to receive care from
their homes. With many physician offices closed, elective procedures
postponed, personal protective equipment difficult to obtain, and an
ongoing infectious disease pandemic that has forced patients to stay
home for their safety, the ability to provide services directly to
patients regardless of where they are located via telehealth has
allowed many vital health-care services to continue. In addition to
facilitating continuity of care for patients being treated for acute
and chronic conditions, telehealth has also facilitated initial
assessment of patients experiencing potential COVID-19 symptoms and
those who have been in close contact with people diagnosed with COVID-
19 to determine if referrals for testing or treatment are indicated
while minimizing risks to patients, practice staff, and others. With
this expansion of services has come a recognition from patients,
physicians, and other providers that telehealth services offer
effective and convenient health care in many circumstances. Congress
must act now to ensure that Medicare patients can continue to access
telehealth services from wherever they are located after the pandemic
ends by modernizing the Social Security Act to keep pace with our
digital future.
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\1\ Coronavirus, Relief, and Economic Security (CARES) Act, Pub L.
No. 116-136, 134 Stat. 281 (2020), https://www.congress.gov/116/plaws/
publ136/PLAW-116publ136.pdf.
However, without further legislative action from Congress, Medicare
beneficiaries who have come to rely on telehealth services during the
PHE will abruptly lose access to these services completely. Under
section 1834(m) of the Social Security Act (SSA), Medicare is
prohibited from covering and paying for telehealth services delivered
via two-way audio-visual technology unless care is provided at an
eligible site in a rural area.\2\ This means that, in order to access
telehealth services, patients must live in an eligible rural location,
and must also travel to an eligible ``originating site''--a qualified
health-care facility--to receive telehealth services, except in the few
cases where Congress has authorized provision of telehealth services in
the home of an individual.\3\ As a result, the 1834(m) restrictions bar
the majority of Medicare beneficiaries from using widely available two-
way audio-visual technologies to access covered telehealth services
unless they live in a rural area, and with a few exceptions, even those
in rural areas must travel to an eligible health-care site.
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\2\ Special Payment Rules for Particular Items and Services, 42
U.S.C. Sec. 1395m(m), https://www.ssa.gov/OP_Home/ssact/title18/
1834.htm.
\3\ For example, substance abuse disorder treatment delivered via
telehealth is explicitly exempted from the geographic and origination
restrictions.
Congress must act now to remove the origination and geographic
restrictions on telehealth coverage for Medicare patients. Continued
access to telehealth services beyond the PHE is critical for patient
populations that have come to rely on its availability. That is why the
AMA supports S. 368/H.R. 1332, the ``Telehealth Modernization Act of
2021,'' which would eliminate the 1834(m) statutory restrictions on
originating site and geographic location, thereby ensuring Medicare
coverage of telehealth services regardless of where the patient is
located. It is critically important that Medicare beneficiaries
continue to be able to access telehealth services from their physicians
without arbitrary restrictions throughout the COVID-19 public health
emergency and beyond.
The PHE Has Demonstrated the Value of Telehealth
The success of telehealth technology adoption during the COVID-19
public health emergency has made it abundantly clear that geographic
and origination restrictions on accessing telehealth services are
outdated and arbitrary given today's technology that allows for access
to digital tools from anywhere. Physicians and patients have seen the
value of telehealth services and should not be forced to stop using
these tools when the public health emergency ends. Some have argued
that statutory changes cannot be made without additional data on how
telehealth services are used, however, this has the problem backwards.
More data is not necessary to determine that the underlying policy
needs to be permanent, but instead can help CMS determine which
services need to continue to be covered or can be safely removed from
the Medicare telehealth list. In the meantime, the certainty that
appropriate telehealth services will be covered would provide
physicians confidence in investing in new technology and give patients
peace of mind that they can continue to access services in a way that
works best for them.
The rapid and widespread adoption of telehealth by physicians in 2020
was one of the most significant improvements in health-care delivery in
decades. The new telehealth coverage and payment policies enabled
physicians to deliver valuable services they previously could not
afford to provide but that their patients needed. With legislative
provisions such as the establishment of the CMS Innovation Center and
Medicare's Quality Payment Program, Congress has sought for many years
to support physician adoption of innovations in the delivery of care.
The successful adoption of telehealth throughout the country has
demonstrated that, if the financial barriers are removed, physicians
will adopt important innovations in the delivery of care that are
necessary to improve their patients' health.
Telehealth technologies allow physicians to increase continuity of
care, extend access beyond normal clinic hours, and help overcome
clinician shortages, especially in rural and other underserved
populations. This ultimately helps health systems and physician
practices focus more on chronic disease management, enhance patient
wellness, improve efficiency, provide higher quality of care, and
increase patient satisfaction. Telehealth has helped increase provider/
patient communication, increase provider/patient trust, and access to
real-time information related to a patient's social determinants of
health (i.e., a patient's physical living environment, economic
stability, or food insecurity), which can lead to better health
outcomes and reduced care costs. The ability to gain greater access to
chronic disease management services and better assess the impact of a
patient's social determinants of health will undoubtedly contribute to
improved treatment and health outcomes for historically marginalized
and minoritized populations as well.
Telehealth services can help patients avoid delaying care that can lead
to expensive emergency department visits and hospitalizations. They
also cut down on trips to the office that may be difficult or risky for
patients with functional or mobility impairments, frail elderly who
need a caregiver to accompany them, those who need to stay home to care
for other family members, and patients who are immunocompromised or
vulnerable to infection. Providing access to telehealth services
creates greater safety and efficiencies for both patients and
physicians, delivering value to the Medicare program.
Physician practices are ready to invest in the technology required to
provide these services; however, it will be very difficult to provide
the sustained financial commitment needed to incorporate delivery of
telehealth services into their workflows if the coverage is only
temporary. The removal of coverage and financial barriers has allowed
the explosive growth in telehealth and certainty about future coverage
is necessary for it to continue. It has allowed CMS to make more
informed decisions about which services to cover, and, in fact, CMS has
expanded coverage of telehealth services greatly during the PHE.\4\
While more data behind current telehealth usage trends may be valuable
to gather evidence about which particular Current Procedural
Terminology' (CPT') codes need to stay on the
Medicare telehealth list, that is a much different concern than whether
nationwide coverage and ability to deliver care to patients wherever
they are located should be available; these determinations are already
appropriately made by CMS.
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\4\ Medicare Physician Fee Schedule 2021, 85 Fed. Reg. 84472
(December 28, 2020), https://www.govinfo.gov/content/pkg/FR-2020-12-28/
pdf/2020-26815.pdf.
While CMS has expanded coverage of telehealth services during the PHE,
only Congress can assure all Medicare beneficiaries can receive equal
access to those services moving forward. Delaying action, such as
extending the current 1834(m) waiver authority, will only make it more
expensive to change the policy permanently in the future.
CMS Already Makes Coverage Determinations on Telehealth Services
CMS currently has all the tools necessary at its disposal to make
determinations about which telehealth services it should cover and at
what payment level. For the duration of the COVID-19 PHE, CMS has added
many services to the list of those that Medicare pays for when they are
provided via telehealth. The newly covered services include emergency
department visits, observation care, hospital and nursing facility
admission and discharge services, critical care, and home care, as well
as services like ventilator management that have been especially
necessary for COVID-19 patients. The newly added services have greatly
assisted physicians during the PHE when both patients and health
professionals needed to maintain physical distance from others as much
as possible. Through telehealth communications, for example, an
emergency physician, potentially assisted by members of the patient's
household, can diagnose, and treat emergency conditions without sick
patients having to endure difficult travel and expose themselves and
others to SARS-CoV-2 and other dangers. In all, CMS added interim
Medicare coverage for more than 150 services for the duration of the
COVID-19 PHE at payment parity with in- person services. Equivalent
payment for telehealth services during the PHE was crucial to ensure
physicians could cover the cost associated with offering virtual care.
In future rulemaking, CMS has indicated it may extend the interim
coverage for a longer period of time to help gather more evidence of
how the services are used when provided via telehealth outside the
context of a pandemic.
The only thing holding CMS back from expanding access to appropriate
telehealth services to its beneficiaries are the outdated restrictions
currently in the statute. Since telehealth is simply a modality for
delivering health care, AMA continues to urge Congress and CMS to
provide payment parity for two-way audio-visual services upon
conclusion of the COVID-19 pandemic.
Telehealth Helps Provide Access to Health Care to Underserved
Communities
Access to telehealth services can help reduce inequalities in care for
underserved communities by providing access to services for patients
regardless of where they are located. Patients in rural areas or
underserved urban communities often have to travel long distances to
access care, especially specialty services including emergency and
critical care. Telehealth can also help eliminate commutes to physician
offices for those with mobility or transportation difficulties.
In conjunction with expanded access to telehealth services, the AMA
supports Congressional efforts to expand high-speed broadband Internet
access to underserved communities and increase digital literacy
education efforts. Patients cannot take advantage of telehealth
services if they do not have the requisite Internet connection to
access them or the appropriate skills to use digital technologies.
Providing digital literacy skills is particularly important for non-
English speaking patients and is another crucial aspect of ensuring
health equity. Solving this problem requires enhanced funding for
broadband Internet infrastructure in rural areas and support for
underserved urban communities and households to gain access to
affordable Internet access, as well as support for patient education on
how to use digital tools.
Concerns About Fraud and Abuse and Overutilization Are Misplaced
Some have raised concerns that expanded coverage of telehealth services
could lead to greater fraud and abuse or duplication of medical
services. The AMA believes these concerns are misplaced given CMS'
existing tools for combating fraud and abuse, the increased ability
telehealth services provide for documentation and tracking, and the
lack of data to suggest that fraud and abuse or duplication are of
particular concern for telehealth services. Therefore, Congress should
not create artificial barriers to telehealth by defining an established
doctor-patient relationship inconsistently with the standard of care or
otherwise creating unique and burdensome fraud and abuse requirements
that would stifle access to telehealth services. The AMA supports
removing restrictions on access to Medicare tele-mental health services
that were included in H.R. 133, the Consolidated Appropriations Act,
2021. Specifically, the new requirement that Medicare beneficiaries
must be seen in person at least once by the physician or non-physician
practitioner during the six-month period prior to the first telehealth
services should be repealed. Such restrictions were not imposed on
tele-mental health services covered by Medicare prior to the passage of
the COVID-19 telehealth waiver, or on tele-mental health services
covered by Medicare under the waiver during the PHE. Moreover, they are
not supported by the data we have seen regarding the benefits of
increased access and improved patient adherence to treatment in tele-
mental health services and they directly conflict with the standard of
care.
CMS and the Office of Inspector General (OIG) at HHS already have all
of the Medicare coverage and payment and fraud and abuse authorities to
monitor telehealth service compliance just as they do any other
Medicare covered service. Additional restrictions do not currently
apply under the Medicare Advantage, the Center for Medicare and
Medicaid Innovation, section 1116 waiver authorities, the existing
Medicare telehealth coverage authority, or other technologies such as
phone, text, or remote patient monitoring.
In recent remarks regarding the potential for telehealth fraud,
Principal Deputy Inspector Grimm of OIG never mentioned any concerns
with OIG's authority or ability to address concerns of fraud and
abuse.\5\ Instead, he described OIG's concerns with ``telefraud''
schemes which he distinguished from telehealth fraud, in which bad
actors use ``telehealth'' as a basis for fraudulent charges for medical
equipment or prescriptions which are unrelated to the telehealth
service at issue. In those cases, fraudulent actors typically do not
bill for the televisit but instead used the sham televisit to induce a
patient to agree to receive unneeded items and gather their info. In
other words, whether or not the telehealth service itself is covered
has no impact on these kinds of fraudulent schemes.
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\5\ Principal Deputy Inspector Grimm on Telehealth (February 26,
2021), https://oig.hhs.gov/coronavirus/letter-grimm-02262021.asp.
Moreover, telehealth services may prove even easier to monitor for
fraud and abuse because of the digital footprint created by these
services, state practice of medicine laws requiring documentation of
these services, and the ability to track their usage with Modifier 95.
Telehealth services are even more likely to have electronic
documentation in medical record systems than in-person services.
Practice of medicine laws in all 50 states permit physicians to
establish relationships with patients virtually so long as it is
appropriate for the service to be received via telehealth. In addition,
two-way audio-visual services can be effectively deciphered and tracked
by CMS via the Modifier 95. The Modifier 95 describes ``synchronous
telemedicine services rendered via a real time Interactive audio and
video telecommunications system'' and is applicable for all codes
listed in Appendix P of the CPT manual. The Modifier 95, along with
listing the Place of Service (POS) equal to what it would have been for
the in-person service, is also applicable for telemedicine services
rendered during the COVID-19 PHE. The requirement to code with the
Modifier 95 enables CMS to properly decipher and track telemedicine
services, thus improving the chances of identifying and rooting out
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fraud, waste, and abuse.
Data analyzed by CMS since the start of the PHE shows that fears of
overutilization are overblown. Data from Medicare claims from Q1 and Q2
show that less than 4% of telehealth spending was for new patient
audiovisual office visits. Moreover, nothing in the data or anecdotal
evidence suggests that telehealth services have been duplicative of in
person services rather than used as an alternative or in addition to in
person care. The AMA will continue to monitor and analyze the data as
it becomes available, but this suggests that there is no reason to
think better access to telehealth will lead to an explosion in
unnecessary services.
As a result, Congress should refrain from imposing new and
discriminatory restrictions on the use of audio-visual communications
technologies, such as restrictions on how a physician-patient
relationship can be established. AMA policy, established in 2014,
states that a valid physician-patient relationship may be established
virtually face-to-face via real-time audio and video technology, if
appropriate for the service being furnished.\6\ It also allows for the
relationship to be established in a variety of other ways such as
meeting standards of care set by a major specialty society. All 50
states and the territories allow a physician-patient relationship to be
established virtually or through other means. The exact parameters vary
by state; however, many state laws are based on an AMA model law.
Congress should not impose a one-size-fits-all requirement on services
furnished via telehealth technology that are in direct conflict with
standards of care and that do not exist for other technologies.
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\6\ American Medical Association, H-480.496: Coverage of and
Payment for Telemedicine, https://policysearch.ama-assn.org/
policyfinder/detail/telemedicine?uri=%2FAMADoc%2FHOD.
xml-0-4347.xml (last modified, 2019).
Gains made in access to telehealth will be greatly hampered if unique
and arbitrary barriers are erected around the use of telehealth
services. Such barriers will have a dramatic and negative impact on
patients seeking care, particularly during the current COVID-19
pandemic, and in any future pandemic where patients need access to care
without the concerns surrounding a visit to a crowded health-care
facility.
Audio-only Services Should Remain Covered
The AMA also strongly supports coverage for audio-only services and has
called on CMS to continue this coverage after the PHE ends. There are
numerous patients and entire communities that have no access to the
Internet connectivity necessary to utilize audio-visual telehealth
services in their homes. There are also medical practices that do not
have sufficient connectivity to provide audio-visual telehealth
services. Patients who cannot utilize audio-visual telehealth services
include those in communities lacking broadband access, those where the
technological capabilities are present, but the patient cannot afford
it, and others who have access to the technology and the connectivity
but do not know how to use it. Inability to use audio-visual telehealth
services is also a matter of health equity. Too often it is the same
communities that face other barriers to good health outcomes who also
face these technology barriers, such as Native Americans living on
reservations and those in the rural South's Black Belt. But patients
who cannot participate in audio-visual telehealth services are no less
sick than those who can, and it is important to their health care to
retain access to these services.
Pursuant to authority granted under the CARES Act, CMS waived the
requirements of section 1834(m)(1) of the Social Security Act and 42
CFR Sec. 410.78(a)(3) for use of interactive telecommunications systems
to furnish telehealth services, to the extent they require use of video
technology for certain services. This has allowed the use of audio-only
equipment to furnish services described by the codes for audio-only
telephone evaluation and management services, and behavioral health
counseling and educational services. Expanded use of audio-visual
telehealth services during the pandemic has made it clear that
requiring the use of video limits the number of patients who can
benefit from telecommunications-supported services, particularly lower-
income patients, and those in rural and other areas with limited
Internet access. It would be inappropriate to prevent these patients
from accessing such services. In addition, we have heard from many
physicians about the need to have access to audio-only services because
a number of their patients, even those who own the technology needed
for two-way real-time audio-visual communication, do not know how to
employ it or for other reasons are not comfortable communicating with
their physician in this manner.
Audio-only services are an important part of a fully integrated care
plan and physicians should be able to permanently deliver E/M
(evaluation and management) services by telephone to patients who need
a telecommunications-based service in the home but who do not have
access to a video connection or cannot successfully use one. Without
access to an audio-only option, limitations in Internet and/or
technology access as well as lack of experience with its use will
increase inequities in access to medical care and widen disparities in
health outcomes.
Flexibilities for the Treatment of Substance Abuse Disorder Should Be
Continued
Early on in the COVID-19 Public Health Emergency, the Drug Enforcement
Administration (DEA) and Substance Abuse and Mental Health Services
Administration (SAMHSA) put several important flexibilities in place to
help DEA-registered physicians manage care for their patients with
opioid use disorder (OUD). During this PHE, physicians who have a
waiver allowing them to prescribe buprenorphine for the treatment of
OUD can initiate and continue this treatment based on telehealth visits
and audio-only visits with patients. Opioid Treatment Programs can also
initiate new patients and treat existing patients being managed with
buprenorphine based on telehealth and phone visits. Patients cannot be
initiated with methadone treatment based on telehealth visits, but
existing patients on methadone can be managed via telehealth or phone.
Opioid Treatment Programs can also provide patients who are stable with
take-home medication.
Based on a survey led by the American Academy of Addiction Psychiatry
and conducted last summer of more than 1,000 physicians and other
health professionals who treat OUD, these new flexibilities were
extremely important in allowing them to continue to manage their
patients' care. A major finding of the survey is that more than 80% of
X-waivered survey respondents want the telehealth options to continue
after the COVID-19 PHE. The AMA has written to the DEA urging that
these flexibilities remain in place at least until the end of the
opioid PHE and believes Congress should support these continued
flexibilities.
Hospital at Home Services Flexibilities Should Remain
A number of other countries pay for delivering services equivalent to
hospital inpatient care to patients in their own homes. These
``hospital at home'' services have been successful in allowing patients
with specific types of conditions that qualify for inpatient care to
receive services in the home and avoid the risks associated with an
inpatient admission. The services are more intensive than can be
supported through traditional home health-care payments. Although some
hospitals in the U.S. were delivering hospital at home care and some
Medicare Advantage plans were paying for it before the PHE, the service
was difficult to sustain or expand without payment support from
Medicare because a minimum number of patients need to participate in
order for the service to be cost-effective. During the pandemic, one of
the key flexibilities that CMS now has allowed is for hospitals to
deliver services to patients in their homes. It would be desirable to
continue this flexibility after the national emergency ends for the
subset of patients who meet the criteria used in hospital at home
programs in the U.S. and other countries.
Medicare Diabetes Prevention Expanded Model Flexibilities Should be
Made Permanent
Through the rulemaking process for the 2021 Medicare physician payment
schedule, CMS adopted important flexibilities that are effective for
the duration of the COVID-19 PHE and in future 1135 waiver emergencies
that could cause a disruption to in-person MDPP services. These MDPP
policies will only apply in emergency situations, however, and not on
an ongoing basis. MDPP services are being significantly underutilized.
If the MDPP flexibilities that have been adopted for COVID-19 and
future emergencies were instead continued as regular, ongoing MDPP
policies, it would significantly strengthen the effectiveness of
diabetes prevention services for Medicare patients with prediabetes.
The AMA strongly urges Congress to pass H.R. 2807, the PREVENT Diabetes
Act.
To furnish virtual services during an emergency period, MDPP suppliers
must already have preliminary or full CDC Diabetes Prevention Program
recognition for in-person services. CMS continues to bar virtual-only
suppliers that have achieved CDC recognition from furnishing MDPP
services, even during the PHE. Under its current regulations, CMS will
require MDPP providers to resume in-person services at the conclusion
of the COVID-19 PHE. Against AMA urging, CMS has declined to allow
virtual providers to participate in MDPP to the fullest extent either
during or after the PHE. CMS regulations also prohibit patients from
participating in their MDPP sessions virtually when offered by
suppliers who provide both in-person and virtual services except during
an emergency period. Many patients with prediabetes are unable to
effectively participate in in-person MDPP sessions, often because they
live far from any supplier location or because the sessions are not
offered at times that are convenient for them. The MDPP should be
modified to allow patients to obtain their session virtually at any
time.
CMS regulations also impose a once-per-lifetime limit on patients
obtaining MDPP services. During an emergency period, patients who
continue their MDPP participation through virtual services will still
be subject to the once-per-lifetime limit, but patients whose MDPP
participation is interrupted by an emergency period will be able to
restart MDPP services with the first core session after the emergency
period ends. Other Medicare behavior modification programs such as
tobacco cessation and obesity counseling do not have lifetime limits
and there is no justification for a once-per-lifetime limit on MDPP
services. This limit should be lifted for all patients, not just those
who discontinue MDPP during a declared emergency.
Conclusion
The AMA thanks the Committee for this hearing and for the careful
consideration of the flexibilities that have been put in place for the
COVID-19 PHE. We look forward to working with the Committee and
Congress to seek solutions that will ensure patients can continue to
benefit from these flexibilities after the end of the PHE.
______
American Medical Rehabilitation Providers Association
529 14th Street, NW, Suite 1280
Washington, DC 20045
Phone: 202-591-2469
Fax: 202-591-2445
The American Medical Rehabilitation Providers Association (AMRPA)
commends the Senate Committee on Finance for its efforts to closely
assess the nation's response to the COVID-19 public health emergency
(PHE) and determine whether and what type of permanent policy changes
should be considered in the PHE aftermath. In particular, AMRPA was
pleased to hear Chairman Wyden remark that there ``is bipartisan
interest in building on the changes that worked well for both seniors
and providers'' during the PHE, as we believe that getting patient and
provider feedback is critical in the assessment of COVID-19 waivers. As
providers who were able to furnish critical care to acute COVID- 19
survivors due to the numerous statutory and regulatory flexibilities
granted to our field, we appreciate the opportunity to offer
recommendations from the inpatient rehabilitation hospital perspective.
AMRPA is the national trade association representing more than 650
freestanding inpatient rehabilitation hospitals and rehabilitation
units of general hospitals (referred to collectively by regulators as
inpatient rehabilitation facilities, or IRFs). As you may be aware,
IRFs have and continue to play a vital role in their communities' PHE
response effort, due in large part to their hospital-level care,
clinical competence, personnel, quality, equipment, and emergency
response/preparedness capabilities that distinguish IRFs from other
post-acute care (PAC) settings. Patients' access to IRFs during the
pandemic has been particularly critical in light of the unprecedented
surge demands faced by acute-care hospitals and the infection control
and safety issues that restricted patients' access to other PAC
options. Through the utilization of waivers granted during the PHE,
AMRPA members have continually reported the long-term, positive impact
that medical rehabilitation has had for both COVID-19 survivors and
other complex patients who required medical rehabilitation care during
the PHE. As the Medicare program now faces a confluence of an aging
population, the new clinical and care delivery challenges presented by
``long- hauler'' COVID-19 survivors, and Trust Fund insolvency
projections, protecting patient access to inpatient rehabilitation has
never been more important. It is therefore vital that Congress takes
steps to ensure IRFs have the appropriate regulatory environment and
resources for the duration of the PHE and beyond.
As background, AMRPA engaged extensively with both Congressional
offices and the Centers for Medicare and Medicaid Services (CMS) since
the beginning of the pandemic regarding the flexibilities that would be
needed to address the surges of both COVID-19 and non-COVID-19 patients
requiring hospital-level care during the PHE. Given that IRFs are
arguably the most closely-regulated post-acute care entity within the
Medicare program, wide-ranging flexibilities were needed with respect
to admission criteria, documentation, and reporting requirements, among
others. CMS leaders conveyed to AMRPA that the comprehensive
flexibilities granted to IRFs during this time were intended to
facilitate timely and effective patient access to IRFs and ensure that
IRF providers were able to dedicate time and resources to patient care
rather than regulatory burdens. As the Finance Committee contemplates a
legislative response that builds off the ``lessons learned'' from the
COVID-19 pandemic and protects patient access to care in an evolving
health-care environment, we appreciate your consideration of our
legislative recommendations informed by the PHE. While our
recommendations may evolve in future stages of the PHE and its
aftermath, our primary asks currently include:
Consider commonsense reforms to key IRF coverage requirements to
better reflect the value of rehabilitation services for patients;
Prohibit the use of prior authorization by Medicare Advantage
plans in all future PHEs and throughout their duration, and implement
significant reforms to current prior authorization practices that
harmfully impeded care over the past year (AMRPA has supported the
recently-introduced H.R. 3173, the Improving Seniors Access to Timely
Care Act, as a key first step in this regard);
Permanently implement some of the critical telehealth-related
waivers and flexibilities granted during the PHE (e.g., the recognition
of physical therapists, occupational therapists, respiratory therapists
and speech-language pathologists as telehealth providers);
Ensure providers can practice across state lines, or at minimum,
authorize interstate licensing immediately upon any future PHE
declaration; and
Reset the implementation of the IMPACT Act timeline to account
for the ongoing burdens on each PAC sector and the need to account for
the COVID-19 PHE in any future payment reform effort.
We believe many of these asks complement the 117th Congress' broader
focus on burden reduction and regulatory modernization efforts, and
AMRPA stands ready to work with your offices as specific legislation is
considered.
Our more detailed recommendations follow:
Using PHE Flexibilities to Modernize IRF Coverage Rules
At the beginning of the pandemic, two key IRF coverage waivers were
granted to maximize patient access to IRFs--the 60% rule and the 3-hour
rule. Even before the PHE, AMRPA urged policymakers to reexamine these
rules and modernize them in light of the significant policy and
operational changes that have occurred since their implementation. With
both rules currently suspended due to the PHE, AMRPA believes it is an
optimal time to reassess and refine these rules.
As background, the current ``60% rule'' broadly requires that 60% of
the IRF's patients must have a qualifying condition in order to be paid
as an IRF under the Medicare program. There are currently 13 such
conditions, including, stroke, spinal cord or brain injury, and hip
fracture, among others. There have been no major categories added for
decades--despite medical and technological advancements that have led
broader patient populations to gain significant clinical benefits from
IRF care. The waiver of the 60% rule during the PHE has improved access
for patients that had conditions other than those categorized as a
compliant condition--such as oncology and cardiac-related conditions,
and COVID-19--and led to improved outcomes and functional recoveries
for such patients. AMRPA therefore urges Congress to direct CMS to
revisit and potentially broaden the 60% rule's ``compliant'' conditions
before putting the rule back into effect. This would be an important
step to both protect patient access and ensure that Medicare
regulations reflect the current state of medicine.
Similarly, AMRPA asks Congress to modernize the 3-hour rule, which
requires an IRF patient to participate in, and benefit from, at least
three hours of rehabilitation therapy per day, five days per week (or
15 hours per week if documented appropriately). Due to a 2010
regulatory change, only physical therapy, occupational therapy, speech
therapy, and/or orthotics and prosthetics are countable therapies
toward the 3-hour threshold. AMRPA recognizes that the volume of
therapy received by IRF patients is among the characteristics that
distinguish IRF care from other PAC settings. At the same time, AMRPA
has advocated for the inclusion of other therapy modalities that
rehabilitation physicians often determine are necessary for patients'
full functional recovery, such as psychological services,
neuropsychological services, and respiratory therapy. AMRPA members
already provide these therapies when needed (despite their exclusion
from the 3-hour rule calculation) given the clear benefit that they
provide for a range of complex patients in IRFs. Their utilization and
the benefit provided to patients clearly demonstrates that these
therapies should be recognized as part of the ``intensive
rehabilitation therapy program'' for which the 3-hour rule is
attributed.
The rationale for counting these modalities toward the 3-hour threshold
is all the more compelling in light of the impact of the PHE waiver.
The aforementioned therapies were particularly beneficial as patients
with acute respiratory disease were treated by IRFs during the
pandemic, and AMRPA members expressed appreciation for the flexibility
provided through the waiver in this regard. As such, AMRPA believes
that they should permanently be allowed to count toward the threshold
in the PHE aftermath. We have already worked with Congressional offices
to discuss a bill that would deliver these much-needed modernizations,
and we look forward to working with the Finance Committee to facilitate
its introduction and advancement in the 117th Congress.
On a related issue, AMRPA requests that the full 3-hour rule waiver be
included within the scope of flexibilities that can be granted by CMS
(via Section 1135 waivers) in future PHEs. This would negate the need
for Congressional action and ensure that this rule be waived promptly
by regulators in emergency circumstances.
Significant Reforms to Prior Authorization Practices
In the first quarter of 2020, many Medicare Advantage (MA) plans
voluntarily waived their prior authorization/pre-authorization policies
to ensure that patients were able to access IRF beds in the safest and
most timely way possible. These voluntary waivers enabled patients that
were ready for clinical intervention to receive such care
expeditiously, rather than incur the 3-5 business day delays that these
policies frequently impart. Unfortunately, after the first few months
of the pandemic, most MA plans reinstated prior authorization
requirements. This severely impeded movement of patients from acute-
care hospitals into PAC settings, exacerbating an already critical
hospital bed shortage. Data that AMRPA has examined from the time
period before, during and after the suspension of prior authorization
made clear that the removal this requirement provided access to complex
patients that otherwise may have been delayed or denied receiving care.
The positive impact of these waivers makes it clear that prior
authorization policies must be fully and immediately suspended in all
future public health emergencies for the emergency's full duration, and
we urge you to include this protection statutorily in future pandemic-
focused legislation.
In addition, AMRPA believes there are a number of reforms that must be
made to prior authorization policies outside of the context of a PHE.
Under current practices, an MA representative who has never seen or
examined the patient, and often lacks training or expertise in
rehabilitation medicine, second- guesses the judgement of the treating
physicians that have deemed an admission to an IRF to be medically
necessary and appropriate. In turn, these prior authorization policies
often cause lengthy delays or inappropriate denials for patients
needing IRF care, which adversely affects outcomes and functional
recovery. With prior authorization practices now generally back in
effect across the nation, AMRPA members report that these policies are
once again compromising timely patient access to timely IRF care.
AMRPA therefore asks Congress to advance H.R. 3173--the Improving
Seniors' Access to Care Act--as an initial and commonsense step towards
prior authorization reform. Importantly, the legislation would direct
HHS to establish that prior authorization decisions to be made in
``real time'' to address the aforementioned delays and inappropriate
referrals tied to current practices. AMRPA believes that 6 hours is an
appropriate ``real time'' measure for an inpatient rehabilitation
admission authorization decision, and we look forward to working with
both Congress and ultimately HHS in this regard. Furthermore, AMRPA
asks the Committee to consider other legislative actions to improve
prior authorization practices, such as:
Strengthen beneficiary protections for all MA enrollees by
ensuring prior authorization requests are reviewed by physicians with
appropriate training and experience in inpatient rehabilitation.
Limit or eliminate the use of proprietary guidelines/decision
tools to ensure enrollees' statutory right to Medicare fee-for-service
benefits are fulfilled and that admission decisions take into account
patient-specific characteristics and conditions.
Telehealth Expansion
Some of the most important waivers granted during the COVID-19 PHE
relate to telehealth expansion, particularly for medical rehabilitation
patients. In particular, AMRPA strongly supported policymakers'
decision to (1) expand the list of telehealth services that can be
provided in the Medicare program via telehealth to include therapy
services, (2) recognize therapists--including physical therapists,
occupational therapists, and speech-language pathologists--as eligible
telehealth providers, (3) relax distant site guidelines, and (4) permit
a broader range of telemedicine in the context of inpatient care--such
as remote consultations and virtual team meetings. Many of our hospital
members report that these waivers allow patients to continue the
outpatient therapy component of their intensive rehabilitation program
without undertaking the risk of entering the hospital or outpatient
care setting. We therefore urge Congress to enact legislation to make
these flexibilities permanent in the PHE aftermath.
Even before the COVID-19 pandemic, AMRPA is on record expressing
support of efforts--such as the CONNECT for Health Act (which was again
recently reintroduced in the 117th Congress)--to modernize telehealth
rules in the Medicare program to better reflect the state of medicine
and technology. Consistent with this position, AMRPA believes that
these outpatient therapy-focused waivers will prove beneficial outside
of a PHE, such as when patients face other obstacles (e.g., weather,
protests, or mobility restrictions) that prevent them from traveling to
an IRF or outpatient therapy site. At the same time, clearer billing
rules--particularly for hospital outpatient departments--may be
required to ensure sufficient uptake. Further, Congress should consider
flexibility within the definition of telehealth, such as allowing
audio-only services for those patients unable to use or without access
to video technology or Internet connectivity. AMRPA therefore believes
that permanent implementation of these telehealth waivers and requisite
guidance to the industry is a commonsense way to improve patient access
to care without compromising quality or safety.
Implementing Interstate Licensing Flexibilities
During the PHE, numerous AMRPA members were able to provide critical
capacity to acute-care hospitals across state lines and provide both
surge and COVID-19 patients with the acute beds they required. The
interstate licensing flexibilities offered by CMS were utilized broadly
by IRF providers and helped ensure that patients received the timely
care they required for survival and recovery, without jeopardizing the
quality of the care they received. AMRPA therefore requests that these
flexibilities be made permanent to alleviate patient access issues and
address arbitrary restrictions on care options when patients live near
state lines. At minimum, AMRPA urges Congress to ensure that interstate
licensing flexibilities are automatically triggered whenever a PHE is
declared to ensure that partner hospitals in different states can
immediately assist each other in furnishing the capacity and provider
access required for their patients. Additionally, and consistent with
our telehealth-related recommendations, AMRPA also recommends that
providers be allowed to practice across state lines via telehealth in
the same way they would be permitted to do so in-person.
Delaying the Implementation Timeline and Considering Other Potential
Changes to the IMPACT Act
As Congress assesses policy changes informed by COVID-19 waivers and
flexibilities, AMRPA urges Members to also be mindful of the lessons
learned by and about post-acute care providers in the context of other
legislative efforts. Specifically, AMRPA believes the PHE requires
policymakers to reconsider the timing and underlying goals of the
unified post-acute care (UPAC) prototype required under the IMPACT Act.
With respect to timing, AMRPA has long been concerned about the data
being used to develop a UPAC prototype given the significant changes in
each of the post-acute care setting payment systems since the
implementation of the IMPACT Act. The current PHE now raises new and
serious concerns about the use of claims and cost data for any year
that the PHE is/was in effect and the years immediately following.
Therefore, as policymakers consider how the COVID-19 PHE should impact
future work related to post-acute care reform, the development of a
UPAC prototype should at the very least be delayed for several years
until useable data is available.
This delay would also allow policymakers to consider the seismic impact
of the COVID-19 PHE on the post-acute care continuum and the permanent
changes in care delivery that will stem from the exact policy changes
being considered through the Committee in this line of work (for
example, the impact of future telehealth expansions). Therefore, AMRPA
urges the Committee to support The Resetting the IMPACT Act (H.R.
2455), which would make these commonsense reforms and reset the
timeframe in a way that could improve the accuracy of a prototype (and
ensure more meaningful stakeholder engagement). We also look forward to
working with the Committee to ensure that any future payment and
coverage changes are informed by the lessons the Committee seeks to
glean from the PHE.
In closing, AMRPA applauds the leadership of the Committee and greatly
appreciates the opportunity to provide comments on how COVID-19 waivers
should inform future policy changes. Should you wish to discuss our
comments further, please contact Kate Beller ([email protected]; 973-
224-4501) or Kristen O'Brien ([email protected]).
Sincerely,
Anthony Cuzzola
Chairman, AMRPA Board of Directors
Vice President/Administrator
JFK Johnson Rehabilitation Institute
Hackensack Meridian Health
______
American Occupational Therapy Association
6116 Executive Boulevard, Suite 200
North Bethesda, MD 20852-4929
[email protected]
301-652-6611
https://www.aota.org/
Pandemic Experience Demonstrates Need to Continue OT Telehealth Options
for Medicare Beneficiaries After the Public Health Emergency
The American Occupational Therapy Association (AOTA) is the national
professional association representing the interests of more than
230,000 occupational therapists, occupational therapy assistants, and
students of occupational therapy. The science-driven, evidence-based
practice of occupational therapy enables people of all ages to live
life to its fullest by promoting participation in daily occupations or
activities. In so doing, growth, development, and overall functional
abilities are enhanced, and the effects associated with illness,
injuries, and disability are minimized.
Telehealth and Occupational Therapy Before the Pandemic
As noted in AOTA's Telehealth in Occupational Therapy backgrounder
(attached), some occupational therapy professionals were providing
occupational therapy (OT) services via telehealth before the COVID-19
pandemic struck, with significant innovation occurring at the Veterans
Administration. The number of OT telehealth encounters increased
dramatically, however, as Congress and CMS reacted quickly to enable
Medicare beneficiaries to receive OT and other therapy services via
telehealth during the declared Public Health Emergency (PHE) to
minimize infection risk.
Congressional action was essential to waive statutory restrictions on
CMS that prevented occupational therapy practitioners and other therapy
providers' ability to provide services to Medicare beneficiaries via
telehealth. CMS responded to Congressional waivers included in the
CARES Act by issuing an emergency rule that added a series of therapy
CPT' codes to the telehealth services list, and then
subsequently issued another rule that included occupational therapy
practitioners as eligible Medicare telehealth providers. This
effectively enabled OTs to provide services via telehealth to Part B
Medicare beneficiaries during the COVID-19 emergency; however, these
waivers are not permanent.
The delivery of OT services via telehealth expanded exponentially after
the CMS waivers were issued, and in response to actions by state
Medicaid plans and private insurance to also allow patients to receive
OT services via telehealth to reduce infection risk. This enabled
occupational therapy professionals to continue to provide essential OT
services, while gaining the necessary experience to fully appreciate
potential benefits to patients that are unrelated to minimizing in-
person contact during a pandemic.
Congressional action is now essential to enable OT services to continue
to be provided to Medicare beneficiaries via telehealth when
appropriate, as CMS has indicated that it does not have the authority
to do so under existing statute. The Expanded Telehealth Access Act
(H.R. 2168) was introduced in the House by Reps. Mikie Sherrill (D-NJ)
and David McKinley (R-WV) to enable OT professionals as well as
physical therapists (PTs), speech-language pathologists (SLPs), and
audiologists to provide services via telehealth under Section 1834(m)
of the Social Security Act. Unless Congress acts, Medicare
beneficiaries will face a telehealth ``cliff'' when the PHE ends,
whereby beneficiaries who are now accustomed to receiving some OT
services via telehealth, suddenly lose access to such services.
Experience During PHE Demonstrates Effectiveness
of OT Services via Telehealth
The rapid expansion of telehealth as a delivery mechanism for OT
services during the PHE has enabled occupational therapists and
occupational therapy assistants to demonstrate the clear value of these
services provided alone or in conjunction with in-person services.
Telehealth has been especially beneficial for people in rural and other
underserved areas and to those for whom travel to receive services was
already a barrier to access, including people with disabilities.
OT practitioners report that telehealth has enhanced the effectiveness
of OT services for Medicare beneficiaries in many ways. It has enabled
more patients to start care on the day ordered and to minimize
cancellations, postponements, and schedule changes that are commonly
connected to transportation, mobility, caregiver availability, weather,
and other issues related to treatment in a clinical setting. This in
turn has enabled some patients to complete treatment sooner and with
fewer visits, which can reduce the cost of care.
Telehealth has also made it much easier to connect with beneficiary
caregivers who are often unable to take the time required to travel
with the patient to in-person visits. This is especially important for
some patients in the Medicare population who rely more heavily on a
caregiver for assistance during appointments and for follow-up in the
home. In addition, telehealth visits have enabled OT professionals to
better identify home safety issues, which are often minimized or not
referenced at all by patients during an office visit. This can be
crucial in preventing falls, addressing functional decline, and
avoiding costly emergency room visits and hospital admissions which, in
turn, can reduce the cost of care.
Research Demonstrates Efficacy of OT Delivered via Telehealth
A study (infographic attached) by Focus on Health Outcomes (FOTO), one
of the major health data registries used by therapists, reported on
five data-driven benefits of therapy when provided via teleheatlh
utilizing differing proportions of in-person and telehealth visits per
patient. The study indicated that therapy provided via telehealth can
promote patient confidence, drive better attendance numbers, and
sustain the continuity of care for existing patients. It also indicated
that therapy services provided via telehealth and non-telehealth were
equally effective in relation to improving the functional status of
patients, with differing mixes of teleheatlh and in-person visits
utilized as needed/desired by the patient. In addition, the study
demonstrated a reduced number of visits per episode of care when
telehealth was involved, and equal patient satisfaction.\1\
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\1\ Data-Driven Benefits of Telehealth for Rehab Therapists (2020).
Net Health, https://www.nethealth.com/5-data-driven-benefits-of-
telehealth-for-rehab-therapists/.
The AOTA Telehealth Position Paper \2\ summarizes how occupational
therapy practitioners use telehealth technologies as a method for
service delivery for evaluation, intervention, consultation,
monitoring, and supervision of students and other personnel. Further,
it references the results of research on the use of telehealth in
rehabilitation or habilitation, which includes occupational therapy.
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\2\ American Occupational Therapy Association (2013). Telehealth.
American Journal of Occupational Therapy, 67(6 Suppl.), S69-S90, http:/
/dx.doi.org/10.5014/ajot.2013.67S69.
There is a growing base of evidence demonstrating the efficacy of
technologically mediated occupational therapy.\3\ Ongoing research at
University of Southern California Mrs. T. H. Chan Division of
Occupational Science and Occupational Therapy Faculty Practice has
shown that increased use of telehealth for pain-management patients
decreased cancellations, increased access, and improved treatment
effectiveness. Patient satisfaction with telehealth is also high. A
more detailed list of their findings follows:
---------------------------------------------------------------------------
\3\ Cason J (2009). A Pilot Telerehabilitation Program: Delivering
Early Intervention Services to Rural Families. International Journal of
Telerehabilitation, 2009;1(1):29-37. Hoffmann T, Russell T, Thompson L,
Vincent A, Nelson M. (2008). Using the Internet to assess activities of
daily living and hand function in people with Parkinson's disease.
NeuroRehabilitation, 23, 253-261. Ng EM, Polatajko HJ, Marziali E, Hunt
A, Dawson DR (2013). Telerehabilitation for addressing executive
dysfunction after traumatic brain injury. Brain Inj. 2013;27(5):548-64.
Ability to access more people with chronic pain by eliminating
the geographic barrier of having to drive to an in-person session. A
recent evaluation of a telehealth group intervention for pain
management, specifically for patients living in rural or remote areas,
revealed that participants benefited from telehealth specialty pain
management services.\4\
---------------------------------------------------------------------------
\4\ Scriven, H., Doherty, D.P., and Ward, E.C. (2019). Evaluation
of a multisite telehealth group model for persistent pain management
for rural/remote participants. Rural and Remote Health, 19(1).
---------------------------------------------------------------------------
Decreased cancellation rates due to pain flare ups or symptom
exacerbations because patients do not have to commute to in-person
sessions, but can participate from the comfort of their own home where
they can access many of their pain management tools (i.e., medication,
heat/ice, self-massage units, lying down as needed, more control over
ambient temperature).
Improved treatment effectiveness due to improved ability to
assess and evaluate a person's home environment and contextual factors,
rather than through verbal discussion or photos. This allows for more
effective problem solving and identification of environmental barriers.
This is especially clear in OT interventions for pain regarding body
mechanics, ergonomics, physical activity routines, sleep positioning,
falls prevention and recovery, and placement of durable medical
equipment for optimal safety.
Improved continuity of care because patients who would travel
long distances to come to the clinic may only be seen for treatment 1x/
month, but with telehealth services, they can be seen weekly for
improved accountability and to support long-term, sustainable behavior
change.
Improved patient satisfaction--patients are reporting improved
participation and effectiveness of treatment because commuting to the
clinic and driving can often be a trigger of pain or stress. By
eliminating this factor, patients avoid starting treatment sessions in
pain or fatigue and are able to participate more effectively during
session.
Reduced social isolation and occupational deprivation--due to
compounding factors of managing a chronic condition and the long-term
effects of pandemic-
related restrictions, patients are reporting feelings of isolation and
reduced functional participation in daily routines and meaningful
activities. Experiencing occupational deprivation can have detrimental
effects on health and wellness, self-efficacy, and identity.\5\ With OT
telehealth, patients can collaborate with their OT to identify
strategies and opportunities to engage in occupations and social
activities to combat isolation, occupational deprivation, and
associated adverse health consequences.
---------------------------------------------------------------------------
\5\ Whiteford, Gail. (2000). Occupational deprivation: global
challenge in the new millennium. British Journal of Occupational
Therapy, 63(5).
Additional research has shown strong strength of evidence that
motivational interviewing, fatigue management, and medication adherence
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performed via telehealth lead to positive outcomes.
Based on this research, both Medicare beneficiaries and the Medicare
Program would see great benefits in quality care, reduced costs, and
reduced hospitalizations if occupational therapy is utilized fully.
AOTA asserts that the same ethical and professional standards that
apply to the traditional delivery of occupational therapy services also
apply to the delivery of services received via telehealth. Occupational
therapy interventions delivered via telehealth can assist patients to
regain, develop, and build functional independence in everyday life
activities to significantly enhance a Medicare beneficiary's quality of
life. Telehealth may also address provider shortages and access
problems, making necessary occupational therapy services available to
underserved beneficiaries in remote, inaccessible, or rural settings
and to beneficiaries with limited mobility outside their home. Further,
occupational therapy is the chief profession with expertise in
activities of daily living and community environments, which may be
better observed and evaluated through telehealth services when the
beneficiary is in their home environment.
Occupational Therapists Describe Benefits of
OT via Telehealth During PHE
AOTA commends the Government Accounting Office for conducting a study
on the use of telehealth during the PHE, and we look forward to seeing
the results of their work. In addition, examples of the use of
telehealth to provide OT services during the PHE follow, as described
by OT professionals:
Telehealth has been crucial for service to our CMS patients in
our Post-ICU multidisciplinary clinic during the pandemic and would
continue to be a vital resource for these patients. Many of these
patients will not be able to access the services for a variety of
reasons if we cannot continue with telehealth.
Telemedicine has been a very helpful but unexpected resource for
service delivery. One of the primary barriers to clients participating
in the 55+ Program in the past has been transportation. Many clients
are fearful of driving, unable to drive due to other health conditions,
or do not have access to a vehicle and alternative transportation is
too expensive. Telemedicine has allowed these clients access to
treatment now.
Initially many of my older adult clients struggled and were
fearful of technology and did not think they would be able to
participate in online treatment. With coaching and assistance, many
clients have overcome these barriers and now are using technology more
to connect with family, friends, and other community resources. It has
helped to decrease isolation for many both for treatment and in the
community.
I am an occupational therapist in an outpatient neurological
clinic. The majority of my patient caseload includes adults and older
adults with comorbidities and/or [who] are immuno-compromised. During
the global pandemic, taking months off of therapy could have resulted
in significant decrease in function for some of the patients I serve.
Our clinic was on the edge of our seats while waiting to hear the CMS
changes to allow occupational therapy providers to provide telehealth
services. Once the change had been made, it opened up a new world of
opportunity for us to serve these patients who so needed skilled
therapy, but were unable to physically come into the clinic. As
occupational therapists, we adapt. I am able to provide individualized,
client-centered care through a new medium that was aligned with the
patient's plan of care to reach their functional goals. Without the
ability to provide the skilled services via telehealth, our clients
would not have received the care they needed. Patients have been
surprised with the effectiveness of telehealth therapy services. If CMS
allows these changes to be permanent, we would be able to better serve
those patients in effective ways through the use of this technology.
Clients who have difficulty with transportation to the clinic or
consistent transportation have been able to receive services and those
that have anxiety with new providers or leaving home have benefitted in
that this is a great bridge to start with to start to expose to social
skills and situations and still provide them with the therapy that they
need to succeed.
One particular patient was a woman with Parkinson's. She and her
husband were sleeping on an air mattress in their den because she had a
hip fracture and was not steady enough to climb the stairs to her
bedroom. After her OT eval, she refused further in-person visits. I
trialed telehealth visits with great success. I was able to have the
husband aim the camera so that I was able to provide placement of
recommended grab bars in the bathrooms, both upper and lower levels, as
well as get a tour of the second level, something I had not been able
to assess at the eval. I was able to help with technique and
positioning for upper extremity exercises, and eventually, I was able
to teach the husband how to assist the patient up/down the stairs,
safely, as well as teach bed mobility so that the patient was able to
sleep in her own bed upstairs versus an air mattress on the floor on
the main level. She and her husband looked forward to my weekly visits
and always updated me on the progress she had made. They were so
grateful for the therapy I was able to provide remotely.
Global Telehealth Issues of Specific Concern to AOTA
While Congressional action is urgently needed now to allow occupational
therapy professionals to provide services via telehealth after the PHE,
AOTA also notes that for telehealth to move forward in any way, several
other issues must also be addressed. In order to maximize the benefit
of telehealth services, the originating site for a telehealth visit
must be the patient's home, especially for OT services as described
above. In addition, there is no justification for a payment
differential for telehealth services, as practice expenses are unlikely
to go down since practitioners need to maintain an office to perform
both telehealth and in-person visits. Additionally, practice expense
may increase as practitioners invest in HIPAA-compliant software and
other technology to assist in telehealth visits. AOTA appreciates the
relaxation of HIPAA requirements during the PHE for telehealth
software; however, these restrictions should be reinstated after the
PHE ends to protect the security of Personal Health Information.
Finally, Congress must allow some limited services to be provided via
audio only, especially in the area of mental health and substance
abuse, with self-care as an example of a code used by OT professionals.
Summary--Congressional Action Essential
to Avoid Therapy Telehealth Cliff
In summary, OT interventions delivered via telehealth have enabled
patients to develop, regain, and build functional independence in
everyday life. Telehealth has also demonstrated advantages over in-
person visits in some situations, especially for people in rural and
underserved areas, and for the large number of seniors in all
communities who face transportation and mobility issues, especially
those with disabilities. Telehealth is also an ideal platform for
conducting home safety evaluations as it provides a window into the
person's home and often great access to their caregiver.
As noted, Congressional action is essential to enable Medicare
beneficiaries to continue to receive OT services via telehealth when
appropriate. Passage of the Expanded Telehealth Access Act (H.R. 2168)
would enable OT professionals as well as PTs, SLPs, and audiologists to
provide services via telehealth under Section 1834(m) of the Social
Security Act. Unless Congress acts, Medicare beneficiaries will face a
telehealth ``cliff'' when the PHE ends, whereby beneficiaries who are
now accustomed to receiving some OT services via telehealth suddenly
lose access to such services. We urge Congress to prevent this outcome.
______
American Pharmacists Association
2215 Constitution Avenue, NW
Washington, DC 20037
Chairman Wyden, Ranking Member Crapo, and Members of the Committee, the
American Pharmacists Association (APhA) is pleased to submit the
following Statement for the Record for the U.S. Senate Finance
Committee Hearing, ``COVID-19 Health Care Flexibilities: Perspectives,
Experiences, and Lessons Learned.''
APhA is the largest association of pharmacists in the United States
advancing the entire pharmacy profession. APhA represents pharmacists
in all practice settings, including community pharmacies, hospitals,
long-term care facilities, specialty pharmacies, community health
centers, physician offices, ambulatory clinics, managed care
organizations, hospice settings, and government facilities. Our members
strive to improve medication use, advance patient care, and enhance
public health.
APhA thanks the Committee for holding this important hearing examining
COVID-19 health-care flexibilities. During the COVID-19 public health
emergency (PHE), pharmacists have demonstrated the ability to
significantly expand access to care and equity in care,\1\ and they
will continue to do so if certain regulatory barriers are permanently
removed. The pandemic has demonstrated how essential and accessible
pharmacists are in the United States. Pharmacists and pharmacies'
lights stayed on from the start of the pandemic and are essential
components of public health infrastructure.
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\1\ National Pharmacy Organizations Unite to Take a Stand Against
Racial Injustice. June 5, 2020, available at: https://www.accp.com/
docs/news/Pharmacy_Statement_On_Racial_Injus
tice.pdf.
As you know, the fight against COVID-19 has demanded the federal
government take action to allow pharmacists and other health-care
professionals to do more of what they are trained to do. By being more
flexible about certain requirements and expanding scope of practice
through new authorities, the federal government made it easier for
pharmacists to provide care to patients during the COVID-19 PHE. The
problem is many of these flexibilities and authorities are not
considered permanent and further action is needed to expand access to
pharmacist-provided services. If action is not taken, patients will not
be able to receive needed care at pharmacies across the country once
---------------------------------------------------------------------------
the PHE ends.
Accordingly, APhA urges Congress to expeditiously use its authority to
pass legislation to make permanent:
Pharmacists' ability to order, authorize, test, treat, and
administer immunizations and therapeutics against infectious diseases;
Removal of operational barriers that address workforce and
workflow issues which previously prevented pharmacists from engaging in
patient care;
Including pharmacists under existing and future telehealth
flexibilities; and
Maintaining compounding flexibilities to address current and
future drug shortages.
Securing Ability of Pharmacists to Order, Authorize, Test, Treat,
Immunize, and Provide Other Services
Many of these new authorities and flexibilities, including pharmacists'
ability to order and administer COVID-19 and childhood vaccines and
COVID-19, influenza, and RSV tests, as well as pharmacy interns and
technicians to administer COVID-19 tests and vaccinations to persons
aged 3 years or older as well as childhood vaccines to individuals ages
3 to 18 years old should continue as they have significantly increased
patient access and care.
Removal of Operational Barriers for Pharmacists
The COVID-19 pandemic has stressed and strained our health-care system
and revealed generations of health inequities in communities of color,
medically underserved, and rural areas. In order to protect public
health, detect and respond to future epidemics, and improve the
equitable delivery of health care, every pharmacist needs to be able to
support health-care teams.
In January 2021, the Department of Health and Human Services (HHS),
under the Public Readiness and Emergency Preparedness Act (PREP Act),
authorized any health-care provider, including pharmacists, who are
licensed or certified in a state to prescribe, dispense, and/or
administer COVID-19 vaccines across state lines, during the public
health emergency.\2\ Congress needs to make this authority permanent to
maintain the ability of pharmacists to fill gaps in primary care and
surge to meet public health crises.
---------------------------------------------------------------------------
\2\ https://www.phe.gov/Preparedness/legal/prepact/Pages/COVID-
Amendment5.aspx.
Additionally, the Centers for Medicare and Medicaid Services (CMS) has
encouraged insurance plans to practice flexibility regarding prior
authorization protocols, refills, deliveries, and pharmacy audits.
These practices have reduced the administrative burden on clinicians
and allowed for more efficient patient care, testing and vaccine
delivery. Given the benefits to patients and the system, we recommend
that Congress pass legislation to require all Medicare Advantage (MA)
and Part D plans to continue offering these flexibilities to prevent
decreased medication adherence in vulnerable populations, especially
older adults and people of color. CMS has also issued policies relaxing
Medicare Part D audit requirements for signature logs. Accordingly, we
recommend Congress make the following policies permanent for MA, Part D
---------------------------------------------------------------------------
plans and contracted pharmacy benefit managers (PBMs):
Relaxing to the greatest extent possible prior authorization
requirements, where appropriate;
Suspending plan-coordinated pharmacy audits during any PHE; and
Waiving medication delivery documentation and signature log
requirements to limit unnecessary contact with sick and potentially
infectious patients.
Including Pharmacists under Existing and Future Telehealth
Flexibilities
The rapid shift to telehealth services during the COVID-19 PHE has
illustrated the value of telehealth long-term, particularly for
patients with mobility issues and those in rural and/or medically
underserved areas. Prior to the PHE, pharmacists were already actively
involved in virtual care delivery for Medicare beneficiaries through
provision of Part B services such as Chronic Care Management (CCM),
Transitional Care Management (TCM), Continuous Glucose Monitoring
(CGM), Remote Patient Monitoring (RPM), and Behavioral Health
Integration (BHI), as well as Medication Therapy Management Services in
the Part D program. The onset of the COVID-19 pandemic has brought
about additional opportunities to leverage pharmacists in telehealth
services, including medication management services, chronic disease
management, education on healthy lifestyle interventions, patient
counseling on point of care diagnostic tests, and more.
APhA recommends Congress take the following steps to enhance patient
access to telehealth services:
Make permanent the authority allowing direct supervision to be
provided using real-time interactive audio and video technology under
incident to physician services arrangements;
Make permanent the authority allowing Medicare-enrolled
pharmacies offering accredited diabetes self-management training (DSMT)
programs to offer DSMT services via telehealth;
Designate pharmacists as practitioners (providers) for the
Medicare Telehealth Benefit, and add patient care services provided by
pharmacists using telehealth to the Medicare Telehealth List;
Ensure Medicare payment for pharmacist-provided telehealth and
in-person services is commensurate with the time and complexity of the
services provided;
Allow for telephonic or video prescription counseling of
patients to facilitate contactless care; and
Make permanent Medicare coverage and payment of audio-only
telephone calls for opioid treatment program therapy, counseling, and
periodic assessments.
Maintaining Compounding Flexibilities to Address Current and Future
Drug Shortages
Drug shortages are another factor that can negatively affect patients
in terms of medication cost and the availability of their treatments.
APhA urges the Committee to consider mechanisms to both better control
the price of medications in shortage and improve tracking and
prediction systems used to identify drugs in shortage. For example, FDA
issued temporary guidance granting flexibility for pharmacists to
compound certain necessary medications under 503A and 503B for
hospitalized patients without patient-specific prescriptions to address
COVID-19. Many of our members have told us FDA's compounding
flexibility is the only reason hospitals were able to keep up with
patient demand. Accordingly, the recent flexibility to compound
medications under both sections 503A and 503B are likely to be
necessary for the foreseeable future, and we strongly urge the
Committee to pass legislation to codify this flexibility to address
drug shortages. We believe maintaining stability within the supply
chain during the global COVID-19 pandemic is crucial. We strongly urge
the Committee to focus on solutions that harness existing relationships
with international trading partners to promote supply chain resiliency
and diversity while avoiding measures that could undermine our ability
to work with the international community.
S. 1362/H.R. 2759, the Pharmacy and Medically Underserved Areas
Enhancement Act
The COVID-19 pandemic has further illustrated how difficult it is for
some patients living in medically underserved communities to access
care and achieve optimal medication therapy outcomes. A strong body of
evidence has shown that including pharmacists on interprofessional
patient care teams with physicians, nurses, and other health-care
providers produces better health outcomes and cost savings. Pharmacists
are one of the most accessible health-care providers in the nation,
with nearly 90% of Americans living within five miles of one of the
nation's 88,000 pharmacies.\3\
---------------------------------------------------------------------------
\3\ NCPDP Pharmacy File, ArcGIS Census Tract File. NACDS Economics
Department.
Despite the fact that many states and Medicaid programs are turning to
pharmacists to increase access to health care, Medicare Part B does not
cover many of the impactful and valuable patient care services
pharmacists can provide. As proven during the COVID-19 pandemic,
pharmacists are an underutilized and accessible health-care resource
who can positively affect beneficiaries' care and the entire Medicare
---------------------------------------------------------------------------
program.
Accordingly, APhA strongly urges the Committee to include S. 1362, the
Pharmacy and Medically Underserved Areas Enhancement Act, recently
introduced by Committee members Charles Grassley (R-IA), Robert Casey
(D-PA), and Sherrod Brown (D-OH), in the Committee's legislative
package to allow pharmacists to deliver vital patient care services in
medically underserved areas to help break down the barriers to
achieving health-care equity in this country, improve patient care,
health outcomes, the impact of medications,\4\ and consequently, lower
health-care costs and extend the viability of the Medicare program.
---------------------------------------------------------------------------
\4\ See, Avalere Health. Exploring Pharmacists' Role in a Changing
Healthcare Environment. May 2014, available at: http://avalere.com/
expertise/life-sciences/insights/exploring-pharmacists-role-in-a-
changing-healthcare-environment. Also, see, Avalere Health. Developing
Trends in Delivery and Reimbursement of Pharmacist Services. October
2015, available at: http://avalere.com/expertise/managed-care/insights/
new-analysis-identifies-factors-that-can-facilitate-broader-
reimbursement-o.
By recognizing pharmacists as providers under Medicare Part B, S. 1362
would enable Medicare patients in medically underserved communities to
better access health care through state-licensed pharmacists practicing
according to their own state's scope of practice. In medically
underserved communities, pharmacists are often the closest health-care
professional and the most accessible outside normal business hours. S.
1362 recognizes that pharmacists can play an integral role in
addressing these longstanding disparities to help meet health equity
goals \5\ and ensure that our most vulnerable patients have access to
the care they need where they live. Helping patients receive the care
they need, when they need it, is a common sense and bipartisan solution
that will improve outcomes and reduce overall costs.
---------------------------------------------------------------------------
\5\ The White House. Executive Order on Advancing Racial Equity and
Support for Underserved Communities Through the Federal Government.
January 20, 2021, available at: https://www.whitehouse.gov/briefing-
room/presidential-actions/2021/01/20/executive-order-advancing-racial-
equity-and-support-for-underserved-communities-through-the-federal-
government/.
---------------------------------------------------------------------------
Conclusion
APhA would like to thank the Committee for holding this important
hearing and for continuing to work with us by making key COVID-19
health-care flexibilities permanent and including S. 1362 in your
legislative package to increase access to pharmacist-provided patient
care services for medically underserved communities to promote health-
care equity. Please contact Alicia Kerry J. Mica, Senior Lobbyist, at
[email protected] or by phone at (202) 429-7507 as a resource as you
consider this legislation. Thank you again for the opportunity to
provide comments on this important issue.
______
American Physical Therapy Association
3030 Potomac Ave., Suite 100
Alexandria, VA 22305-3085
703-684-2782
https://www.apta.org/
May 18, 2021
Senator Ron Wyden Senator Mike Crapo
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Dear Chairman Wyden and Ranking Member Crapo,
On behalf of our more than 100,000 member physical therapists, physical
therapist assistants, and students of physical therapy, the American
Physical Therapy Association appreciates the opportunity to provide a
statement for the record on the committee's hearing ``COVID-19 Health
Care Flexibilities: Perspectives, Experiences, and Lessons Learned.''
APTA is dedicated to building a community that advances the physical
therapy profession to improve the health of society. As experts in
rehabilitation, prehabilitation, and habilitation, physical therapists
play a unique role in society in prevention, wellness, fitness, health
promotion, and management of disease and disability for individuals
across the age span--helping individuals improve overall health and
prevent the need for avoidable health-care services. Physical
therapists' roles include education, direct intervention, research,
advocacy, and collaborative consultation. These roles are essential to
the profession's vision of transforming society by optimizing movement
to improve the human experience.
Value of Physical Therapy Through Telehealth
The ongoing coronavirus pandemic has highlighted the need for patients,
health systems, payers, and providers to rapidly adopt or expand models
and modes of care delivery that minimize disruptions in care and the
risks associated with those disruptions. The expansion of telehealth
payment and practice policies under the section 1135 waivers during
this Public Health Emergency, including permitting physical therapy
services to be furnished via telehealth by physical therapists and
physical therapy assistants across settings has demonstrated that many
needs can be safely and effectively met via the use of technology and
that patients can have improved access to skilled care by leveraging
these resources.
Physical therapy is well-suited for telehealth--primarily as an
enhancement of in-person services, although a telehealth visit also may
replace an in-person visit when needed or indicated. Physical
therapists and physical therapist assistants can use telehealth as a
supplement to in-person services to evaluate and treat a variety of
conditions prevalent in the Medicare population, including but not
limited to Alzheimer's disease, arthritis, cognitive/neurological/
vestibular disorders, multiple sclerosis, musculoskeletal conditions,
Parkinson disease, pelvic floor dysfunction, frailty, and sarcopenia.
Physical therapists make determinations, in consultation with patients
and caregivers, regarding the appropriate mix of in-person and
telehealth services to meet the goals in the plan of care. The
evaluation and treatment of a patient via the use of telehealth allows
the physical therapist to interact with the patient within the real-
life context of their home environment, which is not easily replicable
in the clinic. Patient and caregiver self-efficacy are inherent goals
of care, and telehealth not only allows a physical therapist to
maintain the continuity of care anticipated in the plan of care but
also allows for immediate and effective engagement when a specific
challenge arises. A patient's and/or caregiver's ability to interact in
their own environment with a physical therapist when they are facing a
challenge, rather than waiting for the next appointment, can be
invaluable in supporting the adoption of effective strategies to
improve function, enhance safety, and promote engagement.
Skilled physical therapy interventions delivered through an electronic
or digital medium have the potential to prevent falls, functional
decline, costly emergency room visits, and hospital admissions and
readmissions. Further, physical therapists already are experienced in
modifying exercises for the patient to perform them safely at home, as
a home exercise program is a common element of a treatment plan for
patients who are treated in person. Education and home exercise
programs--including those focused on falls prevention--function
particularly well with telehealth because the physical therapist can
evaluate and treat the patient within the real-life context of their
home environment. This is not easily replicated in the office setting.
Physical therapy progresses patients toward total independence of their
program in their own homes. Telehealth facilitates this objective,\1\
as the physical therapist can progress the patient in their native
environment rather than in a ``simulated'' one in the clinic. Moreover,
a patient's and/or caregiver's ability to interact in their own
environment with a physical therapist can be invaluable in supporting
the adoption of effective strategies to improve function, enhance
safety, and promote engagement. Telehealth expands the clinical impact
of physical therapy by providing patients on-demand access to their
physical therapist to promote increased adherence, access to booster
sessions to ensure sustainability of therapeutic gains and functional
performance, and access to supplemental care in-between in-person
visits to reduce the length of the episode of care and to lower costs.
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\1\ https://clinicaltrials.gov/ct2/show/NCT02914210.
Moreover, physical therapy is not synonymous with exercise. Although
much of skilled physical therapy is high-touch, a significant component
is transition of skills--promoting self-efficacy, environmental
assessment and modification, training and education, and, most
important, ongoing assessment, analysis, and clinical decision-making.
A critical component of physical therapy is the prescription of
carryover techniques, tasks, and activities--not just exercise--by a
patient in their own environment. Physical therapy services performed
---------------------------------------------------------------------------
via telehealth enhance this component of care.
Examples of physical therapy providers using telecommunications
technology to provide real-time, interactive audio and video care
include the following:
Physical therapy practitioners use telehealth technologies to
conduct evaluations or reevaluations \2\ or provide quicker screening,
assessment, and referrals that improve care coordination.
---------------------------------------------------------------------------
\2\ https://pubmed.ncbi.nlm.nih.gov/26658151/.
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Physical therapy practitioners provide interventions use
telehealth by interacting with the patient in real time to provide
instruction in exercise and activity performance, observing return
demonstration and instruction in modifications or progressions of a
program, providing caregiver support, and promoting self-efficacy.
Physical therapy practitioners provide verbal and visual
instructions and cues to modify how patients perform various
activities. They also may suggest that the patient or caregiver modify
the environment for safety reasons, or to potentially produce even more
optimal outcomes.
Physical therapy practitioners use telehealth technologies to
provide prehabilitation and conduct home safety evaluations.
Physical therapy practitioners use telehealth technologies to
observe how patients interact with their environment and/or other
caregivers, and to provide caregiver education.
Physical therapy practitioners can assess the carryover of the
activity modification strategies and activities to determine
effectiveness immediately rather than waiting for the next in-person
visit.
Physical therapists use telehealth to reduce the number of ``in-
clinic'' visits and still maintain important follow-up care. This might
reduce travel time and/or burden for a patient--which, for some
conditions, might result in faster healing. This also prevents any
delays in modifying a program when it needs to be upgraded or
downgraded.
Physical therapists can use technology to satisfy supervision
requirements.
A physical therapist can co-treat with another clinician who is
treating via real-time audio and visual technology.
A treating physical therapist can consult directly with another
physical therapist or physical therapist assistant for collaboration
and/or to obtain specialty recommendations to incorporate into an
existing plan of care.
Physical therapists use telehealth for quick check-ins with
established patients.
Telehealth services furnished by physical therapists and physical
therapist assistants offer cost savings, allow for coordination of
care, and may improve adherence and patient satisfaction. Many studies
\3\ have illustrated the clinical benefit of telerehabilitation for a
variety of conditions, including pelvic floor dysfunction \4\ and
multiple sclerosis.\5\
---------------------------------------------------------------------------
\3\ https://pubmed.ncbi.nlm.nih.gov/26940798/.
\4\ https://www.researchgate.net/publication/
330736628_Telerehabilitation_for_Treating_
Pelvic_Floor_Dysfunction_A_Case_Series_of_3_Patients%27_Experiences.
\5\ https://pubmed.ncbi.nlm.nih.gov/31042118/.
A 2019 study \6\ examined the efficacy of home-based telerehabilitation
versus in-
clinic therapy for adults after stroke, finding that poststroke
activity-based training resulted in substantial gains in patients' arm
motor function whether provided via telerehabilitation or in person.
Other studies \7\ show that home-based telerehabilitation significantly
improved veterans' functional independence, cognition, and patient
satisfaction. See Appendix A for additional studies. Physical
therapists also have been collecting a variety of data related to
health outcomes and ease of use of technology. To promote data
collection, APTA developed a patient satisfaction survey \8\ for
providers to share with their patients, which is available in both
English and Spanish.
---------------------------------------------------------------------------
\6\ https://pubmed.ncbi.nlm.nih.gov/31233135/.
\7\ https://pubmed.ncbi.nlm.nih.gov/26658151/.
\8\ https://www.aptahpa.org/page/COVID19.
When considering the value of telehealth furnished by physical
therapists and physical therapist assistants, Congress should consider
the effects of telehealth on downstream spending. Hospital admissions
and readmissions, emergency department visits, and urgent care visits,
among other expenses, potentially will decrease if patients have access
to both in-person and telehealth services.
Patient Access
Telehealth helps to overcome access barriers caused by distance, lack
of availability of specialists and/or subspecialists, impaired
mobility, and the burden associated with commuting/arranging
transportation to a physical therapy appointment. Using virtual
engagement tools can prevent unnecessary exposure during a pandemic,
epidemic, or even the annual flu season--a feature especially important
for frail and immunocompromised persons. Furthermore, access to
telehealth services is critical for beneficiaries who live in areas
with inclement weather, which is a deterrent to traveling outside of
the home.
For patients who have difficulty leaving their homes without
assistance, lack transportation, or need to travel long distances, the
ability to supplement or replace in-person sessions with those
furnished via telehealth greatly increases access to care and ensures
uninterrupted courses of therapy. Telehealth is a tool to overcome
access barriers caused by distance, unavailability of specialists and/
or subspecialists, inclement weather, and impaired mobility. For
example, a Colorado physical therapist practice that offers treatments
for neurological conditions provides a significant portion of the care
via telehealth, for several reasons: (1) the area's sometimes severe
inclement weather; (2) the patient's vestibular condition that renders
them unable to drive, forcing them to rely on friends or family to
drive them; and (3) a lack of physical therapy providers within a
reasonable driving distance--particularly providers that address
dizziness and balance issues.
Access to health-care services is critical to good health and
functional performance, yet Medicare beneficiaries, particularly those
who reside in rural areas, face a variety of access barriers.
Individuals across the lifespan want the ability to appropriately
access telehealth, and telehealth is key to helping individuals age in
place. If we as a nation truly wish to help individuals age in their
homes, telehealth is a key to making this a reality. As demand for care
to help individuals with chronic conditions continues to grow, Congress
should recommend telehealth payment and coverage policies that will
improve beneficiary access and increase collaboration and efficiency of
care across the care continuum.
Further, access to physical therapy in rural, medically underserved,
and health professional shortage areas often depends on the
availability of physical therapist assistants to provide care under the
supervision of physical therapists. Unfortunately, the 15% Medicare
Physician Fee Schedule payment reduction for services furnished in
whole or in part by physical therapist assistants beginning in 2022
will have a detrimental impact on the ability of physical therapy
providers, particularly in rural areas, to continue to deliver care.
The payment reduction will unfairly penalize providers in rural,
medically underserved, and health professional shortage areas. Access
to medical care already is dwindling in rural localities. Physical
therapists and physical therapist assistants play a crucial role in
bridging these gaps in access to care.
Quality
APTA developed a patient satisfaction survey \9\ about the use of
telehealth for providers to share with their patients in English and
Spanish based on AHRQ's guidance. Copied below are the results from a
physical therapist vestibular practice in Colorado that asked some of
the questions from this survey:
---------------------------------------------------------------------------
\9\ https://www.aptahpa.org/page/COVID19.
The experience was an effective way to get my physical therapy:
70% of respondents strongly agreed; 30% agreed.
Feelings of comfortability being evaluated and treated via
telehealth: 67% of respondents strongly agreed; 20% agreed; 10% were
neutral.
Feelings of physical safety receiving physical therapy treatment
via telehealth: 83% of respondents strongly agreed; 17% of respondents
agreed.
Overall satisfied with the experience: 93% strongly agreed; 7%
agreed.
In response to the question: If a telehealth visit was not
available to you from this PT clinic, how would you plan to receive PT
in future? 10% of respondents said they would seek telehealth from
another clinic, 10% said they would not seek care, 60% said they would
seek in-person care with the clinic, and 17% provided other answers,
including:
``I don't know what I would do.''
``I might not seek care. This is the safest way
for me to receive care.''
In addition, the following are stories shared by Medicare beneficiaries
during the COVID-19 pandemic:
Medicare Beneficiary #1:
The beneficiary was experiencing severe back pain, had
significant physical limitations, and used pain medications daily. She
was ``high risk'' for COVID-19, so she engaged in physical therapy via
telehealth. After an initial evaluation in the clinic and several
telehealth sessions at her home, she is now walking pain-free, can
engage in more physical activity, and has reduced her pain medications.
These telehealth visits have allowed her to care for her husband, who
is in hospice.
Medicare Beneficiary #2:
I am writing to express my gratitude for the telehealth services
that were provided during the COVID-19 pandemic. I was happy to start
in the clinic and then transition to a home-based program so that I
could carry the work into my daily routine, while staying safe at home.
After every meeting, I felt better and felt that I had gotten a good
workout. I would recommend telehealth services to a friend or family
member. Even out of quarantine, I feel as though the telehealth
services may be beneficial to those who cannot go to an appointment in
person. I advocate that Medicare continues to allow telehealth services
to be furnished by physical therapists in the future.
Medicare Beneficiary #3:
I was being treated for thoracic outlet syndrome and referred to
physical therapy. I found my experience most successful. Due to COVID-
19, I was able to do telehealth therapy from home. Once the clinic was
able to reopen, I was able to resume office visits and have continued
to make good progress. I have had a very positive experience.
Medicare Beneficiary #4:
I am writing to express my appreciation for the telehealth
services that were provided during this COVID-19 pandemic. About 7 or 8
weeks ago I had to have physical therapy for a pinched nerve. I
contacted you since my husband was already participating in your
telehealth program. I have been working with the DPT and have had
wonderful results. I have used my 1- and 2-pound weights as well as my
wall to do push-ups. I also use my banister to do rowing exercises. I
would recommend telehealth services to a friend or family member or
anyone who should ask and I'm hoping that these telehealth services
continue in the future. This is a great way to remain safe at home,
which is critical during this pandemic
Recommendations
Current statutes limit Medicare beneficiaries from receiving telehealth
services, including a geography limitation, site limitation, and
provider limitation. Congress must pass legislation that permanently
affords providers and patients the ability to furnish and receive
telehealth, just as they have done during the COVID-19 PHE.
Congress should:
(1) Enact the Expanded Telehealth Access Act of 2021 (H.R. 2168).
This legislation would permanently allow rehabilitation providers to
use telehealth under Medicare after the PHE is declared over.
Specifically, the bill adds physical therapists, physical therapist
assistants, occupational therapists, occupational therapy assistants,
audiologists, and speech language pathologists and facilities that
furnish outpatient therapy, as authorized providers of telehealth under
Medicare.
(2) Enact changes to Section 1834(m)(4)(C)(i) of the Social
Security Act so that telehealth services, including therapy services,
will no longer be restricted by geographic location of the beneficiary
or the originating site. All Medicare beneficiaries should be eligible
to receive telehealth services from their home, whether that home is in
the community or part of an institutional setting.
Federal policies also should advance a definition of parity that
includes equal coverage, reimbursement, and cost-sharing (copayments,
coinsurance, and deductibles) for audio-only telehealth, audio and
visual telehealth, and in-person visits, particularly given the fact
that telehealth is merely a modality to enable physical therapists and
physical therapist assistants, for example, to provide care within
their scope of practice. In addition, such policies should promote
outreach to patients with limited technology and connectivity and offer
flexibility in platforms that can be used for audio and visual (live
video) interactions, audio-only options, online patient portals, etc.
Conclusion
We appreciate the opportunity to provide the committee with our
perspective on the role of telehealth in physical therapy and the need
to continue to provide Medicare beneficiaries this option beyond the
PHE. Should you have any questions, please do not hesitate to contact
David Scala, APTA congressional affairs senior specialist, at
[email protected]. Thank you for your consideration.
Sincerely,
Sharon L. Dunn, PT, Ph.D.
Board-Certified Clinical Specialist in Orthopaedic Physical Therapy
President
______
American Telemedicine Association
901 North Glebe Road, Suite 850
Arlington, VA 22203
T: 703-373-9600
May 19, 2021
The Honorable Ron Wyden The Honorable Mike Crapo
Chair Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC 20515 Washington, DC 20515
RE: ATA Testimony for Senate Finance Committee Hearing on ``COVID-19
Health Care Flexibilities: Perspective, Experience, and Lessons
Learned''
On behalf of the American Telemedicine Association (ATA), thank you for
thoughtfully considering the future of telehealth during the upcoming
Finance Committee hearing entitled, ``COVID-19 Health Care
Flexibilities: Perspective, Experiences, and Lessons Learned'' on
Wednesday, May 19. Federal flexibilities over the past year have
allowed patients to continue to access much-needed care even as the
health-care system was shuddered by the pandemic. This hearing is an
essential step toward determining and enacting commonsense policies
that will ensure Medicare seniors are not pushed off the telehealth
cliff at the end of the current COVID-19 Public Health Emergency (PHE).
Please accept this letter as testimony by the ATA and continue to
consider the ATA as a resource as we work together on this important
bipartisan issue.
As the only organization exclusively devoted to expanding access to
care through telehealth, the ATA appreciates the opportunity to share
our federal policy priorities for 2021. During the COVID-19 PHE,
telehealth has finally become a reality for millions of Americans out
of necessity. This has been possible because of swift, decisive actions
by Congress and the Department of Health and Human Services (HHS).
However, unless Congress acts again before the end of the PHE,
telehealth access will vanish for millions of Medicare beneficiaries
overnight. As you consider how to address this looming telehealth
cliff, we request that you review ATA's Permanent Policy
Recommendations \1\ as well as ATA's Federal Legislative Priorities.\2\
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\1\ https://www.americantelemed.org/policies/ata-recommendations-
for-permanent-telehealth-policy/.
\2\ https://www.americantelemed.org/policies/atas-federal-
telehealth-legislative-tracker/.
We encourage you to ensure policies reflect beneficiaries' and
providers' growing interest in having telehealth as a choice when
accessing care. Data continues to show that Medicare beneficiaries like
telehealth and want to keep it. The nonpartisan Medicare Payment
Advisory Commission's \3\ annual beneficiary survey this year found
that 90% of Medicare respondents were satisfied with telehealth. The
ATA has worked with partners to identify similar trends,\4\ including
nearly two thirds of patients expecting telehealth to continue post-
pandemic. To ensure these patients have the choice to access telehealth
in the future, the ATA has prioritized the following policies for
consideration in the 117th Congress and would greatly appreciate the
Committee's taking these priorities into consideration when drafting
potential telehealth legislation.
---------------------------------------------------------------------------
\3\ http://medpac.gov/docs/default-source/reports/
mar21_medpac_report_to_the_congress_sec.
pdf.
\4\ https://www.americantelemed.org/in-the-news/covid-19-
healthcare-coalition-surveys-patients-on-telehealth-impact-during-
covid-19/.
Remove provisions in law that mandate, for telehealth delivery
of care or reimbursement, a prior in-person relationship between
practitioner and patient.
Allow state licensing boards and practitioners to determine the
appropriate standards of care for patients. This includes removing the
in-person requirement for telemental health services in the recently
signed Consolidated Appropriations Act.
Permanently remove the geographic and originating site barriers
in statute.
The originating site should be wherever the patient is located,
including but not limited to a patient's home.
Enhance HHS authority to determine appropriate telehealth
services and providers.
Ensure Federally Qualified Health Centers (FQHCs) and Rural
Health Clinics (RHCs) can furnish telehealth and receive equitable
reimbursement.
Make permanent HHS's temporary waiver authority for future
emergencies.
Support existing fraud, waste, and abuse resources within HHS,
including the Health Care Fraud and Abuse Control Program.
The ATA is proud that telehealth is a strong bipartisan issue in
Congress. The above listed priorities have been reflected in several
bipartisan bills already under consideration this Congress, including
the Telehealth Modernization Act (S. 368, H.R. 1332), the Protecting
Access to Post-COVID-19 Telehealth Act (H.R. 366), and the soon-to-be-
reintroduced CONNECT for Health Act. The ATA would greatly appreciate
your support of each of these important pieces of legislation.
At minimum, the ATA urges Congress to remove existing statutory
barriers that limit access to care and not simply replace existing
statutory access restrictions with new ones. For far too long, 1834(m)
of the Social Security Act has categorically excluded too many patients
from even having the option to access care via telehealth because of
the law's antiquated and arbitrary barriers whose only purpose is to
limit access to health care. Providers and patients are best suited to
determine clinical appropriateness of medical services, not federal
law. The 1834(m) restrictions are nearing 20 years old, and by allowing
them to persist, Congress will only punish Medicare beneficiaries by
banning their access to technology already available to non-Medicare
patients. As such, the ATA urges the Committee to take great care in
considering the consequences of having restrictions specifically
codified in statute as opposed to allowing these issues to be decided
at the regulatory level. By explicitly and arbitrarily limiting care in
statute through so-called ``guardrails,'' legislators will
unnecessarily stifle innovation and tie the hands of regulators,
providers, and patients. Should the Committee have concerns with cost,
utilization, or telefraud, the ATA stands ready to work with you on our
shared goal of ensuring program integrity. As such, please consider
ATA's recently released Program Integrity Overview \5\ as a resource.
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\5\ https://www.americantelemed.org/wp-content/uploads/2021/03/ATA-
Program-Integrity-One-Pager-3-1-21.pdf.
While the ATA appreciates Congress's recent actions to expand access to
care, specific restrictions on patients, providers, services, or the
modality of care in statute only add to complexities in the health-care
system. One of the ATA's main federal policy priorities is removing the
in-person requirement for telemental health services which was included
in the Consolidated Appropriations Act, 2021, Pub. L. 116-260 (e.g.,
Section 123 establishes coverage and reimbursement of a telemental
health service only if the practitioner has conducted an in-person
examination of the patient in the prior six months and subsequently
continues to conduct in-person exams at such a frequency to be
determined by HHS). The ATA strongly opposes statutory in-person
requirements as they create arbitrary and clinically unsupported
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barriers to accessing affordable, quality health care.
Today, not a single state in the U.S. requires a prior in-person
relationship. At the national level, the association of state
regulators who oversee standards of medical care, the Federation of
State Medical Boards, stated that ``. . . the relationship is clearly
established when the physician agrees to undertake diagnosis and
treatment of the patient, and the patient agrees to be treated, whether
or not there has been an encounter in person between the physician (or
other appropriately supervised health-care practitioner) and patient.''
We cannot ignore the importance of providing all Americans, regardless
of whether they have a medical provider with whom they have an
established relationship, the opportunity to access health care.
Requiring a physician and patient to meet in person before receiving
certain telehealth services would be a huge step backward, and we hope
to work with you to find an alternative to in-person requirements.
Thank you again for holding this important hearing and for your
thoughtful deliberation on how your committee can enable access to
quality health-care services for Medicare beneficiaries. The ATA's
policy development and ultimate recommendations are guided by a
specific set of policy principles \6\ which all support the goal of
promoting a health-care system where people have access to safe,
effective, and appropriate care when and where they need it. Please
know the ATA is honored to continue to be a resource for you, the
Committee, and your dedicated staff. If you have any questions or would
like to further discuss the ATA's perspective, please contact
[email protected].
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\6\ https://www.americantelemed.org/policy/.
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Kind regards,
Kyle Zebley
Public Policy Director
______
Association for Clinical Oncology
2318 Mill Road, Suite 800
Alexandria, VA 22314
T: 571-483-1300
F: 571-366-9530
https://beta.asco.org/
May 19, 2021
The Honorable Ron Wyden The Honorable Mike Crapo
Chair Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
219 Dirksen Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Dear Chairman Wyden and Ranking Member Crapo,
The Association for Clinical Oncology (ASCO) commends the Committee for
holding the May 19, 2021, hearing, ``COVID-19 Health Care
Flexibilities: Perspectives, Experiences, and Lessons Learned.'' We are
pleased to provide the attached comments on regulatory flexibilities
during the pandemic that have made a difference in cancer care.
ASCO is the world's leading professional society representing
physicians who care for people with cancer. With nearly 45,000 members,
our core mission is to ensure that patients with cancer have meaningful
access to high quality, equitable cancer care.
In addition to the attached comments on regulatory policies, ASCO urges
Congress to address the 4% PAYGO cuts before they are scheduled to take
effect in Medicare and extend the Medicare sequestration moratorium. We
appreciate Congress' extension of the Medicare sequestration moratorium
through the end of 2021 but are seriously concerned about the impact a
6% Medicare cut will have on cancer care if PAYGO and sequestration are
not addressed before the end of this year.
Thank you for examining these important issues. If you have questions
on our comments or any other issues related to the treatment of
patients with cancer, please do not hesitate to contact Jennifer
Brunelle at [email protected].
Sincerely,
Monica Bertagnolli, M.D., FACS, FASCO
Chair of the Board
______
December 23, 2020
Alex Azar
Secretary
Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
Dear Secretary Azar,
The nature of the COVID-19 pandemic and resulting public health
emergency required unprecedented response and flexibility across the
health-care sector to avoid disruption in care delivery, continuity of
research activities and to ensure the protection and safety of patients
and health-care workers. Additionally, in the face of economic
pressures created by the pandemic, practices, health-care facilities
and institutions--functioning as employers and businesses--required
similar response and flexibility from state and federal policymakers.
The Association for Clinical Oncology (ASCO) appreciates the
opportunity to provide feedback on The Agency's Request for Information
on Regulatory Relief Efforts to support Economic Recovery.
ASCO is a national organization representing more than 45,000 oncology
professionals who care for people living with cancer. Through research,
education, and promotion of the highest-quality patient care, our
members are committed to ensuring that evidence-based practice for the
prevention, diagnosis, and treatment of cancer are available to all
Americans. ASCO supports major quality initiatives that enhance
performance measurement and improvement, clinical practice guidelines,
big data analytics, and the value of cancer care.
Cancer patients and survivors are one of the most vulnerable patient
populations, and face increased risk related to COVID-19. Prior to the
public health emergency, certain longstanding policies, care delivery
practices and research procedures posed barriers to the efficient
delivery of care and effective clinical research. During the pandemic,
temporary regulatory relief offered by the Agency on some of those same
policies, coupled with the nimbleness of the health-care sector, proved
beneficial to patients and enabled the nation's health-care system to
continue to operate safely during the time of crisis. ASCO commends the
Administration and the Department of Health and Human Services (HHS)
for recognizing the need to modify existing policies that would have
significantly affected care for cancer patients. Like many
organizations, ASCO has taken the opportunity to evaluate whether the
changes in care delivery and research prompted by the pandemic could
inform new approaches to delivery of high quality, high value care and
research moving forward.
ASCO recently published the Road to Recovery Report: Learning from the
COVID-19 Experience to Improve Clinical Research and Cancer Care, which
outlines recommendations based on lessons learned during the pandemic.
Proposed actions and policies aim to make cancer care delivery and
research opportunities more accessible and equitable for patients in
every community. With these recommendations, ASCO intends to address
long-standing cancer care disparities that have been highlighted by the
pandemic. To achieve these goals, certain regulatory flexibilities
driven by the pandemic may need to be permanent--or at least extended
for a minimum of 24 months following expiration of the PHE. This would
enable cancer patients to continue access to life-saving treatments for
their disease, for providers to continue delivery of high-quality
cancer care, and all in the cancer community to benefit from
protections against personal and economic the impacts COVID-19.
Part I: Cancer care delivery--Policies and regulatory action must build
on strategies that have helped to meet patients' most urgent needs in
the worst of the pandemic. Specifically:
Increased access to and equity of care--by making expanded coverage for
telemedicine permanent; preventing Medicaid cuts; ensuring accessible,
affordable and comprehensive insurance plans, and preventing other
threats to patients' health coverage; enhancing grants and other
support for oncology practices in underserved communities; and
sustaining federal safety net programs.
Protecting patient safety--for example, by creating new chemotherapy
infection control standards that account for viral threats like the
novel coronavirus; ensuring reliable access to personal protective
equipment (PPE) and future COVID vaccines; and limiting home infusion
of potentially risky chemotherapy to exceptional circumstances.
Supporting patient and provider well-being--by expanding access to
behavioral health care and psychosocial support for patients; and
enhancing training and support for care teams, which have been
disrupted by staffing changes and burnout in the face of the pandemic.
Additional recommendations related to Cancer Care Delivery can be found
in the Road to Recovery Report.\1\
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\1\ https://ascopubs.org/doi/full/10.1200/JCO.20.02953.
Below, ASCO outlines recommendations for regulatory policies
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implemented temporarily during the PHE to be permanently implemented.
A. Telemedicine--Generally, ASCO supports the flexibility CMS has
implemented to ensure telemedicine is available to more practitioners
and patients during the COVID-19 PHE, and we urge CMS to extend those
expanded telemedicine policies after the expiration of the PHE. In
addition to Medicare beneficiaries, we support the permanent
implementation of these policies for Medicare Advantage as well as
Medicaid enrollees.
4--Notification of Enforcement Discretion for Telehealth Remote
Communications
ASCO supports the use of HIPAA compliant audio/visual technology after
the expiration of the PHE.
Privacy and data security issues and concerns related to health care
information technology (HIT) have been key barriers to adoption of
telemedicine and impact the confidence of patients and practitioners
using these tools. As the use of telemedicine continues to increase, it
will necessarily generate large quantities of personal health
information and data, highlighting the need for data protection. Clear
direction on the application of HIPAA requirements and necessary
liability protections for providers is needed.\2\
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\2\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/advocacy-and-policy/documents/2020-ASCO-Interim-Position-
Statement-Telemedicine-FINAL.pdf.
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111--Communication Technology Based Services (CTBS); and
112--Direct Supervision by Interactive Telecommunications Technology
ASCO supports the permanent implementation of policies allowing the
provision and reimbursement of CTBS for new and established patients.
Additionally, ASCO supports permanent implementation of provisions
allowing direct supervision through interactive telecommunications
technology. However, ASCO does not support direct supervision through
interactive telecommunications technology in the context of home
infusion for anti-cancer therapies outside of the PHE.
Mitigating the need for an in-person visit is critical for cancer
patients, who are at an increased risk during the PHE, but may also
experience similar risks because of compromised immune systems during
cancer treatment. Allowing both new and established patients use of
CTBS to access necessary care during brief communication mitigates the
need for an in-person visit that could represent an exposure risk.
Granting physicians flexibility to provide clinically appropriate and
high-quality care to these beneficiaries via telemedicine can help keep
these vulnerable patients in their homes, reducing unnecessary exposure
to all illnesses, not just COVID-19.
Regarding direct supervision for home infusion of anti-cancer
therapies, ASCO believes that guardrails need to be in place as this
temporary policy introduces the potential for risk.\3\ There is a
paucity of evidence directly comparing the safety of chemotherapy
infusions in the home with treatments delivered in outpatient settings.
Most of the literature examines home infusion in general, which is of
limited utility given the toxicity and hazardous materials specific to
chemotherapy. However, multiple criteria in ASCO's existing safety
standards may be difficult to satisfy in the home infusion context. For
example, safety principles emphasize using more than one practitioner
to verify and document patient name, drug name, dosage, infusion
volume, route/rate of administration, etc., to minimize errors and
prevent patient harm. Within a health-care setting additional trained
staff are available for such verification. In the home infusion
setting, these verifications need to be performed virtually and with
multiple forms of identification, as sending multiple health workers to
supervise home infusions may not be practical or feasible. Most
importantly, certain adverse events that may quickly escalate and
become life-threatening emergencies may not be able to be safely
resolved in the patient's home.\4\
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\3\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/2020-COVID19-IFC1-Comment-Letter.pdf.
\4\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/advocacy-and-policy/documents/2020_Home-Infusion-Position-
Statement.pdf.
In addition to safety concerns outlined above, there are workforce and
reimbursement issues that present challenges with home infusion of
anticancer therapy. An oncology nurse in a clinical setting can safely
supervise infusion of multiple patients at once, compared to single-
patient oversight in the home setting. There may therefore be
insufficient oncology nursing expertise to widely adopt home infusion
and substituting generalist infusion nurses does not provide the same
level of patient safety.\5\
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\5\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/advocacy-and-policy/documents/2020_Home-Infusion-Position-
Statement.pdf.
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113--Telephone Evaluation and Management (E/M) Services Codes
ASCO supports the implementation of permanent policies to allow
Telephone Evaluation and Management Services. ASCO encourages
Policymakers and payers at the national and state levels to ensure
robust, adequate reimbursement and coverage of telemedicine for care
delivery via audio and/or audio and visual formats regardless of site
of service.\6\
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\6\ https://ascopubs.org/doi/pdf/10.1200/jco.2008.21.1680.
State and federal policymakers should make permanent coverage and
reimbursement for audio- visual and when appropriate, audio-only
services and continue to expand coverage for all modes of delivery of
telemedicine. The lack of broadband and/or access to technology for
both patients and physicians will not be limited to the time during the
PHE; therefore, we urge that all respective agencies extend these
regulatory changes beyond the PHE. Patient populations who lack
computer skills or broadband access could potentially benefit
especially from audio-only services.\7\
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\7\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/advocacy-and-policy/documents/2020-ASCO-Interim-Position-
Statement-Telemedicine-FINAL.pdf.
ASCO is committed to supporting efforts that ensure oncologists have
the resources they need to provide high-quality cancer care regardless
of where that care is delivered; therefore, we believe CMS should cover
and reimburse audio-only services. Analysis of data from ASCO practices
shows that of all services provided through technology-based
communications from mid-March through mid-June, audio-only visits make
up 35%-50% of these technology-based visits; virtual check-ins made up
less than 1%.\8\ Cancer patients are relying heavily on audio-only E/M
services and need CMS to ensure they have access to the care they need.
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\8\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/practice-and-guidelines/documents/2020-PracticeNET-COVID19-
Insights.pdf.
ASCO's Policy Statement on Cancer Disparities and Health Equity commits
ASCO to ``support and promote policies, systems, environments, and
practices to address persistent barriers to equitable receipt of high-
quality cancer care across the care continuum.''\9\ CMS should work to
promote health equity through encouraging the use of telemedicine in
all care settings, including but not limited to rural and safety net
providers. CMS should cover and reimburse audio-only services in order
to prevent the unintentional exacerbation of health inequities.
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\9\ https://ascopubs.org/doi/pdf/10.1200/jco.2008.21.1680.
While we agree with the agency that telehealth platforms incorporating
both audio/visual two-way communication--when available--is preferred,
there are instances when this is not possible. This lack of access to
technology, often impacting patients vulnerable to other disparities in
care, will not be limited to the time during the PHE; therefore, we
urge the agency to permanently cover and reimburse audio-only services
beyond the PHE.\10\
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\10\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/ASCO-MPFS-QPP-2021-Comments.pdf.
115--Use of Telecommunications Technology Under the Medicare Home
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Health Benefit
ASCO supports CMS' proposal to permit patient services and/or
monitoring performed through telecommunication technology on a
permanent basis when such services are included as part of the home
health plan of care.
ASCO supports CMS' proposal to make this temporary flexibility provided
during the COVID-19 PHE a permanent part of the Medicare home health
program. This proposal will ensure patient access to the latest
technology and give home health agencies the confidence that that they
can continue to use telecommunications technology as part of patient
care beyond the PHE. Cancer patients, because they are often immuno-
compromised, are an especially vulnerable subset of the Medicare
population. Granting HHAs the flexibility to provide clinically
appropriate and high-quality care to these beneficiaries through
technology can help keep these vulnerable patients in their homes,
reducing unnecessary exposure to all illnesses, not just COVID-19.\11\
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\11\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/2020-2021-Home-Health-Comment-Letter.pdf.
122--Physician Supervision Flexibility for Outpatient Hospitals--
Outpatient Hospital Therapeutic Services Assigned to the Non-surgical
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Extended Duration Therapeutic Services (NSEDTS) Level of Supervision
We believe this flexibility to change the generally applicable minimum
required level of supervision for hospital outpatient therapeutic
services from direct supervision to general supervision for services
furnished by all hospitals and critical access hospitals (CAHs) may
have many positive effects on physician workload. Permanent
implementation could allow physicians to devote more time to clinical
work and allow more flexibility on the part of cancer clinics to
provide more timely care.
ASCO remains committed to ensuring that cancer patients have access to
high quality and safe care. While we support CMS's proposal, we urge
CMS to carefully monitor its implementation to ensure that it does not
unintentionally place some patients at elevated risk for medical
errors.
125--Payment for Medicare Telehealth Services Under Section 1834(m) of
the Act; and 149--Updating the Medicare Telehealth List on a Sub-
regulatory Basis
ASCO supports the permanent coverage and inclusion of additional
services on the Medicare telehealth list, and we encourage CMS to
continue soliciting stakeholder comments and feedback regarding
potential future additions.
In our interim position statement,\12\ ASCO urges CMS to extend the
expanded telemedicine policies after the expiration of the PHE. We
support the permanent and temporary addition of services to the
telehealth list, as this has the potential to increase access to
services for cancer patients.
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\12\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/advocacy-and-policy/documents/2020-ASCO-Interim-Position-
Statement-Telemedicine-FINAL.pdf.
Additionally, ASCO urges CMS to evaluate the safety, quality of care,
and outcomes resulting from telehealth visits and to consider such
evidence and specialty input when considering additions in future
rulemaking.\13\ Since CMS has the authority to add services to the list
of covered Medicare telehealth services, we support updates to the
Medicare Telehealth list on a sub-regulatory basis where there is
demonstrated clinical benefit to the patient and other requirements are
met.
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\13\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/ASCO-MPFS-QPP-2021-Comments.pdf.
B. Testing/PPE--ASCO supports long-term and widespread distribution of
any COVID-19 testing, treatment, or vaccine, to ensure accessibility to
health-care providers and disadvantaged populations. ASCO urges the
Agency to consider prioritizing resources in a transparent and ethical
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way.
74--Policy for Coronavirus Disease 2019 Tests During the Public
Health Emergency (Revised)
ASCO believes there is a need for FDA premarket regulatory review
for high risk tests in addition to CMS CLIA oversight. Physicians rely
on high quality and accurate tests to appropriately diagnose and treat
patients. There is also a need for flexibility in the review and
approval of these tests particularly to inform cancer treatment
planning. This flexibility is particularly important in oncology, as
new information develops rapidly and is disseminated widely, leading to
demand by both physicians and patients for new tests that impact
medical decision-making.
C. Access--As the leading organization for physicians and oncology
professionals caring for people with cancer, ASCO is committed to
promoting access to high quality, high value cancer care.
29--Notifying FDA of a Permanent Discontinuance or Interruption in
Manufacturing Under Section 506C of the FD&C Act Guidance for Industry;
30--Exemption and Exclusion from Certain Requirements of the Drug
Supply Chain Security Act During the COVID--19 Public Health Emergency;
and
61--Notifying CDRH of a Permanent Discontinuance or Interruption in
Manufacturing of a Device Under Section 506J of the FD&C Act During the
COVID-19 Public Health Emergency
ASCO supports the continuation of policies to enhance transparency
in the drug supply chain, assess and strengthen the Food and Drug
Administration's (FDA) efforts to prevent shortages, and empower the
FDA to have drug makers identify and address vulnerabilities in the
supply chains to ensure access to critical medications.
The spread of novel viruses such as COVID-19, and natural disasters
such as hurricanes, have highlighted vulnerabilities in the drug supply
chain that can lead to significant shortages of critical medications
throughout the world. United States drug manufacturers currently rely
on China for a majority of their active pharmaceutical ingredients, and
this issue is being highlighted by the current COVID-19 epidemic. A
disruption in the supply chain, whether caused by manufacturing or
quality issues, will likely leave many patients without the critical
medications they need.
ASCO urges CMS to make permanent policies that would ensure
information about shortages is publicly available. Providing the FDA
with the necessary authority to ensure that drug makers increase
transparency in their supply chains and identify and address potential
manufacturing and quality issues, is critical to guaranteeing patient
access to needed medications.
221--Part D ``Refill-Too-Soon'' Edits and Maximum Day Supply;
226--Prior Authorization;
227--Home or Mail Delivery of Part D Drugs;
285--Prior Authorization [Medicare Advantage]; and
288--Prior Authorization for Part D Drugs.
ASCO urges HHS to implement long-term policies to eliminate
longstanding barriers to access associated with utilization management
policies within the Medicare program, including Medicare Advantage and
Medicare Part D, as well as Medicaid.
ASCO has always advocated for adherence to high quality clinical
pathways as a mechanism to drive appropriate use of medications, rather
than arbitrary utilization management policies that largely focus on
cost rather than clinical evidence. Temporary policies during the
pandemic have relaxed certain utilization management strategies during
the pandemic. ASCO appreciates the relaxation of policies like
``refill-too-soon'' edits, giving patients the ability to obtain the
maximum extended day supply available under their plan to allow an
uninterrupted supply of critical medications. This is critical support
at a time when disruptions to routine care may be expected.\14\
However, despite the attempt to relax utilization policies, ASCO
members report they still experienced significant delays in care
resulting from prior authorization requirements, particularly related
to imaging. The pandemic has highlighted the need for permanent
solutions to utilization barriers. ASCO continues to work with the AMA
and others to achieve reforms related to utilization management. We
call on the Agency to put renewed emphasis on addressing this
longstanding and increasing burden on patients and their providers.
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\14\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/2020-COVID19-IFC1-Comment-Letter.pdf.
Restrictive networks and requirements for patients to use
designated specialty pharmacies for Part D drugs can impair patient
care and access. Patients with cancer should be allowed to seek the
services of their preferred pharmacy, including dispensing physicians.
For cancer patients, this is important as some studies have suggested
that practices with medically integrated services may improve patient
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adherence to treatment regimens.
D. Quality Payment Program--ASCO encourages the Agency to continue
flexibilities in quality reporting across all programs for two years,
allowing these flexibilities to remain in effect through performance
year 2022. This offers critical time for physician practices to adjust
and begin to recover from the repercussions of the COVID-19 pandemic.
106--Merit-based Incentive Payment System (MIPS) Updates
ASCO supports the flexibilities provided to MIPS eligible
clinicians to receive hardship exemptions for performance years 2020
and 2021. We encourage the Agency to enable these flexibilities through
performance year 2022 to allow practices to recover from the impact of
the PHE.
ASCO thanks CMS for recognizing that during this public health
crisis it may be challenging or impossible for physicians, groups, and
virtual groups to meet the data submission deadline due to
circumstances beyond their control. We support flexibilities provided
to MIPS eligible clinicians and group practices to choose to submit
data or to apply for--and in some circumstances, receive
automatically--a hardship exemption. Allowing these flexibilities to
remain in effect through performance year 2022 will be important to
recovery from the repercussions of COVID-19 and to preserving access to
care in communities across the U.S.\15\
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\15\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/2020-COVID19-IFC1-Comment-Letter.pdf.
ASCO supports submission of patient data to a COVID-19 clinical
data registry for participation in Improvement Activity IA--ERP--3 and
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for extending this through the 2021 performance period.
ASCO supports CMS' designation of data entry to clinical registries
as a qualified Improvement Activity for clinicians who are caring for
COVID-positive patients. ASCO established a COVID-19 registry to help
the entire cancer community learn about the pattern of symptoms and
severity of COVID-19 among patients with cancer. The ASCO Registry is
designed to collect both baseline and follow-up data on how the disease
impacts cancer care and cancer patient outcomes during the COVID-19
pandemic--up to 12 months after a patient's COVID-19 diagnosis. Cancer
patients with a COVID diagnosis are a special subgroup of individuals
whose clinical condition need to be understood to ensure effective
treatment protocols and positive health outcomes. ASCO thanks CMS for
confirming that ASCO's Survey on COVID-19 in Oncology Registry is an
acceptable registry for the attestation of this highly weighted
practice improvement activity.
ASCO supports the extension of this IA into 2021. It is likely that
this improvement activity will remain relevant throughout the next year
and possibly beyond, given the unknowns around how long the virus will
persist in the community and possible long-term effects stemming from
infection. Given the impact the coronavirus has on caring for cancer
patients, it is imperative that oncologists submit meaningful
improvement activity data that reflect real-world events and that are
of value to patients and clinicians.\16\
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\16\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/ASCO-COVID-19-IFC3.Comment-Letter.pdf.
With the following recommendations, we aim to make cancer research
opportunities more accessible and equitable for patients in every
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community.
Part II: Clinical cancer research--Implementation of policies to ensure
the clinical trials system is more resilient and flexible, and more
accessible to patients must be a priority. Specifically:
Increase patient access and equity--by continuing remote and virtual
approaches to consent, and other trial procedures; and by better
integrating trials into routine cancer care.
Increase trial efficiency--by streamlining and standardizing regulatory
and training requirements; and using central Institutional Review
Boards and innovative trial designs, including adaptive trials, master
protocols, and common control groups.
Increase flexibility so research will be more resilient in future
crises--for example, by ``cross training'' research teams so that key
functions can be led by various team members; and by sustaining
flexibility, adopted during the pandemic, for site selection,
initiation, and data collection.
ASCO also encourages the Agency to support enhanced data collection
efforts to understand the impact of COVID-19 on patients with cancer,
including its effect on social determinants of health.
Additional recommendations related to Cancer Care Delivery can be found
in the Road to Recovery Report.
ASCO recommends the following policy be permanently implemented after
the PHE.
33--Institutional Review Board (IRB) Review of Individual Patient
Expanded Access Requests for Investigational Drugs and Biological
Products During the COVID-19 Public Health Emergency.
ASCO continues to support the use of central IRBs as one way to
promote efficiency, oversight, and review of clinical trial conduct,
reduce costs and eliminate duplicative reviews by multiple
institutions. During COVID-19, central IRBs were important in
expediting research on testing and treatment. ASCO supports expanded
access to address unmet needs for many patients and the approval to
access investigational therapies should continue to be done so with
establish standards of safety and efficacy.
Many of the flexibilities implemented during the PHE have indeed
provided relief in managing the unprecedented crisis presented by the
COVID-19 pandemic. We encourage the agency to make determinations
regarding the future implication of policies and practices based
emerging data, and lessons learned, and the experiences of patients,
physicians, care teams and health systems, researchers, and research
programs during the COVID-19 pandemic. We thank you for the opportunity
to provide feedback. Should you have any questions, please contact Gina
Baxter at [email protected] or Karen Hagerty at
[email protected].
Sincerely,
Monica M. Bertagnolli, M.D., FACS, FASCO
Chair of the Board
______
Association of American Medical Colleges
655 K Street, NW, Suite 100
Washington, DC 20001-2399
T 202-828-0400
https://www.aamc.org/
The AAMC (Association of American Medical Colleges) thanks the Senate
Finance Committee for convening the May 19 hearing, ``COVID-19 Health
Care Flexibilities: Perspectives, Experiences, and Lessons Learned,''
and for the opportunity to provide written comments for inclusion in
the public record.
The AAMC is a not-for-profit association dedicated to transforming
health through medical education, health care, medical research, and
community collaborations. Its members are all 155 accredited U.S. and
17 accredited Canadian medical schools; more than 400 teaching
hospitals and health systems, including Department of Veterans Affairs
medical centers; and more than 70 academic societies. Through these
institutions and organizations, the AAMC leads and serves America's
medical schools and teaching hospitals and their more than 179,000
full-time faculty members, 92,000 medical students, 140,000 resident
physicians, and 60,000 graduate students and postdoctoral researchers
in the biomedical sciences.
The AAMC appreciates the work that this Committee, the Congress, and
the Centers for Medicare and Medicaid Services (CMS) have done to
provide important flexibilities to ensure that providers can continue
to deliver quality health care for patients during the public health
emergency (PHE). Many of these flexibilities have proven to expand
access to care and should continue to be integrated into the health-
care system beyond the end of the PHE. Specifically, the AAMC urges
Congress to:
Remove patient location and rural site requirements to allow
patients access to telehealth visits in any location.
Reimburse providers the same amount for telehealth services as
in-person visits.
Allow Medicare payment for audio-only services.
Allow patients to access telehealth services across state lines
as appropriate.
Allow for virtual supervision of residents by teaching
physicians.
Allow ``authorized practitioners'' to prescribe buprenorphine
via telehealth.
Improve access to broadband technology.
Eliminate the skilled nursing facility (SNF) three-day prior
hospitalization requirement.
Expand the delivery of inpatient care in patients' homes.
Consolidate all health-related waivers under the authority of
the Health and Human Services (HHS) Secretary.
Telehealth Flexibilities
Teaching hospitals, faculty physicians, and other providers have
responded to the PHE and the waivers and flexibilities provided by
Congress by rapidly implementing telehealth in their settings and
practices in order to provide continued access to medical care for
their patients.Telehealth provides both patients and providers with a
variety of benefits and expands access to care, especially to those in
rural and other underserved areas.
Increased Access for Patients Improves Care: Data from the
Clinical Practice Solutions Center (CPSC),\1\ which contains claims
data from 90 physician faculty practices, shows that in March and April
2020, faculty practices on average were providing approximately 50% of
their ambulatory visits via telehealth, a dramatic increase from the
use of telehealth prior to the pandemic. This is consistent with
reports from CMS regarding telehealth services provided to Medicare
beneficiaries during that time frame.\2\ The use of telehealth expands
care for the frail or elderly, for whom travel to a provider or
facility is risky or difficult even when there is no pandemic.
Telehealth also protects patients from exposure to infectious diseases,
including COVID-19 and the seasonal flu. Physicians can effectively use
telehealth to monitor the care of patients with chronic conditions,
such as diabetes and heart conditions, reducing their risk of hospital
admissions.
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\1\ The Clinical Practice Solutions Center (CPSC), owned by the
Association of American Medical Colleges and Vizient, is the result of
a partnership that works with member practice plans to collect data on
provider practice patterns and performance. This analysis included data
from 65 faculty practices.
\2\ Health Affairs, Early Impact of CMS Expansion of Medicare
Telehealth During COVID-19. July 15, 2020. https://
www.healthaffairs.org/do/10.1377/hblog20200715.454789/full/.
Increased Access to Specialist Care: The use of telehealth
enables specialists, such as pediatric specialists, cancer specialists,
and critical care physicians, to bring their skills to rural areas and
other areas that may not have subspecialty care in their communities.
Immediate availability of a pediatric infectious disease specialist or
a stroke critical care physician via telehealth can be life saving for
those in remote, rural, or small size communities. In addition,
telehealth can be used effectively to provide asynchronous consultation
for front line providers. Patients can benefit from more timely access
to the specialist's guidance and payers benefit from a less costly
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service by avoiding the new patient visit with a specialist.
High Patient Satisfaction: Analyses of surveys of more than
30,000 patients conducted by Press Ganey for services in March and
April 2020 show that patients feel overwhelmingly positive about their
virtual interactions with health-care providers.\3\ According to a
recent Health Affairs article, 79% of patient respondents reported
satisfaction with their telehealth visit and 78% felt that their health
concern could be addressed via telehealth.\4\
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\3\ Press Ganey, The Rapid Transition to Telemedicine: Insights and
Early Trends. May 19, 2020. https://www.pressganey.com/resources/white-
papers/the-rapid-transition-to-telemedicine-insights-and-early-
trends?s=White_Paper-PR.
\4\ ``Congress: Act Now To Ensure Telehealth Access for Medicare
Beneficiaries,'' Health Affairs Blog, May 10, 2021. https://
www.healthaffairs.org/do/10.1377/hblog20210505.751442/full/.
Due to statutory limitations, most of the current flexibilities are
only in place until the end of the PHE. The AAMC believes telehealth is
an important method to deliver health care in many circumstances and
urges Congress to make legislative changes that would preserve these
new practices and the gains we've made in telehealth to date, and to
ensure that reimbursement remains at a level that supports the
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infrastructure needed to provide this level of telehealth services.
The AAMC recommends the following:
Congress Should Remove Patient Location Restrictions and Rural Site
Requirements
The AAMC strongly supports changes made by Congress that waived patient
location restrictions that applied to telehealth service during the
PHE. These changes have enabled CMS to pay for telehealth services
furnished by physicians and other health-care providers to patients
located in any geographic location and at any site, including the
patient's home, during the PHE. We also thank Congress for including
changes in the Consolidated Appropriations Act, 2021 that permanently
allow patients to receive mental health services via telehealth
regardless of the geographic location requirements ordinately
applicable to Medicare telehealth services.
These changes have allowed patients to remain in their home, reducing
their exposure to COVID-19 and reducing the risk of exposing another
patient or their physician to COVID-19. Maintaining such a change even
after the threat of the pandemic is contained would allow patients who
find travel to an in-person appointment challenging to receive vital
care, especially for patients with chronic conditions or disabilities
who need regular monitoring. The AAMC encourages Congress to remove the
rural site requirements and allow the home to be an originating site.
Providers Should be Paid the Same Amount for Telehealth Services as
Services Delivered In-Person
The AAMC strongly recommends that providers be paid the same for
furnishing telehealth services as services delivered in person. The
quality and cost of care delivered is not different if the patient is
seen via telehealth. We recommend Congress provide a facility fee under
the outpatient prospective payment system for telehealth services
provided by physicians that would have been provided in the provider-
based entity.
Teaching hospitals and faculty practice plans have highlighted
significant infrastructure costs to fully integrate their electronic
health record systems with HIPAA-compliant telehealth programs.
Physicians and hospitals employ medical assistants, nurses, and other
staff to engage patients during telehealth visits and to coordinate
care, regardless of whether the services are furnished in person or via
telehealth. Before the virtual visit occurs, the physicians and other
health-care professionals must be provided the technology they need and
acquire a platform to use for the visits. Other staff will contact
patients to complete registration, obtain consent for a telehealth
visit, and ensure that the patient receives the email with a link to
participate in the virtual visit. In addition, staff will educate the
patients on the use of technology as needed to ensure they are able to
participate in the visit.
On the day of the visit, clinical staff reach out to the patient to
provide intake services (e.g., ask for chief complaint, symptoms,
weight, temperature and help the patient identify a review of current
medications and therapies) prior to the patient visit with the
physician or health-care professional. The patient then participates in
the visit with the physician, and at the conclusion of the visit, the
physician must arrange any follow-up plan for the patient related to
their care. Staff will follow-up as needed to schedule any additional
visits for the treating physician or subspecialty referral, tests, or
laboratory studies.
Without sufficient reimbursement, providers may no longer be able to
continue to provide the current level of telehealth services to their
patients.
Congress Should Allow Payment for Audio-Only Services
CMS established a separate Medicare payment for specific audio-only
services to provide reimbursement at the same rates as in-person
visits. However, the final 2021 physician fee schedule rule stated that
this separate payment will no longer exist after the PHE ends, since
CMS does not have the statutory authority to allow coverage and payment
for telephone evaluation and management services.
Audio-only calls improve access to virtual care for patients who do not
have access to the devices or broadband for audiovisual calls, are not
comfortable with digital technology, or do not have someone available
to assist them. During the PHE, coverage and payment for audio-only
calls has been critical to ensure access to care for many patients.
Physicians have been able to provide a wide array of services
efficiently, effectively, and safely to patients using the telephone.
Data from the CPSC shows that approximately 30% of telehealth services
were provided using audio-only telephone technology in April and May
2020. The proportion of telephone/audio-only visits increased with the
age of the patient. CMS data show that nearly one-third of Medicare
beneficiaries received telehealth by audio-only telephone technology
from March through June 2020,\5\ which is consistent with CPSC data.
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\5\ ASPE issue brief: Medicare Beneficiary Use of Telehealth
Visits: Early Data from the Start of the COVID-19 Pandemic (7/18/2020);
Health Affairs Blog; Early Impact of CMS Expansion of Medicare
Telehealth During COVID-19. July 15, 2020. https://
www.healthaffairs.org/do/10.1377/hblog20200715.454789/abs.
Many factors contribute to the high use of audio-only services.
Patients in rural areas or those with lower socioeconomic status are
more likely to have limited broadband access and may not have access to
the technology needed for two-way audio-visual communication. The Pew
Research Center found that about a third of adults with household
incomes below $30,000 per year do not own a smartphone and about 44% do
not have home broadband services.\6\
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\6\ Pew Research Center, Digital divide persists even as lower-
income Americans makes gains in tech adoption. May 7, 2019. https://
www.pewresearch.org/fact-tank/2019/05/07/digital-divide-persists-even-
as-lower-income-americans-make-gains-in-tech-adoption/.
Some providers report that even when their patients have access to
technology that would allow for audio-visual communication, they may be
unable to use the technology without assistance, thus limiting them to
telephone use. For these patients, the only option to receive services
remotely is through a phone. Without coverage and payment for these
audio-only services, there will be inequities in access to services for
these specific populations. We urge Congress to permanently make
changes to allow coverage and payment for audio-only services.
Congress Should Allow Patients to Access Telehealth Services Delivered
Across State Lines
As part of the COVID-19 response, Congress and CMS have allowed
providers to be reimbursed by Medicare for telehealth services across
state lines. This waiver creates an opportunity to improve patient
access to services and to help improve continuity of care for patients
who have relocated or who have traveled to receive their surgery or
other services from a specialist in another state. While CMS has the
authority to allow for payment under federal programs, states need to
act to allow practice across state lines to occur.
The AAMC urges Congress to pass the Temporary Reciprocity to Ensure
Access to Treatment Act (TREAT Act, S. 168, H.R. 708). This bipartisan,
bicameral legislation would expand care for patients by creating a
temporary uniform licensing standard for all practitioners and
professionals that hold a valid license in good standing in any state
to be permitted to practice in every state--including in-person and
telehealth visits--during the COVID-19 public health emergency.
Congress Should Allow for Virtual Supervision of Resident Physicians
During the PHE, CMS has allowed resident physicians to furnish
telehealth services that are virtually supervised by the teaching
physician. In the physician fee schedule final rule, CMS states that
this policy regarding telehealth will be allowed on a permanent basis
only in rural sites.
Resident education is a crucial step of professional development before
autonomous clinical practice and requires varying levels of faculty
supervision depending on where the resident is in training and
developing competency. As part of this development, it is essential for
residents to have the experience with telehealth visits while
supervised as they will be providing them in the future to their
patients when they practice autonomously.
The AAMC recommends that CMS allow residents to provide telehealth
services permanently while a teaching physician is present via real-
time audio-visual communications technology after the PHE ends in all
regions of the country. This change to CMS policy will improve patient
access to care while also enhancing the resident's skills.
Congress Should Allow ``Authorized Practitioners'' to Prescribe
Buprenorphine via Telehealth
The AAMC supports the Substance Abuse and Mental Health Services
Administration's and Drug Enforcement Agency's temporary change to
allow ``authorized practitioners'' to prescribe buprenorphine to new
and existing opioid use disorder patients for maintenance or
detoxification treatment via telehealth examination without the need
for a prior in-person visit. We urge Congress to make this change
permanent to ensure this important expansion is not limited solely to
the current PHE.
Congress Should Takes Steps to Improve Access to Broadband Technology
In many parts of the country, providers and their patients have limited
access to broadband connectivity, which has been a major barrier to use
of telehealth. This is particularly true for rural areas and
underserved communities. The Federal Communications Commission has
reported that 30% of rural residents lack broadband services.\7\ Also,
racial and ethnic minorities, older adults, and those with lower levels
of socioeconomic status are less likely to have broadband access. In
order to expand access to telehealth and other important online
services, we recommend that Congress take steps to increase funding for
broadband access and infrastructure development.
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\7\ Federal Communications Commission, 2018 Broadband Deployment
Report, February 2, 2018. https://www.fcc.gov/reports-research/reports/
broadband-progress-reports/2018-broad
band-deployment-report.
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Other Targeted Health Care Flexibilities
Eliminate the SNF three-day prior hospitalization requirement.
CMS has waived the requirement for a three-day prior hospitalization
for coverage of a SNF stay, which provides temporary emergency coverage
of SNF services without a qualifying hospital stay for those people who
experience dislocations or are otherwise affected by COVID-19. The AAMC
supports this waiver and recommends that the SNF three-day prior
hospitalization requirement be eliminated permanently to better
coordinate and improve care for patients. Eliminating the three-day
stay would rely on physicians' judgment to ensure that their patients
receive the most appropriate care in the most appropriate settings
without creating the possibility of an unforeseen financial burden on
the patient.
Expand the Delivery of Inpatient Care in Patients' Homes
CMS launched the Hospital Without Walls program in March 2020 to allow
hospitals to provide services beyond their existing walls to help
address the need to expand care capacity and to develop sites dedicated
to COVID-19 treatment. The Acute Hospital Care At Home program is an
expansion of this initiative that allows eligible hospitals to have
regulatory flexibility to treat certain patients, who would otherwise
be admitted to the hospital, in their homes and receive Medicare
payment under the Inpatient Prospective Payment System.
The Acute Hospital Care At Home program launched with six health-care
systems that have experience with providing acute hospital care at
home. To date, 129 hospitals within 56 systems located in 30 states--
including many academic medical centers--have received waivers from CMS
to participate in the program.\8\ The increase in hospital
participation underscores the need for flexibility to meet the health-
care needs of certain patients without having to admit them into the
inpatient setting.
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\8\ Updated as May 14, 2021. Updated list available at: https://
qualitynet.cms.gov/acute-hospital-care-at-home/resources.
The AAMC supports the flexibility and benefits this program provides
for patients and urges Congress to maintain these flexibilities after
the end of the PHE.
Consolidate All Health-Related Waivers Under the Authority of the HHS
Secretary
The AAMC is appreciative of the temporary health care-related
regulatory flexibilities and emergency authorities granted by the
federal government in response to the coronavirus. These flexibilities
have been granted by the White House, HHS, and CMS, among others. To
better coordinate these flexibilities, the AAMC recommends that all
health-related waivers be consolidated under the authority of the HHS
Secretary.
For example, Section 1135 waivers have offered essential relief and
assistance for health-care providers during the pandemic by relaxing
several requirements, including practice across state lines and
timelines for federal reporting requirements. For the 1135 waivers to
remain in effect, both a public health emergency and a national
emergency must be declared by the HHS Secretary and President,
respectively. The AAMC recommends that all health-related flexibilities
be under the direction of the HHS Secretary, and not reliant upon the
declaration of a national emergency.
Conclusion
The AAMC is very grateful for the work that this Committee, the
Congress, and the Administration have done to provide important
flexibilities to allow for the expansion of health-care delivery during
the COVID-19 pandemic. We appreciate that the Senate Finance Committee
is reviewing many of these flexibilities and thinking about how to
incorporate them into the health-care system beyond the end of the
public health emergency.
Please feel free to contact AAMC Chief Public Policy Officer Karen
Fisher, JD ([email protected]) or AAMC Senior Director of Government
Relations Leonard Marquez ([email protected]) with any questions or if
we can provide more information. We look forward to continuing to work
with you on these important issues.
______
Better Medicare Alliance
1411 K Street, NW, Suite 1400
Washington, DC 20005
202-735-0037 (office)
202-885-9968 (fax)
BetterMedicareAlliance.org
Statement of Allyson Y. Schwartz, President and CEO
Better Medicare Alliance, on behalf of our Alliance and the 26 million
beneficiaries enrolled in Medicare Advantage, is pleased to submit the
following statement for the record related to the May 19, 2021
Committee on Finance hearing titled COVID-19 Health Care Flexibilities:
Perspectives, Experiences, and Lessons Learned.
Better Medicare Alliance is a community of 160 ally organizations and
more than 500,000 grassroots beneficiary advocates who value Medicare
Advantage and the affordable, high-quality, coordinated care it
provides to over 26 million beneficiaries. Together, our diverse
alliance of health plans, provider groups, aging service organizations,
and beneficiaries share a commitment to ensuring Medicare Advantage is
a high-quality, cost-effective option for current and future
beneficiaries.
As a public-private partnership where seniors and individuals with
disabilities receive Medicare benefits through a private integrated
managed care plan, Medicare Advantage plans are paid a capitated
monthly amount per beneficiary by the Centers for Medicare and Medicaid
Services (CMS). The health plans then take full financial risk for care
and services to enrollees. Capitated payments are determined six months
prior to the start of the contract year and are used to provide
coverage of health-care benefits to enrolled beneficiaries. Payments
are adjusted by the health status of each beneficiary to ensure health
plans receive adequate payment to cover the costs of all beneficiaries.
To ensure the capitated payments reflect the health status and
demographic characteristics of individual beneficiaries, payment to
Medicare Advantage plans are risk adjusted using demographic and
diagnostic information. Risk assessment is required annually for each
beneficiary to calculate a risk score that predicts costs for the
upcoming year. For the risk adjustment process to function properly, it
is necessary to collect data on beneficiaries each year through in-
person office visits, telehealth visits, or in-home health risk
assessments. Accurate documentation of diagnoses by clinicians is a
critical component of the risk adjustment process and ensures
beneficiaries receive the appropriate care management and quality of
services based on their conditions.
Transition to Telehealth During COVID-19 Pandemic
The COVID-19 pandemic, stay-at-home guidance, and advice to avoid
clinical in-person settings unless necessary, particularly for at-risk
populations like those over 65 years old and those with chronic
conditions, led to a nationwide avoidance of in-person clinical care
and delay of elective services. Among Medicare beneficiaries, 8 percent
report forgoing care despite needing health-care services because of
the pandemic.\1\ Reports like this highlight the importance of
providing patients access to health-care services outside the physician
office and resulted in a dramatic and rapid transition of clinical care
being offered through telehealth visits starting in 2020. The use of
telehealth visits has contributed meaningfully to allowing providers
and health plans to reach out to beneficiaries and replace in-person
visits--ensuring those with new medical concerns and those with ongoing
chronic conditions have been able to interact with their providers to
manage their health. Yet, while providers and health plans work
together to provide needed care and reduce the impact of this pandemic
for their patients, utilization of care and services was significantly
lower in 2020 and has not yet fully returned to pre-pandemic levels.\2\
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\1\ https://www.cms.gov/files/document/medicare-current-
beneficiary-survey-covid-19-data-snapshot-infographic-fall-2020.pdf .
\2\ https://www.healthsystemtracker.org/chart-collection/how-have-
healthcare-utilization-and-spending-changed-so-far-during-the-
coronavirus-pandemic/#item-covidcostsuse_marchupdate_3.
Between May 2019 and June 2020, the University of Michigan's National
Poll on Healthy Aging found telehealth visit participation increased
from 4 percent to 30 percent, respectively, among older adults.\3\ The
same poll found the number of providers offering telehealth services
increased from 14 percent to 62 percent during the same period of
time.\4\ More recently, CMS found 64 percent of Medicare beneficiaries
report their provider currently offers telehealth visits, and 45
percent had a telehealth visit since July 2020.\5\
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\3\ https://www.healthyagingpoll.org/report/telehealth-use-among-
older-adults-and-during-covid-19.
\4\ Id.
\5\ https://www.cms.gov/files/document/medicare-current-
beneficiary-survey-covid-19-data-snapshot-infographic-fall-2020.pdf.
In Medicare Advantage, recent polling shows 40 percent of beneficiaries
used telehealth services during the pandemic and gave the experience a
91 percent satisfactory rating.\6\ The risk-bearing payment
arrangements in Medicare Advantage further facilitated the
implementation and expansion of telehealth visits during the pandemic.
Compared to Traditional fee-for-service (FFS) Medicare, Medicare
Advantage had a quicker transition to telehealth visits.\7\ Looking
forward, 48 percent of people 65 years and older report a willingness
to use telehealth despite not having used telehealth before, and 35
percent expect to use telehealth with more frequency in the future.\8\
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\6\ https://bettermedicarealliance.org/wp-content/uploads/2021/01/
BMA_Seniors-on-Medicare-Memo_.pdf.
\7\ https://bettermedicarealliance.org/wp-content/uploads/2020/07/
CIMA-July-2020-Telehealth-Report-FIN.pdf.
\8\ https://static.americanwell.com/app/uploads/2020/09/Amwell-
2020-Physician-and-Consumer-Survey.pdf.
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Impact on Risk Adjustment
Medicare Advantage is unique in requiring an accurate assessment of
each beneficiary every year to determine their health conditions and
ensure risk adjusted payments reflect a beneficiary's current diagnoses
and conditions. It is critical to make use of the tools available to
obtain this data.
Action has been taken by CMS to permit data obtained during audio-video
telehealth visits to provide diagnoses for risk assessment, but the
same is not allowed for data obtained during audio-only visits. Better
Medicare Alliance urges Congress to address this inequity and permit
the same use for audio-only telehealth visits. There are numerous
reasons to support this allowance, most prominently because
beneficiaries do not have equal ability or equivalent access to the
technology needed for audio-video visits. Moreover, providers use
audio-video and audio-only telehealth visits interchangeably to account
for patient preference or capabilities. The distinction for risk
assessment purposes inhibits the ability of providers to utilize these
patient visits to obtain data required under Medicare Advantage.
Omitting the use of data obtained during audio-only telehealth visits
unreasonably limits the use of available, timely, and clinically
accurate data on these patients that could be used to provide the
required information for millions of Medicare beneficiaries. Without
this information, the data required by CMS to inform adequate payment
based on health status will be incomplete and may impact payment
stability for health plans and providers in subsequent years, as well
as out-of-pocket costs and supplemental benefits for beneficiaries.
Better Medicare Alliance appreciates the opportunities provided to
Medicare Advantage plans to offer telehealth visits and provide audio-
video devices to beneficiaries. Over the last year, health plans and
providers have been able to routinely hold virtual visits with
beneficiaries to ensure those most at risk due to chronic conditions
have the attention and medications they need. In addition, health plans
and providers have been able to assess general wellness and identify
and address social risk factors as part of care management available in
Medicare Advantage. Medicare Advantage has been a leader in the rapid
transition to telehealth and in providing attention to non-clinical
needs of beneficiaries to better help beneficiaries maintain their
health and well-being during this unprecedented public health
emergency. Telehealth has ensured continuity of care for millions of
Medicare Advantage beneficiaries during COVID-19.
Barriers to Use of Telehealth Visits
The transition to virtual visits accelerated by the pandemic has
revealed the reality that many older, lower-income, and rural seniors
lack the tools or access necessary to complete audio-video telehealth
visits.\9\
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\9\ https://bettermedicarealliance.org/wp-content/uploads/2020/07/
CIMA-July-2020-Telehealth-Report.pdf.
The rapid uptake in telehealth visits showed the flexibility and
innovation of health plans, providers, and beneficiaries during this
critical time. Nevertheless, the transition is not without barriers,
and the distinction between audio-video and audio-only visits has
highlighted the disparities present in telehealth. Though half of
people over age 65 are willing to try telehealth, many beneficiaries
have limitations that inhibit the use of audio-video telehealth
visits.\10\ The reasons vary, but the potential barriers must be
considered to ensure over 26 million Medicare Advantage beneficiaries
continue to receive care without disruption.
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\10\ https://static.americanwell.com/app/uploads/2019/07/American-
Well-Telehealth-Index-2019-Consumer-Survey-eBook2.pdf.
Beneficiaries must be able to access the technology and devices
necessary for telehealth visits. Access also includes having adequate
Internet, financial means, and functional and cognitive ability.
Together, such limitations of access inhibit a beneficiary's use of
telehealth visits, specifically audio-video visits. While 92 percent of
seniors own a cellphone, only 61 percent have a smartphone.\11\ The
distinction between having a cellphone and smartphone is important
because unlike cellphones, smartphones have the video capability
necessary for an audio-video telehealth visit. Lower income
beneficiaries are less likely to have a smartphone, further limiting
access to audio-video telehealth visits.\12\ A recent study found 32
percent of people 65 and older do not have a smartphone, tablet, or
computer with Internet access at home.\13\
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\11\ https://www.pewresearch.org/Internet/fact-sheet/mobile/.
\12\ https://bettermedicarealliance.org/wp-content/uploads/2020/07/
CIMA-July-2020-Telehealth-Report.pdf.
\13\ https://www.kff.org/policy-watch/possibilities-and-limits-of-
telehealth-for-older-adults-during-the-covid-19-emergency/.
According to the FCC's 2018 Broadband Deployment Report, 24 million
Americans do not have access to broadband Internet at the benchmark
speed of 25 Mbps/3Mbps, which is considered the minimum speed standard
and offers good Internet access. Additionally, the same report found
rural areas lag behind urban areas in the deployment of mobile
broadband and fixed broadband with 68.6 percent of people in rural
areas having access to both compared to 97.9 percent in urban
areas.\14\ Limited, or inadequate access to Internet prevents
beneficiaries from using audio-video telehealth visits.
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\14\ https://www.fcc.gov/reports-research/reports/broadband-
progress-reports/2018-broadband-deployment-report.
Access problems are not limited to the Internet or devices, as some
beneficiaries with functional or cognitive impairments are unable to
utilize audio-video technology. These beneficiaries prefer audio-only
over audio-video telehealth visits. Others may be limited by financial
constraints that prevent them from purchasing the necessary devices and
Internet services. Research found 34 percent of Medicare Advantage
beneficiaries living under the Federal Poverty Level reported no
Internet usage at all.\15\
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\15\ https://bettermedicarealliance.org/wp-content/uploads/2020/07/
CIMA-July-2020-Telehealth-Report-FIN.pdf.
In addition, not all beneficiaries are comfortable with the necessary
technology used for audio-video visits. Nearly seven in ten adults 65
and older say they have a computer, smart phone, or tablet with
Internet access at home, but only 11 percent say they have recently
used a device to talk to a health-care provider through an audio-video
visit.\16\ During COVID-19, a survey of more than 1,000 Medicare
Advantage beneficiaries in December 2020 found 40 percent used
telehealth during the pandemic, an increase from 24 percent in May
2020.\17\ However, nearly one-third of beneficiaries said they are
uncomfortable using telehealth.\18\
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\16\ https://www.kff.org/policy-watch/possibilities-and-limits-of-
telehealth-for-older-adults-during-the-covid-19-emergency/.
\17\ https://bettermedicarealliance.org/news/poll-seniors-give-
telehealth-high-marks-medicare-advantage-satisfaction-smashes-new-
record-2/.
\18\ Id.
Lack of experience or comfort using audio-video technology appears to
influence seniors' preference for audio-only because even those who are
willing to use telehealth often choose audio-only rather than audio-
video visits. When given the option, 60 percent of Medicare Advantage
beneficiaries prefer the telephone over other technology.\19\ Health
providers are also reporting the usage of audio-only telehealth visits
is vastly higher than audio-video telehealth visits. Security Health
Plan reported 75 percent of their telehealth visits as audio-only, and
Kaiser Permanente reported 85 percent of their telehealth visits as
audio-only. CMS found nearly one-third of telehealth visits with
Medicare beneficiaries between mid-March and mid-June 2020 were
conducted by audio-only telephone.\20\ This is equivalent to over 3
million visits and indicates a preference for audio-only telehealth
visits.
---------------------------------------------------------------------------
\19\ https://bettermedicarealliance.org/wp-content/uploads/2020/07/
CIMA-July-2020-Telehealth-Report-FIN.pdf.
\20\ https://www.healthaffairs.org/do/10.1377/hblog20200715.454789/
full/.
More recent data show a majority, or 56 percent, of Medicare
beneficiaries that had a telehealth visit since July 2020 used audio-
only telephone for their visit while only 28 percent used video and 16
percent used both telephone and video.\21\ The share of Medicare
beneficiaries that used audio-only for their telehealth visit was
higher among certain demographics, including beneficiaries 75 years or
older (65 percent), enrolled in both Medicare and Medicaid (67
percent), or living in rural areas (65 percent).\22\ Additionally, the
share of Hispanic (61 percent) and non-Hispanic Black (61 percent)
beneficiaries using audio-only telehealth visits is higher than White
beneficiaries (54 percent).\23\ The differences among demographics
further highlight the disparities present in telehealth and illustrate
the impact omitting data obtained during audio-only telehealth visits
may have on Medicare Advantage beneficiaries.
---------------------------------------------------------------------------
\21\ https://www.kff.org/medicare/issue-brief/medicare-and-
telehealth-coverage-and-use-during-the-covid-19-pandemic-and-options-
for-the-future/.
\22\ Id.
\23\ Id.
Action Needed to Address Constraints on Use of Audio-Only Telehealth
Visits
The public health emergency has led to the recognition of the need to
eliminate barriers and burdens in accessing clinically appropriate
care, especially for those in the Medicare Advantage population. The
importance of telehealth visits during the pandemic in 2020 and 2021 is
unquestionable and calls for Congress to take action to eliminate the
unnecessary and potentially harmful constraints on the assessment and
documentation of current health status to ensure the continuity of care
for millions of people.
Bipartisan legislation introduced in the Senate, the Ensuring Parity in
Medicare Advantage and PACE for Audio-Only Telehealth Act of 2021,
acknowledges and addresses the disparities in the use of telehealth
visits for data collection essential for risk assessments. Audio-only
telehealth has proven to be an extremely valuable tool to ensure
ongoing care is available during this unprecedented national public
health emergency to beneficiaries who cannot access or use audio-video
technology. Clinicians have been conducting audio-only visits in
response to the needs and abilities of beneficiaries and these visits
have been vital to the provision of necessary ongoing care for
beneficiaries. Earlier research showed that telehealth visits produce
similar outcomes as face-to-face appointments for chronic care
management and the diagnoses and treatment were also equivalent.
Research also shows that risk scores do not fluctuate much year over
year.\24\ Excluding clinical data from audio-only visits that may not
have been obtained otherwise means the data may be entirely absent for
those beneficiaries utilizing audio-only visits, despite being
available for reporting in each year of the pandemic.
---------------------------------------------------------------------------
\24\ Flodgren G, Rachas A, Farmer AJ, Inzitari M, Sheppard S.
Interactive telemedicine: effects of professional practice and health-
care outcomes. Cochrane Database of Systematic Reviews 2015, Issue 9.
Art. No.: CD002098. DOI: 10.1002/14651858.CD002098.pub2 .
---------------------------------------------------------------------------
Call for Congress to Act
Data obtained during audio-only visits should be permitted to be used
for risk adjustment purposes as it is essential for accurate risk
adjustment for beneficiaries in the following year and may not have
been collected in any other way due to the pandemic. These visits are
recognized as clinical encounters in every other sense, making it only
reasonable for diagnoses obtained through these patient-clinician
encounters to be permitted to be used for risk adjustment.
By allowing audio-only visits during the ongoing pandemic to be used
for risk assessment purposes, the health and well-being of over 26
million Medicare Advantage beneficiaries will be protected now and in
the future. We strongly urge Congress to take action that recognizes
beneficiary circumstances with respect to and preference for audio-only
telehealth technology and necessitates the flexibility to use audio-
only technology in the collection of clinical and diagnostic data for
risk adjustment purposes.
Better Medicare Alliance thanks the Committee for the opportunity to
submit these comments. We recognize the sponsors of the legislation,
Ensuring Parity in Medicare Advantage and PACE for Audio-Only
Telehealth Act of 2021, for their leadership. We hope to see the
Committee consider this bill in the near future and support its passage
in the Senate. We welcome the opportunity to continue to engage with
the Committee on this important and timely issue.
______
Center for Fiscal Equity
14448 Parkvale Road, Suite 6
Rockville, MD 20853
[email protected]
Statement of Michael G. Bindner
Chairman Wyden and Ranking Member Crapo, thank you for the opportunity
to submit these comments for the record to the Committee. These
comments are similar to those provided on Telehealth to the Ways and
Means Subcommittee on Health on April 28, 2021.
Flexible health-care delivery, especially Telehealth is part of
increased automation in medicine. It began with electronic charting.
The emergence of telehealth predates the pandemic. It started as a
cutting edge way for experts to consult on cases. In recent years, it
has included using radiologists in South Asia to read all manner of X-
Rays and scans, delivering a diagnosis to emergency rooms, urgent care
and doctor's offices.
The question of taxation must be discussed at this point. Perhaps
duties should be included for such off-shore medicine. They certainly
must be in the event value added taxes are established in the United
States. This would bring us into the OECD norm. Senator Hatch has
retired, so it is now safe to talk of such things.
If we adopt Medicare for All, such taxes would be counter-productive.
Without some kind of employer-paid subtraction value added tax, it is
hard to see the creation of an affordable public option, let alone
Medicare for All. Part of any transition would have to include an asset
value added tax, which would include ending Pease and Affordable Care
Act SMI taxes on non-wage income over $200,000. See the attachment for
more information on these proposals.
The pandemic has made telemedicine the new normal. I will be glad to
see it go, or at least play a smaller role. It is hard to get a good
medical history and list of symptoms on a video conference or phone
call. People likely died, either of complications from the pandemic
(like suicide) or SARS-Cov-2. This requires explanation.
The disease occurs in five phases. In phase one, the patient
experiences symptoms of a heavy cold which goes away after a week. This
phase is largely ignored by the medical community because it is
impossible to get to see a doctor in person. To be fair, most patients
manage these symptoms with over-the-counter medication. Symptoms last
for a week. Phase two is asymptotic.
People believe they are well, even if they assume they were suffering
from COVID. In reality, most of the spread of the disease happens
during phases one and two. During this period, people do not have
fevers, coughing and all but one of the symptoms which are used to
screen for COVID.
The intense symptoms start with phase three (SARS2) or phase four
(assuming individuals have some degree of immunity from pulmonary
disease, or possess inhalers--especially steroids--to manage them.
The patients who eventually die do not know that they have COVID. They
believe that symptoms will go away in a week, just as they did in phase
one. Access to primary care at this stage, as well as vital information
on the disease would have saved lives at this point. Add fear of dying
of COVID in the Intensive Care Unit and this fear became a self-
fulfilling prophesy.
The main feature of phase four is crushing fatigue, either from lung
symptoms or the development of immunity. These symptoms are a two week
version of the reaction to either the first shot (for people who have
had the disease) or the booster (for people who have not been sick
previously).
Phase five is the long-term healing, which includes coughing up mucus.
Medications, such as Robitussin, are valuable for these symptoms. This
phase takes a long time to clear.
Deaths are still declining, as the current available vectors are less
likely to die. For a few weeks, they just wish they would. Younger
patients are experiencing the third wave. Minnesota, Michigan and
Ontario are likely still experiencing their first wave. This disease is
spread by sneezing on people you know, usually at home or work. It has
spread from Seattle and New York to the rest of the nation, meeting in
the southwest and moving north. It is running out of places to go.
As more and more people get vaccinated or simply have the disease and
recover, it likely will disappear, like magic. When it does, we can get
back to normal medical practice. Quite a bit of care has been foregone
during the pandemic. There is a lot of catching up to do.
Thank you for the opportunity to address the committee. We are, of
course, available for direct testimony or to answer questions by
members and staff.
Attachment --Tax Reform, Center for Fiscal Equity, March 5, 2021
Individual payroll taxes. These are optional taxes for Old-Age and
Survivors Insurance after age 60 for widows or 62 for retirees. We say
optional because the collection of these taxes occurs if an income
sensitive retirement income is deemed necessary for program acceptance.
Higher incomes for most seniors would result if an employer
contribution funded by the Subtraction VAT described below were
credited on an equal dollar basis to all workers. If employee taxes are
retained, the ceiling should be lowered to $85,000 to reduce benefits
paid to wealthier individuals and a $16,000 floor should be established
so that Earned Income Tax Credits are no longer needed. Subsidies for
single workers should be abandoned in favor of radically higher minimum
wages.
Wage Surtaxes. Individual income taxes on salaries, which exclude
business taxes, above an individual standard deduction of $85,000 per
year, will range from 6.5% to 26%. This tax will fund net interest on
the debt (which will no longer be rolled over into new borrowing),
redemption of the Social Security Trust Fund, strategic, sea and non-
continental U.S. military deployments, veterans' health benefits as the
result of battlefield injuries, including mental health and addiction
and eventual debt reduction. Transferring OASDI employer funding from
existing payroll taxes would increase the rate but would allow it to
decline over time. So would peace.
Asset Value-Added Tax (A-VAT). A replacement for capital gains taxes,
dividend taxes, and the estate tax. It will apply to asset sales,
dividend distributions, exercised options, rental income, inherited and
gifted assets and the profits from short sales. Tax payments for option
exercises and inherited assets will be reset, with prior tax payments
for that asset eliminated so that the seller gets no benefit from them.
In this perspective, it is the owner's increase in value that is taxed.
As with any sale of liquid or real assets, sales to a qualified broad-
based Employee Stock Ownership Plan will be tax free. These taxes will
fund the same spending items as income or S-VAT surtaxes. This tax will
end Tax Gap issues owed by high income individuals. A 26% rate is
between the GOP 24% rate (including ACA-SM and Pease surtaxes) and the
Democratic 28% rate. It's time to quit playing football with tax rates
to attract side bets.
Subtraction Value-Added Tax (S-VAT). These are employer paid Net
Business Receipts Taxes. S-VAT is a vehicle for tax benefits, including
Health insurance or direct care, including veterans' health care
for non-
battlefield injuries and long term care.
Employer paid educational costs in lieu of taxes are provided as
either
employee-directed contributions to the public or private unionized
school of their choice or direct tuition payments for employee children
or for workers (including ESL and remedial skills). Wages will be paid
to students to meet opportunity costs.
Most importantly, a refundable child tax credit at median income
levels (with inflation adjustments) distributed with pay.
Subsistence level benefits force the poor into servile labor. Wages and
benefits must be high enough to provide justice and human dignity. This
allows the ending of state administered subsidy programs and
discourages abortions, and as such enactment must be scored as a must
pass in voting rankings by pro-life organizations (and feminist
organizations as well). To assure child subsidies are distributed, S-
VAT will not be border adjustable.
The S-VAT is also used for personal accounts in Social Security,
provided that these accounts are insured through an insurance fund for
all such accounts, that accounts go toward employee-ownership rather
than for a subsidy for the investment industry. Both employers and
employees must consent to a shift to these accounts, which will occur
if corporate democracy in existing ESOPs is given a thorough test. So
far it has not. S-VAT funded retirement accounts will be equal-dollar
credited for every worker. They also have the advantage of drawing on
both payroll and profit, making it less regressive.
A multi-tier S-VAT could replace income surtaxes in the same range.
Some will use corporations to avoid these taxes, but that corporation
would then pay all invoice and subtraction VAT payments (which would
distribute tax benefits. Distributions from such corporations will be
considered salary, not dividends.
Invoice Value-Added Tax (I-VAT). Border adjustable taxes will appear on
purchase invoices. The rate varies according to what is being financed.
If Medicare for All does not contain offsets for employers who fund
their own medical personnel or for personal retirement accounts, both
of which would otherwise be funded by an S-VAT, then they would be
funded by the I-VAT to take advantage of border adjustability. I-VAT
also forces everyone, from the working poor to the beneficiaries of
inherited wealth, to pay taxes and share in the cost of government.
Enactment of both the A-VAT and I-VAT ends the need for capital gains
and inheritance taxes (apart from any initial payout). This tax would
take care of the low-income Tax Gap.
I-VAT will fund domestic discretionary spending, equal dollar employer
OASI contributions, and non-nuclear, non-deployed military spending,
possibly on a regional basis. Regional I-VAT would both require a
constitutional amendment to change the requirement that all excises be
national and to discourage unnecessary spending, especially when
allocated for electoral reasons rather than program needs. The latter
could also be funded by the asset VAT (decreasing the rate by from
19.5% to 13%).
As part of enactment, gross wages will be reduced to take into account
the shift to S-VAT and I-VAT, however net income will be increased by
the same percentage as the I-VAT. Adoption of S-VAT and I-VAT will
replace pass-through and proprietary business and corporate income
taxes.
Carbon Value-Added Tax (C-VAT). A Carbon tax with receipt visibility,
which allows comparison shopping based on carbon content, even if it
means a more expensive item with lower carbon is purchased. C-VAT would
also replace fuel taxes. It will fund transportation costs, including
mass transit, and research into alternative fuels (including fusion).
This tax would not be border adjustable.
Summary
This plan can be summarized as a list of specific actions:
1. Increase the standard deduction to workers making salaried income
of $425,001 and over, shifting business filing to a separate tax on
employers and eliminating all credits and deductions--starting at 6.5%,
going up to 26%, in $85,000 brackets.
2. Shift special rate taxes on capital income and gains from the
income tax to an asset VAT. Expand the exclusion for sales to an ESOP
to cooperatives and include sales of common and preferred stock. Mark
option exercise and the first sale after inheritance, gift or donation
to market.
3. End personal filing for incomes under $425,000.
4. Employers distribute the child tax credit with wages as an offset
to their quarterly tax filing (ending annual filings).
5. Employers collect and pay lower tier income taxes, starting at
$85,000 at 6.5%, with an increase to 13% for all salary payments over
$170,000 going up 6.5% for every $85,000--up to $340,000.
6. Shift payment of HI, DI, SM (ACA) payroll taxes employee taxes to
employers, remove caps on employer payroll taxes and credit them to
workers on an equal dollar basis.
7. Employer paid taxes could as easily be called a subtraction VAT,
abolishing corporate income taxes. These should not be zero rated at
the border.
8. Expand current state/federal intergovernmental subtraction VAT to a
full GST with limited exclusions (food would be taxed) and add a
federal portion, which would also be collected by the states. Make
these taxes zero rated at the border. Rate should be 19.5% and replace
employer OASI contributions. Credit workers on an equal dollar basis.
9. Change employee OASI of 6.5% from $18,000 to $85,000 income.
______
ERISA Industry Committee
701 8th Street, NW, Suite 610
Washington, DC 20001
Main 202-789-1400
http://www.eric.org/
Introduction and About ERIC
Chairman Wyden, Ranking Member Crapo, and members of the Committee,
thank you for this opportunity to submit a statement for the record on
behalf of The ERISA Industry Committee (ERIC) for the hearing entitled
``COVID-19 Health Care Flexibilities: Perspectives, Experiences, and
Lessons Learned.'' This is a critical hearing, because the Senate
Finance Committee's jurisdiction far exceeds Medicare--policies
determined by this Committee govern the benefits provided by employers,
especially as they affect the rules regarding high deductible health
plans (HDHPs) and the Affordable Care Act (ACA). Our statement details
ways that the Committee and Congress can take decisive action to
consolidate the telehealth gains made by private sector employers
during COVID and consider expanding telehealth policies to the private
sector so that employees and their families can access virtual care.
ERIC is a national nonprofit organization exclusively representing the
largest employers in the United States in their capacity as sponsors of
employee benefit plans for their nationwide workforces. ERIC's member
companies voluntarily provide benefits that cover millions of active
and retired workers and their families across the country. With member
companies that are leaders in every sector of the economy and with
stores, factories, offices, warehouses, and other operations in every
state, ERIC is the voice of large employer plan sponsors on federal,
state, and local public policies impacting their ability to sponsor
benefit plans and to lawfully operate under ERISA's protection from a
patchwork of different and conflicting state and local laws, in
addition to federal law.
You are likely to engage with an ERIC member company when you drive a
car or fill it with gas, use a cell phone or a computer, watch TV, dine
out or at home, enjoy a beverage, fly on an airplane, visit a bank or
hotel, benefit from our national defense, receive or send a package, go
shopping, or use cosmetics.
ERIC member companies voluntarily offer comprehensive health benefits
to millions of active and retired workers and their families across the
country. Our members offer these great health benefits to attract and
retain employees, be competitive for human capital, and improve health
and provide peace of mind. On average, large employers pay around 85
percent of health-care costs on behalf of our beneficiaries--that would
be a gold or platinum plan if bought on anExchange. But we don't buy or
sell health insurance; these plans are self-insured. In other words,
ultimately it is the company that is on the hook for the vast majority
of the costs of our patients' care. Prior to COVID-19, there were an
estimated 181 million Americans who got health care through their job,
with about 110 million of them in self-insured plans like ours.
Employers like ERIC member companies roll up their sleeves to improve
how health care is delivered in communities across the country. They do
this by developing value-driven and coordinated care programs,
implementing employee wellness programs, providing transparency tools,
and adopting a myriad of other innovations that improve quality and
value to drive down costs. These efforts often use networks to guide
our employees and their family members to providers that offer high
value care. ERIC member companies' ERISA plans are not subject to many
of the state and local requirements that apply to fully-insured
products such as those sold on an ACA Exchange, because employers do
not profit from health benefits--in fact, they're a huge expense.
The entire purpose of these benefits is to meet the needs of plan
beneficiaries. Large employers have been essential in connecting
employees and their families to programs and care such as through
telehealth benefits. ERIC's member companies have been pioneers in
offering robust access to telehealth. Telehealth enables our
beneficiaries to obtain the care they need, when and where they need
it, affordably and conveniently. It reduces the need to leave home or
work and risk infection at a physician's office, provides a solution
for individuals with limited mobility or access to transportation, and
has the potential to address provider shortages, especially related to
mental health, and improve choice and competition in health care. And
telehealth is an important tool to help minority communities connect
with doctors who share identity and culture, thus helping these
individuals feel comfortable accessing the health-care system, no
matter where they may be.
Nearly every ERIC member company offers comprehensive telehealth
benefits and did so long before the COVID pandemic. As in most aspects
of health insurance and value-driven plan design, self-insured
employers have been the early adopters and drivers of telehealth
expansion. With the onset of the pandemic, ERIC's member companies led
the way in rolling out telehealth improvements--held back only by
various federal and state government barriers. Congress should take
decisive action to consolidate the telehealth gains made by private
sector employees during COVID and consider expanding telehealth
policies to the private sector so that employees and their families can
access virtual care.
Federal Actions Greatly Improve Telehealth for Medicare Beneficiaries
but Leave the Private Sector Behind
Early on in the pandemic, the Administration and Congress quickly
realized that unnecessary barriers to telehealth care would be a
significant problem for Medicare beneficiaries. Many of those
individuals were quarantined or in areas undergoing lockdowns. Many
were in different states and regions that were experiencing peaks in
hospital and provider capacity. And Medicare's own coverage of
telehealth was nowhere near broad enough to replace much of the care
that would otherwise be foregone due to medical facilities being closed
to non-COVID patients.
The Administration and Congress acted quickly and decisively:
Medicare promptly eliminated state licensure barriers, allowing
a willing and qualified provider to see a willing Medicare patient via
telehealth, without regard to their locations;
Medicare promptly eliminated state telehealth barriers, such as
requirements that patients travel to specific originating sites before
they can access telehealth, limitations related to modality (e.g.,
video-only requirements, etc.), requirements that the provider and
patient have a pre-existing relationship, and more; and
Medicare expanded coverage to include more services for more
patients, covered via telehealth.
These changes massively improved telehealth benefits for Medicare
beneficiaries, instantly unleashing telehealth's vast potential to fill
the voids created by the pandemic and its response--and paving the way
for permanent improvement. In fact, in a December 4, 2020 letter, 49
Congressional leaders called for making these changes permanent. While
ERIC member companies are primarily outside of the Medicare system, we
support making these Medicare improvements permanent. We have endorsed
Senator Schatz's CONNECT for Health Act (S. 1512) to do just this.
Medicare's embrace of telehealth is a boon to private sector patients,
because it advances the creation of infrastructure, the adoption of
telehealth by more providers, and provides proof that telehealth
expansion can produce better access to care and savings.
Unfortunately, very few improvements have been made for patients in the
private sector not covered by Medicare, despite employer efforts to
expand and improve telehealth. Below we detail how private-sector
patients are harmed by the current situation and what the Committee and
Congress can do about it:
Care is still limited in many states only to a patient and provider
both physically located in that state. Many states have failed to join
interstate medical licensing compacts that provide reciprocity for
mental health and other medical providers in other states, expanding
the network of available providers for state beneficiaries to access.
Congress waived these requirements for Medicare and should do the same
for private sector beneficiaries or otherwise effectuate interstate
practice. While some states have signed limited interstate reciprocity
compacts, to recognize limited practice by limited types of providers,
many have provided little or no licensure relief.
Restrictive licensure rules help some providers by essentially
outlawing competition from out of state, but it hinders other providers
from expanding their practice. The failure to recognize interstate
medical licensure reciprocity for telehealth means that for many
patients, the state government has banned them from logging on to their
computer or smartphone and connecting with a readily available and
qualified provider.
Many states still impose unnecessary barriers to the use of
telemedicine. These barriers can range from requiring that a patient
travel to a specific telehealth site before they can connect to a
provider, limiting telehealth to specific technologies (for instance,
requiring two-way video, which may be out of reach by those in rural or
other areas without broadband access or the sophistication to work it,
outlawing the use of ``portals'' and store-and-forward communications
particularly helpful to identify skin conditions, pink eye, etc.),
mandating that a patient can only do a telehealth visit with a doctor
they already have a relationship with, and other barriers. While these
barriers may be imposed under the guise of setting a standard of care
or protecting patients, these requirements really serve to stymie
telehealth, driving more care to (more expensive) in-person settings--
or preventing patients from obtaining care at all--and hampering wider
telehealth adoption.
These restrictions also have significant equity impact creating
barriers that disproportionately affect low-income populations, persons
of color, or those with disabilities. At the same time, they serve to
protect profits for high-income professions.
Rules imposed by the federal government prevent employers from offering
telehealth to many beneficiaries. Employers generally cannot offer
telehealth as an employee benefit, separate from health coverage,
because, under Department of Labor regulations, telehealth benefits are
deemed to be ``a plan'' for the purposes of ACA rules. This
determination requires telehealth benefits to be paired with a full
medical benefit that meets all of the different ACA requirements--1st-
dollar coverage of vaccines, essential health benefits and annual limit
rules, and much more. Because telehealth is, by definition, limited and
conducted remotely, it simply cannot meet all of the ACA requirements
on its own.
To be clear, telehealth is not a ``modality'' of care. For employers,
it is often an entirely different benefit, part of a suite of programs
that are offered to employees and their families. In fact, employers
often use a separate vendor to design and administer their telehealth
benefits, rather than the insurance company or third-party
administrator that services their full medical plan. But the result of
treating this separate benefit as a ``group health plan'' is that
telehealth cannot be offered as a standalone to anyone not enrolled in
the full medical plan, which effectively bans employers from extending
telehealth to all populations, including:
Full-time employees who are not enrolled in the medical plan, or
employees' family members, if the employee is on a self-only plan;
Part-time employees ineligible for the medical benefit;
Seasonal, agricultural, or other temporary workers;
Interns, trainees, and the like; and,
New employees on a waiting period for the full medical plan,
among others.
ERIC notes that this is a serious anomaly--perhaps the first time in
living memory that beneficiaries of government programs have more
access, more flexibility, and in some ways, better benefits than
private sector workers on employer-sponsored plans. Employers are
generally the pioneers in health benefits, experimenting with and
leading the way in driving value, innovation, quality, and flexibility
for patients. Now, because of government barriers, private sector
workers are being left behind.
Administrative action has provided limited relief. On June 23, 2020,
the Department of Labor issued a Frequently Asked Question (FAQ Part
43)\1\ that for the first time, allowed employers to expand standalone
telehealth offerings, but with two key debilitating restrictions:
---------------------------------------------------------------------------
\1\ https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-
activities/resource-center/faqs/aca-part-43.pdf.
(1) Standalone telehealth may only be offered to individuals
---------------------------------------------------------------------------
ineligible for the full medical/surgical benefit; and
(2) Standalone telehealth may be offered to these individuals only
until the end of the public health emergency.
While this FAQ was a step in the right direction, it unfortunately
leaves a number of potential beneficiary cohorts behind (again, younger
workers and those of less economic means are hardest hit), while the
temporary nature served as a significant disincentive for large
employers to implement a major benefit change. It is critical that
Congress make permanent the allowance to offer standalone telehealth
benefits, and expand the offering to unenrolled individuals, in
addition to just those who are ineligible. If not, millions of people
will lose this benefit that has enabled them to access providers,
especially mental health providers, in a timely manner.
We will note one considerable improvement in telehealth that Congress
has made for private sector workers: individuals enrolled in a HDHP
with a health savings account (HSA) can now benefit from 1st-dollar
coverage of telehealth, thanks to the enactment of the ``Telehealth
Expansion Act'' (S. 3539), which was passed into law as part of the
CARES Act (H.R. 748). Unfortunately, this telehealth improvement is
time-limited and set to expire at the end of 2021.
Senators Daines (R-MT) and Cortez Masto (D-NV) have introduced a new
version of the Telehealth Expansion Act, which would make the CARES Act
policy permanent. ERIC strongly supports this legislation. We urge
Congress to swiftly pass the Daines-Cortez Masto bill, and make 1st-
dollar coverage of telehealth permanent, so that workers in these plans
can receive the care they need.
Key Steps the Finance Committee Should Consider to Improve Telehealth
The solutions to many of these problems are within the Committee's
jurisdiction, and employers look forward to continuing to provide
technical assistance to Congress to implement solutions. We urge the
Committee to advance provisions to address each of these barriers to
care for private sector workers and put them on equal footing with
Medicare beneficiaries.
First, Congress should pass the Temporary Reciprocity to Ensure Access
to Treatment (TREAT) Act (S. 168) and enable providers to practice
telehealth across state lines during the COVID-19 pandemic. Telehealth
use has drastically increased over the past year, and some state
licensing restrictions continue to disrupt patients' care. The TREAT
Act would provide temporary state licensing reciprocity for all
licensed and certified practitioners or professionals (those who treat
physical and mental health conditions) in all states for all types of
services (in-person and telehealth) during the COVID-19 Public Health
Emergency. A provider who has achieved a medical license in their own
state should be permitted to practice on the Internet, without states
blocking them from seeing patients--and likewise, a patient who goes
online to see a doctor should not be prevented by state rules from
seeing a qualified provider who is licensed in another state. States
should retain their rights to determine whether providers licensed in
that state will be qualified to write prescriptions or otherwise
develop a scope of practice. However, if a provider in another state
has been deemed qualified, a state should not be permitted to prevent
patients from seeing that provider or prevent the provider from
operating to the fullest extent of their license in that interaction.
For example, not allowing a qualified provider to prescribe medication
during a medical visit or discuss treatment options during a mental
health visit.
Congress should act immediately to ensure that patients who use
telehealth for physical and mental health services will have the best
chance of finding a provider ready and willing to see them on the other
end during the public health emergency. Mental health-care providers
prior to the pandemic were difficult to access, especially for those
not living in urban areas. More than 60 percent of rural Americans live
in mental health professional shortage areas, and the need for care has
only been exacerbated during the COVID-19 pandemic.
Congress' immediate action will enable more competition and access in
telehealth, creating incentives for providers to improve quality and
affordable access for patients. At a time when anxiety and depressive
disorders are at an ultimate high, access for patients is sorely needed
in offering mental health-care services through telehealth.
In the longer term, we urge Congress to enact a permanent solution to
interstate licensure. While this will require addressing some thorny
questions, we have seen significant leadership in the past with respect
to the issue. For instance, in a previous Congress, Congressmen Pallone
and Nunes introduced the TELE-MED Act \2\ to permanently allow
interstate practice for Medicare providers. Congress previously fixed
this issue in the realm of sports medicine as well. While there are
different possible paths forward (national reciprocity, a national
license, one comprehensive interstate compact with financial incentives
for states), employers urge Congress to work through this challenge and
come to consensus on a solution.
---------------------------------------------------------------------------
\2\ https://pallone.house.gov/press-release/pallone-and-nunes-
introduce-tele-med-act.
Second, Congress should establish a simple set of federal standards for
telehealth, eliminating state barriers. We can think of no better
example of interstate commerce than a willing doctor and willing
patient connecting electronically via the Internet to do a telehealth
visit. While it is entirely appropriate for a state to place standards
to regulate the practice of medicine at brick-and-mortar medical
facilities within the state's geographic boundaries, it makes little
sense to have 50 different sets of rules for telehealth (practiced
remotely on the Internet or via phone) depending on where a provider or
---------------------------------------------------------------------------
patient may be located at any given moment.
Congress can also develop a set of rules that protect patients while
maximizing flexibility and care, rather than some of the current
protectionist rules that serve to block patients from care on the state
level. The new set of rules should:
Allow telehealth to establish a patient-provider relationship
through an initial telehealth visit;
Apply the same medical standard of care used for in-person to
telehealth visits;
Ensure that reimbursement is privately negotiated between
providers and payers;
Encourage cross state practice among providers;
Promote continuity of care by encouraging telehealth providers
to coordinate with a patient's primary care provider and
interdisciplinary care team;
Implement ``technology-neutral'' rules for telehealth, to
``future-proof'' rules for advances in technology and best practices,
and eliminate discrimination for patients who may not have access to
broadband Internet or the sophistication to operate video, forward
information, etc.;
Eliminate all ``originating site'' requirements that arbitrarily
limit patient access to telehealth;
Preserve the same informed consent requirements for patients in
telehealth that apply in person; and
Ensure that telehealth providers may prescribe medication to
patients with reasonable limits.
This simple, streamlined set of rules will provide clarity to providers
and maximize access for patients.
Third, Congress should designate standalone telehealth as an ``excepted
benefit'' so that it can be offered to more patients. This is the way
Congress treats other ``add-on'' benefits like vision, dental, long-
term care, cancer-only plans, hospital indemnity insurance, and other
benefits that are health-related but do not constitute a full medical
plan. It would be a simple change by adding the word ``telehealth''
into the appropriate sections of the Internal Revenue Code (IRC), the
Public Health Service Act (PHSA), and the Employee Retirement Income
Security Act (ERISA).
Doing so would not affect an employer's responsibility to offer minimum
essential coverage to employees, nor would it weaken an individual's
responsibility to enroll in such. Employers or insurers could not swap
out telehealth, which is limited in scope and closer to a supplement
than a full medical plan, for a full medical benefit. It would simply
open up employers' ability to offer telehealth benefits to millions of
patients who currently are not allowed--by Congress--to access those
benefits. There is precedent for Congress expanding the definition of
excepted benefits (e.g., Congress previously acted to allow ``limited
duration long term care'' benefits to be offered outside a medical
plan).
In a recent survey, more than 25 percent of ERIC member companies
stated that they would expand telehealth offerings immediately if
Congress permitted it to be offered as a standalone benefit. This
represents billions of dollars in private sector money that is
currently being left on the table, and millions of Americans who could
have access to telehealth coverage and care, if only the government
would get out of the way. Many ERIC member companies are currently
taking advantage of the DOL FAQ allowing limited telehealth expansion,
but action by Congress could greatly increase these numbers, and thus,
greatly increase patients' access to care.
While the Committee considers telehealth advancements for the private
sector, more can be done for the millions of workers (approximately
half the workforce) with HDHP plans. Congress should allow patients
with a HDHP paired with a HSA to access worksite health centers via
1st-dollar coverage as well. Worksite health and wellness centers are
more critical today than ever before, as employers provide their
employees with more widespread and easy access to preventive and
primary care services, including vaccination and diagnostic testing
services at the workplace. And during COVID, many of these health
centers have gone virtual, providing care to workers throughout a given
region, not just confined to a specific worksite. However, under
current law, individual taxpayers may not contribute pre-tax dollars to
an HSA if they also receive certain supplemental health benefits, which
currently includes access to care at a worksite health center. The
resulting policy is that individuals with an HDHP are required to pay
the full price, no discounts, until they have paid through their full
deductible. It's unfair and counterproductive, when employers want our
beneficiaries to use the clinics. ERIC encourages Congress to address
the inequity by permitting individuals to both benefit from discounted
services offered at worksite employee centers and still be eligible to
participate in and provide pre-tax contributions to HSAs.
Counterproductive, Protectionist, Anti-Market Proposals: Worse Than
Doing Nothing
Meanwhile, some stakeholders are asking Congress to implement
telehealth changes that would go in the exact opposite direction,
eliminating competitive markets, promoting low-value care, and reducing
the potential for telehealth to be transformational for the medical
system.
For instance, the Health Care at Home Act would mandate ERISA health
plans to cover telehealth for any service that is covered in person, as
well as mandate that telehealth services be reimbursed at the same
amount as in-person services. Both of these changes fail to expand and
improve telehealth and instead would uproot the blossoming market.
Large employers that offer health coverage through ERISA plans make
decisions on services to cover based on clinical guidelines, evidence,
and best practices. We learn from experience, advice from medical
professional societies, bodies that evaluate quality and efficiency in
health care, and other sources, and then use this information to
develop benefits that drive the most value for our beneficiaries. The
prospect of government imposition of a sweeping coverage mandate within
ERISA plans would be an extreme break from precedent, not to mention a
counterproductive endeavor that would inject more unproven and
potentially low-value care into
employer-sponsored coverage. This, in turn, would reduce the quality of
coverage, while increasing costs for participants. It should be the
responsibility of ERISA plan sponsors, not the government, to determine
what care is appropriate to cover via telehealth settings.
Under current law, providers are free to negotiate telemedicine rates
with payers--which has given rise to a thriving market in which
competition drives cost efficiency, value, quality, and innovation. So,
it should come as no surprise that certain provider groups are eager to
destroy this market and instead set reimbursement by government fiat.
It is wholly inappropriate and unprecedented for the federal government
to mandate payment rates between two private parties.
Further, telehealth is cheaper than in-person care. Telehealth enables
providers to treat more patients more efficiently, with less overhead
cost, fewer staff, and lower expenses associated with operating brick-
and-mortar retail health settings. This has enabled telehealth
providers to offer more competitive rates than in-person, which has
been in no small part responsible for the telehealth renaissance. This
has caused many employers to adopt and offer telehealth benefits long
before the COVID emergency and driven the continuing exploration and
innovation that serves to produce ongoing improvements for patients.
Losing this successful competitive market would be a significant
setback for patients and employers, and ultimately for up-and-coming
providers who otherwise could cultivate opportunities in the telehealth
space.
Conclusion
Thank you for this opportunity to share our views with the Committee.
The ERISA Industry Committee and our member companies are committed to
working with Congress to expand and improve telehealth for millions of
patients in the private sector, and to defeat proposals that would
impose government mandates that make the situation worse, not better.
We look forward to working with you to develop and perfect telehealth
proposals that can be passed in Congress and signed into law by
President Biden.
______
Healthcare Leadership Council
750 9th St., NW, Suite 500
Washington, DC 20001
202-452-8700
May 20, 2021
The Honorable Ron Wyden The Honorable Mike Crapo
Chair Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC 20510 Washington, DC 20510
Dear Chair Wyden and Ranking Member Crapo:
On behalf of the Healthcare Leadership Council (HLC), we thank you for
holding a hearing on, ``COVID-19 Health Care Flexibilities:
Perspectives, Experiences, and Lessons Learned.''
HLC is a coalition of chief executives from all disciplines within
American health care. It is the exclusive forum for the nation's
health-care leaders to jointly develop policies, plans, and programs to
achieve their vision of a 21st century health-care system that makes
affordable high-quality care accessible to all Americans. Members of
HLC--hospitals, academic health centers, health plans, pharmaceutical
companies, medical device manufacturers, laboratories, biotech firms,
health product distributors, post-acute care providers, home care
providers, and information technology companies--advocate for measures
to increase the quality and efficiency of health care through a
patient-centered approach.
The COVID-19 public health emergency (PHE) has highlighted significant
challenges to current models of care delivery. The unprecedented
cooperation between private and public partners creating innovations in
care delivery, information sharing and improved coordination have
served as a guide for future pandemics. HLC thanks Congress and federal
agencies for their work on providing flexibilities so that stakeholders
were able to swiftly adjust to a changing environment. HLC encourages
the Committee to examine lessons learned from the following areas to
make meaningful improvement to health outcomes after the PHE ends:
Data Sharing
A successful COVID-19 response has required coordination among a
diverse set of public and private stakeholders. Each of these groups is
uniquely situated to respond to disaster scenarios. Leveraging their
individual strengths in a systemic, coordinated manner will lead to
greater successes. One critical area where such coordination could be
used is in data access and exchange. Public health officials require
real-time information on a variety of metrics (e.g., PPE levels,
hospital bed count, number of individuals vaccinated) so that they can
tailor their responses as necessary. Private sector health-care
organizations stand at the ready to provide input to government
officials on how best to share information in times of emergency to
support supply chain management and surge redeployment.
Telehealth
One of the greatest lessons from the COVID-19 health pandemic has been
the opportunity to deliver care through telehealth. State imposed stay-
at-home orders limited access to care to vulnerable populations, but
increased use of telehealth has helped to deliver care to these
populations. A recent study found that telehealth use increased over
3,000% during the 12 month period between October 2019 and October
2020.\1\ We greatly appreciate the flexibilities permitted by Congress
and the Department of Health and Human Services (HHS) to expand access
to telehealth services. These waivers, however, are only temporary and
are set to expire at the end of the current PHE. HLC encourages the
Committee to examine regulatory barriers to long-term telehealth use,
particularly the existing prohibition under Section 1834(m) of the
Social Security Act that prevents patients from receiving telehealth
services in their homes and other locations. Limiting where a patient
can access telehealth unnecessarily reduces care options for patients
already underserved by the U.S. health-care system. HLC also encourages
the Committee to examine how to further encourage telehealth use after
the PHE ends. Patients have been overwhelmingly satisfied with their
telehealth experiences and imposing additional regulatory barriers
would limit the ease of such care.\2\ HLC has concerns that adding
clinically unnecessary in-person requirements as a prerequisite to
receiving virtual care would limit the ability of providers to meet
patients where they are and extend access to underserved patient
populations that do not have an existing relationship with a provider.
We encourage the Committee to examine the impact on care for vulnerable
populations before any regulatory guardrails are imposed.
---------------------------------------------------------------------------
\1\ Iain Carlos, Telehealth claim lines jump 3,000% in 1 year,
Becker's Hospital Review (January 7, 2021), https://
www.beckershospitalreview.com/telehealth/telehealth-claim-lines-jump-3-
000-in-1-year.html.
\2\ Telehealth Patient Satisfaction Surges During Pandemic but
Barriers to Access Persist, J.D. Power Finds, J.D. Power (October 1,
2020), https://www.jdpower.com/business/press-releases/2020-us-
telehealth-satisfaction-study.
---------------------------------------------------------------------------
Workforce
The PHE has highlighted the need for a robust health-care workforce so
that it can be quickly scaled and deployed during future disaster
events. HLC supports legislation that would implement a federal waiver
of state licensure and allow for practice at the top of the scope of
license for physicians, nurses, pharmacists, pharmacy technicians and
other health-care professionals in times of disaster. This should also
allow health professionals to work in centralized locations to provide
services, including remote patient monitoring across state lines. We
also encourage Congress to examine legislation that would expedite the
visa authorization process for highly trained nurses who could support
hospitals facing staffing shortages, ensuring hospitals are better able
to respond to rising COVID-19 caseloads in the months ahead. An
adequate supply of nursing staff is critical for hospitals to maintain
services while ensuring that patients are properly cared for during the
public health emergency. The Healthcare Workforce Resilience Act is
critical to strengthening health systems' capacity as we continue to
combat the COVID-19 pandemic, the growing opioid crisis, and other
significant health challenges.
HLC, through its National Dialogue for Healthcare Innovation (NDHI)
initiative on Disaster Preparedness and Response has also partnered
with the Duke-Margolis Center for Health Policy to recommend future
strategies that will lead to better disaster readiness efforts. In this
report,\3\ we focus on three different areas: improving data and
evidence generation, strengthening innovation and supply chain
readiness and improving care delivery approaches. The report highlights
many of the current challenges public and private entities have had in
responding to the COVID-19 health pandemic and makes recommendations on
how to ease future burdens. HLC has also compiled a compendium \4\ of
best practices, highlighting the efforts of our members in responding
to disaster events such as the COVID-19 pandemic as well as natural
disasters.
---------------------------------------------------------------------------
\3\ https://www.ndhi.org/files/1816/1281/7553/
disaster_preparedness_report_FINAL.pdf.
\4\ https://www.hlc.org/wp-content/uploads/2021/02/DP-Compendium-
Final-Final.pdf.
HLC looks forward to working with you on developing lasting
flexibilities for health-care stakeholders so they can quickly respond
to disaster events. Please feel free to contact Tina Grande at
---------------------------------------------------------------------------
[email protected] or 202-449-3433 with any questions.
Sincerely,
Mary R. Grealy
President
______
HealthEquity
15 W. Scenic Pointe Dr.
Draper, UT 84020
P. 855-437-4727
F. 801-727-1005
https://www.healthequity.com/
[email protected]
May 18, 2021
The Honorable Ron Wyden The Honorable Mike Crapo
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
219 Dirksen Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510-6200 Washington, DC 20510-6200
Dear Chairman Wyden and Ranking Member Crapo:
We write to you today to thank you for holding a hearing entitled,
``COVID-19 Health Care Flexibilities: Perspectives, Experiences, and
Lessons Learned.'' Your attention to this critical issue is appreciated
by HealthEquity and by the millions of Americans who utilize telehealth
services.
HealthEquity administers health savings accounts (``HSAs'') and other
consumer-
directed benefits for more than 12 million accounts on behalf of
American workers. We partner with employers, benefits advisors, and
health and retirement plan providers who share our mission to connect
health and wealth and value our culture of remarkable ``Purple''
service.
In response to the COVID-19 pandemic, Congress included temporary
provisions in the CARES Act (Pub. L. 116-136) permitting an HSA-
eligible high deductible health plan to cover telehealth and other
remote services without a deductible or before the deductible has been
met. These temporary provisions providing access to vital care expire
at the end of 2021.
While these provisions are temporary, the growth in telehealth is
likely not. Surveys have shown explosive growth in telehealth since the
pandemic began:
A study in Health Affairs found that 30.1% of all health care
visits--a 23-fold increase--were conducted via telemedicine between
January and June 2020;\1\
---------------------------------------------------------------------------
\1\ Population of 16.7 million participants with commercial
insurance or a Medicare Advantage plan. https://www.healthaffairs.org/
doi/abs/10.1377/hlthaff.2020.01786?journalCode=hlthaff.
---------------------------------------------------------------------------
A coalition of self-insured plan sponsors reported a 28-fold
increase in telemedicine visits between January and May 2020;\2\ and
---------------------------------------------------------------------------
\2\ https://www.prnewswire.com/news-releases/patient-
officehospital-visits-down-telemedicine-visits-up-for-non-covid-19-
health-issues-based-on-claims-analysis-by-health-transformation-
alliance-301236052.html.
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A major telemedicine company reported a 156% increase in
appointments for 2020 compared to 2019.\3\
---------------------------------------------------------------------------
\3\ https://ir.teladochealth.com/news-and-events/investor-news/
press-release-details/2021/Teladoc-Health-Reports-Fourth-Quarter-and-
Full-Year-2020-Results/default.aspx.
These statistics show how critically important telemedicine has become.
Few observers believe the practice of medicine will return to the way
it was before COVID. As society and technology evolve, so should health
---------------------------------------------------------------------------
and tax policy.
We respectfully request that you make the CARES Act telehealth
provisions permanent and support the millions of Americans who have
found telemedicine to be a safe and effective means of receiving
medical care.
Thank you for your attention to this issue. We are happy to be of
assistance in any way.
Sincerely,
Jody L. Dietel, ACFCI, CAS, HSAe
Senior Vice President, Advocacy and Government Affairs
[email protected]
650-577-6372
______
Kaiser Permanente
One Kaiser Plaza, 27th Floor
Oakland, CA 94612
510-271-5999
June 3, 2021
The Honorable Ron Wyden
Chair
U.S. Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510
The Honorable Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510
RE: Kaiser Permanente statement for the record on the committee's May
19, 2021, hearing, ``COVID-19 Health Care Flexibilities: Perspectives,
Experiences, and Lessons Learned''
Dear Chair Wyden and Ranking Member Crapo:
On behalf of Kaiser Permanente, we thank you for holding the ``COVID-19
Health Care Flexibilities: Perspectives, Experiences, and Lessons
Learned'' hearing on May 19, 2021. We commend the committee for
addressing these important issues and offer this statement for the
record.
Kaiser Permanente comprises Kaiser Foundation Health Plan, Inc., the
nation's largest not-for-profit health plan, and its health plan
subsidiaries outside of California and Hawaii; the not-for-profit
Kaiser Foundation Hospitals, which operates 39 hospitals and 724
clinical facilities; and the Permanente Medical Groups, self-governed
physician group practices that employ more than 23,000 physicians and
exclusively contract with Kaiser Foundation Health Plan and its health
plan subsidiaries to meet the health needs of Kaiser Permanente's 12.5
million members.
The COVID-19 pandemic has demonstrated the potential of programs that
provide acute-level care in the home and the inherent value of making
such programs a durable feature of our health care delivery system. We
hope that you will find our experiences in implementing our Kaiser
Permanente Advanced Care at Home programs useful--particularly in the
dynamic and demanding environment of the COVID-19 pandemic--as you
consider policies to expand the availability of these beneficial
innovations to all patients.
Innovating home-based care. Over the past decade, Kaiser Permanente and
several other prominent, well-respected health-care organizations have
pioneered care models that enable patients to receive, from the comfort
of their own homes, care for acute and chronic conditions that
traditionally has been provided in hospital and other medical facility
settings. Many patients benefit immensely from this model of care,
including those with cancer, COVID-19, organ transplants, and chronic
illnesses such as renal failure. The model brings a range of hospital
equipment and services into the patient's home. This can include
infusions; skilled nursing services; medication delivery; and
laboratory, imaging, behavioral health, and rehabilitation services.
Kaiser Permanente at home. At Kaiser Permanente, we have provided safe
and effective advanced care at home for more than 500 patients across
several Kaiser Permanente regions since 2020, and we are working to
expand availability in the coming years. Leveraging advances in
technology that support the virtual delivery of health-care services,
the Kaiser Permanente Advanced Care at Home program temporarily
installs state-of-the-art technology in patients' homes, and our care
at home ``command centers'' direct and coordinate care delivered by our
Permanente Medical Group physicians and care teams. Our specialized
health-care teams deliver the same high-quality, hospital-level care in
patients' homes that they would receive during a traditional hospital
stay.
Through our programs, home-based patients can access their care teams
around-the-clock by phone and video; have their vital signs monitored
virtually; receive in-home visits with a nurse practitioner and other
clinicians such as community paramedics; and have diagnostic testing,
mobile imaging, and various therapies performed safely in their homes.
To facilitate patients' connections to their care teams, we also equip
them with devices and technology, which may include: a computer tablet
for video visits with their care team, a phone with a direct line to
their care team, an emergency-response bracelet, remote-monitoring
devices, and backup Internet access and power supply. Personnel
entering the home are trained to provide excellent patient care,
identify and address challenges associated with the social determinants
of health, and attend to any information technology questions that
might arise during the course of a medical episode. The command center
is staffed by physician specialists in hospital medicine, inpatient
nurses, and program coordinators who can assist patients with the
logistics of timely delivery of medications, materials, and personnel
into the home.
Better outcomes for patients. Programs that provide hospital-level care
at home have been shown to produce better outcomes for patients when
compared with in-hospital care. Several studies have found that home-
based patients had improved outcomes, including reduced lengths of
stay, readmissions, and mortality.\1\ These programs also mitigate the
health risks that patients can face during a traditional
hospitalization, including those from health care--acquired conditions
such as nosocomial infections, delirium, and other harm events.
Hospital care at home takes the infection prevention principles
afforded by a single room in a hospital to the next level of safety.
Delirium events can be reduced because elderly patients are not removed
from their familiar environment.\2\ Nationally, a third of hospitalized
patients will decline from their baseline functional status after a
traditional hospitalization.\3\ These patient harms--which can be the
direct result of hospital stays--are known to be costly, and they can
be reduced or avoided altogether by enrolling the patient in a program
that provides hospital-level care at home.
---------------------------------------------------------------------------
\1\ Johns Hopkins Medicine, ``Hospital at Home,''
www.johnshopkinssolutions.com/solution/hospital-at-home; The
Commonwealth Fund, `` `Hospital at Home' Programs Improve Outcomes,
Lower Costs But Face Resistance from Providers and Payers,''
www.commonwealthfund.org/publications/newsletter-article/hospital-home-
programs-improve-outcomes-lower-costs-face-resistance.
\2\ Caplan GA, Coconis J, Board N, Sayers A, Woods J. Does home
treatment affect delirium? A randomised controlled trial of
rehabilitation of elderly and care at home or usual treatment (The
REACH-OUT trial). Age Ageing. 2006 Jan;35(1):53-60.
\3\ Chodos AH, Kushel MB, Greyson SR, et al. Hospitalization-
associated disability in adults admitted to a safety net hospital. J
Gen Intern Med. 2015; Covinsky KE, Pierluissi E, Johnson CB.
Hospitalization-associated disability. JAMA Oct. 26, 2011;306(16).
Studies confirm that acute-care-at-home programs can result in cost
savings. For example, one study determined that the average cost of
hospital-level care at home was $5,081, compared with $7,480 for acute
hospital care.\4\ On average, these programs reduced costs by more than
$2,000, or 32%.\5\
---------------------------------------------------------------------------
\4\ Ibid.
\5\ Ibid.
Increased patient satisfaction. Acute care-at-home programs have also
been shown to enhance patient satisfaction with their care experience.
Patients overwhelmingly prefer to receive care at home when possible.
According to one national poll, 77% of Americans over the age of 40
would prefer to receive care in the familiar surroundings of their
homes.\6\ In our own experience with Kaiser Permanente Advanced Care at
Home, patients report satisfaction levels across key areas consistently
at or above national averages. On a scale of 1 to 100, our surveyed
patients rated their overall experience with Kaiser Permanente Advanced
Care at Home at 78 (compared with 73, nationally for all hospitalized
patients) and their willingness to recommend the program at 78
(compared with 72, nationally for all hospitalized patients).\7\
---------------------------------------------------------------------------
\6\ Associated Press and National Opinion Research Center at
University of Chicago, ``Long-Term Care in America: Expectations and
Preferences for Care and Caregiving,'' www.
longtermcarepoll.org/long-term-care-in-america-expectations-and-
preferences-for-care-and-caregiving.
\7\ Internal Kaiser Permanente data.
Advancing health equity. Programs that provide hospital-level care in
the home also advance health-care equity by enabling additional support
for more-vulnerable patients. Understanding patients' home environments
firsthand allows us to better assess patient needs related to social
determinants of health and enables the care team to treat the whole
person. When a patient needs additional support, such as healthy food
or transportation assistance, Kaiser Permanente can integrate this
critical information into their care plan and connect the patient to
available community resources to meet these needs, thereby promoting
better care and outcomes. The care team visiting a patient in the home
can assess the patient's diet, medication regimen, safety risks, and
other factors; and, where appropriate, they may intervene in those
underlying contributors to the medical condition in ways that are not
possible for facility-based patients. These valuable insights into the
patient's home environment and our enhanced ability to provide extra
support for their recovery would not be possible with a traditional
---------------------------------------------------------------------------
hospitalization.
Investments in advanced care at home. Kaiser Permanente has long been
an industry leader in developing and implementing home-based care
models, and we believe that this approach will continue to grow in
importance. For years we have provided traditional post-acute hospital
care, home health care, hospice services, and home therapies using
intravenous medications. Today's technologies now facilitate more
advanced, real-time monitoring that is scalable and cost effective. The
regulatory flexibilities issued in response to the pandemic have
allowed additional practitioners to extend the reach of traditional,
hospital-based care teams. The future holds tremendous opportunity to
provide seamless, high-quality, patient-
centered care outside of the four walls of a hospital. Programs that
safely bring acute care into the home environment are most likely to be
successful in the context of an integrated care system that manages the
continuum of care, inclusive of traditional inpatient and outpatient
services. Kaiser Permanente will continue to leverage our clinical
expertise in developing and improving these care delivery models for
our patients and communities and to share our insights for the benefit
of the health-care system at-large.
Policy investment in home-based care innovation. The COVID-19 pandemic
has accelerated the revolution in virtual health care, and these
advancements have been hard-won. In response to the pandemic, the
Department of Health and Human Services and the Centers for Medicare
and Medicaid Services implemented key policy waivers--Hospital Without
Walls and Acute Hospital Care at Home--that enabled providers such as
Kaiser Permanente to deliver patient-centered, high-quality acute care
seamlessly and safely in patients' homes. Currently, these waivers are
set to expire at the end of the public health emergency.
We believe that the time is now to make the investments that those
waivers have enabled a permanent part of health-care delivery in the
United States. We look forward to working with Congress, the Department
of Health and Human Services, and the Centers for Medicare and Medicaid
Services, including the Center for Medicare and Medicaid Innovation, to
accelerate the realization of the future of health-care delivery and
develop a permanent hospital-at-home model for Medicare and Medicaid
beneficiaries.
We thank you and the committee for your engagement on these critically
important issues affecting the future of our health care delivery
system. We would value the opportunity to provide additional
information to you and your staff. Please do not hesitate to contact
Laird Burnett in our Washington, DC office by calling (202) 236-7883,
or to contact either of us.
Very respectfully,
Anthony A. Barrueta Stephen Parodi, M.D.
Senior Vice President Executive Vice President
Government Relations External Affairs
Kaiser Foundation Health Plan, Inc. The Permanente Federation
Kaiser Foundation Hospitals
______
Medically Home Group, Inc.
133 Brookline Avenue
Boston, MA 02215
Chairman Wyden, Ranking Member Crapo, and Members of the Committee,
thank you for allowing Medically Home the opportunity to submit a
statement for the record on COVID-19 health-care flexibilities,
perspectives, experiences, and lessons learned. Particularly, our
statement will address Hospital Without Walls and Acute Hospital Care
at Home waivers and their impact on driving patient centered care
during the COVID-19 public health emergency (PHE).
Medically Home is a Boston-based company that enables hospitals and
health systems to safely care for acutely ill patients in the comfort
and safety of their own homes. Many patients benefit from this model of
care, also referred to as ``Hospital at Home,'' including cancer
patients, COVID-19 patients, transplant patients, and patients with the
exacerbation of chronic illnesses that plague millions of Americans
(e.g., COPD, heart failure, pneumonia, cellulitis, and many other
conditions acute enough to require inpatient level care and safe enough
to be provided at home).
Leading medical providers including Mayo Clinic and Kaiser Permanente
have relied on Medically Home to provide a platform to successfully
implement Hospital at Home programs that improve patients' health,
well-being, and experience, while reducing costs at the same time.
Medically Home's platform achieves these goals by providing clinical
and technological support to hospitals, and by coordinating the
delivery of medically appropriate and necessary equipment, medication,
and supplies to patients' homes on behalf of its hospital customers.
Our hospital partners, currently operating in 7 States, are using their
clinicians to provide care to their patients and receive reimbursement
from public and private payers. Given our unique experience working
with hospitals/providers to safely shift advanced medical care to the
home setting before and during the COVID-19 PHE, we believe we can
provide valuable input on the need to extend the telehealth, Hospital
Without Walls, and Acute Hospital Care at Home flexibilities on behalf
of patients across the country.
Unprecedented collaborations driven by COVID-19 and the opportunity to
expand hospital inpatient care in the home are important to note--
specifically Mayo Clinic and Kaiser Permanente announced last week
their partnership to enable more patients to receive acute care and
recovery services in the comfort, convenience, and safety of their
homes through their investment in, and partnership with, Medically
Home. Their collective goal is prioritizing the democratization of the
finest level of care by providing real time access to Hospital at Home
to rural and underserved communities, including Medicaid beneficiaries.
Today, Mayo Clinic, using Medically Home's platform is already
providing patient care in rural Wisconsin, with patients being referred
by multiple hospitals there, including a critical access hospital.
Perspectives: Background on Hospital at Home
Caring for acutely ill patients in their homes is not a new concept and
has existed for decades. However, the PHE has heightened and reaffirmed
the necessity for acute level services in the home. The telehealth,
Hospital Without Walls, and Acute Hospital Care at Home flexibilities
alleviated hospital overcrowding and, hence, mitigated the spread of
COVID-19.
With over 65 clinical trials published on Hospital at Home models,
previous research on Hospital at Home has indicated that patients who
received hospital care in the home had improved outcomes including
reductions in lengths of stay (LOS), readmissions, and mortality, as
well as increased patient satisfaction.\1\ Studies have also shown that
providing hospital services in the home has resulted in cost savings
and lower utilization. More specifically, they found the average cost
for Hospital at Home care was $5,081 compared to the average $7,480 for
acute hospital care.\2\
---------------------------------------------------------------------------
\1\ https://www.johnshopkinssolutions.com/solution/hospital-at-
home/; https://www.common
wealthfund.org/publications/newsletter-article/hospital-home-programs-
improve-outcomes-lower-costs-face-resistance.
\2\ Ibid.
Prior to the PHE, Hospital at Home had not been widely adopted due to
current regulatory barriers that limit Medicare reimbursement, and
therefore, discourage investment in the program. Specifically, the
interpretation of Section 482.23 of the Medicare Condition of
Participation for Nursing Services, which requires 24-hour nursing
services to be provided in person.
Experiences: Hospital Without Walls and Acute Hospital Care at Home
Waiver
Upon the onset of the COVID-19 pandemic, several leading health systems
took the initiative to implement Hospital at Home models to address the
emerging needs of their patients and communities.\3\ CMS announced
Hospital Without Walls to enable hospitals to provide inpatient
services outside of traditional inpatient settings, including the
patient's home. However, the interpretation of Section 482.23 of the
Medicare Condition of Participation for Nursing Services remained a
barrier.
---------------------------------------------------------------------------
\3\ See, e.g., At-Home Care Designed for COVID Likely Here to Stay
at Cleveland Hospital, available at, https://khn.org/news/at-home-care-
designed-for-covid-likely-here-to-stay-at-cleveland-hospital/; Mayo
Clinic to Launch National Hospital-at-Home Model, available at, https:/
/l.e.crainalerts.com/rts/go2.aspx?h=686177&tp=i-1NGB-E0-7AV-HEuj8-1n-
1efb-1c-HEsTa-l4mTp
LeEm0-dJjLK; Pandemic Forced Insurers to Pay for In-Home Treatments.
Will They Now Disappear?, available at, https://
www.leavenworthtimes.com/zz/news/20200616/pandemic-forced-insurers-to-
pay-for-in-home-treatments-will-they-now-disappear.
We applaud HHS for subsequently waiving this requirement via the Acute
Hospital Care at Home waiver, and we request Congress and HHS to
consider permanently extending this waiver to allow the 24-hour nursing
requirement to be fulfilled virtually. According to CMS data,\4\ since
announced in December 2020, the number of approved waivers has
increased to 129 hospitals, 56 hospital systems, in 30 states.
---------------------------------------------------------------------------
\4\ https://qualitynet.cms.gov/acute-hospital-care-at-home/
resources.
Due to this waiver being specific to the COVID-19 PHE and the upfront
investment (cost, time, etc.) required to operate a Hospital at Home
program, we believe participation will likely level off in the future
if there is no long-term extension of the waiver (or worse, without CMS
participation, some of these hospitals may stop offering the program
altogether). As well, those currently operating programs will lose
their investment and no longer receive Medicare payment for hospital
inpatient care provided in the home.
Lessons Learned: Regulatory Barriers Continue Outside of Current
Waivers
After the PHE ends, the home will no longer be a permissible
originating site for telemedicine and telehealth services, as well as
for acute level of care services. Extending the Hospital Without Walls
and telehealth flexibilities to allow the home to be a permissible
originating site for these services is critical to reduce stress on the
system, allow providers to determine the best and safest setting for
their patients to receive care, and improve access for patients in
rural and underserved communities.
We believe these regulatory flexibilities should be made permanent
beyond the PHE and will be an effective foundation for establishing
Medicare reimbursement that is specific to Hospital at Home services.
We applaud HHS for providing these flexibilities to ensure hospital
services in the home during the PHE, and we encourage Congress and HHS
to consider extending these flexibilities as a new model of care that
prioritizes patient safety, patient choice, and patient care needs
while providing access to those who need it most.
Recommendations: Future of Patient Centered Care Post-PHE
Beyond the PHE, the United States health system should move towards a
more resilient health-care delivery future where patients are empowered
to choose their homes as a location for their care because we now have
the technical and logistical capabilities to make safe and cost-
effective high quality inpatient care in the home a reality nationwide.
Moreover, equipping patients and hospitals with the flexibility to
determine the best and safest setting to receive care has been and will
continue to be critical for access to care and resiliency as hospitals
address the variations in patient demands, facility capacity, and
staffing following the PHE.
Maintaining the current waivers and flexibilities beyond the PHE will
be critical to optimize all efforts by our health-care systems to meet
the changing needs of their communities. The COVID-19 PHE has changed
the landscape of health-care delivery. The industry has discussed
innovations in telehealth and health-care delivery outside of
traditional care settings for some time, and the PHE has been a
catalyst for the industry's implementation of these new care delivery
methods (after all, Hospital at Home is not a new concept in health
care and has been practiced by some systems for the last 20 years).
These flexibilities have proven to be effective methods for care
delivery during the PHE and we are advocating for the extension of
these regulatory flexibilities to allow the model to fully scale.
Indeed, these tools make our health-care system more resilient and
accessible, enabling it to meet the operational and financial
challenges presented by the pandemic and other potential health
emergencies.
Extending these waivers is an important step towards advancing the
future of health-care delivery. Hospital at Home can offer a future
where patients and their providers can determine the most appropriate
care settings and provide population-specific targeted approaches to
care delivery. In 2017, the Physician-Focused Payment Model Technical
Advisory Committee (PTAC) recommended two Hospital at Home proposals to
the HHS Secretary for implementation: Mt. Sinai's Hospital at Home Plus
Model (HaH-Plus) and Marshfield Clinic's the Home Hospitalization: An
Alternative Payment Model for Delivering Care in the Home (HH-APM).
Former Secretary Azar had expressed interest in testing home-based,
hospital-level of care models and agreed with PTAC that these models
hold promise for testing. To date neither model has been implemented.
Medically Home and our partners are interested in developing similarly
proposed reimbursement pathways for Hospital at Home.
Conclusion
Due to the regulatory barriers outlined above, which will return post-
PHE, hospitals have been and/or will again be wary about and
disincentivized from implementing or scaling hospital at home. This
includes the access to care for underserved communities, and the
innovations and superior financial, clinical, and satisfaction outcomes
of providing acute level care in the home that Hospital at Home
provides. Therefore, we request Congress and HHS to consider a
permanent extension of the telehealth, Hospital Without Walls, and
Acute Hospital Care at Home waivers beyond the PHE to mitigate the
residual impacts of COVID-19 on public health and encourage broader
adoption of providing patient centered health-care services in the
home.
We again thank you for the opportunity to submit a statement for the
record to the Committee, on behalf of our hospital customers and their
patients across the country, we look forward to continuing to work with
Congress and HHS to ensure that access and quality care are available
to citizens during and beyond the PHE, as well as to further provide
groundwork for greater innovations in health-care delivery for the
future.
______
Moving Health Home Coalition
1100 H Street, NW
Washington, DC 20005
https://movinghealthhome.org/
June 2, 2021
The Honorable Ron Wyden
Chair
U.S. Senate
Committee on Finance
Washington, DC 20515
The Honorable Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
Washington, DC 20515
RE: Moving Health Home Testimony for Senate Finance Committee Hearing
on ``COVID-19 Health Care Flexibilities: Perspectives, Experiences, and
Lessons Learned''
On behalf of Moving Health Home (MHH), we appreciate your thoughtful
consideration of the COVID-19 flexibilities that allow clinical care to
be provided in the home during the Committee's hearing entitled,
``COVID-19 Health Care Flexibilities: Perspectives, Experiences, and
Lessons Learned'' held on Wednesday, May 19, 2021. MHH is a coalition
of pioneering health-care organizations with a bold vision to make the
home a site of clinical service. We are thankful for the opportunity to
submit testimony outlining the need for a temporary extension of the
Hospitals Without Walls (HWW) flexibilities to collect additional data
and lessons learned. However, a comprehensive Hospital at Home model is
needed to fully leverage the promise of home as a clinical site for
care.
We ask that Congress temporarily extend the HWW program for an
additional two years while simultaneously authorizing a permanent model
that allows hospitals to deliver inpatient hospital services to
Medicare beneficiaries at home.
The value of home care was demonstrated during the COVID-19 pandemic,
as continued to be seen as hospitals leverage temporary waivers to
offer a greater range of inpatient services in alternate sites of care,
including the home. To date, more than 100 hospitals have leveraged
temporary authority to deliver care outside their four walls; 132
hospitals and 58 health systems across 31 states are delivering care to
patients in their homes through the Acute Hospital Care at Home (AHCAM)
waiver.\1\, \2\ Hospital at Home programs have been studied
for decades both in the United States and internationally. The research
overwhelmingly demonstrates that Hospital at Home programs are at least
as safe as traditional in-patient care, improve clinical outcomes and
patient satisfaction, and reduce the total cost of care.
---------------------------------------------------------------------------
\1\ https://qualitynet.cms.gov/acute-hospital-care-at-home/
resources.
\2\ https://www.gao.gov/assets/gao-21-575t.pdf.
---------------------------------------------------------------------------
Background: Hospitals Without Walls Flexibilities and Acute Hospital
Care at Home Waiver
In March 2020, the Centers for Medicare and Medicaid Services (CMS)
introduced the Hospitals Without Walls (HWW) initiative, which provided
broad regulatory flexibility for hospitals to provide services in
locations beyond their existing walls. This temporary, blanket waiver
authority is focused on reducing hospital capacity to better address
COVID-19.
Later that year in November, CMS announced the Acute Hospital Care at
Home (AHCAH) program that would cover hospital-level care at home for
Medicare fee-for-service (FFS) beneficiaries at approved sites. This
temporary, individual waiver requires that prospective health systems
apply to the program and are subject to approval by CMS based on their
ability to meet certain requirements. The HWW initiative built the
foundation for the AHCAH program, operating sequentially.
Comprehensive Hospital at Home Model Is Needed
With the help of nearly 25 leading health-care organizations and
experts in the field, MHH is advocating for legislation that would
permanently implement a Medicare Hospital at Home program, which is
currently in draft form. MHH's proposal is built on decades of research
and would allow for sustainable, long-term adoption of inpatient
services at home designed to improve patient experience and outcomes,
reduce federal spending, and increase access and patient choice.
That said, MHH asks that Congress temporarily extend the HWW program
for an additional 2 years while simultaneously authorizing a permanent
model that allows hospitals to deliver inpatient hospital services to
Medicare beneficiaries at home. While MHH is supportive of a two-year
extension of the HWW flexibilities, including the AHCAH program, we
believe it is not the correct long-term solution for broad adoption of
inpatient services at home for the following reasons:
- We Should Not Build Programs Based on Waivers--Temporary waivers
are a bridge to enable care in the home to continue for a time-limited
period post-pandemic, but do not fully leverage the promise of home-
based care. They continue to rely on fee-for-service payment, while our
goal would be to integrate a value-based mechanism into the program.
- Hospital at Home Models Reduce Costs--Home care models that
combine inpatient hospital services with post-acute care post-discharge
from the home can result in 44 percent lower total cost of care.\3\ In
general, Hospital at Home programs have realized savings of 30 percent
or more per admission, while maintaining equivalent or better
outcomes.\4\
---------------------------------------------------------------------------
\3\ https://www.carecentrix.com/news/avalere-report-finds-
carecentrix-model-of-post-acute-care-lowers-total-cost-of-care-by-
improving-outcomes-and-reducing-readmissions-ed-visits.
\4\ https://pubmed.ncbi.nlm.nih.gov/16330791/.
- Hospital at Home Models Improve Quality--Quality results for
care in the home are comparable to or better than those realized for
facility-based care. Published data of Hospital at Home programs from
across the U.S. demonstrate reduction in average length of stay by one-
third, readmissions by 24 percent, mortality by 20 percent,
complications (e.g., delirium and falls), and emergency department
visits.\5\, \6\, \7\, \8\
---------------------------------------------------------------------------
\5\ https://www.commonwealthfund.org/publications/newsletter-
article/hospital-home-program-new-mexico-improves-care-quality-and-
patient.
\6\ https://www.acpjournals.org/doi/10.7326/M19-0600.
\7\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6143103/.
\8\ https://pubmed.ncbi.nlm.nih.gov/16330791/.
- Consumers Prefer to Receive Care in the Home--The pandemic has
taught us that home-based care is preferred by many patients. According
to a recent study, 61 percent of seniors would like to receive health-
care services in their home.\9\ Long before COVID-19, evidence pointed
to home as a preferred site of care, including a study that found three
in four adults 50 years and older would prefer to age in their homes
and communities.\10\
---------------------------------------------------------------------------
\9\ https://www.signifyhealth.com/blog/for-older-americans-the-
home-must-become-a-choice-for-patients.
\10\ https://www.aarp.org/research/topics/community/info-2018/2018-
home-community-preference.html.
- Pandemic Experience Has Further Demonstrated it Is Safe to
Provide Care in the Home--The pandemic caused an explosion of home-
based care, in part due to regulatory flexibilities such as the AHCAH
waiver. Early data comparing pre-pandemic to now show that utilization
of home- based services, such as home visits, has increased sevenfold
in some cases.\11\ These experiences demonstrate that care in the home
is possible and safe.
---------------------------------------------------------------------------
\11\ https://academic.oup.com/gerontologist/article/61/1/78/
5921231.
Building on the longstanding evidence base, the success of delivering
more care at home during the pandemic, and patient preference for home-
based care, Congress has an opportunity to act by temporarily extending
the HWW program for an additional two years while simultaneously
authorizing a permanent model that allows hospitals to deliver
---------------------------------------------------------------------------
inpatient hospital to Medicare beneficiaries at home.
Thank you again for holding this important hearing and for your
thoughtful deliberation on how your committee can enable Americans the
freedom to choose home as a clinical site of care. We look forward to
working with you on this critical effort. Please contact Jeremiah McCoy
at [email protected] with any questions.
Sincerely,
Krista Drobac
Founder
______
National Association of Chain Drug Stores
1776 Wilson Blvd., Suite 200
Arlington, VA 22209
703-549-3001
www.nacds.org
Statement of Steven C. Anderson, FASAE, CAE, IOM,
President and Chief Executive Officer
Introduction
The National Association of Chain Drug Stores (NACDS) appreciates the
opportunity to submit a statement for the record for the Senate Finance
Committee's hearing, ``COVID-19 Health Care Flexibilities:
Perspectives, Experiences, and Lessons Learned.'' NACDS represents
nearly 40,000 pharmacies (traditional drug stores, supermarkets and
mass merchants with four or more pharmacies) who employ nearly 3
million individuals, including pharmacists and pharmacy technicians,
among others.
NACDS commends the Committee's work to build better health by
considering flexibilities granted during the Public Health Emergency.
The nation called on pharmacies to deliver COVID-19 testing,
vaccination, and other critical preventive care services to communities
during the pandemic. Pharmacies seamlessly rose to the challenge, in
large part due to more than a decade of pandemic preparedness and
collaborative planning. Importantly, the COVID-19 flexibilities granted
to pharmacies were instrumental in driving better health and fostering
equity across communities. In reviewing lessons learned with an eye
toward the future, these flexibilities should be made permanent to
foster sustained and equitable access to pharmacy care.
I. A Decade of Pharmacy Preparedness Significantly Strengthened the
Nation's COVID Response
Pharmacies have spent the last decade building upon lessons learned
from the 2009 H1N1 pandemic, including piloting pharmacy vaccination
strategies. These planning efforts across industry and government paved
the way for pharmacy's central position in the nation's COVID-19
response.
Consider these highlights demonstrating how this preparedness
translated into results for communities across America:
Vaccination: Building on years of pandemic planning and
exercises, the Federal Retail Pharmacy Program (FRPP) was established
to leverage pharmacy's strengths for public benefit:
Americans can conveniently get COVID-19 vaccines
at 40,000 pharmacies nationally thanks to the FRPP, leveraging 21
national pharmacy chains and independent pharmacy networks.\1\
---------------------------------------------------------------------------
\1\ https://www.cdc.gov/vaccines/covid-19/retail-pharmacy-program/
index.html.
---------------------------------------------------------------------------
More than 40% of these sites are already in zip
codes with high social vulnerability--a Centers for Disease Control and
Prevention (CDC) index identifying communities needing more care.\2\
---------------------------------------------------------------------------
\2\ https://www.whitehouse.gov/briefing-room/statements-releases/
2021/03/29/fact-sheet-president-biden-announces-90-of-the-adult-u-s-
population-will-be-eligible-for-vaccination-and-90-will-have-a-
vaccination-site-within-5-miles-of-home-by-april-19/.
---------------------------------------------------------------------------
In March, a fraction of these pharmacies provided
over 5 million vaccinations in just 4 days.\3\ And, recent data show
that of all FRPP vaccination doses 46% have been administered to people
of color.\4\
---------------------------------------------------------------------------
\3\ https://www.politico.com/news/2021/03/29/covid-vaccine-sites-
478233.
\4\ President Biden Meets Virtually with a Bipartisan Group of
Governors. Remarks by Dr. Nunez-Smith. May 11, 2021. https://
www.youtube.com/watch?v=e-8oTbbPA94.
Testing: Pharmacies ramped up across states establishing more
than 6,000 live testing sites that processed nearly 10 million samples
under a public-private partnership with the Department of Health and
Human Services (HHS).\5\
---------------------------------------------------------------------------
\5\ By the Numbers--Coronavirus Pandemic Whole-of-America Response.
March 8, 2021. https://content.govdelivery.com/attachments/USDHSFEMA/
2021/03/09/file_attachments/171
7220/By%20the%20Numbers.COVID.FINAL.Mar.%208.2021.pdf.
---------------------------------------------------------------------------
Nearly three-quarters of these sites serve areas
with moderate to high-social vulnerability.\6\
---------------------------------------------------------------------------
\6\ https://www.hhs.gov/about/news/2021/01/07/hhs-continues-
community-based-testing-sites-covid-19.html.
Everyday Care: Beyond providing COVID-19 vaccinations and
testing, pharmacies kept their doors open throughout the pandemic,
offering needed preventive care, dispensing critical medications,
administering routine and catch-up vaccinations to adults and children,
and providing patients with education and referrals.
II. Critical Flexibilities Paved Way for Expanded Access to COVID-19
Care at Pharmacies
The significant contributions made by pharmacies in supporting their
communities throughout the COVID-19 pandemic were largely made possible
by flexibilities granted during the Public Health Emergency.
Specifically, federal actions taken under the PREP Act \7\,
\8\, \9\ leveraged pharmacies to provide enhanced public
access to COVID-19 testing, COVID-19 vaccines, and routine and catchup
vaccines for those 3-18 years old. Such actions, along with Congress
requiring health insurers to cover COVID-19 testing and vaccination
costs without out-of-pocket expenses,\10\ were monumental.
Collectively, these actions unleashed pharmacy teams from onerous and
unnecessary federal and state barriers that have historically
prohibited them from providing such services to populations more
broadly. These actions also removed cost barriers for patients.
---------------------------------------------------------------------------
\7\ U.S. Department of Health and Human Services, August 2020,
available at HHS Expands Access to Childhood Vaccines during COVID-19
Pandemic.
\8\ U.S. Department of Health and Human Services, October 2020,
available at Advisory Opinion 20-03 on the Public Readiness and
Emergency Preparedness Act and the Secretary's Declaration under the
Act.
\9\ U.S. Department of Health and Human Services. (December 2020).
Fourth Amendment to the Declaration Under the Public Readiness and
Emergency Preparedness Act for Medical Countermeasures Against COVID-19
and Republication of the Declaration, available at https://www.phe.gov/
Preparedness/legal/prepact/Pages/4-PREP-Act.aspx.
\10\ https://www.healthaffairs.org/do/10.1377/hblog20200326.765600/
full/.
Briefly, a high-level overview of flexibilities that were instrumental
---------------------------------------------------------------------------
for expanding access to care at pharmacies include:
COVID-19 Testing at Community Pharmacies: Critical actions taken
by Congress, HHS, and the Centers for Medicare and Medicaid Services
(CMS) abolished barriers in a stepwise manner to accelerate
availability of pharmacy-based COVID-19 testing locations. Effectively,
this helped spearhead efforts to break down barriers to pharmacy-based
testing across many states and expand community access to the clinical
expertise of pharmacies.
Through multiple actions under the PREP Act, HHS
authorized pharmacists to order and administer COVID-19 tests, and to
leverage pharmacy technicians for COVID-19 testing.\11\,
\12\ HHS further clarified that federal guidance under the PREP Act
preempts any state or local restrictions.\13\ Additionally, CMS
released guidance supporting pharmacy enrollment in Medicare as CLIA
labs \14\ and limiting cost sharing for COVID-19 testing.
---------------------------------------------------------------------------
\11\ Guidance for Licensed Pharmacists, COVID-19 Testing, and
Immunity under the PREP Act. (April 2020). https://www.phe.gov/
Preparedness/legal/prepact/Documents/pharmacist-guidance-COVID19-PREP-
Act.pdf.
\12\ U.S. Department of Health and Human Services Office of the
Assistant Secretary for Health. October 20, 2020. Guidance for PREP Act
Coverage for Qualified Pharmacy Technicians and State-Authorized
Pharmacy Interns for Childhood Vaccines, COVID-19 Vaccines, and COVID-
19 Testing. https://www.hhs.gov/sites/default/files/prep-act-
guidance.pdf.
\13\ https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-
documents/advisory-opinion-20-02-hhs-ogc-prep-act.pdf.
\14\ See Section 6003 of the Families First Coronavirus Response
Act and Section 3713 of the CARES Act.
COVID-19 Vaccinations and Routine Childhood Vaccinations at
Pharmacies: Similar to testing, the federal government took critical
actions to clear the pathway for vaccinations at pharmacies throughout
the pandemic. Doing so removed barriers that otherwise would have
greatly limited the pharmacy team's ability to serve the public.
In addition to expanding access to COVID-19
vaccination, HHS aimed to improve childhood vaccination rates--hindered
by stay-at-home orders and a decline in provider office visits. This
was accomplished by expanding the ability for the pharmacy team
(pharmacists, pharmacy interns, and pharmacy technicians) to provide
immunizations to children more comprehensively across states.\15\ This
action was further clarified and reaffirmed by the
agency.\16\, \17\
---------------------------------------------------------------------------
\15\ U.S. Department of Health and Human Services. (August 2020).
HHS Expands Access to Childhood Vaccines during COVID-19 Pandemic.
\16\ U.S. Department of Health and Human Services. (October 2020).
Advisory Opinion 20-03 on the Public Readiness and Emergency
Preparedness Act and the Secretary's Declaration under the Act.
\17\ U.S. Department of Health and Human Services. (December 2020).
Fourth Amendment to the Declaration Under the Public Readiness and
Emergency Preparedness Act for Medical Countermeasures Against COVID-19
and Republication of the Declaration. https://www.phe.gov/Preparedness/
legal/prepact/Pages/4-PREP-Act.aspx.
---------------------------------------------------------------------------
Specifically, these actions authorized:
Pharmacists to order and administer, and appropriate
pharmacy staff to administer, Advisory Committee on Immunization
Practices (ACIP)-recommended childhood vaccines for persons 3-18 years
old; and Food and Drug Administration (FDA)-authorized or FDA-licensed
COVID-19 vaccinations to persons ages 3 and older.\18\
---------------------------------------------------------------------------
\18\ https://www.hhs.gov/sites/default/files/third-amendment-
declaration.pdf; https://www.
hhs.gov/sites/default/files/licensed-pharmacists-and-pharmacy-interns-
regarding-covid-19-vaccines-immunity.pdf; and https://www.hhs.gov/
sites/default/files/prep-act-guidance.pdf.
These government actions supporting pharmacy-based immunization and
COVID-19 testing have been paramount in helping smooth the complex and
erratic nature of state-by-state rules and regulations. The existing
patchwork outside of temporary flexibilities can create significant
patient access barriers, especially in states that have yet to
modernize their statutory limits. While not all barriers have been
abolished, pharmacies have leveraged these flexibilities effectively to
operationalize broader delivery of care services.
III. Recommended Permanent Changes to Drive Health and Foster Equity
Beyond the COVID-19 Pandemic
Communities have long relied on pharmacies to deliver quality care to
all populations, including the high-risk and socially
vulnerable.\19\, \20\ Through the COVID-19 response, the
nation has built an infrastructure that allows Americans to benefit
from quality, accessible, and equitable pharmacy care services. As we
shift to COVID-19 becoming endemic and a return toward a focus on
routine care services, communities ought to maintain their access to
pharmacy care. And, as we look ahead to the next pandemic, tremendous
opportunities exist to transform these flexibilities from temporary to
permanent, preventing duplicative efforts in the future. NACDS urges
Congress to retain and build on the existing flexibilities to implement
permanent pharmacy authority and payment mechanisms. Doing so would
help Americans continue reaping the benefits of care services at
pharmacies they know and trust into the future.
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\19\ Gaskins RE. Innovating Medicaid: The North Carolina
Experience, NC Med J. 2017, available at https://www.ncbi.nlm.nih.gov/
pubmed/28115558.
\20\ Berenbrok LA, Gabriel N, Coley KC, Hernandez I., Evaluation of
Frequency of Encounters With Primary Care Physicians vs Visits to
Community Pharmacies Among Medicare Beneficiaries, JAMA Netw Open.
2020;3(7):e209132, available at doi:10.1001/jamanetworkopen.
2020.9132.
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Conclusion
As we look beyond the COVID-19 pandemic, pharmacies will continue to be
important care destinations for patients. Health equity will rightfully
remain a driving force in health care moving forward with care
destinations, like pharmacies, meeting patients where they are.
Further, mental health and substance abuse likely will emerge as
lasting behavioral health impacts of the pandemic. We raise these
forward leaning issues to say that pharmacies have experience providing
destigmatizing care and routinely provide for patients essential
screenings, counseling, treatment, and linkage to care. Oftentimes,
pharmacies are the entry point for patients into the health-care
system, further underscoring their value on a patient's health-care
team. As the COVID-19 response shifts into recovery, pharmacies
continue to serve their communities on the frontlines to meet their
evolving health-care needs.
NACDS thanks the committee for the opportunity to offer our support for
your tremendous work. We implore you to build on these lessons learned
by transforming temporary flexibilities into permanent pharmacy
authority and payment mechanisms to support the health and wellness of
Americans beyond the pandemic. We welcome the opportunity to discuss
these issues further. Please reach out to NACDS' Chris Krese, Senior
Vice President of Congressional Relations and Communications at
[email protected] or 703-837-4650.
______
National Indian Health Board
910 Pennsylvania Ave., SE
Washington, DC 20003
Chairman Wyden, Ranking Member Crapo, and Members of the Committee,
thank you for holding this critical hearing ``COVID-19 Health Care
Flexibilities: Perspectives, Experiences, and Lessons Learned.'' On
behalf of the National Indian Health Board (NIHB) and the 574
federally-recognized sovereign American Indian and Alaska Native (AI/
AN) Tribal Nations we serve, NIHB submits this testimony for the
record.
Background--COVID-19 Flexibilities and Impact in Indian Country
As of June 1, 2021, the Indian Health Service (IHS) reported 197,459
positive COVID-19 cases, with a cumulative percent positive rate of
8.8% across all 12 IHS Areas.\1\ However, IHS numbers are highly likely
to be underrepresented because case reporting by Tribally-operated
health programs, which constitute roughly two-thirds of the Indian
health system, are voluntary. According to data analysis by APM
Research Lab, AI/ANs are experiencing the second highest aggregated
COVID-19 death rate at 51.3 deaths per 100,000. On March 12, 2021, the
CDC reported that AI/ANs were 3.7 times more likely than non-Hispanic
white people to be hospitalized and 2.4 times more likely to die from
COVID-19 infection. Reporting by state health departments has further
highlighted disparities among AI/ANs
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\1\ Indian Health Service. COVID-19 Cases by IHS Area. https://
www.ihs.gov/coronavirus/.
According to the Centers for Disease Control and Prevention
(CDC), AI/AN People are 1.7 times (70%) more likely to be diagnosed
with COVID-19 when compared to non-Hispanic white people.
According to the CDC, AI/ANs are 3.7 times (370%) more likely to
require hospitalization when compared to non-Hispanic white people.
According to the CDC, AI/ANs are 2.4 times (240%) more likely to
die from COVID-19-related infection when compared to non-Hispanic white
people.
There have been 6,206 AI/AN deaths related to COVID-19
complications since the pandemic was declared. Nearly 60% of these
deaths are from New Mexico, Arizona, and Oklahoma.\2\
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\2\ National Indian Health Board. May 26, 2021. CDC Provisional
Death Report, 6,533 Deaths, an increase of 51 weekly Deaths. https://
public.tableau.com/app/profile/nihb.edward.fox/viz/
May262021CDCProvisionalDeathReport6533Deathsanincreaseof51weeklyDeaths/
May262021CDC
ProvisionalDeathReport6533Deathsanincreaseof51weeklyDeaths_.
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In Alaska, 34.8% of the total state's deaths are reported to be
AI/ANs.\3\
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\3\ National Indian Health Board. May 26, 2021. CDC Provisional
Death Report, 6,533 Deaths, an increase of 51 weekly Deaths. https://
public.tableau.com/app/profile/nihb.edward.fox/viz/
May262021CDCProvisionalDeathReport6533Deathsanincreaseof51weeklyDeaths/
May262021CDC
ProvisionalDeathReport6533Deathsanincreaseof51weeklyDeaths_.
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The disparity in COVID-19-related death rates is not evenly
shared across all AI/AN age groups. Young AI/ANs are experiencing the
most significant disparities. Among AI/ANs aged 20-29 years, 30-39
years, and 40-49 years, the COVID-19-related mortality rates are 10.5,
11.6, and 8.2 times, respectively, higher when compared to their white
counterparts.\4\
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\4\ Arrazola J, Masiello MM, Joshi S, et al. COVID-19 Mortality
Among American Indian and Alaska Native Persons--14 States, January-
June 2020. MMWR Morb Mortal Wkly Rep 2020;69:1853-1856. DOI: http://
dx.doi.org/10.15585/mmwr.mm6949a3external icon.
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Across 23 states, the cumulative incidence rate of laboratory-
confirmed COVID-19 infections was 3.5 times (350%) higher among AI/ANs
persons than non-
Hispanic white persons.\5\
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\5\ Hatcher SM, Agnew-Brune C, Anderson M, et al. COVID-19 Among
American Indian and Alaska Native Persons--23 States, January 31-July
3, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1166-1169. DOI: http://
dx.doi.org/10.15585/mmwr.mm6934e1.
Unfortunately, the adverse effects of COVID-19 in Indian Country extend
beyond these sobering public health statistics. Collectively, the IHS,
Tribal, and Urban health system (known as the I/T/U), has been
chronicly underfunded since its inception, and has relied on third-
party revenue to stay afloat. Despite its underfunding, Indian Health
Care Providers (IHCPs) have found innovative ways to provide quality
care, even during the pandemic. The I/T/U system has taken full
advantage of the flexibilities that CMS extended, allowing for leverage
of new technologies; and recouping what would have otherwise been lost
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revenue, which is sorely needed.
One key flexibility is the ``Four Walls'' waiver that is extended
through October 2021.This waiver, while not direcetly a result of the
pandemic, has been crucial for the I/T/U system in dealing with COVID-
19 This extension allows I/T/U clinics to receive the Medicaid 100%
Federal Matching Assistance Percentage (FMAP) for services provided to
an AI/AN Medicaid Beneficiary at sites outside the ``for walls'' of a
clinic. These external sites can include remote vaccination and testing
sites that have been commonplace in the public health emergency and
allow treatment in otherwise underserved communities. These ancillary
sites for care have long been important to providing quality care
throughout Indian Country. Still, once this extension expires, an
essential source of revenue for the I/T/U system will be diminished.
Telehealth has proven to be an invaluable tool to provide quality care
during the public health emergency, and the flexibilities for its usage
and reimbursement have been crucial to its expanded adoption. According
to IHS, since initiating telehealth expansion, the agency has
experienced an 33-fold increase in telehealth visits.\6\ Additionally,
the Government Accountability Office (GAO) released a report analyzing
the federal response to COVID-19, showing IHS allocated $95 million of
the $1.032 billion in total funding received under the CARES Act toward
telehealth. While this adoption of telehealth as an alternative to in-
person care is useful, much of Indian Country faces structural
challenges to leveraging this new technology. Due to a significant lack
of broadband infrastructure, only 46.6% of houses on Tribal lands have
access to fixed terrestrial broadband at standard speeds established by
the Federal Communications Commission (FCC).\7\ Many of our Tribal
citizens are unable to access necessary telehealth-based care from the
safety of their homes.
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\6\ Todet, R.A.M. (2021, April 28). IHS expanded telehealth to
provide care during COVID-19 pandemic. Indian Health Service Newsroom.
https://www.ihs.gov/newsroom/ihs-blog/april2021
/ihs-expanded-telehealth-to-provide-care-during-covid-19-pandemic/.
\7\ U.S. Department of the Interior. (2020). Expanding Broadband
Access. Indian Affairs. https://www.bia.gov/service/infrastructure/
expanding-broadband-access.
Our Tribal communities have endured a great many pandemics and
tragedies in our history. Our people experience significant historical
and intergenerational trauma resulting from genocide, forced relocation
from our homelands, forced assimilation into western culture, and
persecution of our Native cultures, customs, and languages. As a
result, AI/ANs experience some of the highest rates of suicide, drug
overdose, post-traumatic stress, and mental illness compared to all
other races. While Indian Country remains resilient and committed to
solutions, the COVID-19 emergency has reignited the historical trauma
experienced at the hands of historical plagues such as smallpox and
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tuberculosis.
Congress reaffirmed the federal trust responsibility for health care
under the permanent reauthorization of the Indian Health Care
Improvement Act (IHCIA) when it declared that ``. . . it is the policy
of this Nation, in fulfillment of its special trust responsibilities
and legal obligations to Indians . . . to ensure the highest possible
health status for Indians and urban Indians and to provide all
resources to effect that policy.''
It is essential to remember that these obligations exist in perpetuity.
As such, the federal government must ensure that Tribes are
meaningfully and comprehensively included in any congressional review
of COVID-19 flexibilities and support. While we appreciate the
resources and flexibilities allocated for Indian Country thus far--
including the $1.032 billion appropriated to Indian Health Service
(IHS) under the CARES Act, the $64 million under the Families First
Coronavirus Response Act, the $1 billion under the Consolidated
Appropriations Act of 2021, and the $6.094 billion under the American
Rescue Plan--these one-time additional funding increases and temporary
regulatory flexibilities are not sufficient to stem the tide of decades
of underfunding and neglect.
Policy Recommendations
To ensure that the efficiencies in health-care delivery, put in place
as a response to the public health emergency, are built upon and not
lost, we urge the committee to pass the following policy priorities.
1. Amend the Social Security Act to ensure that all services
provided through an Indian health-care program are eligible for
reimbursement at the OMB all-inclusive rate.
In 2016, CMS issued a Dear State Health Official (SHO) letter
explaining that only services rendered within the Four Walls of an IHS
or Tribal (I/T) clinic are eligible for Medicaid reimbursement at the
all-inclusive rate (100% FMAP). CMS's interpretation means that if a
service is rendered outside the Four Walls of a clinic by an IHS or
contracted provider, the provided health service is not eligible for
the same reimbursement under Medicaid. It is common practice within the
Indian health-care system to use an ancillary site (like a school) or
send providers into the community to deliver health-care services. In
the SHO letter, CMS offered a solution that requires two actions, one
by the Indian health program and another by the State Medicaid Agency.
If IHS or Tribal clinics want to receive the ``clinic'' rate for
Medicaid services provided outside the four walls, the I/T facilities
must first convert to Federally Qualified Health Centers (FQHC). The
state also needs to file a State Plan Amendment (SPA) to grant the
Tribal FQHCs authority to bill at the ``clinic'' rate. With CMS
approval, the Indian health program can receive the encounter rate, and
the state is automatically paid at the 100% FMAP--increasing
reimbursement to the I/T clinics while reducing the state's
contribution to Medicaid
This presents multiple issues--first, Indian health programs may not
want to convert to FQHCs for reasons other than to receive the
reimbursement, as the conversion itself is burdensome. Second, not all
States have good working relationships with the Tribes, and if no
relationship (or a poor one) exists, the state may not see the benefits
of amending its Plan. (One advantage is that Medicaid services to AI/
ANs are reimbursed at 100 percent FMAP). Because this reimbursement
depends on the state's action, it adds to the uncertainty for the
Tribes, and in some ways, undermines the Tribes' status as sovereign
governments.
This year CMS authorized an extension to its four walls grace period
through October 31, 2021, to allow more I/T clinics to convert to
Tribal FQHCs. One can expect that another extension will be requested
given the CMS solution's onerous burden. The solution CMS proposed in
its SHO letter and subsequent Frequently Asked Questions (FAQs) was
only a band-aid. The agency's actions do not sufficiently address the
reimbursement parity Tribes seek for delivering Medicaid services in a
community-centered way. NIHB and other Tribal Organizations have
advocated for a permanent fix to CMS's Four Walls issue for more than
three years.
2. Expand the Medicaid 100% FMAP to Urban Indian Organizations.
The COVID-19 pandemic has created significant financial hardships for
IHCPs. While I/T/U clinics receive 100% FMAP for services provided to
AI/AN Medicaid beneficiaries, this FMAP does not permanently extend to
Urban Indian Organizations (UIOs). In the American Rescue Plan, signed
into law on March 11th, the 100% FMAP was expanded to UIOs for two
years. While this temporary extension is crucial in providing
additional federal dollars to UIOs to provide quality care, this FMAP
increase must be made permanent to fulfill the Federal Government's
trust responsibilities to AI/AN individuals.
3. Increase flexibility in Medicare Definition of Telemedicine
Services.
COVID-19 has demonstrated the importance of telehealth to increase
access to providers during the pandemic. But it has also demonstrated
it can increase access to needed primary, specialty, and behavioral
health services, particularly in rural areas. The telehealth
flexibilities Medicare has made available during the public health
emergency should be made permanent to the maximum extent possible. In
addition, much of Indian Country is located in rural areas and lacks
access to more advanced audio and video real-time communication
methods. As a result, Medicare should allow telehealth to be provided
through audio-only telephonic and two-way radio communication methods
when necessary, and grant maximum reimbursement for services rendered
through these modalities.
4. Expand access to telehealth in the Indian Health System through
increased funding and technical fixes.
Limitations in the availability of AI/AN-specific COVID-19 data are
contributing to the invisibility of the adverse impacts of the pandemic
in Indian Country within the general public. Senior IHS officials,
including Chief Medical Officer Dr. Michael Toedt, have stated publicly
that existing deficiencies with the IHS health IT system are inhibiting
the agency's ability to adequately conduct COVID-19 disease
surveillance and reporting efforts.\8\ Lack of health IT infrastructure
has also seriously hampered the ability of IHS and Tribal sites to
transition to a telehealth-based care delivery system. While mainstream
hospitals have been able to take advantage of new flexibilities under
Medicare for the use of telehealth during the COVID-19 pandemic, IHS
and Tribal facilities have not because of insufficient broadband
deployment and health IT capabilities. The IHS Tribal Budget
Formulation Working Group previously outlined the need for a roughly $3
billion investment to fully equip the Indian health system with an
interoperable and modern health IT system. It is critical that Congress
provide meaningful investments in health IT technologies for the Indian
health system to ensure accurate assessment of AI/AN COVID-19 health
disparities and equip IHCPs with the tools to seamlessly provide
telehealth-based health services.
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\8\ Toedt, R.A.M. (2021, May 21). Testimony from RADM Michael Toedt
on Examining the COVID-19 Response in Native Communities: Native Health
Systems One Year Later before Senate Committee on Indian Affairs.
HHS.gov. https://www.hhs.gov/about/agencies/asl/testimony/2021/04/14/
examining-covid-19-response-native-communities-native-health-systems-
one-year-later.html.
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5. Permanently Extend Waivers under Medicare for Use of Telehealth
CMS has temporarily waived Medicare restrictions on the use of
telemedicine. Yet, for many Tribes that lack broadband and/or
telehealth capacity and infrastructure, it is not financially feasible
to purchase expensive telehealth equipment for a short-term authority.
Making the telehealth waivers permanent would ensure that the
telehealth delivery system remains a viable option for delivering
essential medical, mental and behavioral health services in Indian
Country, and helps close the gap in access to care.
Conclusion
The federal government's trust responsibility to provide quality and
comprehensive health services for all AI/AN Peoples extends to every
federal agency and department. As the only national Tribal organization
dedicated exclusively to advocating for the fulfillment of the federal
trust responsibility for health, NIHB is committed to ensuring the
highest health status and outcomes for those affected with COVID-19 and
all Indian Country. We continue to appreciate your dedication to Indian
health priorities and remain committed to working with you to protect
and preserve the mental, physical, behavioral, and spiritual health of
Indian peoples in the future.
______
98point6
701 5th Ave, #2300
Seattle, WA 98104
(866) 657-7991
https://www.98point6.com/
U.S. Senate
Committee on Finance
Dirksen Senate Office Building
Washington, DC 20510-6200
RE: Hearing held Wednesday, May 19, 2021, ``COVID-19 Health Care
Flexibilities: Perspectives, Experiences, and Lessons Learned''
To Members of the Senate Finance Committee:
98point6 is pioneering a new approach to primary care. By pairing
artificial intelligence (AI) and machine learning technology with
board-certified physicians, our vision is to make primary care more
accessible and affordable, leading to better health outcomes. 98point6
believes in meeting patients where they are by offering private, modern
communication-enabled diagnosis and treatment via a HIPAA-compliant
mobile application to increase primary care utilization and enable
earlier medical intervention with reduced costs of overall care. As
Congress debates lessons learned from the COVID-19 pandemic, we believe
there are two changes that should become long term policy improvements:
(1) making telehealth benefits an ``excepted benefit'' under Employee
Retirement Income Security Act (ERISA), which is consistent and in-line
with a current Tri-Agency (Department of Labor (DOL), Department of
Health and Human Services (HHS), and Department of Treasury) temporary
relief; and (2) making permanent a waiver that allows a high deductible
health plan (HDHP) to retain its status as an health savings account
(HSA)-qualified HDHP--wherein participants may make contributions to a
HSA--if telehealth coverage is provided before the deductible. These
changes will allow for continuity of coverage and access to virtual
care for many individuals.
During the COVID-19 medical demand surge, 98point6 clinic volume
exceeded 200% growth from the start of the year, with COVID-related
concerns accounting for over 40% of all patient visits. The physician
team at 98point6 and our technology-assisted approach to care enabled
quality care delivered expediently, with the platform incorporating
standards based on research, outcomes, and clinical quality monitoring
of pandemic guidelines. Telehealth services offer a transformative
paradigm shift for the uninsured, underinsured, and populations with
limited access to physician care to readily access quality, inexpensive
basic medical and primary care services. Amid the COVID-19 pandemic,
telehealth has emerged as a viable and cost-effective solution across
all demographic groups, including racial and ethnic minorities and
rural populations lacking access to brick and mortar medical
facilities.
Health disparities among racial and ethnic minority populations have
been both highlighted and exacerbated by the COVID-19 pandemic.
Disproportionately represented among ``essential worker'' categories,
racial and ethnic minorities experience lower rates of employer-
provided or other private health-care coverage. Employers representing
more than three million part-time, non-benefits-eligible employees
stand ready and willing to provide telehealth or virtual care benefit
options at no cost to these employees, but are prohibited from doing so
without exposure to penalties under, for example, the ERISA.
Under current law, when telehealth or virtual health-care services are
provided by an employer, the benefit is considered a ``group health
plan'' under ERISA (subject to mandates absent an exception, which
trigger per-day penalties). ERISA Sec. 733 and DOL regulations (29 CFR
Sec. 2590.732)--and conforming Internal Revenue Service (IRS) and HHS
statutes and regulations--do not include telehealth or virtual care as
an excepted benefit under ERISA. On June 23, 2020, DOL, HHS, and
Treasury jointly issued an FAQ pertaining to the Families First
Coronavirus Response Act, the Coronavirus Aid, Relief, and Economic
Security Act (CARES) and other health coverage issues related to COVID-
19, that provided temporary relief from most group market reforms under
part 7 of ERISA, title XXVII of the Public Health Service Act, and
chapter 100 of the Internal Revenue Code to employers wishing to
provide telehealth or other remote care services to employees
ineligible for any other employer-sponsored group health plan. This
temporary relief has proven to be beneficial as a short-term fix,
subject to the public health emergency, but a permanent solution is
required to ensure long-term benefits of telehealth services can be
accessed, across the spectrum of Americans in need.
Telehealth and remote care services should be an ERISA-excepted benefit
when paid entirely by the employer or other plan sponsor. To that end,
Representative Jackie Walorski (R-IN) introduced legislation in the
116th Congressional session, the Telehealth Benefit Expansion for
Workers Act, to permit telehealth services offered under a group plan
or group health insurance coverage as ERISA-excepted benefits (by
adding, ``Benefits for telehealth services'' to Section 2791(c)(2)).
This legislation is expected to be re-introduced in the current
Congressional session.
In addition, the CARES Act clarified in Section 3701 that a HDHP
retains its status as an HSA-qualified HDHP--wherein participants may
make contributions to a savings account (HSA)--if telehealth coverage
is provided before the deductible. This exception ends December 31,
2021. Most employers have taken advantage of this provision to waive
fair market value charges for telehealth and remote care services
through December 31, 2021, further enabling the policy goal of health-
care access and inclusivity.
As employers begin preparing for coverage requirements and changes
affecting off-calendar year plan years, however, potential mid-year
changes may subject unwitting participants to billing inconsistencies
upon termination of the CARES Act telehealth deductible waiver
(impacting HDHP/HSAs). Similarly, employers utilizing calendar year
plans are now considering how and when to communicate the impending
elimination of the CARES Act telehealth or other remote care services
waiver. Elimination of the waiver will require employees to pay the
fair market value for telehealth benefits if the employees participate
in a HSA-qualified HDHP. To address this irregularity and the fact that
employees' out-of-pocket expenses are increased, the Internal Revenue
Code should be amended to provide a permanent exemption for telehealth
services by adding, ``or telehealth and other remote care,'' to Section
223(c)(1)(B).
Permanent relief for telehealth services under ERISA penalties and HDHP
waivers would enable employers to continue to provide important access
to safe, high-quality health care for many of the 21 million part-time
workers in America as well as the 28 million uninsured. Provision of
telehealth services will improve health outcomes across the demographic
spectrum, with highest gains among ethnic and racial minorities and
those most impacted by the COVID-19 pandemic. Telehealth is estimated
to save the health-care system up to $6 billion, factoring preemptive
care and early detection, as well as ensuring communities have a
lifeline to reliable health information. The statutory corrections
requested would neither add to the federal budget nor be subject to a
Congressional Budget Office score, as the telehealth services
contemplated would continue to be employer-funded.
The COVID-19 pandemic has illustrated the immense benefits of
telehealth services. The technology is available now to ensure that
more Americans, including part-time ``essential'' workers--and the
racial and ethnic minorities disproportionately comprising this
category--as well as rural Americans without ready access to medical
care, can access quality basic medical and primary health-care
services.
Telehealth has proven benefits and public policy should reflect the
technological shifts and consumer preferences that incentivize
employers to provide telehealth services for expanded groups of
employees (part-time workers) and at lower employee cost (in HDHP/HSA
models). These two minor changes would bring significant benefits
across the U.S. public health landscape.
Sincerely,
Robbie Cape
CEO and co-founder
______
Ochsner Health
1514 Jefferson Highway
New Orleans, LA 70121
phone (504) 842-3000
www.ochsner.org
Hon. Ron Wyden Hon. Mike Crapo
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
219 Dirksen Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Re: May 19th Hearing: ``COVID-19 Health Care Flexibilities:
Perspectives, Experiences, and Lessons Learned''
Dear Chairman Wyden and Ranking Member Crapo:
On behalf of Ochsner Health (Ochsner), our physicians, nurses, and
other health professionals and the tens of thousands of patients and
communities we serve in Louisiana and Mississippi, we thank you for
this opportunity to submit to you and your Senate Committee on Finance
colleagues comments regarding the May 19th hearing on ``COVID-19 Health
Care Flexibilities: Perspectives, Experiences, and Lessons Learned.''
We commend you for your recognition to take time now to hold a hearing
to examine the impact of telehealth on the COVID-19 response, and how
those lessons learned may inform future federal policy with respect to
telehealth.
We thank you in advance for your attention to our recommendations and
the comments that may be submitted by our colleagues from associations
representing health and hospital systems. Making permanent a number of
the current federal telehealth waivers and other policy changes,
expanding coverage and payment for telehealth and digital medicine
services and devices, and otherwise supporting and facilitating the
utilization of virtual care will help ensure that more patients have
access to care, not just during emergency circumstances. These much-
needed changes will help facilitate access to care for individuals from
underserved and/or rural communities, and enable better access for
those with mobility, transportation, and other challenges.
We stand ready to share our lessons learned over the past 14 months as
we have addressed the myriad challenges associated with COVID-19 and
how we have successfully deployed telehealth and digital medicine to
care for patients with COVID-19 as well as maintain continuity of
primary and specialty care for patients, families, and communities
during this challenging and unprecedented time. We welcome the
opportunity to be a resource to you, your staff, and Finance Committee
members as you examine this critically important topic.
Summary of Policy Recommendations
We know that the topic of telehealth is an incredibly important and
time sensitive issue and as such, wish to draw your immediate attention
to our policy recommendations below, which can be found in further
detail on pages 6-10 of this document. Background on Ochsner and our
digital medicine and telehealth programs can be found on pages 2-5. Our
COVID-19 telehealth and virtual care lessons learned are enumerated on
pages 5-6.
The following provides a summary of the policy changes we urge Congress
and CMS to support. These recommendations are informed by our
experience in providing care throughout the public health emergency
(PHE) and, in particular, being an early ``hot spot'' for the pandemic.
With these changes, patients will have improved access to the primary,
specialty, urgent, and emergency care they need and deserve.
Make permanent the range of waivers associated with the
provision of telehealth. Specifically, make permanent the flexibilities
associated with: patient location, relationship between patient and
provider, and the types of services that can be provided via
telehealth. Further, maintain reimbursement for telehealth services at
the in-person rate and permanently waive the application of copayments
to remote patient monitoring services and other non-face-to-face
services.
Given the significant focus during the hearing on audio-only
telehealth, we wish to note that the provision of audio-only telehealth
services is an important aspect of telehealth, particularly for
individuals who may not have access to broadband, smart devices, or
other technology that enable a video-visit. Audio-only telehealth can
help bridge the health care digital divide, address equity, and
otherwise expand access to care for certain individuals and
communities. Audio-only also is a clinically appropriate way to conduct
low acuity visits, communicate with established patients, and
coordinate care with patients as part of a remote patient monitoring
program. To that end, we urge that reimbursement for audio-only
telehealth be maintained under traditional Medicare (fee-for-service)
beyond the PHE.
Ensure that during a PHE cross jurisdictional licensure can be
automatic, presuming certain conditions are met.
Modify the Emergency Medical Treatment and Labor Act (EMTALA) to
allow new types of medical screenings, such as pre-screenings that use
technology that can help divert non-emergent cases to other,
appropriate settings.
Expand covered remote monitoring services to allow for
beneficiary participation and Medicare coverage and reimbursement for
more than one program, which will increase access, ease patient day-to-
day care, and improve health outcomes.
Provide digital medicine and telehealth tools/devices to
Medicare patients at no cost to increase patient uptake of these
services.
Ensure patient access to TeleStroke services by establishing
separate Medicare payment for providers giving both TeleStroke consult
and same day inpatient care to Medicare beneficiaries experiencing
acute stroke.
Expand Medicare beneficiary access to non-stroke telehealth
services for acute neurological conditions.
Expand access to intensive care unit (ICU) telehealth.
Provide payment to providers who are offering additional levels
of remote monitoring for patients through programs such as TeleStork.
About Ochsner
Ochsner, headquartered in New Orleans, is one of the nation's leading
integrated not-for-profit academic health systems. Ochsner--as a leader
in value-based care and delivery system innovation--provides a
comprehensive range of services through its clinically integrated
network of a combination of owned, managed and affiliated hospitals,
and nearly 200 total sites of care located throughout Louisiana and
Mississippi. We are proud that our innovative partnership model through
the Ochsner Health Network (OHN) allows many communities to maintain
local ownership and control of their hospitals, while bringing to bear
the benefit of the experience and breadth of the Ochsner clinical and
operational teams. Ochsner offers a wide array of specialized and
nationally ranked services with its 4,500 affiliated physicians,
including more than 1,600 employed physicians practicing in over 90
specialties and subspecialties, and more than 30,000 employees. Each
year Ochsner and its physician partners serve over 1 million individual
patients who come from every state in the nation and more than 70
countries.
Louisiana regularly ranks near the bottom of the United States in
nearly all health indicators, with a population that has a high
prevalence of a number of risk factors for poor health outcomes,
including obesity, tobacco use, poverty, diabetes, and cardiovascular
disease. More than five years ago, Ochsner leaders recognized that it
would take innovative strategies and deployment of new technologies and
interventions to tackle these myriad challenges.
In response to the demand for better care at a lower cost and greater
convenience to patients, Ochsner created an innovation lab,
innovationOchsner (iO) to improve health through innovation with the
following quadruple aim: improve the patient experience of care,
improve the health of populations, reduce the per capita cost of health
care, and improve the work life of the provider of care. The strategies
to achieve these goals are: operational efficiency, differentiate
product or service, create customer intimacy, and improve quality and
safety. We are proud that our investment and focus in this area has
resulted in ground-breaking innovations, which are measurably improving
patient care and outcomes, and are reducing inefficiencies and costs.
iO has developed numerous digital medicine programs, particularly for
those affected by chronic disease, in particular hypertension and
diabetes, that are transforming the patient experience, enhancing
health, and well-being, while reducing costs. More than 19,000 patients
have been cared for in the Digital Medicine program, 80% of which are
still enrolled. In addition, Ochsner provides more than 100 telehealth
services to more than 185 hospital and clinic partners. Further,
Ochsner continues to innovate in the direct-to-consumer market, with
offerings such as Ochsner Anywhere Care for primary and urgent care
needs.
Ochsner's innovative digital medicine approach using wearable
technologies, remote monitoring, and virtual provider visits is
substantially improving patient health outcomes at a lower cost.
Particularly for patients who are managing complex diagnoses and
chronic disease we are easing the patient care experience by allowing
them to receive the care they need, when and where they need it. And,
critically, our pioneering telehealth program is meaningfully
increasing patient access to medical services in rural areas of
Louisiana and Mississippi where, in certain cases, no such access
existed before. For many--and a growing population of our patients--
telehealth and digital medicine are the standard of care and a
preferred way in which they interface with the health-care system.
Examples of Ochsner Digital Medicine Offerings \1\
---------------------------------------------------------------------------
\1\ To learn more about Ochsner's digital medicine programs see the
following article: Washington Post: https://www.washingtonpost.com/
business/economy/these-louisiana-physicians-can-monitor-your-blood-
pressure--and-you-dont-even-have-to-leave-your-living-room/2018/07/11/
6d57f198-7beb-11e8-93cc-6d3beccdd7a3_story.html.
Ochsner's Hypertension Digital Medicine (HTNDM) program uses a
connected blood pressure cuff to transmit blood pressure readings from
the patient's home to be monitored by an Ochsner care team, which
includes a pharmacist and health coach. This program has been shown to
be three times more effective than traditional care at having patients
achieve blood pressure control over 180 days, while also increasing
patients' medication adherence and patient activation, and reducing the
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total cost of care.
An analysis by Blue Cross Blue Shield found that participants in the
HTNDM medication adherence program led to an overall decrease in
emergency department visits and inpatient hospital stays. The same
analysis also found that the program saved $77 per member, per month,
based on claims data and total cost of care.
Our Digital Diabetes Medicine (DDM) program uses a prescription,
Bluetooth-
enabled digital glucometer to monitor a patient's blood sugar levels
and other health indicators. This program also has achieved results
that are better than traditional care methods, including reductions in
A1C, decreases in hypoglycemic events and diabetes distress, and
increases in adherence to recommended health maintenance activities.
The Connected Maternity Online Monitoring (MOM) program provides
pregnant patients with a Bluetooth-enabled blood pressure cuff and
scale that interfaces with the electronic health record. This allows
patients to perform remote monitoring during pregnancy, and as
appropriate, decrease the number of in person prenatal visits, while
increasing the frequency of monitoring for potential pregnancy
complications. Analysis of data from early implementation of the
program demonstrates that not only does it allow for earlier detection
of hypertension in pregnancy, but also increases compliance with post-
partum blood pressure monitoring in the initial days and weeks
following delivery.
Examples of Ochsner's Telehealth Offerings
Ochsner deploys telehealth to deliver specialty, primary, and urgent
care to patients near and far. We are proud to have created a network
of hundreds of physicians who reside out of state and who--through
multi-state licensure and the telehealth licensure compact--can deliver
high quality care to our patients via telehealth, helping to ensure
better access to care for underserved communities.
Access to specialty care has been expanded through the utilization of
physicians with multi-state licensure who can treat patients via
telehealth. Our ``hub'' and ``spoke'' model allows us to leverage our
specialty physician workforce and expertise located in New Orleans to
locations throughout Louisiana and Mississippi. For example, Ochsner
provides emergency virtual psychiatric services, cutting emergency room
wait times for psychiatric care at our partner sites by 50%. Telehealth
can meaningfully increase patient access to telepsychiatry and
telebehavioral health services for many patients in rural and
underserved areas who are currently without access to such care.
Ochsner's TeleStroke program provides 24-hour/7-days per week coverage
by vascular neurologists who--through telehealth--are immediately
available to emergency department physicians in rural hospitals to help
them quickly diagnose and treat patients presenting with symptoms of a
possible stroke. The program has been instrumental in successfully
treating thousands of patients (more than 300 patients per month) in a
timely manner, and allows these facilities to remain open and
successfully caring for patients in their own communities. Seventy
percent of TeleStroke patients now stay local; prior to the program's
implementation, nearly all patients were transferred.
Ochsner's TeleStork program, using live streaming of maternal and fetal
health records, provides 24/7 monitoring to laboring mothers. Rapid
detection of labor distress and maternal or fetal decompensation and
facilitating early interventions by our specialty care team is helping
reduce adverse maternal and neonatal outcomes. Since initiated in
August 2016, there has been a 50% decrease in term unexpected Neonatal
Intensive Care Unit (NICU) admissions in TeleStork facilities. Not only
are the interventions effective in improving outcomes, but they have
also been successful in driving changes in clinical practice that
result in a decrease in the need for interventions, all of which
ultimately lead to improvements in birth outcomes of newborns within
the program.
In 2019, we announced a partnership with Tyto Care, the health-care
industry's first all-in-one modular device for remote medical exams.
This partnership expands Ochsner's current telehealth offering, a
consumer-facing virtual visit platform called Ochsner Anywhere Care,
which is powered by national telehealth leader American
Well'. The Ochsner Anywhere Care Health Kit, powered by Tyto
Care, is a portable health kit that enables patients to capture
physical examination data at home using a handheld device with a
digital camera and various attachments and then share it with a
provider using the Ochsner Anywhere Care app. It is designed to
replicate the exams performed during an in- office visit, by providing
high-quality digital sounds of the heart and lungs, digital images and
video of the ears, throat and skin, and body temperature. Special
adaptors are included for examining the ears, throat, skin for taking
body temperature, and listening to heart and lung sounds. To see a
demonstration video visit: https://ochsner.tytocare.com/.
Since the pandemic began, we have sold thousands of Ochsner Anywhere
Care Health Kits and through their deployment expanded access to
primary and urgent care, allowing these patients to have access to care
from the safety of their own homes. It is important to note that an
Ochsner Anywhere Health Kit is not required for an Ochsner Anywhere
Care or other telehealth visit, but it does provide tools to capture
and share exam data, which can prove to be helpful for a provider
making a diagnosis and treatment recommendation.\2\ This offering has
potential to expand access to care, particularly for individuals with
mobility limitations, including disabilities and transportation
challenges, as well as provide access to individual and families in
rural and underserved communities. Further, through funding we received
through the Federal Communications Commission (FCC) COVID-19 Telehealth
Program, we have been able to purchase and are actively disseminating--
at no cost to patients--nearly 12,000 devices to support patients in
participating in our HTNDM, DDM, and Connected MOM programs.
---------------------------------------------------------------------------
\2\ The Ochsner Anywhere Health Kit, powered by Tyto Care, retails
for $299 with $10 flat shipping if ordered online at www.ochsner.org/
healthkit. It is also available for purchase at Ochsner pharmacy
locations https://www.ochsner.org/services/pharmacy/, O Bar retail
stores https://www.ochsner.org/shop/o-bar, Ochsner Fitness Centers
https://www.ochsnerfitness.
com/, and Ochsner Total Health Solutions https://www.ochsner.org/
locations/ochsner-total-health-solutions. Some insurance providers may
provide a discount or partial reimbursement; it is recommended that
consumers contact their insurance provider for more information.
Having additional resources allowed us to expand the reach of our
digital medicine programs, which in turn, supported our ability to
maintain continuity of care--and in some cases begin important health
monitoring--of patients with hypertension and/or diabetes as well as
support our patients during an important time during their pregnancy.
With the availability of the FCC telehealth device funding, we are
particularly pleased that we have been able to expand enrollment of
Medicare and Medicaid beneficiaries in our digital medicine programs,
as making the devices available free of charge has removed a
significant participation barrier for many patients.
Lessons Learned from COVID-19
Prior to the COVID-19 PHE, Ochsner had long-advocated that Congress,
the U.S. Department of Health and Human Services (HHS), and the Centers
for Medicare and Medicaid Services (CMS) expand coverage and
reimbursement for telehealth and digital medicine services and
associated connected devices. We theorized that improvement in how
these services and the associated devices are covered and reimbursed
would accelerate their adoption, increase access to care, and in turn,
leverage their potential in supporting patient engagement, expand
provider access to more accurate and timely patient data, and enhance
the patient experience.
Now, more than a year into the pandemic, we have real world experience
and have seen this theory come to fruition. These technologies and care
delivery modalities are making a difference in the lives of people
diagnosed with COVID-19, those suspected as having COVID-19, and for
patients who need access to non-COVID-related primary or specialty
care. Fully deploying telehealth and digital medicine to our Medicare,
Medicaid, and commercially insured patients has helped to maintain
continuity and coordination of care, as well as allowed for expanded
access to care to patients who previously had been underserved. In many
cases, Ochsner has been able to reach patients who previously have had
limited or no access to such services--particularly in rural and
underserved areas where health-care disparities persist.
Over the course of the COVID-19 pandemic, Ochsner has observed in
patient reported data a significant increase in utilization of
telehealth services by minority populations, particularly among Blacks,
where the percentage of patients completing virtual visits doubled. At
the height of the COVID-19 outbreak in the ``hot spot'' state of
Louisiana, Ochsner delivered more than 60 percent of visits to patients
via telehealth--making Ochsner the leading health-care system in the
South in the delivery of telehealth during the public health crisis.
From the March to December 2020 period, we are proud to have deployed
virtual visits in a robust manner to sustain continuity of care and
reduce the risk of COVID-19 exposure for patients, family members, and
providers. Specifically, during this period:
We provided an estimated 291,100 total virtual visits to adult
and pediatric patients;
Virtual visits were delivered across all primary, medical and
surgical specialties, with the bulk of care being primary care,
behavioral health, and medical specialties;
Approximately 30% (87,389) of our virtual visits were with
Medicare beneficiaries; and
Almost 40,000, or 14%, of virtual visits were with people with
Medicaid coverage.
While Ochsner was able to quickly and adeptly expand our telehealth and
digital medicine offerings due to our existing programs and
infrastructure, other hospitals, health systems, and providers required
significant time, resources, equipment, and training--of health
professionals and patients--to scale up their remote care offerings,
which in turn, caused some delay in patients receiving health-care
services and outpatient treatment. We feel strongly that the nation's
health-care system must maintain these advances during non-pandemic
times to ensure that the infrastructure, practice, familiarity, and
resources are in place so irrespective of what threat may emerge--
natural disaster, bioterrorism, or infectious disease--that we have a
strong, existing system so physicians, nurses, and hospitals can
continue to provide health-care services across the care continuum.
Ochsner Policy Recommendations
The telehealth waivers granted by HHS and CMS have been critical to
Ochsner's quick expansion and implementation of telehealth and digital
medicine services. Since the start of the PHE and the advent of the
waivers, in our telehealth program, we have seen an 89% increase in
Louisiana patients from rural areas, as defined by the Health Resources
and Services Administration. This increase is due to numerous factors,
including a significant boost in patient interest in remote care and
quick patient adoption to remote care. We commend HHS and CMS for
providing these flexibilities and respectfully request that the
Congress work with CMS and HHS to enact legislation and modify
regulations, as applicable, to make these waivers permanent and ensure
that we do not lose the gains made in telehealth and virtual care.
Telehealth Waivers Prioritized for Permanent Change
While all of the telehealth waivers provided by HHS and CMS have
enhanced our ability to serve patients throughout the COVID-19 public
health crisis, Ochsner believes that the following waivers, in
particular, have enabled and fostered successful deployment of
telehealth services to patients and these policy changes should be
maintained once the pandemic has abated so that more patients--
especially those in rural and underserved areas--can access treatment
and receive more comprehensive and coordinated care.
1. Patient location: The ability of patients to receive telehealth
services from any location, including their homes, has given patients
access to services where in many cases they could not have accessed
care. Telehealth has reduced the need to travel for patients who are
not as mobile and provides scheduled or on demand care and support
through difficult stages of well-being. For example, telehealth has
allowed patients in rural and remote areas without reliable
transportation to more easily receive treatment by eliminating travel
burden. For those patients with limited resources, telehealth has
eliminated the cost of travel time and additional time away from work
to receive an in-person visit. Further, for institutional-based
patients such as those residing in skilled nursing facilities (SNFs),
telehealth has given them the ability to remain in their care setting,
minimizing both health risk and burden. Hence, making permanent the
waiver permitting patients to receive telehealth from any location will
eliminate a significant barrier for many patients who, before the
telehealth expansion, faced challenges in accessing the services they
need to get well and stay healthy.
2. Reimbursement at the in-person visit rate: Reimbursing for
telehealth visits at the in-person rate has enabled Ochsner to offer
services to patients in a financially sustainable and scalable manner.
Adequate reimbursement for telehealth at the in-person visit rate
ensures that providers receive appropriate payment for the full range
of care they provide in the context of a remote visit. For example,
often patients submit photographs, videos, and other medical
information (e.g., blood pressure readings, blood sugar data, etc.) in
advance that their providers take time to review and analyze prior to--
or following--a telehealth encounter. In a face-to-face encounter this
often is done in real time and is reflected in the in-person payment
amount. Further, providing reimbursement at the same rate as in-person
care recognizes that the provision of telehealth services requires
resources, such as technology and other infrastructure.
3. New services eligible for telehealth delivery: The significant
expansion in the types of health-care services that can be delivered
via telehealth has given Ochsner a way to reach patients previously not
possible in many instances. For example, delivering occupational,
speech/language, and physical therapy services via telehealth to
patients in their homes or in SNFs has given patients new or increased
access to care that improves quality of life and health outcomes. Pain
management and palliative care and hospice patients and families have
also benefited from the ability to connect with their providers through
telehealth.
4. No required established relationship between practitioner and
patient: Without the requirement of an established relationship between
the patient and provider, Ochsner has been able to immediately serve a
wider population of patients and address their care needs. Many
patients living in rural and underserved communities do not have a
regular source of health care and therefore do not have an established
relationship with a provider. Making this waiver permanent will remove
a significant barrier in access to treatment, especially for those many
patients in rural and underserved communities who in many cases
historically have received fragmented care.
5. Waiver of Medicare remote patient monitoring and other non-
face-to-face services copayments: The HHS Office of the Inspector
General (OIG)'s waiver of the Anti-Kickback Statute (AKS) for cost-
sharing obligations for non-face-to-face services furnished through
various modalities, including remote patient monitoring, remote monthly
care management, virtual check-ins, and telehealth visits has
eliminated a substantial barrier in patient access to care where, in
many cases, patients simply do not have the resources to pay for
services that are not immediate care needs but who could benefit from
the care provided.
For example, as noted earlier, primary and secondary preventive
services like Ochsner's DDM and HTNDM programs have reduced unnecessary
emergency department visits, decreased inpatient admissions, increased
medication adherence, and improved annual screening compliance, but
unfortunately have been hindered by copayment barriers. Given the
demographics of the Ochsner patient population, affordability of care
is a serious impediment to our ability to manage chronic disease for
too many of our patients. According to Kaiser Family Foundation,
approximately 20% of Medicare beneficiaries in fee-for-service have no
type of supplemental coverage, which makes paying out-of-pocket costs
more challenging. Coinsurance often stands in the way of patients
seeking and receiving the care they need, particularly for Medicare
patients with limited resources.
Remote monitoring, such as our hypertension program, typically involves
a monthly ``charge'' to cover the costs of having the data reviewed by
the health-care team and additional involvement by the physician should
any adjustments to treatment or the care plan need to be made. We know
from our clinical experience that for many beneficiaries the cost of
the monthly out-of-pocket fee caused them to decline the opportunity to
enroll in a digital medicine program. Yet, over the past 14 months,
with the copayments waived, we have noted a significant increase in
enrollment and participation among patients who need these programs,
which in turn will help improve their health and reduce costs over
time. Permanently waiving the copayment requirement for these non-face-
to-face services will meaningfully improve access and much better
enable Ochsner to more effectively and comprehensively care for
patients, especially for patients in rural and underserved areas where
significant disparities in care remain and must be addressed.
Other Waiver Related Policy Recommendations
In addition to the telehealth waivers enumerated above, HHS and CMS
have provided additional waivers during the PHE that have strengthened
our ability to continue to provide health-care services and outpatient
treatment during the pandemic. Based on our experience with these
waivers, we recommend that Congress and CMS work together to address
the following:
1. Cross jurisdictional licensure in the event of a PHE: In the
event of a PHE, there should be automatic allowance of CMS physician or
non-physician practitioner licensing requirements when the following
four conditions are met: (1) must be enrolled as such in the Medicare
program; (2) must possess a valid license to practice in the state,
which relates to his or her Medicare enrollment; (3) is furnishing
services--whether in person or via telehealth--in a state in which the
emergency is occurring in order to contribute to relief efforts in his
or her professional capacity; and (4) is not affirmatively excluded
from practice in the state or any other state that is part of the
emergency area. This change would have no effect on state licensure
requirements.
2. Modify EMTALA: The 1135 emergency waiver authority has allowed
the Secretary to waive enforcement of EMTALA. In response to the
current PHE the Secretary allowed hospitals to redirect patients who
present at the emergency department to an alternative screening site
and to transfer individuals with an unstable emergency medical
condition. To use these waivers, many health systems relied on
technology to screen patients upon emergency department arrival.
Outside of a PHE, such screening tools would not typically meet the
medical screening requirements under EMTALA.
While EMTALA is necessary to ensure that all patients have
access to emergency medical care, we urge Congress to revise the
statute to allow for new types of medical screenings. Specifically,
many health systems hope to employ pre-screenings that use technology
that can help divert non-
emergent cases to other settings. The current medical screening
requirements are so extensive that patients remain in the full queue of
emergency department patients before it is determined that they could
be diverted to another setting of care. More often than not, the
patient is treated in the hospital after long wait times rather than
being directed to nearby outpatient departments or physician practices,
where the patient could have received appropriate care in a timelier
manner and at lower cost to the patient and health-care system. We
envision appropriate guardrails could be put in place by requiring
hospitals to have their pre-screening approaches approved by CMS and
requiring additional data submissions on patient diversion.
Other Policy and Payment Recommendations
1. Expand covered remote monitoring services to allow for
beneficiary participation and Medicare coverage and reimbursement for
more than one program, which will increase access, ease patient day-to-
day care, and improve health outcomes: Federal health programs should
permit patients to participate in as many remote monitoring programs as
their health needs dictate. A significant number of patients have more
than one chronic condition (e.g., hypertension and diabetes) that would
benefit from remote monitoring. Currently, Medicare only provides
payment for one remote monitoring program/initiative, generally
resulting in the provider receiving reimbursement for the program to
which the patient consents first. Ochsner treats patients who would
benefit from being enrolled in both our HTNDM and DDM programs because
they have both hypertension and diabetes. For example, in Louisiana
among Medicare beneficiaries aged 65 and older 65.63% have hypertension
and 27.99% have diabetes.\3\ Hypertension is twice as common among
people with diabetes as those without it and an estimated two-thirds of
people with diabetes have elevated blood pressure and/or are treated
for hypertension.\4\ Among the population we treat at Ochsner, an
estimated 75% of patients with diabetes also have hypertension. Many
chronic care Medicare beneficiaries have multiple comorbid conditions.
CMS data for Louisiana show that 28.63% of Medicare beneficiaries in
the state have 2-3 chronic conditions and annual Medicare per capita
spending for this group of patients is $5,999.\5\ As such, the Medicare
program and patients could benefit from allowing providers to offer a
variety of remote monitoring services at the same time for all
applicable documented diagnoses. Federal health programs should permit
providers to bill for all remote monitoring services applicable to a
patient's diagnoses to foster increased patient access to more
coordinated and more comprehensive care, ultimately, resulting in
improved patient health outcomes at a lower total cost-of-care.
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\3\ https://portal.cms.gov/wps/portal/unauthportal/
unauthmicrostrategyreportslink?evt=20480
01&src=mstrWeb.2048001&documentID=69E5BACC452E9CC0D72D6DA872A90AF6&visMo
de=
0¤tViewMedia=1&Server=E48V126P&Project=OIPDA-
BI_Prod&Port=0&connmode=8&ru
=1&share=1&hiddensections=header,path,dockTop,dockLeft,footer.
\4\ https://www.hopkinsmedicine.org/health/conditions-and-diseases/
diabetes/diabetes-and-high-blood-pressure.
\5\ https://portal.cms.gov/wps/portal/unauthportal/
unauthmicrostrategyreportslink?evt=20480
01&src=mstrWeb.2048001&documentID=69E5BACC452E9CC0D72D6DA872A90AF6&visMo
de=
0¤tViewMedia=1&Server=E48V126P&Project=OIPDA-
BI_Prod&Port=0&connmode=8&ru
=1&share=1&hiddensections=header,path,dockTop,dockLeft,footer.
2. Provide digital medicine and telehealth tools/devices to
Medicare patients at no cost to increase patient uptake of these
services: Patients often need technology or tools to support their
health and well-being and allow for better care management by their
provider team. As explained above, Ochsner's successful digital
medicine programs require the use of connected smart devices that
communicate with the care team. Patients must purchase these devices--
in some cases entirely out-of-pocket and in other cases with some cost-
sharing and some coverage. Unfortunately, as noted above, out-of-pocket
expenses often preclude patients from accessing to the care, services,
and tools they need to stay healthy and prevent catastrophic episodes
of care. In our experience, approximately 10% of patients decline to
participate in our digital medicine programs when they learn they have
to pay for the device out-of-pocket. Therefore, Congress should expand
Medicare payment policy to include full coverage of digital medicine
devices (e.g., Bluetooth-enabled blood pressure cuff, Bluetooth-enabled
digital scale, Bluetooth-enabled digital glucometer) and telehealth
devices (e.g., Tyto Anywhere Care kit) and do so without any cost-
sharing requirements. The overwhelming response to the Congressionally
established COVID-19 Telehealth Program at the FCC has demonstrated the
need for a funding mechanism for these devices. Ochsner has seen
firsthand the willingness of patients to participate in these
beneficial programs when they have affordable access to them. Expanding
access to these important patient engagement and support tools will
help providers leverage the full value and improved patient health
---------------------------------------------------------------------------
outcomes that digital medicine and telehealth care can offer.
3. Ensure patient access to TeleStroke services by establishing
separate Medicare payment for providers giving both TeleStroke consult
and same day inpatient care to Medicare beneficiaries experiencing
acute stroke: Ochsner commends the Congress for expanding Medicare
beneficiary access to TeleStroke services as part of the Bipartisan
Budget Act (BBA) of 2018. To foster further Medicare beneficiary access
to TeleStroke services, Congress should permit Medicare to make two
separate payments to a single provider for both a TeleStroke consult
and the work of a subsequent stroke admission on the same day if the
admitting hospital both provides the initial TeleStroke consult and
later admits the patient after transfer due to the acuity level of the
patient's stroke.
4. Expand Medicare beneficiary access to non-stroke telehealth
services for acute neurological conditions: Patients in rural and
underserved communities typically have significantly less access to
treatment for acute neurological diseases. To build on the important
expansion of TeleStroke care, Ochsner requests that Medicare provide
unrestricted telehealth coverage for other non-stroke acute
neurological conditions that typically require consultations with
emergency departments to achieve optimal patient health outcomes. These
include diagnostic questions of numbness, weakness, vertigo, confusion,
headache, tremors and seizures, leading to treatment of complications
of spinal cord injury, nerve compression, brain tumors, Multiple
Sclerosis (MS), Parkinson's disease, Alzheimer's disease, epilepsy,
Amyotrophic Lateral Sclerosis (ALS), and many other conditions. Similar
to the request for TeleStroke above, Congress should allow Medicare to
make two separate payments to a single provider for both a non-stroke
telehealth consult of an acute neurological condition and the work of a
subsequent inpatient admission on the same day related to that
condition if the admitting hospital provides both the initial
telehealth consult and later admits the patient after transfer due to
the acuity level of his or her neurological condition. Patient access
to acute neurological telehealth services should not be limited by
geographic or originating site requirements in the original Medicare
telehealth statute.
5. Expand access to intensive care unit (ICU) telehealth: In many
cases, patients in rural and underserved areas have to travel
significant distances to receive emergency care. Through Ochsner's
innovative telehealth offerings, we can give telehealth ICU consults
that save meaningful time to treatment in many instances where
immediate access to care can result in the likelihood of significantly
better patient health outcomes. Congress should provide unrestricted
Medicare coverage for telehealth ICU consults (i.e., no originating or
geographic site limitations) so that all beneficiaries can access the
emergent care they need as quickly as possible.
6. Provide payment to providers who are offering additional levels
of remote monitoring for patients through programs such as TeleStork.
Offerings like TeleStork provide an additional level of specialized
monitoring and clinical support to providers who are caring for
maternity patients who may be at higher-risk for poor maternal and
fetal outcomes. Because the care is not delivered directly to the
patient there is no reimbursement provided for the service, yet in our
experience it is cost-effective and cost-saving.
Conclusion
The federal waivers outlined above have allowed Ochsner's telehealth
and virtual care programs to operate at their full potential, and in
doing so, have demonstrated that telehealth and virtual care are high
quality, efficient, and effective ways to treat patients safely both
inside and outside of the clinic and hospital settings. Ochsner urges
the permanent extension of these critically important waivers; making
these changes permanent will allow us to continue providing care to
patients that may otherwise go unserved.
Further, we thank you for considering our additional recommendations
for ways to modify federal coverage and reimbursement policy to
facilitate the provision of virtual care and patient monitoring in a
cost effective and convenient manner and in a way that also reduces
patients' unnecessary exposure to infectious disease, such as COVID-19.
We believe that by strengthening our nation's telehealth, virtual care,
and digital medicine infrastructure we will be able to maintain the
access to care gains made over the past year and support hospitals and
providers in continuing to provide care throughout the PHE and
otherwise.
We thank you for your consideration of our recommendations and stand
ready to serve as a resource. Sincerely,
Will Crump
Director of Public Health Policy
______
Partnership for Employer-Sponsored Coverage
1212 New York Avenue, Suite 1100
Washington, DC 20005
The Partnership for Employer-Sponsored Coverage (P4ESC) appreciates the
Senate Finance Committee holding this hearing to discuss options for
continuing health-care delivery and policy flexibilities implored
during the COVID-19 pandemic. P4ESC believes that the time is ripe to
modernize laws to increase access to telehealth services as patients,
health providers, and coverage plan sponsors adapted to remote working
and social distancing measures by utilizing this care delivery method
and benefit offered by many employers.
As an advocacy alliance of employment-based organizations and trade
associations representing businesses of all sizes and millions of
Americans who rely on employer-sponsored health coverage every day,
P4ESC is working to ensure that employer-sponsored coverage is
strengthened and remains a viable, affordable option for decades to
come.
P4ESC appreciates the COVID-related policies adopted over the last year
to help employees and businesses, including expanding telemedicine
availability to employees. Congress should build on this policy to
provide employers with the ability to enhance employee coverage
permanently. P4ESC is eager to work on bipartisan legislation to expand
employee access to telemedicine, including enabling employers to offer
a telehealth service plan to all employees regardless of their
enrollment in the employer's medical coverage.
P4ESC supports: (1) treating telehealth services as an excepted benefit
which would enable employers to offer this type of coverage to part-
time and variable workforces, and other employees not enrolled in the
employers' medical plan; (2) reforming licensure requirements to enable
services to be offered across state lines; (3) establishing a national
set of standards for telemedicine services to address state-based
requirements that have not kept pace with technology, practice site and
remote working advances, including eliminating originating site and
prior provider relationship requirements; and (4) clarifying that CARES
Act telemedicine provisions are effective for plan years on or after
January 1, 2019 (employer plan years vary between non-calendar and
calendar year basis).
According to the Society for Human Resource Management's (SHRM)
Navigating COVID-19: Impact of the Pandemic on Mental Health,\1\ ``the
COVID-19 pandemic has put unprecedented strain on workers' mental
health the research finds that a majority of employees are experiencing
symptoms of depression, but very few are receiving care.'' Findings
include:
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\1\ https://www.shrm.org/hr-today/trends-and-forecasting/research-
and-surveys/documents/
shrm%20cv19%20mental%20health%20research%20presentation%20v1.pdf.
Two out of three employees report experiencing symptoms of
depression sometimes amid widespread lockdowns
More than two in five employees feel burned out, drained, or
exhausted by work
37 percent of employees have not done anything to cope with
depression-related symptoms and only 7 percent have reached out to a
mental health professional
The pandemic has offered employees the ability to receive mental and
behavioral health services via telemedicine, and we strongly support
making this access permanent. As noted in testimony before the House
Education and Labor Committee hearing \2\ on April 15, 2021, James
Gelfand of the ERISA Industry Committee (ERIC) stated ``[w]hen COVID-19
caused many employers to shift to remote work or reduced employee
presence onsite, many worksite clinics went virtual, offering mental
and behavioral health via telehealth. Some clinics expanded eligibility
to other employees in the same state, who may not be based at the same
site. This helped create continuity for employees undergoing care, and
a new access point for many others.''
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\2\ 04-15-21 ERIC Testimony--E&L Mental Health Hearing [Final].pdf.
Further, in an op-ed published in The Hill \3\ on May 28, 2020, SHRM's
Emily M. Dickens, Chief of Staff, Head of Government Affairs and
Corporate Secretary, wrote ``[g]reater access to telemedicine,
including telepsychiatry, will provide the resources for employees to
navigate all health-care options and privately seek the help that they
need. The convenience of this offering will benefit employers and their
employees because such services can be received at home and after work
hours during a time when personal and professional schedules are
anything but definite for so many workers.''
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\3\ https://thehill.com/opinion/healthcare/500017-assist-mental-
health-of-workers-by-increasing-access-to-telemedicine.
In the employer benefits space, telehealth services come in different
forms, such as: the ability for employees to be treated by a health
provider or practice, with whom they already have a relationship, in a
telemedicine setting instead of through a traditional in-office visit;
and access to a telehealth service vendor which is included in a
benefits package offering, similar to a dental or vision plan, that is
separate from the medical plan but provides the ability to be connected
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to a physician or health professional for a consultation.
In the later example, the separate telehealth vendor program can
legally be provided to full-time employees enrolled in the employer
medical plan but not to other groups of the workforce. Part-time and
seasonal employees, and full-time employees who declined the employer
medical plan cannot access the telehealth vendor program because this
type of stand-alone benefit would violate the coverage rules under the
Affordable Care Act's (ACA) employer mandate. P4ESC supports
legislation to enable employers to offer these excepted benefit
telehealth service plans to all employees, regardless of their
eligibility for or enrollment in an employer's medical plan. Offering
this type of telehealth service to employees is not at all meant to
circumvent an employer's responsibility to offer a medical plan to
full-time employees under the ACA's employer mandate.
Additionally, as the Committee considers ways to improve access to
telehealth services, P4ESC urges you to also consider network access
and availability of behavioral and mental health providers. Employers
and employees face challenges in finding available and affordable
behavioral and mental health-care providers. Some behavioral and mental
health providers--particularly those in rural areas--decline to
participate in health insurance networks. In the case of most self-
insured plans under the Employee Retirement Income Security Act of 1974
(ERISA), employers rent insurance carriers' provider networks. The
decision to join a network lies with the provider, subject to network
standards.
Because so many behavioral and mental health providers choose not to go
in-
network, employees can often face large out-of-network bills for care
sought. It is important to stress that efforts to evaluate the
availability of behavioral and mental health providers in health
insurance networks must also consider whether these providers make
themselves available and affordable to employees. Coverage requirements
and civil monetary penalties on employers and insurance carriers are
counterproductive, particularly regarding access and affordability,
unless there is a countervailing requirement enforced by equal
penalties for providers to participate in one or more networks.
The Partnership for Employer-Sponsored Coverage welcomes the
opportunity to provide input and speak in further detail. Benefits
offerings and coverage plans in the employer-sponsored system are as
diverse as employers themselves. There is no one-size-fits-all employer
plan, and the functionality of a business is centered around a
productive, thriving, and healthy workforce. As a coalition
representing businesses of all sizes, we have the unique ability to
provide operational input across the full spectrum of the employer
system--from the smallest family business to the largest corporation.
American Health Policy Institute
American Hotel and Lodging Association
American Rental Association
Associated Builders and Contractors, Inc.
Associated General Contractors of America
Auto Care Association
Business Group on Health
The Council of Insurance Agents and Brokers
The ERISA Industry Committee (ERIC)
FMI--The Food Industry Association
HR Policy Association
National Association of Health Underwriters
National Association of Wholesaler-Distributors
NFIB--National Federation of Independent Business
National Restaurant Association
National Retail Federation
Retail Industry Leaders Association
Society for Human Resource Management
______
Premier Inc.
444 North Capitol Street, NW, Suite 625
Washington, DC 20001
T 202-393-0860
F 202-393-6499
https://www.premierinc.com/
The Premier health-care alliance appreciates the opportunity to submit
a statement for the record on the Senate Finance Committee hearing
titled ``COVID-19 Health Care Flexibilities: Perspectives, Experiences,
and Lessons Learned'' on May 19, 2021. We applaud the leadership of
Chairman Wyden and Ranking Member Crapo and members of the Committee
for holding this hearing to evaluate the lessons learned during the
pandemic and what the important flexibilities that have played in
safely expanding access to care during the pandemic and options to
extend telehealth capabilities into the future.
Many of the waivers and temporary regulatory changes granted during
this period have significantly improved health-care providers' ability
to combat the epidemic. These actions have also highlighted key
opportunities to modernize health-care delivery by removing outdated
regulations. Premier's hope is that by identifying temporary policies
that proved successful in improving and innovating health care for
Americans during this challenging time, we can pinpoint changes that
should be made permanent or implemented on a broader scale beyond the
pandemic.
Safely Treating Patients through Telehealth
Premier greatly appreciates Congress acting to broadly expand permitted
uses of telemedicine and telehealth during the public health emergency
in the Coronavirus Preparedness and Response Supplemental
Appropriations Act and the Coronavirus Aid, Relief, and Economic
Security (CARES) Act. These provisions have allowed beneficiaries
beyond just those in rural areas to receive telehealth services in
their home from an expanded set of providers, including through audio-
only communications, and provided payments to match in-office rate for
clinicians who typically provide care in an office. As such, telehealth
has provided a lifeline during the pandemic for individuals in all
geographic areas who still need access to health care when traditional
care delivery approaches are interrupted.
Premier data for more than 30,000 ambulatory providers nationwide shows
that the use of virtual visits in the outpatient space have averaged
14.2 percent since the pandemic (an increase of nearly 30X compared to
pre-pandemic) with a 31 percent better no-show rate than in-person
visits. With this concentrated experience over the past year, providers
have learned how to best deploy telehealth and patients are
overwhelmingly reporting high satisfaction with their virtual care
visits. As a result, it is now seen as a valuable and potentially cost-
effective addition to health-care delivery.
As health systems and providers continue to support their communities
and navigate a new normal after the pandemic, they are concerned that a
retreat to prior rules will limit provider care delivery innovation for
Medicare beneficiaries. A permanent expansion of telehealth policies
will require appropriate guardrails. Recognizing more time is needed to
determine the best approaches for permanent telehealth expansion in
fee-for-service, Premier urges Congress to permanently extend to all
alternative payment models (APMs) the telehealth coverage and payment
policies that were operationalized under the public health emergency.
Providers in APMs are incented to use telehealth only when it is most
appropriate as they are responsible for the cost of care and improving
quality. A survey \1\ conducted by Premier found that providers
participating in accountable care organizations (ACOs) drew heavily on
their population health capabilities to manage COVID-19 cases and keep
people staying at home healthy, including by quickly ramping up the use
of telehealth.
---------------------------------------------------------------------------
\1\ https://www.premierinc.com/newsroom/press-releases/premier-inc-
survey-clinically-integrated-networks-in-alternative-payment-models-
expanded-value-based-care-capabilities-to-manage-covid-19-surge.
We believe Congress should immediately start with allowing greater
flexibility around the types of technology that can be used, adopting
additional services, and exploring additional telehealth flexibilities
through Center for Medicare and Medicaid Innovation (CMMI) models and
other Medicare APMs. While telehealth waivers are available for APMs,
they are far more limited than the waivers provided during the public
health emergency. The greatest flexibility should be awarded in models
in which providers bear downside risk, such as in global budgets and
capitated payments. Providing greater telehealth flexibility in models
will be a tremendous incentive for providers to transition from fee-
for-service to value and total-cost-of-care and other risk-based
---------------------------------------------------------------------------
models.
As Congress considers how to make expanded telehealth a permanent part
of our health-care system, we also encourage lawmakers to explore
increasing telehealth access across all of Medicare fee-for-service and
Medicare Advantage by granting Centers for Medicare & Medicaid (CMS)
greater authority to set regulation on allowable health services and
payment for telehealth services.
With appropriate guardrails, Congress should also take action to:
Provide temporary state licensing reciprocity for telehealth
during the pandemic by passing the Temporary Reciprocity to Ensure
Access to Treatment (TREAT) Act (S. 168/H.R. 708).\2\,\3\
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\2\ https://www.congress.gov/bill/117th-congress/senate-bill/168.
\3\ https://www.congress.gov/bill/117th-congress/house-bill/708.
Ensure audio-only telehealth continues to be an effective source
of health care for all seniors during the course of the COVID-19 public
health emergency by passing the Ensuring Parity in MA for Audio Only-
Telehealth Act (S. 150).\4\ This bill would count diagnoses obtained
from audio-only telehealth services for risk adjustment purposes under
the Medicare Advantage program to ensure that health costs are
adequately covered while providing the information care teams need to
manage patient care.
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\4\ https://www.congress.gov/bill/117th-congress/senate-bill/150.
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Ensuring Continued Movement to Value-Based Care
The pandemic has required greater care coordination across the
traditional health-care silos as providers work to manage infected
patients in the most effective settings. According to a Premier
survey,\1\ leading health systems and providers operating in value
models were able to rapidly implement strategies to respond to COVID-
19, expanding care management, call centers and remote/home monitoring
and other capabilities to respond to COVID-19. Moreover, if we had made
more progress in value-based care prior to COVID-19, with more entities
in global budgets or capitation, we could have avoided the financial
challenges many providers faced. We urge Congress to support a
continued emphasis on movement to value by:
Incenting providers to move to downside risk arrangements by
extending the Advanced APM bonus by five years and giving CMS the
authority to set the thresholds to qualify for the bonus;
Fixing a perverse flaw in the Medicare Shared Savings Program
that penalizes organizations in certain communities that are achieving
savings for the Medicare program by including their ACO population in
their spending benchmark calculation; and
Removing risk adjustment caps from value models so that the
complexity of patients is recognized in the benchmark.
Conclusion
In closing, the COVID-19 public health emergency has illuminated the
need to allow more flexibility in Medicare payment and delivery system
models so that providers can tailor care to the specific needs of
beneficiaries and their communities. This is especially true for
providers serving rural and underserved communities. Congress and the
Administration can build on the limited flexibilities for telehealth
and APMs granted during the public health emergency and make other key
changes to open doors to providers who are seeking to better serve
their Medicare populations through accountable delivery system models
that focus on care coordination, improved outcomes and value.
The Premier health-care alliance appreciates the opportunity to submit
a statement for the record on the Senate Finance Committee hearing on
COVID-19 health-care flexibilities. Premier is available as a resource
and looks forward to working with Congress as it considers policy
options to continue to address this very important issue.
If you have any questions regarding our comments or need more
information, please contact Blair Childs, Senior Vice President of
Public Affairs, at blair--childs@
premierinc.com.
______
Psychiatric Medical Care, LLC
8 Cadillac Drive, #230
Brentwood, TN 37027
May 19, 2021
Dear Chairman Wyden and Ranking Member Crapo:
Psychiatric Medical Care (PMC) appreciates the opportunity to submit a
statement for the record to the Senate Finance Committee on ``COVID-19
Health Care Flexibilities: Perspectives, Experiences, and Lessons
Learned.'' PMC applauds the members of the Finance Committee for their
rapid action to expand access to telehealth services during the COVID-
19 pandemic and strongly believes this expansion of health-care access
should be maintained to address other health issues, such as America's
ongoing behavioral health needs.
Founded in 2003 and headquartered in Nashville, TN, PMC is a leading
behavioral health-care management company. Focused on addressing the
needs of rural and underserved communities, PMC manages inpatient
behavioral health units, intensive outpatient programs, and telehealth
services in more than 25 states. The company's services provide
evaluation and treatment for patients suffering from depression,
anxiety, mood disorders, memory problems, post-traumatic stress
disorder, and other behavioral health problems.
Critical Access Hospitals (CAHs) have provided outpatient hospital
services via telecommunications technology during the COVID-19 pandemic
by leveraging the Center for Medicare and Medicaid Services (CMS)
waiver of the provider-based regulations described in ``Hospitals: CMS
Flexibilities to Fight COVID-19.''\1\ CMS clarified that hospitals
could use this flexibility to designate a patient's home as provider-
based and treat services rendered to such a patient in their home via
telecommunications technology as if they were being performed in-
person.\2\ This flexibility to leverage virtual care to its full
potential has proven crucial to meeting surging behavioral health needs
during the COVID-19 pandemic. However, even after the COVID-19 public
health emergency comes to an end, America's behavioral health crisis
will continue.
---------------------------------------------------------------------------
\1\ https://www.cms.gov/files/document/covid-hospitals.pdf.
\2\ 85 Fed. Reg. 27750, 27563 (May 8, 2020).
Unfortunately, public health experts expect that the opioid crisis
public health emergency, which has been exacerbated by the COVID-19
pandemic and further compounded the country's behavioral health
challenges, will also continue. Indeed, in the months since COVID-19
brought the nation to a standstill, more than 40 states have recorded
increases in opioid-related deaths.\3\ Additionally, approximately 20
percent of the rural population experiences mental illness \4\ and are
disproportionally impacted by the opioid epidemic (SUD often co-
occurring with mental illness).\5\ Approximately 48,000 people die by
suicide every year--the 10th leading cause of death in the United
States.\6\ These suicide rates were 40 percent higher in rural areas
than in large urban areas (and are increasing at a faster rate).\7\
---------------------------------------------------------------------------
\3\ https://www.ama-assn.org/system/files/2020-10/issue-brief-
increases-in-opioid-related-overdose.pdf.
\4\ Rural Health Reform Policy Research Center (2014). The 2014
update of the rural-urban chartbook, available on Gateway at https://
www.ruralhealthresearch.org/publications/940.
\5\ Keyes KM, Cerda M, Brady JE, Havens JR, Galea S. Understanding
the rural-urban differences in nonmedical prescription opioid use and
abuse in the United States. Am J Public Health. 2014;104(2):e52-e59.
\6\ National Vital Statistics System--Mortality Data (2018) via
CDC, www.cdc.gov/nchs/fastats/suicide.htm.
\7\ National Advisory Committee on Rural Health and Human Services,
Policy Brief and Recommendations, ``Understanding the Impact of Suicide
in Rural America,'' December 2017.
These challenges are particularly acute for Medicare beneficiaries.
Approximately 33 percent of widowers become depressed--and while
elderly adults represent only 13 percent of the population, they
represent approximately 20 percent of all suicide
deaths.\8\, \9\ At the same time, approximately 68 percent
of elderly adults have little awareness about how to recognize and be
treated for depression.\10\
---------------------------------------------------------------------------
\8\ National Institute of Mental Health, The Many Dimensions of
Depression in Women: Women at Risk (1999).
\9\ National Institute of Mental Health, Older Adults: Depression
and Suicide Fact Sheet (1999).
\10\ Depression in Older Adults: More Facts, Mental Health America
(n.d.). Retrieved from http://www.mentalhealthamerica.net/conditions/
depression-older-adults-more-facts.
In addition to maintaining access to critical services, the ability of
CAHs to furnish outpatient behavioral therapy via telehealth has also
improved continuity of care by easing some of the transportation
barriers intrinsic to rural settings, which are invariably exacerbated
during the winter months even in the absence of COVID-19. In other
words, CAHs serve communities defined by barriers in accessing medical
care, and CMS' flexibilities have enabled CAHs to not only maintain
access to outpatient behavioral therapy during the COVID-19 period of
health emergency, but these flexibilities have also driven CAHs to
identify and implement more efficient and clinically appropriate
---------------------------------------------------------------------------
delivery of care models that leverage telecommunications technology.
These rural behavioral health challenges are both a moral and economic
imperative for communities across the nation. These are exactly the
issues that Congress intended CAHs to address as providers of essential
services in rural communities, and the telecommunications flexibilities
granted during the COVID-19 pandemic that enable these facilities to
meet these challenges should continue.
Why CAHs Are Different
As you know, CAHs receive their designation because they are viewed as
critical health-care hubs within their rural areas and communities.
This designation excludes CAHs from the outpatient prospective payment
system (OPPS) for outpatient services unless they elect otherwise,
because Congress understood that payment under the OPPS would generally
not be adequate. Under the standard payment methodology for CAHs, a CAH
receives payment for outpatient services under a reasonable (``fair
market'') cost-based methodology. More specifically, many CAHs as an
institution receive payment for outpatient hospital services they
furnish to patients and then pay the medical staff according to their
own internal policies.
However, the telehealth statute is currently structured to provide fee
schedule payment to ``physicians'' and ``practitioners,'' not
reasonable cost payment to institutions like CAHs. Specifically, with
respect to telehealth services under section 1834(m) of the Medicare
statute, section 1834(m)(2) requires that the payment for telehealth
services be made ``to a physician or practitioner located at the
distant site . . .''. Further, the terms ``physician'' and
``practitioner'' are defined in statute and may not generally include
the state-licensed health-care professionals that CAHs rely on, by
virtue of their rural location and scarce labor market, to provide
outpatient behavioral therapy to their patients.
Unless Congress preserves CAH's existing reasonable cost payment
methodology under which they receive payment for behavioral health
services furnished via telecommunications technology during the PHE,
CAHs will be unable to provide these services after the end of the PHE
because Medicare cannot pay CAHs as an institution for ``telehealth''
services under a reasonable cost methodology. For a CAH to be able to
furnish behavioral health services via ``telehealth,'' it would need to
affirmatively elect to bill under the OPPS for all outpatient services,
which undermines the reimbursement flexibility Congress intended to
provide to CAHs in the first place. Even then, the CAH would not be
paid reasonable costs, and instead the ``physician'' or
``practitioner'' would be paid by Medicare the Medicare fee schedule
amount for their professional services. Moreover, as discussed above,
CAHs rely on state-
licensed providers to furnish behavioral health services, and many of
these providers may not be eligible to bill as ``physicians'' or
``practitioners'' under the Medicare program. These limitations would
leave many Medicare beneficiaries in rural communities served by CAHs
without mental health services, and would represent a significant
decrease in our national capacity to address rural mental health needs.
Recommendation
Psychiatric Medical Care requests that the Senate Finance Committee
take action to ensure that this important strengthening and expansion
of rural behavioral health capability is preserved at the end of the
public health emergency.
Our preferred action in response to this problem would be a
change to section 1834(g)(1) of the Social Security Act.i
This approach would retain the standard billing structure that CAHs use
and understand, while allowing the Centers for Medicare and Medicaid
Services the flexibility to continue the delivery of virtual care by
these facilities under that provision (rather than 1834(m)). CMS would
retain its authority to make evidence-based decisions as to the
services covered under this recommendation.
Psychiatric Medical Care would also support a two-year extension
of CMS's Hospital Without Walls flexibilities that are currently
allowing the delivery of these telehealth services by CAHs, so that the
Finance Committee can better understand the importance of these
services--particularly with respect to the delivery of behavioral
therapy services to seniors in rural areas.
Finally, it is important to understand that while Congress passed
legislation allowing the Medicare program to cover the provision of
mental health services offered in the patient's home through telehealth
in December 2020, that legislation did not make permanent the
flexibilities afforded under the ``provider-based'' waivers that
currently allow CAHs to bill telehealth services as if they were
furnished in-person during the PHE. Without this flexibility, many CAHs
will have significantly reduced capacity to provide behavioral health
services through telehealth after the PHE expires.
We strongly encourage the members of the Finance Committee to Act to
preserve these services for rural seniors. We look forward to
continuing to work with you to expand access to health care for
Americans.
Sincerely,
J.R. Greene, FACHE
_______________________________________________________________________
i Legislative Text for Consideration
(a) EXPANDING TELEHEALTH FOR CRITICAL ACCESS HOSPITALS. Section
1834(g)(1) of the Social Security Act (42U.S.C. 1395m) is amended to
read as follows:
`` (1) IN GENERAL.--The amount of payment for outpatient
critical access hospital services of a critical access hospital is
equal to 101 percent of the reasonable costs of the hospital in
providing such services, unless the hospital makes the election under
paragraph (2).
``(A) SPECIAL PAYMENT RULE FOR TELEHEALTH SERVICES.
``(i) IN GENERAL. Notwithstanding subsection (m)
critical access hospitals may receive payment under this paragraph for
outpatient critical access hospital services that are furnished via
telecommunications technology, which may include the use of audio or
visual equipment permitting two-way, real-time interactive
communication between the patient and health-care professional at the
critical access hospital.
``(ii) INITIATION OF OUTPATIENT CRITICAL ACCESS
HOSPITAL SERVICES VIA TELECOMMUNICATIONS TECHNOLOGY. Services described
in clause (i) may also be initiated via telecommunications technology
as long as such services complement a plan of care that includes in-
person care at some point, as may be appropriate.''
(b) EFFECTIVE DATE. The amendments made by this section shall apply to
covered outpatient critical access hospital services furnished on or
after January 1, 2022.
______
TechNet
805 15th Street, NW, Suite 708
Washington, DC 20005
Telephone 202-650-5100
Fax 202-650-5118
www.technet.org
May 19, 2021
U.S. Senate
Committee on Finance
Dirksen Senate Office Building
Washington, DC 20510
RE: ``COVID-19 Health Care Flexibilities: Perspectives, Experiences,
and Lessons Learned''
Chairman Wyden and Ranking Member Crapo:
Thank you for the opportunity to submit a statement for the record
regarding the Senate Committee on Finance Hearing titled ``COVID-19
Health Care Flexibilities: Perspectives, Experiences, and Lessons
Learned.'' We appreciate the efforts you are making to prioritize
greater access to health-care services through telehealth as the nation
recovers from the devastating COVID-19 pandemic, and we wanted to share
with you TechNet's federal policy principles on telehealth.
TechNet is the national, bipartisan network of technology CEOs and
senior executives that promotes the growth of the innovation economy by
advocating a targeted policy agenda at the federal and 50-state level.
Our diverse membership includes dynamic American businesses ranging
from startups to the most iconic companies on the planet and represents
over three and a half million employees and countless customers in the
fields of telehealth, information technology, e-commerce, the sharing
and gig economies, advanced energy, cybersecurity, venture capital, and
finance.
Telehealth has fundamentally altered how patients experience care. New
communication technologies allow health-care professionals to provide
patients with medical care and services in convenient, affordable, and
accessible ways. TechNet supports efforts that affirmatively enable the
use of technology neutral, innovative systems to treat patients
remotely and ensure the physician-patient relationship can be
maintained and strengthened. The COVID-19 pandemic has demonstrated how
critically important this is, as an increasing number of patients need
to access safe, timely, and effective care. For example, the number of
patients reporting at least one telehealth visit has increased by 57
percent since the start of the pandemic (Doximity).
With the onset of the pandemic, Congress provided the authority for
Centers for Medicare and Medicaid Services (CMS) to lift the antiquated
restrictions that conditioned eligibility for telehealth services on
the location of a patient and the site of care. CMS also significantly
expanded telehealth by approving more than 80 services eligible for
reimbursement under traditional Medicare while allowing Medicare
Advantage plans to use telehealth for the purposes of risk adjustment.
These are only a few of the regulatory flexibilities Congress
authorized to increase and enhance virtual care, and we believe that
many of these temporary measures should be made permanent. Telehealth
should be supported as a tool to practice medicine and ensure patients
have access to affordable health-care options despite their proximity
to health-care facilities or personal barriers restricting
accessibility.
We look forward to working with you on this and other critical issues
facing our nation. Please don't hesitate to reach out if we can be a
resource on these important issues or if you have any questions. I can
be reached at [email protected] or (202) 372-7000.
Best regards,
Carl Holshouser
Senior Vice President
______
Teladoc Health, Inc.
2 Manhattanville Rd.
Purchase, NY 10577
June 2, 2021
The Honorable Ron Wyden The Honorable Mike Crapo
Chair Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC 20515 Washington, DC 20515
RE: Teladoc Health Statement on the U.S. Senate Committee on Finance
Hearing, ``COVID-19 Health Care Flexibilities: Perspectives,
Experiences, and Lessons Learned''
Dear Chairman Wyden and Ranking Member Crapo,
Teladoc Health welcomes the opportunity to submit a statement for the
record for the May 19, 2021, U.S. Senate Committee on Finance hearing,
``COVID-19 Health Care Flexibilities: Perspectives, Experiences, and
Lessons Learned.'' We appreciate your interest in leveraging telehealth
and virtual care services to improve outcomes, expand access, address
disparities, and reduce health-care costs for all Americans.
Founded in 2002, Teladoc Health is the world's only integrated virtual
care system for delivering, enabling and empowering whole-person
health--from wellness and prevention to acute care to complex health-
care needs. The integrated services from Teladoc Health include
telehealth, expert medical services, AI and analytics, and licensable
platform services. With more than 2,400 employees, the organization
delivers care in 175 countries and in more than 40 languages,
partnering with employers, hospitals and health systems, and more than
50 health plans in the U.S. to transform care delivery. Teladoc Health
serves more than 40 percent of Fortune 500 employers, as well as
thousands of small businesses, labor unions, and public-sector
employers, which offer our virtual care services to their employees.
More than 70 million Americans access high-quality health-care support
through Teladoc Health and our providers. In 2020, Teladoc Health
Medical Group clinicians and therapists delivered more than 10.6
million unique virtual visits. Our hospital and health system clients
completed more than 3.5 million patient visits using our technology
platform. Additionally, more than 600,000 members use Livongo solutions
to manage a range of chronic conditions. Our behavioral health solution
saw an increase in use by over 500 percent in 2020.
While clinicians have used telehealth and virtual care services for
decades, many Americans were unable to access virtual care due to
overly restrictive and outdated policies at the state and federal
level. In many cases, these barriers disproportionately impacted urban
and underserved communities that rely on Medicare and Medicaid.
Yet, during the COVID-19 pandemic, telehealth proved to be a lifeline--
providing Americans with access to critical health-care services while
keeping vulnerable patients out of clinics and hospitals. Now, across
the United States, at unprecedented levels, clinicians are leveraging
virtual services to extend access to mental health, chronic condition
management, primary and specialty care, and other critical services for
patients who otherwise would not be able to see a physician in person.
In terms of our services, Teladoc Health expects total patient visits
to be between 12.5 million and 13.5 million for 2021 and we expect
similar patient volume growth for our hospital and health system
clients as they move to virtualize more aspects of care delivery post
pandemic.
From a policy perspective, increased use of telehealth services was
augmented by several key policy changes that Congress helped enable
through the Families First Coronavirus Response Act (FFCRA) and the
Coronavirus Aid, Relief, and Economic Security (CARES) Act and which
the Centers for Medicare and Medicaid Services further encouraged by
waiving restrictions on exactly how, where, and who can access and
deliver virtual care services.
Prior to the pandemic, only 13,000 Medicare beneficiaries accessed a
telehealth service per week. Leveraging emergency flexibilities,
providers delivered care to more than nine million beneficiaries via
telehealth from March through June 2020. This alone underscores the
critical role that virtual care can play in providing expanded, high-
quality, convenient, and cost-effective access to many in-demand
health-care services.
Without additional legislative changes, many of the temporary
flexibilities implemented during the current public health emergency
will expire, and patients, including beneficiaries enrolled in
traditional fee-for-service Medicare, will continue to face
substantial, outdated barriers to obtaining critical virtual care
services.
Concerns With Respect to In-Person Requirements
for Medicare Telehealth Services
As you and your colleagues consider the path forward for telehealth, we
urge you to consider the unintended consequences of relying on in-
person requirements as a policy tool. Given the bipartisan objectives
of the Committee with respect to Medicare, we believe that restricting
telehealth coverage for seniors using mandated prior in-person visits
is not a viable strategy and would control costs in much the same
manner as the existing statutory restrictions--by arbitrarily
restricting access to care for America's seniors. Restrictions on
telehealth that mandate a prior in-
person relationship are clinically unnecessary, exacerbate health
inequities, and would conflict with existing safeguards at the state
level that would add to the existing regulatory morass that providers
must navigate when delivering care virtually.
Health Equity and Racial Disparities
As of 2019, 23% of Americans report not having a relationship
with a doctor or health-care provider.\1\
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\1\ KFF. ``Adults Who Report Not Having a Personal Doctor/Health
Care Provider by Race/
Ethnicity,'' October 13, 2020. https://www.kff.org/other/state-
indicator/percent-of-adults-reporting-not-having-a-personal-doctor-by-
raceethnicity/.
23% of Black and 39% Hispanic Americans do not
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have a pre-existing relationship with a health-care provider.
In Oregon, 42% of Hispanic Americans do not have
a pre-existing relationship with a health-care provider.
Nearly 30% of all Idahoans do not have a pre-
existing relationship with a health-care provider.
States Regulate the Practice of Medicine and Have Implemented Robust
Safeguards
The use of technology does not alter the ethical, professional, and
legal requirements around the provision of appropriate medical care by
clinicians. The role of Medicare is to regulate and establish payment
and coverage for Medicare physician and non-physician provider
services, not to regulate the practice of medicine or nursing, which
has long been the prerogative of the states.
Over the past decade all 50 states and DC have passed legislation to
remove requirements for prior in-person consultations to establish a
valid physician-patient relationship, so long as the standard of care
is upheld. Today, not a single state in the U.S. mandates a prior in-
person consult to establish a relationship. The evidence has been clear
for some time that in-person requirements were, and remain, unnecessary
and have no clinical basis of support. In fact, in 2014, the Federation
of State Medical Boards (FSMB), the association of state regulators
that oversee standards of medical care, issued guidance and model
policy to state medical boards on regulating telehealth, that included
safeguards to ensure providers are required to meet the appropriate
standards of care when delivering care using technology.\2\
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\2\ https://www.fsmb.org/siteassets/advocacy/policies/
fsmb_telemedicine_policy.pdf.
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Patient Choice and Continuity of Care
In the past, some state medical associations have expressed concern
that telehealth would allow other providers to ``come between a patient
and their doctor.'' In response, nearly all states have incorporated
requirements into their telehealth statutes to ensure continuity of
care by requiring that patients' medical records from telehealth
consults be shared with each patient's primary care provider (with
patient consent) or be readily and easily accessible to a patient to
provide to their primary care provider or specialist.
The solution to enhancing continuity of care is to redouble efforts
toward patient-centered health data interoperability rather than
mandate that a patient sees a provider in person. The 21st Century
Cures Act, the ONC Cures Act Final Rule, and the CMS Interoperability
and Patient Access rule have accelerated the ability for a patient to
access their personal health information and as implementation
proceeds, will facilitate nationwide access to health records for
patients, health-care providers, and payers.
Patients should have the choice to see any provider. Survey data from
the pandemic shows that more than 70 percent of patients using
telehealth saw their own doctor. The remaining 30 percent represent the
millions of Americans who did not have a pre-existing relationship with
a provider due to widespread Primary Care and Mental Health workforce
shortages but were able to use telehealth to establish a relationship
and receive care from a provider licensed in their state.
We cannot ignore the importance of providing all Americans, regardless
of whether they have a medical provider with whom they have an
established relationship, the opportunity to access health care. For
years Congress has urged patients and consumers to make smart decisions
about their health-care spending. Telehealth is simply a modality and
is a safe and economical way to access quality health care with the
patient in the driver's seat.
Antitrust Issues
The U.S. Federal Trade Commission (FTC) and the US Department of
Justice have conducted numerous investigations into anti-competitive
behavior from state medical societies and state medical boards that
have used regulatory requirements for a prior in-person visit to
restrict access and limit patient choice.
In fact, FTC staff recently submitted comments to CMS and addressed in-
person requirements for Medicare telehealth services, noting the impact
on competition, innovation, choice, and price:
As discussed in a number of FTC staff advocacy comments, in-
person examination requirements prevent licensed health-care
providers from providing telehealth care that they otherwise
would deem appropriate. Such restrictions potentially reduce
competition, innovation, consumer choice, and the supply and
quality of care, and may also increase price. Accordingly, FTC
staff advocacy comments have opposed proposed laws and
regulations that prohibit the use of telehealth for initial, as
well as subsequent evaluations. Rather, FTC advocacy has
favored flexible provisions that allow the licensed
practitioner in the best position to weigh access, health, and
safety considerations to decide whether to use telehealth. Such
policies, which allow the patient-practitioner relationship to
be established by telehealth and typically hold the
practitioner to an in person standard of care, are supported by
several physicians' organizations.
Program Integrity
Antifraud enforcement and investigations of waste and abuse in federal
health programs must be a priority. However, Congress must not allow
program integrity concerns to inappropriately limit Medicare
beneficiaries' access to needed care. Arbitrarily restricting
telehealth coverage for seniors, including mandated prior in-
person visits, is not a viable program integrity strategy.
In fact, in a recent statement, Principal Deputy Inspector General
Christi A. Grimm stated unequivocally that bad actors using
telecommunication services to perpetrate ``telefraud'' should not be
conflated with the legitimate practice of telemedicine or imply that
telehealth services are at greater risk of abuse than in-person
services under Medicare.
Inspector General Grimm's statement is consistent with an HHS-OIG 2018
audit that found that the limited number of improper telehealth
payments were the result of deficiencies in Medicare claims forms or
the result of providers who inadvertently billed for telehealth
delivered to beneficiaries outside of the 1834(m) geographic site
restrictions.
Comprehensive anti-fraud statutes exist at both the federal and state
level. HHS OIG and CMS have extensive program integrity policies and
procedures in place to leverage existing authorities to address all
fraud, waste, and abuse, including improper payments. However, Congress
must ensure HHS and CMS have the necessary tools to combat bad actors
and provide robust funding for critical antifraud programs.
Bipartisan consensus exists across a range of telehealth and digital
health issues. We have presented recommendations in the appended white
paper intended to provide a framework for how best to advance
telehealth and virtual care both in preparation for future public
health emergencies and on a permanent basis to ensure expanded access
to quality care in the U.S. As detailed there, and noted previously in
this letter, these changes can, and should, be made without
unnecessarily limiting patient access to clinically appropriate care.
Thank you for the opportunity to provide a statement for the record. If
you have any questions or would like to further discuss our
recommendations, please do not hesitate to contact me.
Sincerely,
Claudia Duck Tucker
Senior Vice President
Government Affairs and Public Policy
______
Expanding Access to Care Through Proven, Quality, and Cost-Effective
Digital Health Technology
Federal Policy Recommendations
January 2021
Overview
Health-care providers have long used telehealth and remote technology
to provide timely access to needed health services, enhance the patient
experience, improve health outcomes and reduce costs. During the COVID-
19 pandemic, telehealth has proven to be a lifeline--providing
Americans with access to critical health-care services while keeping
vulnerable patients out of clinics and hospitals. Now, across the
United States, clinicians are leveraging virtual services and platforms
to extend access to mental health, primary and specialty care, and
other critical services for patients who otherwise would not be able to
see a physician in person. More Americans than ever have engaged with a
provider through synchronous real-time video or asynchronous
technologies to access lifesaving prescriptions, receive follow-up care
after an in-person procedure, or avoid high-cost ER and urgent care
clinics for minor conditions.\1\ Providers in underserved communities
are deploying telehealth solutions to ``beam'' in specialists from
across the country to rapidly respond and treat critical stroke
patients, augment and support ICU's and NICU's, and use remote
technologies to monitor long-term care patients and help patients
overcome chronic diseases.
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\1\ ``Synchronous'' means an exchange of information regarding a
patient occurring in real time. ``Asynchronous'' means an exchange of
information regarding a patient that does not occur in real time,
including the secure collection and transmission of a patient's medical
information, clinical data, clinical images, laboratory results, or a
self-reported medical history, https://www.americantelemed.org/wp-
content/uploads/2020/10/ATA-_Medical-Practice-10-5-20.pdf.
These rapid advances in virtual care were made possible, in
part, because federal policymakers advanced a number of
legislative and regulatory changes to enhance patient access
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during the COVID-19 public health emergency.
For example, Congress provided the Department of Health and Human
Services (HHS) authority to waive Medicare's longstanding geographic
and originating site restrictions on telehealth.\2\ HHS and the Centers
for Medicare and Medicaid Services (CMS) also leveraged emergency
authority to waive many of the in-person requirements for services
across Medicare programs while allowing Medicare Advantage plans to add
new virtual care benefits and use telehealth for risk adjustment
purposes.\3\, \4\ Congress also allowed high-deductible
health plans (HDHP) with a health savings account (HSA) to cover
telehealth services prior to a patient reaching their deductible.\5\
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\2\ Section 3703, H.R. 748, CARES Act.
\3\ https://www.cms.gov/about-cms/emergency-preparedness-response-
operations/current-emergencies/coronavirus-waivers.
\4\ Centers for Medicare and Medicaid Services. Applicability of
diagnoses from telehealth services for risk adjustment. April 10, 2020,
https://www.cms.gov/files/document/applicability-diagnoses-telehealth-
services-risk-adjustment-4102020.pdf.
\5\ Section 3701, H.R. 748, CARES Act.
These and other temporary COVID-19 policy changes have, overnight,
opened the door to virtual care services that were previously
unavailable to many patients in the U.S. In response, Teladoc has
worked alongside our clients and partners--health systems, health
plans, and employers--to help meet new demand as Americans have
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embraced virtual care on an unprecedented scale.
As of 2020, more than 70 million Americans have paid access to high-
quality health-care support through Teladoc Health clinicians and
therapists. In 2020, Teladoc Health Medical Group clinicians and
therapists delivered more than 10.6 million unique visits. Our hospital
and health system clients completed more than 3.5 million patient
sessions using our technology platform. Additionally, as of Q3 2020,
more than 540,000 members use Livongo solutions for chronic conditions.
Overall, Teladoc Health has seen utilization of services stabilize at a
level that is 40% higher than before the COVID-19 pandemic with total
visits expected to exceed 10 million for 2020.
In terms of Medicare, prior to the pandemic, only 13,000 beneficiaries
accessed a telehealth service per week. Leveraging emergency
flexibilities, providers delivered care to more than 9 million
beneficiaries via telehealth from March through June 2020. This alone
underscores the critical role that virtual care can play in providing
expanded, high-quality, convenient, and cost-effective access to many
in-demand health-care services.\6\
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\6\ Early Impact of CMS Expansion of Medicare Telehealth During
COVID-19, Health Affairs Blog, July 15, 2020, https://
www.healthaffairs.org/do/10.1377/hblog20200715.454789/full/.
This experience has made clear that there is no clinical basis
for the long-standing restrictions that have prevented Medicare
beneficiaries from accessing services via telehealth from their
homes, and it is time for Congress to finally take action to
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permanently extend access to virtual care.
As policymakers look to the future, it is important to note that
telehealth is not a separate care delivery system. From a patient and
provider perspective, telehealth is a tool to deliver health-care
services by a licensed health-care professional to a patient at a
different location. Since health care and the practice of medicine are
primarily regulated at the state level, state legislatures and
professional boards determine how and when clinicians can deliver care
remotely. This provides federal policymakers with the opportunity to
leverage federal health programs to incentivize and promote access to
virtual care.
As Congress and the Administration work to expand access to care,
efforts to harmonize federal and state requirements must be a priority
to prevent fracturing an already complex patchwork regulatory landscape
that has long hindered the uptake and adoption of virtual care. For
example, in all 50 states, state law allows physicians to establish a
relationship with a patient virtually.\7\ However, in recent years some
legislative proposals to expand Medicare telehealth services would
require a patient to see a provider in-person before they are eligible
for telehealth benefits. Not only are such in-person requirements
clinically unnecessary, but they are also out of step with a decade of
telehealth reform at the state level and would exacerbate the patchwork
regulatory environment that hinders patients' access to virtual care.
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\7\ https://www.ama-assn.org/system/files/2018-10/ama-chart-
telemedicine-patient-physician-relationship.pdf.
In short, the challenges and shortcomings revealed by the pandemic have
exposed a fragile and inflexible U.S. health-care delivery system.
Without additional legislative changes at the state and federal level,
many of the temporary flexibilities implemented during the current
public health emergency will expire, and patients, including
beneficiaries enrolled in traditional fee-for-service Medicare, will
continue to face substantial, outdated barriers to obtaining critical
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virtual care services.
As Congress and the Biden Administration take stock of recent
temporary COVID-19 policy changes and consider the important
role that virtual care has played in improving care delivery
during the pandemic in the U.S., efforts should focus on:
1. Determining if the authorities put in place by Congress and
the Administration are sufficient for future public health emergencies,
including pandemics.
2. Identifying and permanently extending certain flexibilities
and authorities made available during the public health emergency.
As policymakers work to answer these questions, we encourage continued
engagement with stakeholders to ensure that post-pandemic policies
reflect the preferences of patients and the realities of those on the
front lines of care delivery. Bipartisan consensus exists across a
range of telehealth and digital health issues. The recommendations
proposed in this document are intended to provide a framework for how
best to advance telehealth and virtual care both in preparation for
future public health emergencies and, perhaps most importantly, on a
permanent basis to ensure expanded access to quality care in the U.S.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Teladoc Health is empowering all people everywhere to live
healthier lives by transforming the health-care experience. Recognized
as the world leader in whole-person virtual care, Teladoc Health
leverages clinical expertise, advanced technology and actionable data
insights to meet the evolving needs of consumers and health-care
professionals.
For more information, please visit teladochealth.com or follow
@TeladocHealth on Twitter.
Enhance Health-care Access, Convenience, and Outcomes
Virtual care technology can serve as a powerful equalizer by
eliminating the barriers of time, distance, and geography and
empowering patients to overcome the challenges and limitations of
accessing in-person health care. Post pandemic, federal health programs
must ensure that patients can access high-quality telehealth services
anywhere, including the home. For a wide range of health-care services,
providers utilizing telehealth have demonstrated the ability to provide
the same level of care as in-office visits and shown that, in both
rural and urban underserved areas, telehealth serves as the only means
by which patients can quickly and conveniently access quality care.
Before the waiver authority granted through the Families First
Coronavirus Response Act (FFCRA) and expanded under the Coronavirus
Aid, Relief, and Economic Security (CARES) Act, traditional Medicare
allowed seniors and individuals with disabilities covered under the
program to receive telehealth services only when located in certain
rural areas of the country and at an eligible ``originating site''--
usually a clinic or hospital. This regulatory imbalance between in-
person care and telehealth prevented the health-care system from
leveraging the agility and convenience of virtual care with no clinical
basis of support. These unnecessary and outdated restrictions were
waived during the COVID-19 pandemic but will require action from
Congress to be eliminated permanently.
Recommendation 1.1: Congress must reform 1834(m) of the Social
Security Act and permanently eliminate the geographic and originating
site requirements to enable Medicare beneficiaries to access telehealth
services outside of federally designated rural areas and, importantly,
from home.\8\
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\8\ Social Security Act, Pub. L. No. 104-321. Codified at 42 U.S.C.
Sec. 1320b-5.
Recommendation 1.2: Under current authority, CMS should
permanently allow Medicare Advantage organizations to use telehealth,
including both real-time interactive video and audio, for the purposes
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of risk adjustment.
Recommendation 1.3: Section 1135 of the Social Security Act
provides HHS with authority to waive many of the requirements that
could potentially limit the provision of virtual care during a national
emergency, including EMTALA, Physician Self-Referral, HIPAA, and
requirements that a provider be licensed in the state of the patient as
a condition of participation in federal health programs. Under FFCRA
and the CARES Act, Congress gave HHS additional authority to waive
restrictions on telehealth during the COVID-19 pandemic. However, the
waiver authority is limited to the COVID-19 PHE determination. Congress
should ensure HHS and CMS can act quickly during future pandemics and
natural disasters by granting permanent waiver authority for all public
health emergencies under Section 1135 of the Social Security Act.
Incentivize 21st Century Virtual Care
Federal health programs should incentivize the expansion of virtual
care and reimburse providers for all forms of telehealth. In addition,
patients and payers should have more flexibility to use account-based
plans and innovative coverage arrangements to help finance care.
Private payers should compensate health-care providers for delivering
virtual care; however, a provider and health plan should have the
ability and flexibility to agree to reimbursement rates based on market
conditions.
Recommendation 2.1: Congress should permanently allow pre-
deductible coverage for telehealth and other remote care services for
high-deductible health plans (HDHPs) paired with a health savings
account (HSA).
Recommendation 2.2: CMS has historically taken a conservative
approach to expanding telehealth services under traditional Medicare
FFS. In response to COVID-19, CMS broadly expanded the list of eligible
telehealth services available to beneficiaries for the duration of the
PHE. COVID-19 has demonstrated that providers are able to responsibly
deliver care remotely, and CMS should seek to broadly expand the list
of eligible Medicare telehealth services that are demonstrated to be
safe, effective, and clinically appropriate. For services that CMS
needs additional evidence before initiating permanent coverage, the
agency should create an additional pathway that would cover telehealth
services on a temporary basis and allow providers to develop the
evidence that the agency believes necessary for adding a service on a
permanent basis.
Recommendation 2.3: Under Medicare FFS, there are two payment
rates for many physicians' services based on the site of service: the
facility rate; and the non-facility, or office, rate. For telehealth
services, Medicare has historically reimbursed the billing provider at
the facility rate since the costs (i.e., staff and equipment) for the
telehealth service were borne by the originating site where the patient
is located, not by the provider at the distant site. This payment
methodology has worked for delivery models where networked, affiliated
hospitals and practices share costs. However, when the home is made an
eligible originating site, payment rates must adequately compensate
providers so as not to incentivize and favor in-person visits over
virtual.
Recommendation 2.4: While reforming Medicare FFS to allow for
telehealth must remain a priority, the power of telehealth to address
costs and improve outcomes is best leveraged within risk-bearing
payment arrangements. As CMS continues to pilot and expand value-based
care models, expanding flexibility to use virtual care must be a
cornerstone of key payment reform initiatives moving forward.
Recommendation 2.5: Congress should ensure Medicare enables
virtual chronic condition prevention and management, including virtual-
only providers in the Diabetes Prevention and the Diabetes Self-
Management and Training Programs.
Recommendation 2.6: Congress should designate standalone
telehealth as an ERISA excepted benefit to ensure that virtual services
can be offered as a supplement to employees and dependents who are
eligible for traditional group health coverage and to employees--and
their dependents--who are ineligible for employer group health
coverage.
Ensure Patient Choice and Provider Autonomy
The paradigm for health care has shifted in response to the rapid
growth and ubiquity of digital technology. Prior to COVID-19, patients'
expectations for how care is delivered had already significantly
changed, and the pandemic further accelerated these trends. Given the
speed and proliferation of digital health, patients should be afforded
the ability to choose the technology by which they want to interact and
engage with their health-care provider. To expand patient choice,
health-care services accessed and delivered remotely should not be held
to a different standard than services provided in-person. The form of
communication, or modality, should be determined by clinicians, in
consultation with their patients, provided that it is sufficient to
evaluate and diagnose the condition and meet the standard of care.
As the COVID-19 pandemic has demonstrated, Americans that do not have
access to high speed Internet or broadband have challenges in accessing
a provider through real-time video, and have come to rely on telephone
and interactive audio visits to access care. A clinically appropriate
telehealth encounter--when it includes informed consent, affirmative
identification of patient and treating provider, a patient evaluation
and diagnosis in accordance with the standard of care, and an
appropriate treatment plan--should not be limited by arbitrary
legislative or regulatory restrictions. Policymakers should pursue a
technology neutral approach and allow health-care providers to
determine what technology is best to treat patients. Telehealth should
not have clinicallyunsubstantiated barriers to technologies if it is
safe, effective, appropriate, and complies with HIPAA and all related
state privacy requirements.
Recommendations 3.1: As Congress seeks to address the outdated
geographic restrictions in traditional Medicare FFS, it should avoid
imposing requirements for a prior in-person visit or limits on the type
of technology that may be used for a telehealth encounter.
Recommendations 3.2: Congress should not limit Medicare
beneficiaries' access to telephone-based communications, which has
proven safe and effective across a range of use cases during the COVID-
19 pandemic.
Recommendations 3.3: Congress and CMS should expand support for
asynchronous telehealth technologies, including remote patient
monitoring, to ensure beneficiaries are not limited to accessing
virtual care via real-time video.
Recommendations 3.4: To address the ongoing substance abuse
crisis, Congress must ensure that DEA finalizes the telemedicine
special registration rule which would allow DEA-registered
practitioners to prescribe controlled substances, such as certain kinds
of medication-assisted treatment, without an in-person medical
evaluation. The DEA has temporarily waived requirements during the
COVID-19 PHE; however, the agency will need to promulgate and finalize
the rule to ensure providers can continue to treat and prescribe
controlled substances to patients post-pandemic.
Address Digital Literacy and Expand Telehealth Access to Underserved
Communities
Underserved rural and urban communities, tribal nations, racial and
ethnic minorities, and vulnerable patient populations all have higher
prevalence of chronic conditions and should have equitable access to
telehealth and digital health services. The pandemic has revealed that
connectivity is a critical health-care resource and a prerequisite for
expanding access to high-quality care. A patient should not be denied
access to virtual care because they live in a community that lacks
sufficient broadband access, cannot afford the appropriate technology,
or are not comfortable using a computer or device. Underserved patient
populations deserve the same savings, convenience, and access to care
as patients elsewhere. Health disparities must be accounted for in
federal health programs, and virtual care reform efforts should be
coupled with targeted federal investment to help bridge the digital
divide and help ensure autonomy and access for all seniors and
caregivers that want to use it.
Recommendation 4.1: To address racial, ethnic, and income-based
disparities while ensuring Americans in both rural and urban
communities are not left behind, Congress must advance a national
strategy toconnect all Americans via broadband and 5G, with robust
investments targeted toward underserved areas of the US.
Recommendation 4.2: Building on the investments made in recent
COVID-19 relief legislation, Congress should continue to invest in
telehealth and remote care infrastructure for health systems that serve
vulnerable patient populations, Federally Qualified Health Centers
(FQHC), Rural Health Clinics (RHC) and Community Behavioral Health
Centers (CCBHC), expand existing HRSA telehealth grant and technical
assistance programs, and task HHS with developing a national strategy
to support community health workers (CHW) to identify and work with
high-risk patients who need help with understanding how to use
technology to ensure all Americans can access virtual care.
Recommendation 4.3: HHS and CMS should work with stakeholders to
develop education and training resources that account for age, socio-
economic, geographic, cultural and linguistic differences in how
beneficiaries interact with technology and ensure seniors and Medicaid
beneficiaries can fully leverage digital health technologies.
Recommendation 4.4: Congress and the Administration should revisit
cost-
sharing requirements for digital health. Monthly recurring copays for
remote patient monitoring and other virtual care solutions can serve as
a deterrent to those living with chronic and complex conditions that
may benefit most from ongoing care management solutions.
Ensure Patient Privacy and Address Cybersecurity Risks
The protection of patient privacy and personal data are critical to the
expansion of virtual care. Balanced federal health data privacy and
cybersecurity policy are necessary to support innovation; however,
telehealth and digital health technologies must be required to mitigate
cybersecurity risks and protect patients' privacy and personal health
data. Coordinated disclosure, information sharing, patient and provider
education, and the development of consensus standards must remain the
cornerstone of cybersecurity policy for regulated devices, mobile
applications, and related health-care products to ensure that risks to
patients and providers are mitigated.
Recommendation 5.1: Post-pandemic, the HHS Office of Civil Rights
(OCR) should swiftly end the current COVID-19 PHE HIPAA enforcement
discretion policy and ensure virtual care and telehealth encounters are
conducted via secure HIPAA-compliant platforms designed to protect PHI.
Patients should be assured that health-care providers are complying
with HIPAA's privacy, security, and breach notification requirements
when receiving care virtually.
Recommendation 5.2: While the Federal Trade Commission (FTC) has
some authority to regulate organizations that are not considered
covered entities under HIPAA, the FTC's authority is limited to
practices that are ``unfair or deceptive.'' To better protect patients
and consumers and address the patchwork privacy framework for health
data in the U.S., Congress should establish a Commission to study and
issue recommendations for the protection of individual privacy that
balances the need to preserve innovation, with clear rules of the road
for the appropriate use of health information by mobile application and
platform developers.
Recommendation 5.3: The Food and Drug Administration (FDA), HHS,
and other health-care regulators already have broad authority to
strengthen the cybersecurity requirements for regulated devices and
products that could potentially be exploited by bad actors. Federal
agencies must prioritize the recognition, promotion, and direct
participation in the development of private sector consensus standards
to ensure manufacturers and developers have a consistent framework for
implementing cybersecurity safeguards. Given today's dynamic threat
landscape, Congress and relevant agencies should also facilitate
collaboration with health-care delivery organizations, medical device
manufacturers, independent security experts, and academia through
public-private partnerships to ensure that these stakeholders are able
to quickly address and resolve emerging cybersecurity threats to
patients and providers.
Expand Patient Health Data Portability and Ensure Interoperability of
Digital Health Technology
The COVID-19 pandemic has demonstrated the importance of patients and
providers having access to health-care data when and where they need
it. Over the past decade, progress has been made to incentivize the
adoption of technologies that are capable of exchanging electronic
health information; however, data remains siloed and inaccessible
across much of the health-care system. Congress and the Administration
must remain committed to advancing a patient-centered interoperable
health-care system that empowers patients and enables providers to
deliver safe and efficient care.
Recommendation 6.1: CMS and ONC should remain committed to
implementing the 21st Century Cures Act, including robust enforcement
of the CMS Interoperability and Patient Access Final Regulation and the
ONC Interoperability and Information Blocking Final Regulation--both of
which will advance the uptake of patient access application programming
interfaces (APIs) and facilitate greater provider-to-provider and
payer-to-payer data exchange. COVID-19 has placed an unprecedented
burden on the nation's health-care system, and the agencies should
extend implementation deadlines in line with the COVID-19 PHE.
Protect Patients and Taxpayers
The economic benefits of robust antifraud and abuse enforcement under
existing federal law are much larger than monetary settlements when
accounting for deterrence effects, including long-lasting changes in
physician behavior and wasteful medical procedures.\9\ Antifraud
enforcement and investigations of waste and abuse in federal health
programs must be a priority. However, Congress must be cautious about
letting program integrity concerns dictate virtual care policy in
traditional Medicare FFS. Arbitrarily restricting telehealth coverage
for seniors, including mandated prior in-person visits, is not a viable
program integrity strategy for Medicare. Such a strategy would cause
Medicare Advantage and private health plans members to receive more
robust telehealth benefits and could exacerbate health-care
disparities. As virtual care is expanded, the federal agencies tasked
with protecting federal health programs--and ultimately beneficiaries
and taxpayers--must be appropriately equipped to maximize and leverage
currently available technologies and strategies to audit claims and
enhance fraud investigations.
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\9\ Howard, David H, and Ian McCarthy. ``Deterrence Effects of
Antifraud and Abuse Enforcement in Healthcare.'' Working Paper. Working
Paper Series. National Bureau of Economic Research, October 2020,
https://www.nber.org/papers/w27900.
HHS OIG and CMS must continue to invest in innovative
strategies, appropriate private sector best practices, and
leverage artificial intelligence and predictive analytics
rather than rely on policies that would restrict access to
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virtual care.
Recommendation 7.1: HHS OIG and CMS have extensive program
integrity policies and procedures in place to address fraud, waste,
abuse, and improper payments. Congress should ensure HHS and CMS have
the necessary tools to combat bad actors and provide robust funding for
critical antifraud programs. Teladoc Health believes that the existing
public-private partnership codified under Sec. 124, Public-Private
Partnership for Health Care Waste, Fraud, and Abuse Detection, H.R.
133, Consolidated Appropriations Act, 2021 can significantly advance
efforts to mitigate and prevent telehealth from being utilized as an
avenue for fraud and abuse. We recommend strengthening the public
private partnership by ensuring experts with experience in virtual care
are included and represented on the executive board.
Recommendation 7.2: States should maintain responsibility for
regulating the practice of medicine to ensure the full resources of the
state are available for the protection of any patients that receive
services that fall short of the standard of care. Federal policy should
support and incentivize the adoption of interstate licensure compacts
and other related licensure portability policies to ensure that
clinicians can treat patients safely across state lines.
Infuse Innovation into Federal Health-care Programs
More than seven million federal employees have access to Teladoc Health
solutions through their Federal Employees Health Benefit Program. There
is great potential to empower those in federal service through
contracting opportunities with entities like the Department of Veterans
Affairs, the Department of Defense and the Indian Health Service.
Supporting and caring for federal health beneficiaries with chronic
conditions is a complex process that draws on many clinical and
financial resources from across the federal government. From devices
and supplies to care management, nutrition, clinic visits, and
specialist consults, the points of contact for a beneficiary, and the
associated agency cost/payment flows, are numerous.
Modern digital disease management solutions offer the potential to make
things easier and meet federal health beneficiaries where and when they
need support the most. Connected data can be combined with intelligent
support and empathetic coaching that is available all day every day.
Unfortunately, most federal beneficiaries with chronic conditions have
little access to management tools such as this. Depending on their
disability status, federal beneficiaries receive various levels of care
from appointments to medications and testing. Across Medicare/Medicaid,
VA, and IHS, beneficiaries are now receiving video visits via
telehealth, as well as a small number receiving home-based remote
monitoring. This piecemeal approach does not allow for scale or
comprehensive cost analysis and is complicated for both beneficiary and
federal agency alike.
Recommendation 8.1: Congress must continue to invest and ensure
that federal health-care program beneficiaries through the Office of
Personnel Management (OPM), the Department of Veterans Affairs (VA),
the Department of Defense (DoD) and the Indian Health Services (IHS)
have access to telehealth and other innovative virtual care offerings
to manage their health and wellness.
Recommendation 8.2: As hospital systems, health plans, and
employers, are seizing on modern virtual care methods to support their
patients and beneficiaries with chronic conditions, VA, DOD, and IHS
should create pathways to pursue Alternative Payment Models (APMs) for
chronic conditions and diabetes management.
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