Connected Care Clips – June 19
Welcome to this week’s edition of the Alliance for Connected Care Clips. Please click the button below to see our newsletter.
[maxbutton id=”10″ ]
Healthcare Leaders Form Taskforce on Telehealth
Healthcare Leaders Form Taskforce on Telehealth Policy
View a pdf version here.
Amidst an unprecedented increase in the use of remote medical services, 20 of the nation’s leading healthcare voices today announced the formation of a Taskforce on Telehealth Policy aimed at developing long-term recommendations. The taskforce will be convened by the National Committee for Quality Assurance, Alliance for Connected Care, and the American Telemedicine Association (ATA).
The group – representing a broad spectrum of plans, providers, consumer advocates and health-quality experts from the public, private and non-profit sectors – will develop consensus recommendations for policymakers on how to maximize the benefits of telehealth services while maintaining high standards for patient safety and program integrity. Other priorities to be addressed include the integration of remote care into the healthcare ecosystem and ensuring the quality, accessibility, and efficacy of telehealth.
The need for a comprehensive review of telehealth policy is highlighted by some remarkable data collected since March. Every element of healthcare has been affected by the major increases in telehealth and remote patient care. Many patients and providers have experienced the capabilities of telehealth for the first time and are interested in continuing to use it. Traditional (fee-for-service) Medicare has seen the number of remote visits increase from roughly 12,000 per week to over a million per week, according to recent comments from Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma.
The Commonwealth Fund found that, in the mid-April peak of the current spread, in-person visits fell by nearly 70 percent, with telehealth visits offsetting as much as 20 percent of that decline. Many public and private payers, including CMS, have substantially relaxed telehealth restrictions during the pandemic.
“We need to get this moment in healthcare right by optimizing the quality and value of telehealth for everyone,” said NCQA President Margaret (Peggy) O’Kane. “The fact that such an accomplished group of people are willing to dedicate their time, on short notice, to this task speaks to how high the stakes truly are.”
“The value of telehealth during this emergency is undeniable, and the policy changes that were made by Congress and the Trump Administration were essential,” said Alliance for Connected Care Executive Director Krista Drobac. “This taskforce can take what we have collectively learned in the past three months and develop thoughtful recommendations that will provide access to remote care for the long term while balancing cost, quality and judicious use of taxpayer dollars.”
“The ATA was proud to represent our industry at yesterday’s Senate Committee on Health, Education, Labor and Pensions hearing on telehealth, helping to build the case for extending access to virtual care indefinitely. This Telehealth Policy Task Force will help to maintain a strong, unified, and compelling voice needed to cement those gains,” added Ann Mond Johnson, CEO, the ATA. “Telehealth has played a vital role in responding to the pandemic, driving a rapid transformation in how care is delivered. Working together, we must ensure access to care for all who need it.”
The Taskforce on Telehealth will hold its first meeting on Monday, June 29, and deliberate through the summer. Final recommendations will be issued in early September. A full list of Taskforce on Telehealth members is below.
Peter Antall, MD, Chief Medical Officer, Amwell
Regina Benjamin, MD, Chief Executive Officer, BayouClinic/Gulf States Health Policy Center, former Surgeon General of the United States
Krista Drobac, Executive Director, Alliance for Connected Care
Yul Ejnes, MD, Clinical Associate Professor of Medicine, Brown University; Board of Regents Chair-Emeritus, American College of Physicians
Rebekah Gee, MD, Chief Executive Officer, Louisiana State University Health System
Nancy Gin, MD, Executive Vice President of Quality & Chief Quality Officer, Kaiser Permanente Federation
Kate Goodrich, MD, Senior Vice President Trend and Analytics, Humana
Ann Mond Johnson, Chief Executive Officer, American Telemedicine Association
Chuck Ingoglia, President & Chief Executive Officer, National Council for Behavioral Health
Chris Meyer, Director of Virtual Care, Marshfield Clinic
Megan Mahoney, MD, Chief of Staff, Stanford Health Care, Clinical Professor, Division of Primary Care and Population Health, Stanford University
Peggy O’Kane, President, National Committee for Quality Assurance
Sean Cavanaugh, Chief Administrative Officer, Aledade
Kerry Palakanis, DNP, APRN, Executive Director, Connected Care Operations, Intermountain Healthcare
Nicholas Uehlecke, Federal Liaison, US Department of Health & Human Services (non-voting)
Michelle Schreiber, MD, Director, Quality Measurement & Value-Based Incentives Group, Center for Clinical Standards & Quality, Centers for Medicare & Medicaid Services
Dorothy Siemon, JD, Senior Vice President for Policy Development, AARP
Julia Skapik, MD, MPH , Medical Director, Informatics, National Association of Community Health Centers
Jason Tibbels, MD, Chief Quality Officer, Teladoc Health
Andrew Watson, MD, Vice President, University of Pennsylvania Medical Center
Cynthia Zelis, MD, MBA, Chief Medical Officer, MD Live
CDC Telehealth Guidance
Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic
CDC issued guidance for healthcare systems, practices, and providers using telehealth services to provide virtual care during and beyond the COVID-19 pandemic. The guidance describes the landscape of telehealth services, provides strategies to increase telehealth uptake, and offers potential limitations of telehealth – one of which includes interstate licensure challenges and other regulatory issues that may vary by state.
The guidance can be viewed here.
View more telehealth guidance on our COVID-19 Resources page
Other Telehealth Guidance Documents
Guidance on Fraud and Anti-kickback Regulations from the HHS Inspector General
In response to the public health emergency, leading provider organizations and the Alliance for Connected Care expressed interest in ensuring the ability of providers to waive co-pays or provide some telehealth services at no cost — to encourage more seniors to access needed care. These waivers would normally implicate the federal anti-kickback statute, the Civil Monetary Penalty and Exclusion Law related to kickbacks, and the Civil Monetary Penalty Law’s prohibition on inducements to beneficiaries.
On March 17, the HHS Office of the Inspector General (OIG) issued a policy statement assuring providers that they could make these changes without risk of triggering the Federal anti-kickback statute, the civil monetary penalty and exclusion laws related to kickbacks, or the civil monetary penalty law prohibition on inducements to beneficiaries. In a supplemental FAQ, OIG indicated that the policy is not limited to services defined by CMS as “telehealth visits” and instead applies to a broad category of non-face-to-face services furnished through various modalities including telehealth visits, virtual check-in services, e-visits, monthly remote care management, and monthly remote patient monitoring.
On April 3, HHS OIG issued a policy statement stating that the agency will exercise its enforcement discretion not to impose administrative sanctions for certain Stark Law violations that had been waived by HHS during the public health emergency. The Physician Self-Referral Law, commonly referred to as the Stark law, prohibits physicians from referring patients to receive “designated health services” payable by Medicare or Medicaid from entities with which the physician or an immediate family member has a financial relationship, unless an exception applies.
- April 23 OIG Advisory Opinion
- April 3 OIG – Stark Law Policy Statement
- March 24 Frequently Asked Questions
- March 17 OIG Policy Statement
- March 17 OIG Factsheet
Guidance for Federally Qualified Health Centers and Rural Health Clinics from the Centers for Medicare and Medicaid Services
The CARES Act added Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to the list of eligible providers. This change allows FQHCs and RHCs to act as distant site providers allowing them to provide telehealth services for the duration of the public health emergency.
In response to the new changes, CMS posted an article for RHCs and FQHCs on expanded flexibilities during the COVID-19 public health emergency for services provided to Medicare beneficiaries.
These new flexibilities include:
- New payment for telehealth services, including how to bill Medicare
- Expansion of virtual communication services
- Revision of home health agency shortage requirement for visiting nursing services
- Consent for care management and virtual communication services
- Accelerated/advance payments
Guidance on Telemedicine Prescribing of Controlled Substances from the Drug Enforcement Administration
While a prescription for a controlled substance issued by means of the Internet (including telemedicine) generally requires an in-person medical evaluation, the Controlled Substances Act contains certain exceptions to this requirement. One such exception occurs when the Secretary of Health and Human Services has declared a public health emergency. Traditionally, a prescribing practitioner who has previously conducted an in-person medical evaluation may issue a prescription for a controlled substance regardless of whether a public health emergency has been declared.
The Drug Enforcement Administration announced that as long as the Secretary’s designation of a public health emergency remains in effect, DEA -registered practitioners may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation, provided all of the following conditions are met (as defined under Section 802(54)(D):
- The prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice
- The telemedicine communication is conducted using an audio-visual, real-time, two-way interactive communication system.
- The practitioner is acting in accordance with applicable Federal and State law.
Guidance from the Food and Drug Administration (updated June 5)
Remote Patient Monitoring
On June 5, FDA issued updated guidance to expand the availability and capability of non-invasive remote monitoring devices to facilitate patient monitoring while reducing patient and healthcare provider contact and exposure to COVID-19 for the duration of the COVID-19 public health emergency. In the new guidance, the agency said it will not object to limited modifications to the indications, claims, functionality, or hardware or software the devices, listed here, as long as they do not impose undue risk.
On April 23, FDA issued guidance on non-invasive fetal and maternal monitoring used to support patient monitoring during the COVID-19 pandemic. FDA indicated that increasing the availability of these devices may increase access to important prenatal data without the need for in-clinic visits and facilitate patient management while reducing the need for in-person visits. The April 23 policy creates:
- For devices previously cleared only for use in hospitals or other health care facilities, a change to the indications or instructions regarding use in the home setting
- Modifications to devices, including changes in hardware or software, to allow for increased remote monitoring capability
- Modifications to devices to make the device more mobile for facilitating transfer into and out of a transportation vehicle and into a patient’s home.
Asynchronous (Store-and-Forward)
On April 23, FDA issued guidance to help increase availability and capability of imaging systems needed for diagnosis and treatment monitoring of lung disease in patients during the COVID-19 pandemic. These imaging products include medical x-ray, ultrasound, magnetic resonance imaging systems, and image analysis software that are used to diagnose and monitor medical conditions. FDA states that increasing the availability of mobile and portable imaging systems may increase options to image patients inside and outside of healthcare facilities, which could help to reduce the spread of COVID-19. The April 23 policy make several changes:
- Modifications to Indications, Technical Specifications, Functionality, Hardware, Software, and Materials of Imaging Systems
- Modifications to Indications and Functionality of Ultrasound Imaging Systems
- Modifications to the Indications and Functionality of Image Analysis Software
- Validation of Changes Made to Hardware, Software, Materials, or Duration of Use
- In addition, FDA recommends that the products described above include labeling that helps users better understand the product modifications
- Clinical Decision Support Software for Imaging related to COVID-19 and Co-existing Conditions
- Policy to Help Increase Availability and Minimize Supply Chain Disruptions
Guidance from the HHS Office for Civil Rights (OCR) on the Health Insurance Portability and Accountability Act (HIPAA)
HHS OCR is responsible for enforcing certain regulations issued under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended by the Health Information Technology for Economic and Clinical Health (HITECH) Act, to protect the privacy and security of protected health information. HHS OCR recognizes that during the COVID-19 national emergency, covered health care providers subject to HIPAA Rules may seek to communicate with patients and provide telehealth services through remote communications technologies. These technologies may not comply with the requirements of the HIPAA Rules.
In response to the rapid expansion of telehealth and the need to communicate with patients, OCR issued a “Notification of Enforcement Discretion” for telehealth remote communications during the public health emergency. It clarifies the ability of telehealth to be delivered through platforms such as Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, without risk that OCR might seek to raise HIPAA compliance concerns.
Guidance on Clinical Laboratories
CMS issued a memo to laboratory surveyors to provide guidance on the review of pathology slides, proficiency testing, alternate collection devices, and requirements for a Clinical Laboratory Improvement Amendment (CLIA) certificate during the COVID-19 public health emergency. Recognizing the urgency of the public health emergency and the need to promote innovative uses
of technology to increase capacity and avoid exposure risks, CMS is exercising enforcement discretion to ensure pathologists may review pathology slides remotely.
Medicaid Guidance Documents During the COVID-19 Pandemic
Medicaid Guidance from the Centers for Medicare and Medicaid Services
For purposes of Medicaid, telemedicine seeks to improve a patient’s health by permitting two-way, real-time interactive communication between the patient, and the physician or practitioner at the distant site. This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.
Reimbursement for Medicaid covered services, including those with telemedicine applications, must satisfy federal requirements of efficiency, economy, and quality of care. States are encouraged to use the flexibility inherent in federal law to create innovative payment methodologies for services that incorporate telemedicine technology. For example, states may reimburse the physician or other licensed practitioner at the distant site and reimburse a facility fee to the originating site. States can also reimburse any additional costs such as technical support, transmission charges, and equipment. These add-on costs can be incorporated into the fee-for-service rates or separately reimbursed as an administrative cost by the state. If they are separately billed and reimbursed, the costs must be linked to a covered Medicaid service.
CMS continues to issue and update guidance for states seeking to expand telehealth for Medicaid in response to the COVID-19 public health emergency. It is important to note that this guidance does not create new policy, but reminds states about the flexibility that exists in the Medicaid program. While Medicaid is jointly funded by federal and state governments, states have flexibility in designing and administering their program. This flexibility has created a great deal of variation in telehealth laws and reimbursement policies.
Recent federal guidance on teleheath in Medicaid:
- FAQs for State Medicaid Agencies and CHIP Agencies – Updated May 5
- Telehealth Toolkit to Accelerate State Use of Telehealth in Medicaid and CHIP – Updated December 6
- April 2 Rural Health Medicaid Telehealth Flexibilities and Medicaid SUD Treatment via Telehealth Guidance
- March 17 Medicaid Telehealth Guidance
- General Medicaid Telehealth Guidance
Please note that the Alliance has several pages devoted to state policy that may be relevant to Medicaid, including:
State Medicaid Telehealth Waivers & Temporary Flexibilities During COVID-19
The Alliance compiled a 50-state chart of Medicaid telehealth waivers and temporary flexibilities during COVID-19. For more information on Medicaid during the COVID-19 PHE please see our Medicaid Guidance Documents During the COVID-19 Pandemic.
Loading...
Reload document 
Open in new tab The Coronavirus Pandemic and the Transformation of Telehealth
The Coronavirus Pandemic and the Transformation of Telehealth
Find on our: COVID-19 Telemedicine Research & Reports
According to FAIR Health data, telehealth claim lines increased 4,347% nationally from March 2019 to March 2020 – with the most pronounced increase in the Northeast at more than 15,500% – further indicating the effects of the COVID-19 pandemic. In addition, most of the increase was found in mental health.
Loading...
Loading...
COVID-19 Telehealth Polling
The Alliance for Connected Care has compiled polls on patient and provider adoption, acceptance, and satisfaction with telehealth during the COVID-19 public health emergency. This chart has also been added to our Studies & Reports page. The Alliance will continue to update the chart with telehealth polls as they are published.
COVID-19 Telehealth Polls – Patient and Provider Adoption, Acceptance, and Satisfaction
| Study Group | Telehealth Polls: Summary | Date of Publication | Link to survey |
|---|---|---|---|
| Seniors | A poll from the University of Michigan’s Institute for Healthcare Policy and Innovation of more than 2,000 adults aged 50 to 80 finds an increase in telehealth visits from 4% as of May 2019 to 26% between March and June 2020. Other significant findings include: • They feel very or somewhat comfortable with video conferencing technologies: 64%, up from 53% in 2019 • At least one of their health providers offer telehealth visits: 62%, up from 14% • They are interested in using telehealth to connect with a provider they had seen before: 72%, up from 58% • They are interested in using telehealth for a one-time follow-up appointment after a procedure or operation: 63%, up from 55% • They have concerns about privacy during a telehealth visit: 24%, down from 49% • They are concerned they would have difficulty seeing or hearing the provider during a video visit: 25%, down from 39% | August, 2020 | Additional information can be found here. |
| A survey of more than 1,000 Medicare eligible consumers aged 64 and older conducted from July 17 to July 20 finds seniors are embracing telehealth and digital technologies. Telemedicine usage jumped 340% among Medicare-eligible seniors since the start of the COVID-19 pandemic and nearly one-third of consumers age 64 and older say they monitor their health using a wearable. Prior to COVID-19 only 1 in 10 used telemedicine. During COVID-19, 44% have used telemedicine and 43% say they intend on using it after, according to the survey. | August, 2020 | Additional information can be found here. | |
| A new poll of more than 1,000 seniors found 52% are comfortable using telehealth to receive health care. Of those who have used telehealth during the coronavirus, 91% reported a favorable experience, and 78% are likely to complete a medical appointment via telehealth again in the future. | May, 2020 | Additional information can be found here. | |
| Findings from the latest KFF Health Tracking Poll finds that the majority of older adults have an internet connection and communicate via smartphone, tablet, or computer to talk with friends. However, while 68% of adults 65 and older said they have a computer, smartphone, or tablet with internet access at home, only 11% said they have used the device to communicate with a health care provider in the past two weeks. KFF indicates that this number will likely rise as stay-at-home orders are extended. | April, 2020 | Additional information can be found here. |
|
| Adults | Change Healthcare and Harris Poll conducted a survey of more 2,000 Americans to better understand the consumer experience of finding, accessing, and paying for healthcare today. The vast majority of consumers agree that COVID-19 will fundamentally change how we receive healthcare in American, with 80% saying that COVID-19 has made telehealth an indispensable part of the healthcare system. • 3 in 4 consumers believe telehealth is the future of telemedicine. The vast majority of consumers agree that COVID-19 will fundamentally change how we receive healthcare in American, with 80% saying that COVID-19 has made telehealth an indispensable part of the healthcare system. • 65% plan to use telehealth more often than they did before the pandemic. 1 in 4 used telehealth for the first time due to COVID-19, while 16% have used it more often. 79% who used telehealth for the first time during the pandemic said they plan to use telehealth more in the future. | July, 2020 | The full report can be downloaded here. |
| A March survey found that 59% of the 500 U.S. consumers surveyed said they are more likely to use telehealth services now than previously, and 36% said they would switch their physician in order to have access to virtual care. | March, 2020 | Additional information can be found here. | |
| A survey of 2,000 adults across the U.S. on perceptions of telehealth during COVID-19 found that more than 95% of respondents who had used telehealth said they already have or would consider scheduling another telehealth appointment in the future. The most cited advantages to telehealth were quicker and greater access to care and avoiding overcrowded wait rooms. | March, 2020 | Additional information can be found here. | |
| Providers | A survey of more than 1,300 physicians found that more than 90% are treating some or all of their patients via telehealth. Additionally, roughly 60% of physicians currently using telemedicine tools during the public health emergency said they plan to use telemedicine more often than they were pre-COVID. | April, 2020 | Additional information can be found here. |
| A survey of more than 800 physicians found that close to half (48%) are treating patients via telemedicine, up from 18% in 2018. | April, 2020 | Additional information can be found here. | |
| A survey found that all 20 accountable care organizations (ACOs) surveyed are implementing telemedicine solutions, with 16% relying on AI and automation to identify and reach high-risk patients. | April, 2020 | Additional information can be found here. | |
| A survey of more than 600 healthcare providers found that 41% were using telemedicine technology, up from 22 percent in a 2018 survey. In addition, roughly 28% of the practices surveyed offered telehealth-only visits. | March, 2020 | Additional information can be found here. | |
| Other | The latest Modern Healthcare CEO Survey finds that health system CEOs see a wave of innovation in telehealth over the next year. In addition, 92.9% of CEOs cited telehealth as a technology with the most potential to support response to the COVID-19 pandemic. | May, 2020 | Additional information can be found here. |
April CMS COVID-19 Interim Final Rule Summary
On April 30, the Centers for Medicare and Medicaid Services has released another Interim Final Rule, implementing significant additional changes for telehealth. Specifically, this Interim Final Rule includes more changes created using the statutory authority of Coronavirus Aid, Relief, and Economic Security Act (CARES Act). These changes come from both new 1135 waivers and the interim final rule – both summarized in the below document.
- CMS expanded the ability to practice telehealth services to all providers eligible to bill Medicare. This should fix concerns about physical therapists, occupational therapists, speech language pathologists, and others not being on the distant site provider list.
- CMS increased Medicare payment rates for the previously-created audio-only E&M codes, but has not broadly allowed audio to be used for all telehealth delivery. There are focused expansions of audio-only listed here and below in the summary.
- CMS gave itself the authority to make future changes to the telehealth services list through sub-regulatory guidance.
- Rural Health Clinics and Federally Qualified Health Centers may bill Medicare for telehealth as per the CARES Act.
CMS Resources:
- CMS Press release
- Regulation: Medicare and Medicaid IFC: Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (CMS-5531 IFC) (PDF)
- CMS 1135 Blanket Waivers
Summary:
Loading...
Telehealth Guidance Documents for Employee Benefit Plans
The Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury prepared FAQs regarding implementation of the Families First Coronavirus Response Act (FFCRA) and the CARES Act. Section 6001 of the FFCRA requires group health plans and health insurance issuers offering group or individual health insurance coverage to provide benefits for certain items and services related to diagnostic testing for the detection of or the diagnosis of COVID-19. Under the FFCRA, plans and issuers must provide this coverage without imposing any cost-sharing requirements (including deductibles, copayments and coinsurance) or prior authorization or other medical management requirements.
Further, DOL issued additional FAQs designed to help employee benefit plan participants and beneficiaries, as well as plan sponsors, and employers, impacted by the COVID-19 outbreak understand their rights and responsibilities under Title I of the Employee Retirement Income Security Act of 1974 (ERISA). This guidance – in reference to the above FAQs – permits plans to:
- Add telehealth and other remote health services, in addition to services related to diagnosis and treatment of COVID-19, mid-year and without providing 60 days’ advance notice as required under federal law.
- COVID-19 FAQs for Participants and Beneficiaries