At one community health network, asynchronous telehealth is expanding access to primary care services for patients.

By Emily Sokol, MPH

June 15, 2021 – Store-and-forward or asynchronous telehealth often stays out of the headlines, but one community health network is using the telehealth modality to extend primary care services for their patients.

Experts say the technology is best fit for clinical situations where a provider can gather and analyze data before coming to a clinical decision. That’s because asynchronous telehealth allows for the electronic transmission of medical information that does not need to be read or interpreted live.

In a primary care setting, this allows the primary care physician to connect with specialty care providers and handle all the patient’s needs in one visit. Patients do not need to take extra time off from work or wait potentially months to be connected with a specialist. All of a patient’s concerns can be handled in one care visit.

“Asynchronous telehealth has the most potential to change how care is delivered,” Richard Albrecht, telehealth network director of Community Health Network of CT Holdings, Inc. told Insights during a conversation about the division’s latest research. “I see virtual text care or AI-empowered text access for our patients as being the next thing.”

Telehealth’s use undeniably exploded during the last year, but asynchronous services fill a different gap in care than video telehealth. Asynchronous telehealth is particularly useful in specialty care and, when rolled out across one hospital, it can improve patient outcomes by reducing the risk of rehospitalization and death.

Community Health Network of CT Holdings, Inc. is among a handful of provider organizations that is pioneering asynchronous telehealth. In fact, the organization started its entire telehealth program with asynchronous services.

Asynchronous telehealth is efficient and allows many specialty services to be conducted in a primary care setting, which, as traditionally one of the lowest cost of care settings, can generate a return on investment quickly.

“By utilizing asynchronous services, you can do more in the primary care setting without disrupting the workflow too much,” Albrecht furthered.

A truly integrated asynchronous program could show specialist recommendations in the EHR, so when the primary care provider is seeing the patient, she can address the specialist recommendations concurrently.

Still, one of the biggest challenges to implementing any telehealth program is supportive funding and asynchronous programs are no exception. Provider organizations without technology to support asynchronous services have an even larger upfront investment to purchase the technology, implement it across their organization, and train providers to use it.

To overcome this challenge, Community Health Network of CT Holdings, Inc. got creative. First, the organization outlined the problem they were trying to address—they were seeing a higher rate of patients with diabetes than the national average. A key quality measure of diabetes care is routine eye screenings, so the organization looked for teleophthalmology partners.

“After looking across the marketplace, we found a solution that was a good fit for primary care,” he explained. But they still lacked funding to bring in the solution to their community health centers.

“I found funding from some non-traditional places,” Albrecht continued. The Lions Club of American actually became their trusted partner and helped fund the program as it aligned with their mission to preserve vision.

“I met with the local chapter one night and told them about our vision for saving vision. And they came back with some funding to help us initiate the program,” Albrecht furthered.

The two organizations formed a long-term partnership, and the Lions Club helped fund the program for several years until it was successful enough to be self-funded.

Today, the program has grown to four- to five-times its original size, according to Albrecht, and it is one of the largest asynchronous ophthalmology programs in the Northeast.

Leveraging a non-traditional funding source, Community Health Network of CT Holdings, Inc. grew an idea for asynchronous vision care into a self-sustaining program that helps close patient care gaps.

Aside from supportive funding, Albrecht says his organization’s success is tied to leadership buy-in.

“You most need the leadership and the belief from leadership to push telehealth into the organization,” he explained. “That’s going to proliferate through the organization.”

Without buy-in from leadership, change can be challenging. People like Albrecht can easily become the bad guy when asking providers to change the way they are delivering care.

“I’m the person who’s bringing something new to people who are crazy busy,” he continued.

With leadership buy-in, his job becomes easier. The onus shifts from the individual provider changing the way she has delivered care for years to the organization to rethink its values. Many organizations are currently undergoing this transformation as the pandemic forced telehealth into the spotlight.

But asynchronous telehealth is still the most infrequently used telehealth modality, used by only 17 percent of provider organizations. Other telehealth solutions like live video conferencing and remote patient monitoring see higher uptake, with adoption rates at 96 percent and 35 percent, respectively, according to the same survey.

Continuing to grow a telehealth department and strategy will require investments into all forms of telehealth services as each has a niche role to play in a hybrid care delivery world. Asynchronous telehealth should not be dismissed as its evident with supportive, sometimes creative, funding and leadership buy-in the technology can help provider organizations improve patient outcomes.

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Telehealth became an important aspect of clinical response to COVID-19 during the early days of the pandemic and remains an essential tool for physicians to connect with patients.

At the Becker’s Healthcare Telehealth Virtual Forum on Nov. 2-3, healthcare executives from across the U.S. gathered to discuss the big challenges and opportunities in telehealth and virtual care.

Here are eight takeaways from the event:

1. Organizations that had already made investments in telehealth infrastructure in the last three to six years said they were better prepared to scale up virtual care services. Some of these systems still face practical challenges, such as webcams being on backorder, as they respond to an increased demand for telehealth services.

2. Telemedicine has been a lifeline for many U.S. health systems during the pandemic and offers a huge opportunity to expand access to care, but there are still barriers to care for individuals without broadband internet access or connected video-recording devices. Healthcare executives will be responsible for addressing these disparities in the future.

3. The role telehealth will play in healthcare delivery after the pandemic is contingent on a number of factors, including federal and state regulations, consumer demand and the type of care being delivered. While telehealth will almost certainly play a major role in behavioral health and primary care services, how it will integrate in specialty care is less clear.

4. To widen their digital front door, hospitals need to make digital workflows as simple as any other app that patients and physicians use. Hospitals also have to ensure patient information from a virtual visit is readily accessible in an EHR.

5. Artificial intelligence is used in a very basic form for telehealth today, typically in chatbots that interact with patients and triage them to the right level of care. However, there are seemingly endless possibilities for integrating AI into healthcare. Especially as healthcare organizations gather more information on telemedicine, AI can provide decision support about future treatment options and proactively suggest the most cost-effective treatment setting to patients.

6. Consumer and payer demand will drive the business model for telehealth after the pandemic. Patients will expect telehealth and virtual care options, and payers will incorporate telehealth into their value-based care models, but that transition will likely shift more risk to providers that are largely still in a fee-for-service environment.

7. Over the next five years, one of the biggest hurdles for new virtual care and telehealth technology will be the governance structure at health systems. It will be essential for providers to partner with vendors to make sure new technology and virtual care initiatives serve the patient population equally.

8. The pandemic has forced health systems to change the way they train clinicians and patients on telehealth. Health systems needed to innovate and take new approaches given the amount of demand they faced in a condensed timeframe. Leaders recommend creating training materials in chapters that are easy to update since platforms may change. 

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As the health care industry continues to navigate through challenges in an uncertain and rapidly-evolving landscape, we’ve learned that what worked a year ago may no longer make sense in today’s socially distanced, shelter-in-place environment.

Changing consumer needs — and expectations — have dictated many of this year’s latest trends, reflecting an urgency for safe, convenient, and affordable high-quality care in the right setting, at the right time. From expanding virtual care through emerging technologies to designing new benefit and coverage solutions, the Covid-19 pandemic has accelerated innovation in our delivery models and changed how people can access care.

Adoption of telehealth

Providing alternatives to the in-person provider visit is the largest trend this year. In addition to 24/7 nurse advice lines and virtual video visits from a computer or mobile device, we’ve also seen wellness checks, chronic disease management, and mental health services all go virtual.

With telehealth services being widely adopted in the marketplace, high quality, around-the-clock care is more readily available to those who might not otherwise have access. Sutter Health alone has expanded its telehealth services from serving 20 patients per day just a few months ago to serving more than 7,000 patients virtually per day.

Telehealth is not only helping protect individuals and communities from the spread of illness, but it can also be a convenient, cost-effective alternative to traveling to an appointment or urgent care center when appropriate. Additionally, patients report preferring meeting doctors and clinicians from the comfort of their own homes, and according to a study from Harvard Business Review, 74 percent of patients reported that they felt telehealth visits actually improved their relationship with their doctor.

A virtual-first approach to care

Whether working from home while helping kids with distance learning or living an on-the-go lifestyle, recent trends show that people want flexible alternatives to the traditional primary care model that fits their busy schedule and considers all aspects of their physical, emotional, and mental wellness.

An example of this is Tera — a virtual-first care model that gives patients access to a primary care physician (PCP) and a dedicated care team through video visits, phone consultations, email messages, or in-person visits when needed. This coordination of care is backed by a fully integrated network of hospitals and providers who use the Sutter Electronic Health Record to instantly access and securely share critical health information with other Sutter clinicians, allowing them to deliver care that’s personal, safe, and highly coordinated.

Convenient online resources

In this digital age, consumers have come to expect complete online connectivity when accessing health care resources. Organizations and health plans are meeting this demand by offering 24/7 access to online self-service portals for scheduling appointments, paying bills, printing ID cards, viewing documents, and corresponding with a care team.

Mobile apps take customer service and convenience to the next level. For example, Sutter Health’s My Health Online app offers users the ability to message doctors and care teams, schedule appointments and sign up to get text messages if earlier appointments become available, book a video visit with their Sutter PCP and some Sutter specialists, find a nearby walk-in clinic, or enjoy contactless check-in all from their mobile device. In most areas, users can also request renewals of their prescriptions and have them delivered right to their doorstep.

Individuals who have a health plan through their employer that encourages virtual access to new and innovative models of care may more proactively manage their health. This, along with access to a fully integrated network of care, will help keep them healthy and productive — and improve your bottom line.

Sutter Health Plus, a provider-sponsored HMO affiliated with Sutter, is uniquely positioned to give employers and their employees in Northern California comprehensive access to high-quality care that is safe, personal, affordable and accessible. Reach out to the sales team for help finding the right health plan during this year’s open enrollment.

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SEPTEMBER 9, 2020

The COVID-19 pandemic, and the corresponding need for social distancing, has catapulted telehealth into the mainstream. According to some estimates, the proportion of ambulatory patient visits using telehealth (video, phone, or e-visit) increased from 10 percent before the pandemic to more than 90 percent during the pandemic. These shifts have been buttressed by temporary policy changes introduced by the Centers for Medicare and Medicaid Services (CMS), including a marked increase in telehealth reimbursement rates. Before the pandemic, a 2019 survey reported that nearly 77 percent of physicians raised reimbursement as a serious obstacle to telehealth adoption. The rapid rise in adoption rates suggest that the CMS policy changes have been welcomed and are effective for providers.

On August 3, the Trump administration signed an executive order directing the Department of Health and Human Services to extend these temporary measures beyond the public health emergency to make them permanent. CMS immediately announced changes in the 2021 physician fee schedule that will make the new telehealth billing codes permanent, allowing Medicare providers to bill for home-based telehealth visits and for an expanded suite of telehealth services. While these telehealth policy changes are critical to promoting telehealth adoption, policies now need to move beyond reimbursement rates to help providers integrate telehealth into routine care.

From April to July 2020, in partnership with the New York City Department of Health and Mental Hygiene’s Bureau of Equitable Health Systems (BEHS), we conducted six repeated surveys of primary care providers working in mostly small independent practices (across the survey waves, an average of 54 percent of respondents reported working in a practice with  three or fewer providers) in New York City, an early US epicenter, to track their adoption of telehealth during the pandemic. The average survey response rate was 5 percent from an internal BEHS listserv of 5,300 primary care providers, and 84 percent of those who accessed the survey responded with the highest response rate in Wave I (491 responses). Their responses confirmed the role of timely regulatory changes in facilitating telehealth adoption, and their hope for these changes to “stay permanently for better primary care delivery.” However, their responses also called attention to five additional action items for policy makers and insurers to support to achieve a seamless integration of telehealth into primary care (exhibit 1). What follows are five specific recommendations for further action: 

Exhibit 1: Recommendations for policy makers and insurers to support telehealth use by primary care providers, and representative responses

Harmonize The Reimbursement Criteria

First, despite the increased telehealth reimbursement rates announced by CMS and commercial insurers, there was widespread confusion due to the plethora of variables determining the reimbursements, such as the HIPAA compliance of the platform, duration of the tele-visit, tele-visit modality, originating site, coverage parity, and payment parity for video versus phone versus in-person office visits. Moreover, these variables differ by states and insurers. When asked if they have been reimbursed for telehealth services, more than a third of our respondents reported that they “don’t know.” Nearly 55 percent of respondents reported that “uncertain reimbursements” were a barrier to using telehealth. Small independent practices, which made up a large proportion of our survey respondents, often do not have the necessary administrative resources to sift through a long variable list. To promote integration of telehealth, policy makers and insurers will need to reduce the existing heterogeneity of payments to mitigate confusion and uncertainties around billing for telehealth.

Create Billing Codes Or Payment Models For The Additional Work Required To Offer Telehealth

Second, fee-for-service reimbursements for telehealth fail to account for the time practices are spending to coordinate telehealth visits and help patients access these services. In our survey, providers reported a number of activities that are not reimbursable and hence not incentivized in the fee-for-service system, including: coordinating tele-visit schedules, creating materials and providing one-to-one sessions to help patients download and use video conferencing platforms for tele-visits, and having dedicated staff call patients in advance of their appointments to test their video and audio capabilities. Given the significant adjustments and workflow changes required for telehealth use, value-based or population-based capitation models can better account for the expenses associated with these team-based and technology-enabled models of care.

Provide Coverage For At-Home Monitoring Devices

Third, to do remote monitoring providers rely on patients being able to measure their health indicators at home, which requires patients to have access to appropriate devices and equipment. Remote monitoring is critical for effective telehealth. In their suite of supportive measures for telehealth, the 2019 CMS final rule announced coverage for remote patient monitoring in the form of three CPT billing codes. However, these codes pay for provider-level expenses in the initial setup of monitoring devices and for the ongoing monitoring of physiologic parameters, rather than for the compatible equipment required by the patients. Some of the large health care systems provide equipment free of charge to their patients to facilitate remote monitoring. However, such a cost is not easy for independent primary care practices to absorb. The great majority (77 percent) of our survey sample of mostly small independent practices reported that their patients bought the devices on their own. Some patients may not have the means to purchase the devices on their own, which can affect the quality of telehealth being delivered and in turn increase the likelihood of adverse health outcomes for these patients. There is a clear need for insurers to support patients’ access to and training in the use of monitoring equipment at home.

Incentivize The Development Of And Access To Patient- And Provider-Centered Telehealth Technology

Fourth, providers reported several flaws in telehealth technology that impacted its usability for patients from different socioeconomic backgrounds and for providers in different practice settings. Providers proposed several examples of necessary improvements in telehealth technology, including: a user-friendly platform for patients to share images of body parts and exchange diagnostic information, platforms with built-in language translations to enhance communication with populations with limited English proficiency, electronic health records (EHRs) that allow appropriate telehealth documentation and are compatible with telehealth billing codes, and EHRs that are interoperable with health monitoring apps for information exchange. More than a third of providers also indicated that their patients lacked access to reliable internet, which was a barrier to using telehealth, particularly the video component. Some health systems have begun to incorporate language interpreters into their video platforms and provide low-cost internet access to their patients. However, independent primary care practices often lack the capacity to garner such resources and will need policy-level support to address these barriers. Financial incentives and national payment policies can support the needed advancement in digital health applications and revamp its clinical value and quality for providers and patients. Financial incentives for telehealth vendors are needed to accelerate the building of improved telehealth platforms to address these flaws. National payment policies for telehealth use can also help increase demand on the provider and patient side, which can stimulate telehealth vendors to respond.

Review, Revise, And Communicate Telehealth Malpractice Policies

Lastly, providers raised concerns about malpractice claims related to telehealth. Despite growing advocacy for telehealth, related malpractice policies are largely undeveloped. A multitude of factors explain why several carriers of liability insurance coverage have not embraced telehealth. For example, providers licensed to practice in one state could be subjected to liability laws from another state if they deliver telehealth services to patients across state borders. There is also limited information about the standards of care or damage caps, and patients might be more likely to sue providers they have not met in person. The consequence is often an exclusion of telehealth services from the malpractice insurance policies, creating concerns among providers about telehealth use. Regional health departments should give providers more guidance on legal liabilities related to telehealth. This is particularly true for independent practices that do not work within larger systems, and thus lack the capacity to address the complexities of malpractice policies.

Conclusion

There is an urgent need for strategies to support the integration of telehealth into primary care. The recent executive order and CMS policy extension indicate that telehealth is no longer a short-term fix but is fast becoming a core and enduring function in primary care delivery. The extension of the telehealth policies holds promise in expanding access to high-quality care. However, access is classically defined as having five domains: affordability, availability, accommodation, accessibility, and acceptability. The present telehealth policies address only the first two domains, which is not enough to fully integrate telehealth into routine care delivery. Other policies, as recommended above, can optimize telehealth access and quality by promoting “accommodation,” “accessibility,” and “acceptability” for telehealth, to complement increased reimbursements. Failing to address these barriers—which affect the least resourced primary care practices that are primarily serving the most vulnerable patients—will only serve to widen patient-level disparities in access to quality telehealth care. These gaps offer actionable opportunities for public and private insurers and policy makers to intervene and improve the integration of telehealth into primary care.

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Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19

Since the beginning of the COVID-19 Public Health Emergency, the Trump Administration has issued an unprecedented array of temporary regulatory waivers and new rules to equip the American healthcare system with maximum flexibility to respond to the 2019 Novel Coronavirus (COVID-19) pandemic. These temporary changes will apply immediately across the entire U.S. healthcare system for the duration of the emergency declaration. The goals of these actions are to 1) expand the healthcare system workforce by removing barriers for physicians, nurses, and other clinicians to be readily hired from the community or from other states; 2) ensure that local hospitals and health systems have the capacity to handle a potential surge of COVID-19 patients through temporary expansion sites (also known as CMS Hospital Without Walls); 3) increase access to telehealth in Medicare to ensure patients have access to physicians and other clinicians while keeping patients safe at home; 4) expand in-place testing to allow for more testing at home or in community based settings; and 5) put Patients Over Paperwork to give temporary relief from many paperwork, reporting and audit requirements so providers, health care facilities, Medicare Advantage and Part D plans, and States can focus on providing needed care to Medicare and Medicaid beneficiaries affected by COVID-19.

Medicare Telehealth

Clinicians can now provide more services to beneficiaries via telehealth so that clinicians can take care of their patients while mitigating the risk of the spread of the virus. Under the public health emergency, all beneficiaries across the country can receive Medicare telehealth and other communications technology-based services wherever they are located. Clinicians can provide these services to new or established patients. In addition, health care providers can waive Medicare copayments for these telehealth and other non-face-to-face services for beneficiaries in Original Medicare.

Under the CARES Act, CMS is waiving the requirements of section 1834(m)(1) of the ACT and 42 CFR § 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 waiver allows 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. Unless provided otherwise, other services included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site.

CMS is waiving the requirements of section 1834(m)(4)(E) of the Act and 42 CFR § 410.78 (b)(2) which specify the types of practitioners that may bill for their services when furnished as Medicare telehealth services from the distant site. The waiver of these requirements expands the types of health care professionals that can furnish distant site telehealth services to include all those that are eligible to bill Medicare for their professional services. As a result, a broader

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range of practitioners, such as physical therapists, occupational therapists, and speech language pathologists can use telehealth to provide many Medicare services.

Additionally, we are modifying the process to add services to the Medicare telehealth services list and instead, will consider adding appropriate services as they are requested, on a sub-regulatory basis as practitioners are actively learning how to use telehealth as broadly as possible. A complete list of all Medicare telehealth services can be found here: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.

To enable services to continue while lowering exposure risk, clinicians can now provide the following additional services by telehealth:

• Emergency Department Visits, Levels 1-5 (CPT codes 99281-99285)
• Initial and Subsequent Observation and Observation Discharge Day Management (CPTcodes 99217-99220; CPT codes 99224-99226; CPT codes 99234-99236)
• Initial hospital care and hospital discharge day management (CPT codes 99221-99223;CPT codes 99238-99239)
• Initial nursing facility visits, All levels (Low, Moderate, and High Complexity) and nursingfacility discharge day management (CPT codes 99304-99306; CPT codes 99315-99316)
• Critical Care Services (CPT codes 99291-99292)
• Domiciliary, Rest Home, or Custodial Care services, New and Established patients (CPTcodes 99327-99328; CPT codes 99334-99337)
• Home Visits, New and Established Patient, All levels (CPT codes 99341-99345; CPTcodes 99347-99350)
• Inpatient Neonatal and Pediatric Critical Care, Initial and Subsequent (CPT codes 99468­99469; CPT codes 99471-99473; CPT codes 99475-99476)
• Initial and Continuing Intensive Care Services (CPT code 99477-994780)
• Care Planning for Patients with Cognitive Impairment (CPT code 99483)
• Group psychotherapy (CPT code 90853)
• Psychological and Neuropsychological Testing (CPT codes 96130-96133; CPT codes96136-96139)

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• Therapy Services, Physical and Occupational Therapy, All levels (CPT codes 97161­97168; CPT codes 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521­92524, 92507)
• Radiation Treatment Management Services (CPT codes 77427)

Remote Evaluations, Virtual Check-Ins & E-Visits

• Medicare patients may have a brief communication service with practitioners via anumber of communication technology modalities including synchronous discussion overa telephone or exchange of information through video or image. Clinicians can provideremote evaluation of patient video/images and virtual check-in services (HCPCS codesG2010, G2012) to both new and established patients. These services were previouslylimited to established patients.
• Licensed clinical social workers, clinical psychologists, physical therapists, occupationaltherapists, and speech language pathologists can provide e-visits. E-visits are non-face­to-face communications with their practitioner by using online patient portals. (HCPCScodes G2061-G2063).

Telephone Evaluation, Management/Assessment and Management Services, and Behavioral Health and Education Services

• A broad range of clinicians, including physicians, can now provide certain services bytelephone to their patients.
• Medicare payment for the telephone evaluation and management visits (CPT codes99441-99443) is equivalent to the Medicare payment for office/outpatient visits withestablished patients effective March 1, 2020.
• When clinicians are furnishing an evaluation and management (E/M) service that wouldotherwise be reported as an in-person or telehealth visit, using audio-only technology,practitioners may bill using these telephone E/M codes provided that it is appropriate tofurnish the service using audio-only technology and all of the required elements in theapplicable telephone E/M code (99441-99443) description are met.
• Using new waiver authority, CMS is also allowing many behavioral health and educationservices to be furnished via telehealth using audio-only communications. The full list oftelehealth services notes which services are eligible to be furnished via audio-onlytechnology, including the telephone evaluation and management visits:

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Remote Patient Monitoring

• Clinicians can provide remote patient monitoring services to both new and establishedpatients. These services can be provided for both acute and chronic conditions and cannow be provided for patients with only one disease. For example, remote patientmonitoring can be used to monitor a patient’s oxygen saturation levels using pulseoximetry. (CPT codes 99091, 99457-99458, 99473-99474, 99493-99494)
• Current CPT coding guidance states that the remote physiologic monitoring servicedescribed by CPT code 99454 (device(s) supply with daily recordings or programmedalerts transmission each 30 day(s)), cannot be reported for monitoring of less than 16days. For purposes of treating suspected COVID-19 infections, Medicare will allow theservice to be reported for shorter periods of time than 16 days as long as the other coderequirements are met.

Removal of Frequency Limitations on Medicare Telehealth

To better serve the patient population that would otherwise not have access to clinically appropriate in-person treatment, the following services no longer have limitations on the number of times they can be provided by Medicare telehealth:

• A subsequent inpatient visit can be furnished via Medicare telehealth, without thelimitation that the telehealth visit is once every three days (CPT codes 99231-99233);
• A subsequent skilled nursing facility visit can be furnished via Medicare telehealth,without the limitation that the telehealth visit is once every 30 days (CPT codes 99307­99310)
• Critical care consult codes may be furnished to a Medicare beneficiary by telehealthbeyond the once per day limitation (CPT codes G0508-G0509).

Other Medicare Telemedicine and Remote Patient Care

• For Medicare patients with End Stage Renal Disease (ESRD), clinicians no longer musthave one “hands on” visit per month for the current required clinical examination of thevascular access site.
• For Medicare patients with ESRD, we are exercising enforcement discretion on thefollowing requirement so that clinicians can provide this service via telehealth:individuals must receive a face-to-face visit, without the use of telehealth, at leastmonthly in the case of the initial 3 months of home dialysis and at least once every 3consecutive months after the initial 3 months.

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• To the extent that a National Coverage Determination (NCD) or Local Coverage Determination (LCD) would otherwise require a face-to-face visit for evaluations and assessments, clinicians would not have to meet those requirements during the public health emergency.
• Beneficiary consent should not interfere with the provision of non-face-to-face services. Annual consent may be obtained at the same time, and not necessarily before the time, that services are furnished.
• Physician visits: CMS is waiving the requirement in 42 CFR 483.30 for physicians and non-physician practitioners to perform in-person visits for nursing home residents and allow visits to be conducted, as appropriate, via telehealth options.
• Opioid Treatment Programs: Patient counseling and therapy services can be provided by telephone only in cases where the beneficiary does not have access to two-way interactive audio-video communication technology. Periodic patient assessments can be conducted via two-way interactive audio-video communication technology and may be provided by telephone only in cases where the beneficiary does not have access to two-way interactive audio-video communication technology.

Workforce

• Medicare Physician Supervision Requirements: For services requiring direct supervision by the physician or other practitioner, that physician supervision can be provided virtually using real-time audio/video technology.
• Supervision Requirements for Non-Surgical Extended Duration Therapeutic Services: Direct supervision is not required at the initiation of non-surgical extended duration therapeutic services provided in hospital outpatient departments and critical access hospitals. Instead, a general level of supervision can be provided for the entire duration of these services, so the supervising physician or practitioner is not required to be immediately available.
• Medicare Physician Supervision and Auxiliary Personnel: The physician can enter into a contractual arrangement that meets the definition of auxiliary personnel at 42 CFR 410.26, including with staff of another provider/supplier type, such as a home health agency (defined under § 1861(o) of the Act) or a qualified home infusion therapy supplier (defined under § 1861(iii)(3)(D)), or entities that furnish ambulance services, that can provide the staff and technology necessary to provide care that would ordinarily be provided incident to a physicians’ service (including services that are allowed to be performed via telehealth). In such instances, the provider/supplier would seek payment for any services provided by auxiliary personnel from the billing practitioner and would not submit claims to Medicare for such services.

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• Medicare Advanced Practice Nonphysician Practitioners: Nurse practitioner(NPs), clinical nurse specialists (CNSs), certified nurse-midwives (CNMs), and physician assistants (PAs) can supervise diagnostic tests as authorized under state law and licensure. These practitioners will need to continue the required statutory relationships with supervising or collaborating physicians.
• Physical Therapists and Occupational Therapists: The treating physical or occupational therapist who developed or is responsible for the maintenance program plan may delegate the performance of maintenance therapy services to a therapy assistant when clinically appropriate. This will free up the therapist to furnish other needed services during the PHE requiring his/her evaluative and assessment skills.
• Pharmacists: As auxiliary personnel, pharmacists can provide services incident to the professional services of a physician or nonphysician practitioner who bills Medicare Part B under the Physician Fee Schedule (PFS), if incident to rules are met and payment for the services is not made under Medicare Part D. The services must be provided in accordance with the pharmacist’s scope of practice and applicable state law.
• Teaching Physicians: Under the so-called primary care exception at section 415.174, a teaching physician may meet the requirement to review a visit furnished by a resident remotely using audio/video real time communications technology during the PHE. This flexibility can be helpful in the event that the teaching physician is not available to be present with the resident due to quarantine or social distancing.
• Physician Services: CMS is waiving 482.12(c)(1-2) and (4), which requires that Medicare patients in the hospital be under the care of a physician. This allows hospitals to use other practitioners, such as physician’s assistant and nurse practitioners, to the fullest extent possible. This waiver should be implemented in accordance with a state’s emergency preparedness or pandemic plan.
• National coverage determinations (NCDs) and Local Coverage Determinations (LCDs): To the extent NCDs and LCDs require a specific practitioner type or physician specialty to furnish or supervise a service, during this public health emergency, the Chief Medical Officer or equivalent of a hospital or facility will have the authority to make those staffing decisions.
• CMS is exercising enforcement discretion and will not enforce the current clinical indications in LCDs for therapeutic continuous glucose monitors during this public health emergency. This change is intended to permit more COVID-19 patients with diabetes to better monitor their glucose and adjust insulin doses from home.

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• Practitioner Locations: Temporarily waive Medicare and Medicaid’s requirements that physicians and non-physician practitioners be licensed in the state where they are providing services. State requirements will still apply. CMS waives the Medicare requirement that a physician or non-physician practitioner must be licensed in the State in which s/he is practicing for individuals for whom 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 1135 emergency area. A physician or non-physician practitioner may seek an 1135-based licensure waiver from CMS by contacting the provider enrollment hotline for the Medicare Administrative Contractor that services their geographic area. This waiver does not have the effect of waiving State or local licensure requirements or any requirement specified by the State or a local government as a condition for waiving its licensure requirements.
• Modification of 60-day limit for Substitute Billing Arrangements (Locum Tenens): CMS is modifying the 60-day limit in section 1842(b)(6)(D)(iii) of the Social Security Act to allow a physician or physical therapist to use the same substitute for the entire time he or she is unavailable to provide services during the COVID-19 emergency plus an additional period of no more than 60 continuous days after the public health emergency expires. On the 61st day after the public health emergency ends (or earlier if desired), the regular physician or physical therapist must use a different substitute or return to work in his or her practice for at least one day in order to reset the 60-day clock. Without this flexibility, the regular physician or physical therapist generally could not use a single substitute for a continuous period of longer than 60 days, and would instead be required to secure a series of substitutes to cover sequential 60-day periods. The modified timetable applies to both types of substitute billing arrangements under Medicare fee-for-service (i.e., reciprocal billing arrangements and fee-for-time compensation arrangements, formerly known as locum tenens).

Note: Under the Medicare statute, only 1) physicians and 2) physical therapists who furnish outpatient physical therapy services in a health professional shortage area (HPSA), a medically underserved area (MUA), or a rural area can receive Medicare fee-for-service payment for services furnished by a substitute under a substitute billing arrangement. In addition, Medicare can pay for services under a substitute billing arrangement only when the regular physician or physical therapist is unavailable to provide the services. Finally, as provided by law, a regular physician or physical

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therapist who has been called or ordered to active duty as a member of a reserve component of the Armed Forces may continue to use the same substitute for an unlimited time even after the emergency ends.

•Provider Enrollment: CMS has established toll-free hotlines for physicians, non-physicianpractitioners and Part A certified providers and suppliers establishing isolation facilitiesto enroll and receive temporary Medicare billing privileges. CMS is providing thefollowing flexibilities for provider enrollment:

• Waive certain screening requirements.
  • Postpone all revalidation actions.
  • Allow licensed physicians and other practitioners to bill Medicare for servicesprovided outside of their state of enrollment.
  • Expedite any pending or new applications from providers.
  • Allow practitioners to render telehealth services from their home without reportingtheir home address on their Medicare enrollment while continuing to bill from yourcurrently enrolled location.
  • Allow opted-out practitioners to cancel their opt-out status early and enroll inMedicare to provide care to more patients.
• Student Documentation: In the CY 2020 Physician Fee Schedule (PFS) final rule, weadopted simplified medical record documentation requirements for physicians andcertain nonphysician practitioners to allow the billing clinician to review and verify,rather than redocument, information added to the medical record by any member ofthe health care team. During the public health emergency, this principle applies acrossthe spectrum of all Medicare-covered services, and will also apply to therapists so thatthey may review and verify, rather than redocument, notes added to the medical recordby any other member of the health care team, including therapy or other students.

Medicare COVID-19 Diagnostic Testing and Reporting

• COVID-19 Diagnostic Testing: Practitioners can be paid for assessment and specimencollection for COVID-19 testing using the level 1 evaluation and management code CPTcode 99211. In light of the public health emergency, Medicare will recognize this code tobe billed for all patients, not just established patients. This approach helps physicianpractices to operate testing sites during the PHE.

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• Physician or Practitioner Order for COVID-19 tests: Medicare will not require an order from a treating physician or nonphysician practitioner as a condition of Medicare coverage of COVID-19 testing during the PHE. CMS similarly removed these requirements for an influenza virus diagnostic laboratory test and any other diagnostic laboratory test that is necessary to establish or rule out a COVID-19 diagnosis. FDA requirements for a prescription and state requirements around ordering diagnostic tests would still apply. CMS has also removed certain documentation and recordkeeping requirements associated with orders for these COVID-19 diagnostic tests and related tests as these requirements would not be relevant in the absence of an order. CMS still expects laboratories to furnish the results of COVID-19 tests to the beneficiary. Consistent and regular reporting of all testing results to local officials is critical to public health management of the pandemic, we would expect any clinician or laboratory receiving results to report those results promptly consistent with state and local public health requirements, typically within 24 hours.

Patients Over Paperwork

• “Stark Law” Waivers: The physician self-referral law (also known as the “Stark Law”) prohibits a physician from making referrals for certain healthcare services payable by Medicare if the physician (or an immediate family member) has a financial relationship with the entity performing the service. There are statutory and regulatory exceptions, but in short, a physician cannot refer a patient to any entity with which he or she has a financial relationship. On March 30, 2020, CMS issued blanket waivers of certain provisions of the Stark Law regulations. These blanket waivers apply to financial relationships and referrals that are related to the COVID-19 emergency. The remuneration and referrals described in the blanket waivers must be solely related to COVID-19 Purposes, as defined in the blanket waiver document. Under the waivers, CMS will permit certain referrals and the submission of related claims that would otherwise violate the Stark Law. These flexibilities include:

• Hospitals and other health care providers can pay above or below fair market value for the personal services of a physician (or an immediate family member of a physician), and parties may pay below fair market value to rent equipment or purchase items or services. For example, a physician practice may be willing to rent or sell needed equipment to a hospital at a price that is below what the practice could charge another party. Or, a hospital may provide space on hospital grounds at no charge to a physician who is willing to treat patients who seek care at the hospital but are not appropriate for emergency department or inpatient care.
  • Health care providers can support each other financially to ensure continuity of health care operations. For example, a physician owner of a hospital may make a personal loan to the hospital without charging interest at a fair market rate so that the hospital can make payroll or pay its vendors.

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• Hospitals can provide benefits to their medical staffs, such as multiple daily meals, laundry service to launder soiled personal clothing, or child care services while the physicians are at the hospital and engaging in activities that benefit the hospital and its patients.
  • Health care providers may offer certain items and services that are solely related to COVID-19 Purposes (as defined in the waivers), even when the provision of the items or services would exceed the annual non-monetary compensation cap. For example, a home health agency may provide continuing medical education to physicians in the community on the latest care protocols for homebound patients with COVID-19, or a hospital may provide isolation shelter or meals to the family of a physician who was exposed to the novel coronavirus while working in the hospital’s emergency department.
  • Physician-owned hospitals can temporarily increase the number of their licensed beds, operating rooms, and procedure rooms, even though such expansion would otherwise be prohibited under the Stark Law. For example, a physician-owned hospital may temporarily convert observation beds to inpatient beds to accommodate patient surge during the COVID-19 pandemic in the United States.
  • Some of the restrictions regarding when a group practice can furnish medically necessary designated health services (DHS) in a patient’s home are loosened. For example, any physician in the group may order medically necessary DHS that is furnished to a patient by one of the group’s technicians or nurses in the patient’s home contemporaneously with a physician service that is furnished via telehealth by the physician who ordered the DHS.
  • Group practices can furnish medically necessary MRIs, CT scans or clinical laboratory services from locations like mobile vans in parking lots that the group practice rents on a part-time basis.
• National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) on Respiratory Related Devices, Oxygen and Oxygen Equipment, Home Infusion Pumps and Home Anticoagulation Therapy: CMS will not enforce clinical restrictions in certain NCDs and LCDs that would otherwise restrict coverage of these devices and services for COVID-19 patients during the public health emergency. Clinicians will have more flexibility in determining patient needs for respiratory related devices and equipment and the flexibility for more patients to manage their treatments at the home but will need to continue to document those decisions in the medical record.
  • Signature Requirements: CMS is waiving signature and proof of delivery requirements for Part B drugs and Durable Medical Equipment when a signature cannot be obtained because of the inability to collect signatures. Suppliers should document in the medical

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record the appropriate date of delivery and that a signature was not able to be obtained because of COVID-19.

• Changes to MIPS: We have made three updates to the Merit-based Incentive Payment System (MIPS) in the Quality Payment Program. Specifically, we are:

• Modifying the MIPS Extreme and Uncontrollable Circumstances policy – Individual MIPS eligible clinicians who have not submitted any MIPS data by the extended deadline of April 30, 2020 will automatically receive a neutral payment adjustment in 2021 (this automatic policy does not apply to groups or virtual groups). Alternatively, if a MIPS eligible clinician, group, or virtual group has submitted some MIPS data but is unable to complete their 2019 MIPS data submission because they have been adversely affected by the COVID-19 public health emergency, they can submit an application based on extreme and uncontrollable circumstances by April 30, 2020 at 8 p.m. ET to request reweighting of their MIPS performance categories for the 2019 performance year. These are important changes for clinicians who have been impacted by the COVID-19 outbreak and may be unable to submit their MIPS data during the current submission period;
  • Adding one new Improvement Activity for the CY 2020 performance period that, if selected, would provide high-weighted credit for clinicians within the MIPS Improvement Activities performance category. In order to receive credit for this activity, a MIPS eligible clinician must participate in a clinical trial utilizing a drug or biological product to treat a patient with COVID-19 and report their findings through a clinical data repository or clinical data registry for the duration of their study. This would help contribute to a clinician’s overall MIPS final score, while providing important data to help treat patients and address the current COVID­19 pandemic; and
  • Delaying the implementation of the Qualified Clinical Data Registry (QCDR) measure testing and data collection policies by 1 year. Both QCDR measure approval criteria necessitate that QCDRs collect data from clinicians in order to assess the measure, and we anticipate that QCDRs may be unable to collect, and clinicians unable to submit, data on QCDR measures due to prioritizing the care of COVID-19 patients.
• Accelerated/Advance Payments: In order to provide additional cash flow to healthcare providers and suppliers impacted by COVID-19, CMS expanded and streamlined the Accelerated and Advance Payments Program, which provided conditional partial payments to providers and suppliers to address disruptions in claims submission and/or claims processing subject to applicable safeguards for fraud, waste and abuse. Under this program, CMS made successful payment of over $100 billion to healthcare providers and suppliers. As of April 26, 2020, CMS is reevaluating all pending and new

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applications for the Accelerated Payment Program and has suspended the Advance Payment Program, in light of direct payments made available through the Department of Health & Human Services’ (HHS) Provider Relief Fund. Distributions made through the Provider Relief Fund do not need to be repaid. For providers and suppliers who have received accelerated or advance payments related to the COVID-19 Public Health Emergency, CMS will not pursue recovery of these payments until 120 days after the date of payment issuance. Providers and suppliers with questions regarding the repayment of their accelerated or advance payment(s) should contact their appropriate Medicare Administrative Contractor (MAC).

Medicare appeals in Fee for Service, Medicare Advantage (MA) and Part D

• CMS is allowing Medicare Administrative Contractors (MACs) and Qualified Independent Contractor (QICs) in the FFS program 42 CFR 405.942 and 42 CFR 405.962 and MA and Part D plans, as well as the Part C and Part D Independent Review Entity (IREs), 42 CFR 562, 42 CFR 423.562, 42 CFR 422.582 and 42 CFR 423.582 to allow extensions to file an appeal;
• CMS is allowing MACs and QICs in the FFS program 42 CFR 405. 950 and 42 CFR 405.966 and the Part C and Part D IREs to waive requirements for timeliness for requests for additional information to adjudicate appeals; MA plans may extend the timeframe to adjudicate organization determinations and reconsiderations for medical items and services (but not Part B drugs) by up to 14 calendar days if: the enrollee requests the extension; the extension is justified and in the enrollee’s interest due to the need for additional medical evidence from a noncontract provider that may change an MA organization’s decision to deny an item or service; or, the extension is justified due to extraordinary, exigent, or other non-routine circumstances and is in the enrollee’s interest 42 CFR § 422.568(b)(1)(i), § 422.572(b)(1) and § 422.590(f)(1);
• CMS is allowing MACs and QICs in the FFS program 42 C.F.R 405.910 and MA and Part D plans, as well as the Part C and Part D IREs to process an appeal even with incomplete Appointment of Representation forms 42 CFR § 422.561, 42 CFR § 423.560. However, any communications will only be sent to the beneficiary;
• CMS is allowing MACs and QICs in the FFS program 42 CFR 405. 950 and 42 CFR 405.966 and MA and Part D plans, as well as the Part C and Part D IREs to process requests for appeal that don’t meet the required elements using information that is available 42 CFR § 422.562, 42 CFR § 423.562.
• CMS is allowing MACs and QICs in the FFS program 42 CFR 405. 950 and 42 CFR 405.966 and MA and Part D plans, as well as the Part C and Part D IREs, 42 CFR 422.562, 42 CFR

423.562 to utilize all flexibilities available in the appeal process as if good cause requirements are satisfied.

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Additional Guidance

• The Interim Final Rules and waivers can be found at: https://www.cms.gov/about­cms/emergency-preparedness-response-operations/current-emergencies/coronavirus­waivers.
• CMS has released guidance to providers related to relaxed reporting requirements forquality reporting programs at https://www.cms.gov/files/document/guidance-memo­exceptions-and-extensions-quality-reporting-and-value-based-purchasing-programs.pdf.

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The post CMS Flexibilities to Fight COVID-19 – Physicians and Other Clinicians appeared first on mTelehealth.

By Casey Ross @caseymross

Federal health officials on Monday unveiled a new primary care experiment that seeks to pay doctors for providing stepped-up services that keep patients healthy and out of the hospital, an effort they say will transform basic medical services for tens of millions of American patients.

The initiative, called CMS Primary Cares, includes five new payment options for small and large providers, allowing them to take varying levels of financial responsibility for improving care and lowering costs. It broadly seeks to change how primary care is delivered in the U.S. by rewarding doctors for improving management of patients with chronic illnesses such as diabetes and high blood pressure, and averting expensive trips to the hospital.

Health and Human Services Secretary Alex Azar called the program “an historic turning point in American health care” that is projected to enroll a quarter or more of the 44 million Americans served by traditional Medicare.

“This initiative will radically elevate the importance of primary care in American medicine,” Azar said, adding that it will “move [the nation] toward a system where providers are paid for outcomes rather than procedures, and free up doctors to focus on the patients in front of them, rather than the paperwork we send them.” STAT Plus: Exclusive analysis of biotech, pharma, and the life sciences.

The effort to implement value-based care is a popular talking point in American medicine, but has yet to be fully implemented. This new initiative is the most sweeping attempt to date to change primary care, an area that accounts for about 3 percent of costs but influences the trajectory of illnesses that account for a much greater percentage of expenses.

Whether this experiment will induce large numbers of providers to participate, or result in significant changes, remains to be seen. Participation is voluntary, so officials will have to convince large numbers of primary care physicians that it will benefit them. They projected Monday that a quarter of primary practices will join. The federal Centers for Medicare and Medicaid Services will allow primary care practices to apply for the new programs this summer, with the goal of implementing them in 2020.

The initiative may spur physicians to increase the use of technology, telehealth services, and remote patient monitoring to deliver stepped-up care to patients. It does not expressly say that Medicare will pay providers for responding to weekend emails or text messages from chronically ill patients, or for doing online or in-home visit to address emergent problems as soon as they arise. But those are the kinds of measures health officials want to encourage primary care doctors to take.

“Providers will have greater flexibility to spend these resources how they want, allowing them to come up with innovative ways to care for patients — and receive significant savings if they keep patients healthier than expected,” Azar said. Related: Medicare’s solution for saving primary care: blow up the office visit

The need for reforming America’s system of paying for health care was reinforced by recent CMS projections that U.S. spending on medical services will grow 5.5 percent annually over the next eight years, reaching nearly $6 trillion by 2027. That would equate to 19.4 percent of the nation’s total economic output.

But transforming to a value-based system of care is especially difficult because it requires setting a clear and universal definition of what value is, and then figuring out how to measure it. The task also requires adjusting for variability among providers’ populations of patients — some doctors take care of sicker patients, overall, than others — as well as differences in the size of their practices and the underlying social and economic needs of their patients.

Past attempts to reform primary care payments have generated widespread complaints from physicians who argued that the government failed to recognize the cost of collecting and reporting a wide array of new data on patients, which made it all but impossible for smaller practices to participate. For example, participation in Comprehensive Primary Care Plus required many practices to update their electronic health systems, but did not provide them with adequate funding to do so.

The new payment programs unveiled Monday create two basic pathways called Primary Care First and Direct Contracting. Here’s how they work:

Primary Care First

The model, designed for small practices, will include a monthly per-patient payment to providers to cover the total cost of caring for patients, eliminating the need to manage fluctuations in revenue. Providers would be paid a bonus for keeping patients healthy, but could lose a certain share of their practice’s revenue if they get sicker. It also creates a payment option that authorizes higher payments for practices that specialize in care of high-need patients with chronic conditions. Related: Drug spending could rise 6.1 percent annually by 2020, federal projections show

The program will be tested for five years and is scheduled to begin in January 2020.

“Providers will be eligible for significant payments if their patients stay healthy and at home,” said Adam Boehler, director of Medicare’s innovation institute. He said the model creates a risk that participants could lose 10 percent of their revenue, but gain as much as 50 percent, with performance to be measured based on “risk adjusted hospitalizations.”

Boehler added that doctors who earn $200,000 today could earn up to $300,000, depending on their ability to keep patients healthier.

Direct Contracting

This model is designed for larger provider organizations and serves as a replacement for a program known as Next Generation ACO (Accountable Care Organization). It includes three payment options with varying levels of financial risk.

One option allows for a provider to share financial risk with the government by receiving a fixed monthly payment for total costs or a portion of anticipated primary care costs, while another option allows a provider to take full risk for managing the monthly payment. If the practice keeps patients healthy and out of the hospital, they profit. If not, they lose money and must cover the extra costs of caring for their patients.

“It’s time that we put patients in the driver’s seat so that providers can compete for their loyalty through a combination of service, price, and overall experience,” Boehler said. “When you pay for quality outcomes, instead of volume, you transform a health care system that caters to special interests into a market-based system in which providers compete for the right to take care of each patient.”

A third option is designed to allow the provider to accept the full financial risk of caring for patients in a defined geographic region. The program is designed to focus on large organizations with experience in managing the needs of their local populations, as opposed to national providers that may deal with patients across many markets. Officials said they are still soliciting public feedback on details of the model and will seek to launch it in the middle of 2020.

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