MedPAC Talks Telehealth

Expanded telehealth is here to stay, members of the Medicare Payment Advisory Commission agreed at their September public meeting.

What they do not yet know is in what form.

Among the issues that need to be addressed in any post-COVID-19 expansion of Medicare-covered telehealth services are:

  • Whether affording access to telehealth services would exacerbate the digital divide and leave some Medicare beneficiaries with less access to care than others.
  • Whether audio-only coverage, temporarily permitted during the pandemic, should be continued.
  • Whether greater use of telehealth might foster greater use of low-value services.
  • Whether use of non-HIPAA-compliant video technology should continue to be permitted.

Learn more about MedPAC’s deliberations on telehealth in the Healthcare Dive article “MedPAC commissioners hint at telehealth policies that may stick post-COVID-19” and see the presentation that formed the basis for the discussion of this issue at MedPAC’s recent public meeting.

 

MedPAC Meets

Last week the Medicare Payment Advisory Commission met in Washington, D.C. to discuss a number of Medicare payment issues.

The issues on MedPAC’s September agenda were:

  • the coronavirus pandemic and Medicare
  • context for Medicare payment policy
  • report on the Protecting Access to Medicare Act of 2014’s changes to the Medicare clinical laboratory fee schedule
  • expansion of telehealth in Medicare
  • Medicare coverage for vaccines

MedPAC is an independent congressional agency that advises Congress on issues involving the Medicare program.  While its recommendations are not binding on either Congress or the administration, MedPAC is highly influential in governing circles and its recommendations often find their way into legislation, regulations, and new public policy.  Because so many patients of private safety-net hospitals are insured by Medicare, MedPAC’s deliberations are especially important to those hospitals.

Go here for links to the policy briefs and presentations that supported MedPAC’s discussion of these issues.

Loan Repayment Looms for Hospitals

Unless Congress intervenes, hospitals will soon begin repaying massive federal loans they received to help them cope with the COVID-19 public health emergency.

The loans, authorized by the federal CARES Act, were made through the Accelerated and Advance Loan Program, and in all, Medicare made nearly $100 billion in such loans to providers.  Under the legislation, Medicare was to begin recouping the loans 120 days after hospitals received them, with recoupment coming by Medicare ceasing to pay hospitals’ Medicare claims until the full amount of the loan was repaid.

Now the loans are coming due but hospitals are saying they are not ready to forego all of their Medicare revenue.

While some hospital groups have asked for 100 percent forgiveness for the loans, others are calling for a combination of extending the payback period and reducing the interest rate for those that fail to complete repayment in a timely manner.

In a letter to Senate leaders last month on behalf of private safety-net hospitals, NASH wrote that it

… urges you to forgive the federal Medicare revenue advanced to hospitals through the CARES Act’s Accelerated and Advance Payment Program. Because of the unprecedented length and persistence of this public health emergency, we believe many hospitals – especially safety-net hospitals – will never recover the revenue we have lost in recent months. Most of us expect to be able to restore financial equilibrium, but we will not be able to do so if we have this enormous debt hanging over our heads.

Both House Democrats’ HEROES Act and Senate Republicans’ HEALS Act attempt to address the loan situation – albeit in different ways – but neither calls for forgiving the loans entirely.

Learn more about the challenges hospitals face with their obligation to repay Accelerated and Advance Loan Program money and how Congress is looking at that challenge in this Washington Post article.

MedPAC Reports to Congress

MedPAC has submitted its annual report to Congress.

The congressionally mandated report, titled Report to Congress:  Medicare and the Health Care Delivery System, consists of seven chapters:

  • Realizing the promise of value-based payment in Medicare: an agenda for change.
  • Challenges in maintaining and increasing savings from accountable care organizations (ACOs).
  • Replacing the Medicare Advantage quality bonus program.
  • Mandated report: Impact of changes in the 21st Century Cures Act to risk adjustment for Medicare Advantage enrollees.
  • Realigning incentives in Medicare Part D.
  • Separately payable drugs in the hospital outpatient prospective payment system (OPPS).
  • Improving Medicare’s end-state renal disease (ESRD) prospective payment system (PPS).

While MedPAC’s recommendations are not binding on Congress or the administration, they are highly respected and often find themselves worked into new law or regulations.

Go here to see MedPAC’s news release accompanying the report and here to find the report itself.

NASH Calls for More COVID-19 Legislation

On Tuesday the National Alliance of Safety-Net Hospitals wrote to Senate leaders and asked them to advance legislation with five major COVID-19-related policy initiatives that private safety-net hospitals seek:

  1. An additional $100 billion for hospitals.
  2. A 14-point increase in the federal medical assistance percentage (FMAP).
  3. A 2.5 percent increase in states’ Medicaid disproportionate share (Medicaid DSH) allotments and another delay in implementation of Affordable Care Act-mandated cuts in those allotments.
  4. Reduced interest rates and a longer payback period for Medicare payments advanced to hospitals through the CARES Act’s Accelerated and Advance Payment Program.
  5. Prevention of implementation of the Medicare fiscal accountability regulation (MFAR).

Learn more from NASH’s letter to Senate majority leader Mitch McConnell and Senate minority leader Chuck Schumer.

Coronavirus Update for Tuesday, June 2

Coronavirus update for Tuesday, June 2, 2020 as of 2:45 p.m.

NASH Advocacy

On Tuesday, the National Alliance of Safety-Net Hospitals wrote to Senate leaders and asked them to advance legislation with five major COVID-19-related policy initiatives:

  1. An additional $100 billion for hospitals.
  2. A 14-point increase in the federal medical assistance percentage (FMAP).
  3. A 2.5 percent increase in states’ Medicaid disproportionate share (Medicaid DSH) allotments and another delay in implementation of Affordable Care Act-mandated cuts in those allotments.
  4. Reduced interest rates and a longer payback period for Medicare payments advanced to hospitals through the CARES Act’s Accelerated and Advance Payment Program.
  5. Prevention of implementation of the Medicare fiscal accountability regulation (MFAR).

Learn more from NASH’s letter to Senate majority leader Mitch McConnell and Senate minority leader Chuck Schumer.

On Monday NASH submitted formal comments to CMS on an interim final rule published in April to help health care providers respond to the COVID-19 emergency.  NASH expressed support for the changes CMS introduced.

Centers for Medicare & Medicaid Services

Food and Drug Administration

The Joint Commission

Federal Funding Opportunities for Hospitals

  • NASH has prepared a document that collects and presents in one place the various new federal funding opportunities for hospital resulting from legislation addressing the COVID-19 public health emergency.  Find that document here.

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Coronavirus Update: March 31, 2020

Coronavirus Update: March 31, 2020.

Yesterday the federal Centers for Medicare & Medicaid Services (CMS) published a major update of Medicare and Medicaid regulations that included blanket waivers of a large number of Medicare and Medicaid regulations and requirements.  The following is a summary of the major aspects of this new regulation.

New Policies and Waivers From Medicare and Medicaid Regulations and Requirements

CMS has introduced dozens of changes that involve waivers from current regulations and requirements.  A comprehensive, 26-page CMS document describing these changes can be found here and below are the highlights organized into four broad categories:

  • increasing hospital capacity (what CMS calls “hospitals without walls”)
  • expanding the health care workforce
  • increasing the use of telehealth in Medicare
  • reducing paperwork

Increasing Hospital Capacity

  • CMS is waiving the enforcement of section 1867(a) of EMTALA to permit hospitals to screen patients at off-site locations to help prevent the spread of COVID-19.
  • CMS is waiving certain requirements under the Medicare conditions of participation allow for flexibilities during hospital and psychiatric hospital surges, permitting non-hospital buildings/space to be used for patient care and quarantine sites.
  • For the duration of the public health emergency, CMS is waiving certain requirements under the Medicare conditions of participation and the provider-based department requirements to permit hospitals to establish and operate as part of the hospital any location meeting those conditions of participation for hospitals that continue to apply during the public health emergency. This waiver also permits hospitals to change the status of their current provider-based department locations to the extent necessary to address the needs of hospital patients.
  • CMS is waiving requirements to permit acute-care hospitals to house acute-care inpatients in excluded distinct part units, such as excluded distinct part unit inpatient rehabilitation facilities or inpatient psychiatric facilities, where the distinct part unit’s beds are appropriate for acute-care inpatients.
  • CMS is permitting acute-care hospitals with excluded distinct part inpatient psychiatric units to relocate inpatients from the excluded distinct part psychiatric unit to acute-care beds and units as a result of a disaster or emergency.
  • CMS is permitting acute-care hospitals with excluded distinct part inpatient rehabilitation units that, as a result of a disaster or emergency, need to relocate inpatients from the excluded distinct part rehabilitation unit to an acute-care bed and unit.
  • CMS is waiving certain physical environment requirements. Provided that the state has approved the location as one that sufficiently addresses safety and comfort for patients and staff, CMS is waiving requirements to allow for a non-skilled nursing facility building to be temporarily certified and available for use by a skilled nursing facility in the event there are needs for isolation processes for COVID-19-positive residents, which may not be feasible in the existing skilled nursing facility structure to ensure care and services during treatment for COVID-19 are available while protecting other vulnerable adults.
  • CMS is waiving certain conditions of participation and certification requirements for opening a nursing facility if the state determines there is a need to quickly stand up a temporary COVID-19 isolation and treatment location.
  • CMS is waiving requirements to temporarily allow for rooms in a long-term care facility not normally used as a resident’s room to be used to accommodate beds and residents for resident care in emergencies and situations needed to help with surge capacity.

Expanding the Health Care Workforce

  • CMS is waiving current requirements to permit physicians whose privileges will expire to continue practicing at the hospital and for new physicians to be able to practice before full medical staff/governing body review and approval to address workforce concerns related to COVID-19.  CMS also is waiving requirements about details of the credentialing and privileging process.
  • CMS is waiving the requirement that Medicare patients be under the care of a physician.
  • CMS is waiving requirements that a certified registered nurse anesthetist (CRNA) work under the supervision of a physician. CRNA supervision will be at the discretion of the hospital and state law.
  • CMS is waiving the requirement that a skilled nursing facility and nursing facility may not employ anyone for longer than four months unless they meet current training and certification requirements. CMS is not waiving the requirement that such facilities ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents’ needs.
  • CMS is waiving the requirement that physicians and non-physician practitioners must perform in-person visits for nursing home residents and will permit visits to be conducted, as appropriate, via telehealth options.
  • CMS is temporarily waiving requirements that out-of-state practitioners be licensed in the state where they are providing services when they are licensed in another state. CMS will waive the physician or non-physician practitioner licensing requirements when the following four conditions are met:
    • must be enrolled as such in the Medicare program;
    • must possess a valid license to practice in the state which relates to his or her Medicare enrollment;
    • is furnishing services – whether in person or via telehealth – in a state in which the emergency is occurring to contribute to relief efforts in his or her professional capacity; and,
    • is not affirmatively excluded from practice in the state or any other state that is part of the 1135 emergency area.
    • This 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.
  • CMS has a toll-free hotline for physicians and non-physician practitioners and Part A-certified providers and suppliers establishing isolation facilities to enroll and receive temporary Medicare billing privileges. CMS is waiving the following screening requirements:
    • application fee,
    • criminal background checks associated with fingerprint-based criminal background checks,
    • site visits,
    • postpone all revalidation actions,
    • allow licensed providers to render services outside of their state of enrollment,
    • expedite any pending or new applications from providers,
    • allow physicians and other practitioners to render telehealth services from their home without reporting their home address on their Medicare enrollment while continuing to bill from their currently enrolled location, and
    • allow opted-out physicians and non-physician practitioners to terminate their opt-out status early and enroll in Medicare to provide care to more patients.
  • CMS has issued blanket waivers of sanctions under the Stark Act.  The blanket waivers may be used now without notifying CMS.  Individual waivers of sanctions under section 1877(g) of the Act may be granted upon request.  For more information, go here and here.

Increasing the Use of Telehealth in Medicare

  • CMS is waiving the requirement that physicians and non-physician practitioners must perform in-person visits for nursing home residents and will permit visits to be conducted, as appropriate, via telehealth options.
  • Clinicians can provide virtual check-in services to new and established patients.
  • CMS will pay for telephone evaluation and management services provided by physicians and the same services provided by qualified non-physician health care providers. These services may be used for telephone-only evaluation and management services.
  • Licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech language pathologists can perform e-visits via telehealth.
  • Limits have been lifted for subsequent inpatient visits, subsequent skilled nursing visits, and critical care consult codes.
  • Physicians may provide supervision virtually using real-time audio/visual technology for services that require direct supervision by a physician or other type of practitioner.
  • For additional information on new flexibilities in the use of telehealth for Medicare patients, go here.

Reducing Paperwork

  • CMS is waiving various requirements that limit and define the use and documentation of verbal orders in a hospital.
  • CMS is waiving reporting requirements when patients who have passed away required soft restraints prior to their death.  If restraints were a factor in the death, the usual reporting requirements apply.
  • CMS is waiving the current requirements for providing “detailed information” in discharge planning as long as discharging hospitals continue to provide the data patients and their families need to make decisions about appropriate post-acute care.  This does not waive the requirement that patients have all of the necessary medical information they need for their post-acute setting.
  • While maintaining the discharge planning requirements that ensure that patients are discharged to an appropriate setting with the necessary medical information, CMS is waiving some of the specific components of discharge information acute-care hospitals are ordinarily required to provide.
  • CMS is waiving requirements involving the organization and staffing of medical records departments and requirements for the form and content of medical records and is allowing for flexibility in completion of medical records within 30 days following discharge from a hospital.
  • CMS is waiving the requirements for hospitals to provide information about their advance directive policies to patients.
  • CMS is waiving the requirement that hospitals participating in Medicare and Medicaid must have a utilization review plan that meets specified requirements. CMS is waiving the entire utilization review condition of participation.
  • CMS is waiving – for “surge facilities” only – the requirement that the emergency services function operate according to written policies and procedures during surge periods.
  • CMS is waiving the requirement that hospital emergency preparedness policies and procedures include specified elements for the emergency preparedness communication plans of hospitals when a hospital is a surge site.
  • CMS is waiving requirements for hospital quality assessment and performance improvement programs that address the scope of the program, the incorporation and setting of priorities for the program’s performance improvement activities, and integrated quality assurance and performance improvement programs. The requirement that hospitals maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program remains.
  • CMS is waiving the requirement that providers must have a current therapeutic diet manual approved by the dietitian and medical staff readily available to all medical, nursing, and food service personnel. Such manuals would not need to be maintained at surge capacity sites.
  • CMS is waiving the requirement for nursing staffs to develop and keep current a nursing care plan for each patient and to have policies and procedures in place establishing which outpatient departments are not required to have a registered nurse present.
  • Completed 2019 Occupational Mix Surveys, Hospital Reporting Form CMS-10079, for the Wage Index Beginning FY 2022, are due to the Medicare Administrative Contractors (MACs). CMS is granting an extension for hospitals nationwide affected by COVID-19 until August 3, 2020.
  • CMS is waiving requirements that govern pre-admission screening and annual resident review (PASARR) to permit states and nursing homes to suspend these assessments for new residents for 30 days. After 30 days, new patients admitted to nursing homes with a mental illness or intellectual disability should receive the assessment as soon as resources become available.
  • CMS is waiving many paperwork requirements for home health agencies, skilled nursing facilities, nursing facilities, end-stage renal dialysis facilities, home health agencies, and hospices. Find those changes here (pages 9-16).
  • Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) in the fee-for-service program may allow extensions to file an appeal. CMS is allowing MACs and QICs in the fee-for-service program and the MA and Part D independent review entities (IREs) to:
    • waive requests for timeliness requirements for additional information to adjudicate appeals;
    • process appeals even with incomplete appointment of representation forms;
    • process requests for appeals that do not meet the required elements using information that is available; and
    • use all flexibilities available in the appeal process if good cause requirements are satisfied.

Others

  • CMS offers stakeholders examples of section 1135 waivers available to individual providers.  Find those examples here beginning on page 23.
  • CMS is waiving certain patient rights involving copies of medical records, patient visitation limits, and quarantine processes in states that have had more than 50 confirmed COVID-19 cases.

For further information:

To learn more about these changes, you may wish to consult the following resources:

The following is the latest information from the administration and federal regulators as of 4:30 today.

The White House

President Trump has issued a presidential memorandum to the Secretary of Defense and the Secretary of Homeland Security authorizing the use of the National Guard to provide COVID-19-related services to the states of Connecticut, Illinois, Massachusetts, and Michigan, with the federal government to pay 100 percent of the cost of such a deployment.  The federal assumption of 100 percent of this cost expires in 30 days.

Centers for Medicare & Medicaid Services

Department of Health and Human Services

The Department of Health and Human Services has posted a news release in which it outlines the steps it has taken and will be taking to accelerate clinical trials for possible COVID-19 vaccines and to prepare for the manufacture of approved vaccines.

U.S. Public Health Service

The U.S. Public Health Service has issued a letter on optimizing ventilator use during the COVID-19 pandemic.

Food and Drug Administration

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MedPAC Offers 2021 Medicare Rate Recommendations

MedPAC has recommended to Congress changes in Medicare payment rates in the coming year.

In its annual report to Congress, the Medicare Payment Advisory Commission recommended the following rate changes:

  • acute-care hospitals – a two percent rate increase and a suggestion that the difference between this two percent increase and the payment increase specified by law be used to increase the rewards hospitals may earn under Medicare’s hospital value incentive program.  As a result, the value incentive program would offer a possible 0.8 percent in bonus payments, and with the recommended elimination of the 0.5 percent penalty for which hospitals are at risk, hospitals could average net increases of 3.3 percent.
  • ambulatory surgical centers – no rate increase and a requirement that such facilities report cost data
  • physicians – rates updated as already provided for by law
  • long-term acute-care hospitals – a two percent increase
  • inpatient rehabilitation facilities – a five percent rate reduction
  • skilled nursing facilities – no rate increase
  • dialysis facilities – rates updated as already provided for by law
  • hospice services – no rate increase and the aggregate hospice cap should be wage-adjusted and reduced 20 percent
  • home health agencies – a seven percent rate reduction

While MedPAC’s recommendations to Congress are not binding on the administration, its work is highly respected and is considered influential in the setting of Medicare rates.

Learn more about MedPAC’s recommendations on rates and other aspects of federal Medicare reimbursement policy in the MedPAC document Report to the Congress:  Medicare Payment Policy.

MedPAC Meets

Last week the Medicare Payment Advisory Commission met in Washington, D.C. to discuss a number of Medicare payment issues.

The issues on MedPAC’s March agenda were:

  • Addressing Medicare Shared Savings Program vulnerabilities
  • The role of specialists in alternative payment models and accountable care organizations
  • Realigning incentives in Medicare Part D
  • Redesigning the Medicare Advantage quality bonus program
  • Mandated report: Impact of changes in the 21st Century Cures Act to risk adjustment for Medicare Advantage enrollees
  • Improving Medicare’s end-stage renal disease prospective payment system
  • Separately payable drugs in the hospital outpatient prospective payment system

MedPAC is an independent congressional agency that advises Congress on issues involving the Medicare program.  While its recommendations are not binding on either Congress or the administration, MedPAC is highly influential in governing circles and its recommendations often find their way into legislation, regulations, and new public policy.

Go here for links to the policy briefs and presentations that supported MedPAC’s discussion of these issues.

Comfort, Not Quality, Woos Patients

People are more likely to recommend a hospital based on the comfort they felt when hospitalized rather than the quality of the care they received, a new study has found.

Good food, rooms with a view, friendly nurses, peace and quiet, more television channels, and other amenities impress patients more than higher survival rates and lower hospital-acquired conditions rates.

These are among the findings from an analysis of patient satisfaction data from 3000 hospitals between 2007 and 2010.

This has long been a concern of NASH, and in the past, NASH wrote to federal regulators in response to proposals to use patient survey results in Medicare quality purchasing programs, explaining that

… we believe some of the [federal government’s] survey’s questions are biased against large urban hospitals.  We think it is inappropriate, for example, to compare the degree of quietness of a seventy-five-year-old hospital with semi-private rooms located in a congested urban area with that of a new facility with private rooms located on a sylvan, multi-acre campus set well off any major thoroughfares. 

Learn more about how inpatients view their hospital experiences and how those experiences shape how they rate hospitals in Oxford Academic’s Social Forces article “Patients as Consumers in the Market for Medicine: The Halo Effect of Hospitality” and find a summary of that analysis in the HealthLeaders Media article “Hospitality Trumps Clinical Outcomes When It Comes To Patient Satisfaction.”