Last week the Centers for Medicare and Medicaid Services (CMS) issued their proposed rule for the Calendar Year 2021 Home Health Prospective Payment System. The rule proposes to permanently finalize the allowances made during the COVID-19 public health emergency (PHE) for use of telecommunications technology by Home Health Agencies (HHAs). Although the Social Security Act specifies that telecommunications technology cannot substitute for in-person home health services, CMS acknowledges ways in which technology can be used to improve patient care, especially during the COVID-19 PHE. The rule includes an example of a circumstance in which virtual visits can be added to a patient’s plan of care, not as a substitute but as an additional measure in the context of the COVID-19 PHE. CMS states that they believe the provision of in-person visits and encounters using telecommunications technology can also apply outside of the PHE.
The specific changes CMS is seeking to finalize that were originally included in the first COVID PHE interim final rule (IFC) include:
- Allowing HHAs to continue to report the costs of telehealth/telemedicine as an allowable administrative cost on their cost report. The instructions would be modified to reflect a broader use of telecommunications technology.
- Provide for the use of remote patient monitoring and other communications or monitoring services, consistent with a patient’s plan of care. The plan of care should describe how the use of the technology is tied to the patient-specific needs and goals as identified in a comprehensive assessment.
Comments are requested on both of these proposals. CMS notes that finalizing these interim policies would be fulfilling an element of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) which requires the Secretary to consider ways to encourage the use of telecommunications systems, including remote patient monitoring and other communications or monitoring services for home health services. The rule also indicates that finalizing these policies would allow HHAs who may have been unsure whether or not to invest in telecommunications systems, to do so confidently knowing the policies will be in place to support those expansions. CMS also makes a point of reminding stakeholders that telecommunications technology must be inclusive and made accessible for patients who have disabilities that may make utilizing the technology a challenge.
To read the full CMS proposed rule on the CY 2021 home health prospective payment system or submit comments, visit its listing on the Federal Register.
School may not be in session, but telehealth programs across the nation are busy addressing the needs of students stuck at home during the pandemic – including a growing number in need of mental health counseling.
– School may not be in session because of the coronavirus pandemic, but that doesn’t mean school-based telehealth programs are shuttered. In many cases, they’re busier than ever.
While originally designed to treat non-acute health concerns and keep students in school, connected health platforms have evolved to handle a variety of issues, including chronic care management and behavioral health concerns. Those concerns haven’t gone away during the COVID-19 emergency, and are often exacerbated because students are stuck at home, with perhaps even less access to healthcare than at school.
(For more coronavirus updates, visit our resource page, updated twice daily by Xtelligent Healthcare Media.)
In Massachusetts, a telemental health program run through Athol Hospital for students in two high schools pivoted to a home-based program in mid-March, when the schools closed. Maureen Donovan, the hospital’s program manager, said counselors had to transition from seeing students via telehealth in a room at school to connecting wherever and whenever a student could find the time and space at home to talk.
“Now that we’re at home, we’ve seen things that we’ve never seen before,” Donovan said during a recent virtual session hosted by the Northeast Regional Telehealth Resource Center and Mid-Atlantic Telehealth Resource Center.
Donovan said the program – based in rural region of the Bay State – had to find ways to ensure access for students who didn’t have access to telemedicine technology or broadband at home. In addition, counselors often had to deal with a noisy home environment that often intruded on a student’s privacy.
“We’re trying – we’re trying to have family support and sibling support,” she said, noting students would sometimes call in from their car or another remote location, or text-message or e-mail counselors to keep the lines of communication going.
“They’re all doing what they need to do to have sessions,” she said.
Donovan expects that the program, currently serving more than 100 students, will remain home-based if and when schools reopen this fall. She said school districts will place a heavy emphasis on academic activities during whatever becomes of the school day, to make up for time lost to the pandemic, and programs like the telemental health platform will need to work around the edges.
“School is going to be very different,” she said, and a telemedicine platform “will allow us to be flexible” in meeting student needs.
In some areas, particularly rural and underserved regions, the school nurse may be a student’s only access to healthcare. School districts have often partnered with local health systems to make sure primary care needs were being met.
When these schools shifted from in-person education to virtual education, they had to make sure their healthcare services were virtual as well.
“A lot of folks don’t realize that school nurses are still working full time,” says Josh Golomb, CEO for Hazel Health, a national provider of telehealth services for schools. “What those nurses quickly asked us to do is offer Hazel at home. Students still need healthcare.”
Robert Darzynkiewicz, Hazel’s chief medical officer, points out that the COVID-19 crisis not only sent students home from school – it closed or severely limited access to primary care providers. Parents stopped going to the doctor’s office with their children.
With that in mind, school districts, local health systems and providers like Hazel Health worked to emphasize telehealth as an option. They pushed services out to the home not as a means of replacing what was lost when schools closed, but to make sure people were able to access care.
Golomb, noting his business has increased significantly over the past two months, says school districts are now learning the value of a telehealth platform.
“This has heightened the realization that they need to be offering more services,” he says. “The simple part of healthcare is what we actually see during the school day … but there’s a lot more” that goes into a school health program.
With re-opening on the horizon, Golomb and Darzynkiewicz say school districts are now scrambling to prepare for what will be a much different environment – and they’re peppering healthcare providers with questions about how to set things up. How should schools handle COVID-19 testing for both staff and students, and what do they do when someone tests positive? And how will traditional healthcare services still be made available?
Like Donovan, Golomb says school districts will rely more heavily on telehealth platforms that can offer services at home – particularly services like chronic care management and behavioral health. They’re looking at more wrap-around services, he says, that complement the academic program while offering better and more convenient access to care.
“Our goal is to be where the kids are,” Darzynkiewicz says.
In colleges and universities, the telehealth platform is just as important, if not more so. Campus health centers are, in many cases, the sole source of healthcare for students during the school year. And being stuck at home doesn’t make things any easier.
“There’s a strong need for psychiatric services and counseling no matter where they are,” says Anne Fisher, a clinical psychiatrist and head of the wellness center at the New College of Florida, which “went from 100 percent in-person to 100 percent online” in March.
Fisher says students face a wide variety of behavioral health concerns and stresses in a college setting, ranging from sex and gender identity issues to the challenges of coping with classes and social life away from home. Those issues are still there even when the student is home, and they can’t walk over to the health center to chat with a counselor.
“This is a crucial time in their life,” she says, noting that her center sees roughly 40 percent of the college’s 800-student population. One moment they’re living on or near the campus, she says, “and the next moment they’re back at home. Suddenly they’re a kid in the house again.”
Fisher says her department’s telehealth platform is more important now than ever, but the challenges are daunting. Privacy and security issues abound with virtual care, and there’s the added difficulty of making sure that out-of-state students can access the service.
“These things get trickier when you’re remote,” she says.
As well, while the school will re-open, perhaps this fall, the campus will be decidedly different. COVID-19 protocols will affect how many students live in a dorm, how meals are delivered, even how students interact with elderly faculty and staff who are more susceptible to the virus. Older buildings will have to be thoroughly cleaned, maybe even reconfigured.
“Generally, counseling centers are stuck wherever they can be stuck,” Fisher says. “Old offices in older buildings, or converted spaces with poor ventilation.”
With an emphasis on healthcare, or healthier activities, that will change. And in an effort to reduce the need for major construction and renovation projects, as many programs as possible will be transitioned to telemedicine platforms, giving providers and students more freedom to connect when and where they can find the time and space. As well, there will be more emphasis on pushing resources out to students through virtual platforms, including mHealth apps.
“I think this is going to change (campus) healthcare a lot … especially mental healthcare,” she says.
Today, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule [CMS-1730-P] that proposes routine updates to the home health payment rates for calendar year (CY) 2021, in accordance with existing statutory and regulatory requirements. This proposed rule also includes a proposal to make permanent the regulatory changes related to telecommunications technologies in providing care under the Medicare home health benefit beyond the expiration of the public health emergency (PHE) for the Coronavirus Disease 2019 (COVID-19) pandemic.
This rule includes a proposal to adopt the revised Office of Management and Budget (OMB) statistical area delineations as described in OMB Bulletin 18-04 and proposes to apply a 5 percent cap on wage index decreases in CY 2021. Finally, this rule proposes Medicare enrollment policies for qualified home infusion therapy suppliers and updates the home infusion therapy services payment rates for CY 2021.
The proposed rule can be downloaded from the Federal Register at: https://www.federalregister.gov/documents/2020/06/30/2020-13792/medicare-and-medicaid-programs-cy-2021-home-health-prospective-payment-system-rate-update-home
Strengthening Medicare – Further Promoting Telecommunications Technology in Medicare
In an effort to promote efficiencies, this rule proposes to permanently finalize, beginning January 1, 2021, the amendment to the home health regulations outlined in the March 30, 2020 Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency Interim Final Rule (85 FR 19230). This would mean that home health agencies (HHAs) can continue to utilize telecommunications technologies in providing care to beneficiaries under the Medicare home health benefit beyond the COVID-19 PHE, as long as the telecommunications technology is related to the skilled services being furnished, is outlined on the plan of care, and is tied to a specific goal indicating how such use would facilitate treatment outcomes.
The use of technology may not substitute for an in-person home visit that is ordered on the plan of care and cannot be considered a visit for the purpose of patient eligibility or payment; however, the use of technology may result in changes to the frequencies and types of in-person visits as ordered on the plan of care. This rule also proposes to allow HHAs to continue to report the costs of telecommunications technology as allowable administrative costs on the home health agency cost report beyond the PHE for the COVID-19 pandemic. These proposed changes are one of the first flexibilities provided during the COVID-19 PHE that CMS is proposing to make a permanent part of the Medicare program. These proposals would ensure patient access to the latest technology and give home health agencies predictability that they can continue to use telecommunications technology as part of patient care beyond the PHE.
Updates to the Home Health Prospective Payment System (HH PPS) rates for CY 2021
This rule proposes routine, statutorily-required updates to the home health payment rates for CY 2021. CMS estimates that Medicare payments to HHAs in CY 2021 would increase in the aggregate by 2.6 percent, or $540 million, based on the proposed policies. This increase reflects the effects of the proposed 2.7 percent home health payment update percentage ($560 million increase) and a 0.1 percent decrease in payments due to reductions made in the rural add-on percentages mandated by the Bipartisan Budget Act of 2018 for CY 2021 ($20 million decrease). This rule also proposes to update the home health wage index including the adoption of revised Office of Management and Budget (OMB) statistical area delineations and limiting any decreases in a geographic area’s wage index value to no more than 5 percent in CY 2021.
Proposals and Updates to the Home Infusion Therapy Benefit for CY 2021
This rule proposes to implement Medicare enrollment policies for qualified home infusion therapy suppliers and proposes updates to the CY 2021 home infusion therapy services payment rates using the CY 2021 Physician Fee Schedule amounts.
For additional information about the Home Health Prospective Payment System, visit https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/HomeHealthPPS/index.html and https://www.cms.gov/center/provider-Type/home- Health-Agency-HHA-Center.html.
For additional information about the Home Health Patient-Driven Groupings Model, visit https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/HH-PDGM.html.
For additional information about the Home Infusion Therapy Services benefit, visit – https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Home-Infusion- Therapy/Overview.html.
CCHP’s executive director, Mei Kwong, provides an easy to follow breakdown of the complicated structure of telehealth policy in the United States. Ms. Kwong compares the complexities of the current policy landscape to the many layers of an onion. PPT slide deck for this presentation can be found here: https://www.cchpca.org/sites/default/…
A bill before Congress calls on the Health and Human Services Department and the Government Accountability Office to produce separate studies on how telehealth has been used to address the coronavirus pandemic.
– While Congress is under mounting pressure to extend telehealth coverage past the coronavirus pandemic, some lawmakers want to make sure the evidence is there to support those moves.
A bill introduced in the House last week calls on both the Health and Human Services Department and the Government Accountability Office to conduct separate studies of telehealth use and outcomes during the ongoing emergency. Known as the KEEP Telehealth Options Act, the bill aims to give lawmakers a detailed accounting of the connected health landscape.
(For more coronavirus updates, visit our resource page, updated twice daily by Xtelligent Healthcare Media.)
“COVID-19 has unexpectedly pulled us into a demonstration of how effective and important telehealth options are for older Iowans or those who live farther from a health center,” Rep. Cindy Axne (D-IA), who co-sponsored the bill with Rep. Troy Balderson (R-OH), said in a press release. “What we have now is a golden opportunity to document how telehealth services were implemented and where improvements can be made so we can chart a path to keeping these options available for patients who won’t stop needing them when this pandemic is over.”
This isn’t the only bill to call for a telehealth study. Earlier this month, Rep. Robin Kelly (D-IL) unveiled the Evaluating Disparities and Outcomes of Telehealth During the COVID-19 Emergency Act of 2020 (HR 7078), which would reportedly call on HHS to study telehealth use during the emergency and report back to Congress one year after the emergency has ended.
This latest bill gives HHS six months to finish its study and report back to Congress. It calls on the agency to analyze actions taken during the COVID-19 emergency to enhance telehealth coverage for Medicare, Medicaid and the Children’s Health Insurance Program (CHIP), including new services and providers who qualify for reimbursement and analyses of telehealth use by rural, minority, low-income and elderly populations, telemental health services and the impact on public health.
The bill gives the GAO seven months to complete its study and report back to Congress, and calls on the agency to focus on the efficiency, management and successes and failures of expanded telehealth access, as well as any increase in fraudulent activities.
While telehealth has generally been cast in a positive light in how it’s been used to help the healthcare industry address care during the pandemic, critics have maintained that there haven’t been enough studies to prove its value. Prior to the pandemic, many telehealth bills in Congress
Idaho Gov. Brad Little on Monday signed an executive order to make the loosened restrictions around telemedicine permanent.
The announcement comes as Idaho’s caseload of newly confirmed coronavirus continues to grow. As of Saturday, more than 3,500 Idahoans had tested positive for the virus, and on three straight days last week — Thursday, Friday and Saturday — new cases exceeded 100 each day.
Earlier this year, Little’s office announced that multiple regulations regarding health care via telecommunications and licensing of medical professionals would be waived due to the pandemic. The governor waived 125 other regulations last month in order to get health care workers, such as retired workers, relicensed to expedite the response to an increasing COVID-19 caseload.
Due to the restrictions being lifted, there were about 117,000 telehealth visits from March to May. By comparison, there were only 3,000 telehealth visits in the same time frame of 2019.
“Our loosening of health care rules since March helped to increase the use of telehealth services, made licensing easier, and strengthened the capacity of our health care workforce, all necessary to help our citizens during the global pandemic,” Little said. “We proved we could do it without compromising safety. Now it’s time to make those health care advances permanent moving forward.”
During a press conference, Little referenced the executive orders he signed when he first took office in January 2019.
A bill introduced this week would enable providers to use telehealth to treat patients in any location up to 180 days after the emergency, bypassing site restriction and interstate licensing guidelines.
– A new bill before Congress aims to allow providers unfettered use of telehealth for six months after the end of the COVID-19 emergency.
Introduced this week by Senators Marsha Blackburn (R-TN) and Ted Cruz (R-TX), the Equal Access to Care Act would allow licensed providers to use telehealth in any state to treat patients in any location for up to 180 days after the end of the national emergency.
(For more coronavirus updates, visit our resource page, updated twice daily by Xtelligent Healthcare Media.)
“The location of the provision of such services shall be deemed to be the (state in which the provider is located) and any requirement that such physician, practitioner, or other provider obtain a comparable license or other comparable legal authorization from the (state in which the patient is located) with respect to the provision of such services (including requirements relating to the prescribing of drugs in such secondary State) shall not apply,” the bill states.
“Telehealth has proven to be an effective tool for providing patients access to health care, including during and prior to the COVID-19 pandemic,” Blackburn said in a press release. “Removing bureaucratic red (tape) will result in more services in more places by more providers so that Americans can get care without the risk of exposing themselves to COVID-19 in a doctor’s office or hospital.”
“Expanding healthcare access in the communities hit hardest by the coronavirus pandemic is crucial to our nation’s recovery,” added Cruz, who’d first announced plans to submit the bill in April. “This bill will remove bureaucratic barriers that for too long have stood in the way of effective telemedicine, and will help ensure the American people have their healthcare needs met – regardless of where they live or where their doctor is licensed – and equip our healthcare providers with the capacity they need to treat patients and ultimately defeat this virus.”
The bill would bypass two particular sticking points in telehealth adoption: site-based restrictions and licensing.
State and federal regulators – especially the Centers for Medicare & Medicaid Services – have long regulated where telehealth can be delivered, most often restricting those sites to healthcare facilities and rural areas. With the onset of the pandemic, many states and CMS have enacted emergency measures to expand access to new sites, such as the patient’s home, community health centers, clinics and skilled nursing facilities.
Some states are moving to make those rules permanent, and Congress is under increasing pressure to address that issue as well.
The licensure issue is trickier. Telehealth advocates have long argued that there should be an easier way for a provider to treat a patient in another state, either through an interstate licensure process or license portability – or even one national license. But interstate licensure compacts have been slow to gain broad acceptance, and critics say each state should have the authority to regulate who delivers healthcare in that state.
The one exception is the Department of Veterans Affairs, whose physicians were granted approval to treat veterans in any location via telehealth with passage of the Veterans E-Health & Telemedicine Support (VETS) Act in 2017.
Due to the COVID-19 emergency, veterans are logging onto the VA Video Connect app more than 120,000 times a week to access care, a 1,000 percent increase in traffic compared to a typical three-month span.
– Veterans used telehealth to access care more than 120,000 times a week during the height of the coronavirus pandemic, according to the Department of Veterans Affairs.
That’s more than a 1,000 percent increase over the usual traffic recorded on the VA Video Connect mHealth app, officials said. The three-year-old platform, touted as one of the nation’s best connected health programs, typically sees 10,000 visits a week.
“As we near the three-year anniversary of the launch of VA Video Connect, even during these challenging times, VA has and continues to maintain access to high-quality health care for Veterans,” VA Secretary Robert Wilkie said in a press release announcing the statistics. “As the service becomes more popular, VA remains committed to providing a seamless user experience to ensure Veterans have access to care where and when they need it.”
With many of the nation’s 2.6 million veterans living in remote locations, dealing with mobility or transportation issues or simply hesitant to travel to the nearest hospital, the nation’s largest health system has been moving to embrace connected health. The number of veterans accessing healthcare through telehealth jumped 17 percent from 2018 to 2019, while virtual visits made through the VA Video Connect app jumped 235 percent.
That popularity has caught the eye of a couple Senators who say the VA could use more support.
Roughly one month ago, Senators Kelly Loeffler (R-GA) and Kyrsten Sinema (D-AZ) introduced a bill aimed at expanding the ranks of care providers licensed by the VA to use telehealth.
The bill, called the VA Mission Telehealth Clarification Act, expands on the landmark VA Mission Act, signed into law in June 2018, which greatly expanded the VA’s telemedicine and mHealth network by, among other things, giving VA care providers the authority to treat veterans in any location.
A companion bill was filed in the House in June 2019 by US Rep. Earl “Buddy” Carter (R-GA), who noted the original act allowed only doctors to deliver care.
“This meant that only doctors could provide services through telehealth, not students, interns, residents or fellows,” he said. “This is a major problem especially for interns, residents and fellows who have graduated medical school and are training to become full time doctors because they are not able to get the necessary experience in telehealth at the VA until the time they become fully licensed.”
With their bill, Loeffler and Sinema put the emphasis on hardships caused by COVID-19.
“Increasing telehealth access for Arizona veterans will help keep them safe during the Coronavirus pandemic and make health care more accessible today and into the future,” Sinema said in a press release.
In his announcement, Wilkie said the VA is taking steps to expand veteran access to healthcare through telemedicine and mHealth technology. The agency has distributed more than 26,000 tablets to veterans and is working with wireless carriers like Verizon, T-Mobile and Sprint to ensure access without incurring data charges.
Of the 31 changes federal policymakers have enacted so far to ease access to virtual care, senators wondered: How many should be made permanent?
ince the start of the COVID-19 pandemic, federal policymakers have enacted 31 changes to enable greater access to telehealth. In a hearing this week, members of the Senate Committee on Health, Education, Labor and Pensions asked how many of those changes should be made permanent – and how to make sure the most vulnerable won’t get left behind.
“Today we have the opportunity to consider how we can deploy telehealth to expand access to healthcare for everyone,” said Sen. Tina Smith, D-Minn.
Smith called attention to the nationwide calls for action sparked by the police killing of her constituent, George Floyd, and urged her colleagues to consider how telehealth can be a vehicle for health equity.