CMS Announces Comprehensive Strategy to Enhance Hospital Capacity Amid COVID-19 Surge
Agency outlines flexibilities to maximize Acute Hospital Care at Home, Ambulatory Surgical Centers to decompress hospitals treating COVID-19 patients
Today, the Centers for Medicare & Medicaid Services (CMS) outlined unprecedented comprehensive steps to increase the capacity of the American health care system to provide care to patients outside a traditional hospital setting amid a rising number of coronavirus disease 2019 (COVID-19) hospitalizations across the country. These flexibilities include allowances for safe hospital care for eligible patients in their homes and updated staffing flexibility designed to allow ambulatory surgical centers (ASCs) to provide greater inpatient care when needed. Building on CMS’s previous actions to expand the availability of telehealth across the nation, these actions are aimed at allowing health care services to be provided outside a hospital setting while maintaining capacity to continue critical non-COVID-19 care, allowing hospitals to focus on the increased need for care stemming from public health emergency (PHE).
“We’re at a new level of crisis response with COVID-19 and CMS is leveraging the latest innovations and technology to help health care systems that are facing significant challenges to increase their capacity to make sure patients get the care they need,” said CMS Administrator Seema Verma. “With new areas across the country experiencing significant challenges to the capacity of their health care systems, our job is to make sure that CMS regulations are not standing in the way of patient care for COVID-19 and beyond.”
Acute Hospital Care at Home
In March 2020, CMS announced the Hospitals Without Walls program, which provides broad regulatory flexibility that allowed hospitals to provide services in locations beyond their existing walls. Today, CMS is expanding on this effort by executing an innovative Acute Hospital Care At Home program, providing eligible hospitals with unprecedented regulatory flexibilities to treat eligible patients in their homes. This program was developed to support models of at-home hospital care throughout the country that have seen prior success in several leading hospital institutions and networks, and reported in academic journals, including a major study funded by a Healthcare Innovation Award from the Center for Medicare and Medicaid Innovation (CMMI).
The program clearly differentiates the delivery of acute hospital care at home from more traditional home health services. While home health care provides important skilled nursing and other skilled care services, Acute Hospital Care at Home is for beneficiaries who require acute inpatient admission to a hospital and who require at least daily rounding by a physician and a medical team monitoring their care needs on an ongoing basis.
To support these efforts, CMS has launched an online portal https://qualitynet.cms.gov/acute-hospital-care-at-home to streamline the waiver request process and allow hospitals and healthcare systems to submit the necessary information to ensure they meet the program’s criteria to participate. CMS will also closely monitor the program to safeguard beneficiaries by requiring hospitals to report quality and safety data to CMS on a frequency that is based on their prior experience with the Hospital At Home model.
Ambulatory Surgical Center Flexibility
As part of Hospital Without Walls, CMS also previously announced regulatory flexibility that allowed ASCs – facilities that normally provide same-day surgical care – the ability to be temporarily certified as hospitals and provide inpatient care for longer periods than normally allowed, with the appropriate staffing in place. ASCs are normally subject to a requirement that patients only remain in their care for less than 24 hours or require admission to a regular hospital.
Today, CMS is announcing an update to that regulatory flexibility, clarifying that participating ASCs need only provide 24-hour nursing services when there is actually one or more patient receiving care onsite. The program change provides ASCs enrolled as hospitals the ability to flex up their staffing when needed and provide an important relief valve in communities experiencing hospital capacity constraints, while not mandating nurses be present when no patients are in the ASC. The flexibility is available to any of the 5732 ASCs throughout the country seeking to participate and will be immediately effective for the 85 ASCs currently participating in the Hospital Without Walls initiative. CMS expects this flexibility will allow these and additional ASCs enrolled as hospitals to serve as an added access point that will allow communities to maintain surgical capacity and other life-saving non-COVID-19, like cancer surgeries. Allowing these types of treatments to occur in designated ASCs enrolled as hospitals while hospitals are managing any surges of COVID-19 would allow vulnerable patients to receive this needed care in settings without known COVID-19 cases.
Today’s announcement builds upon the critical work by CMS to expand telehealth coverage to keep beneficiaries safe and prevent the spread of COVID-19. CMS has expanded the scope of Medicare telehealth to allow Medicare beneficiaries across the country to receive telehealth services from any location, including their homes. CMS also added over 135 services such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services, that could be paid when delivered by telehealth The flexibilities announced today, and the aggressive action taken by CMS to remove barriers to telehealth, ensure patients and providers have options when receiving and providing care given the challenges and additional stress placed on hospitals and the health care system during the COVID-19 PHE.
To view the Acute Hospital Care At Home initiative and application, please visit: CMS’: https://qualitynet.cms.gov/acute-hospital-care-at-home
For more on the ambulatory surgical center flexibilities, please see: https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/guidance-processing-attestation-statements-ambulatory-surgical-centers-ascs-temporarily-enrolling
To view comments from health systems participating in the Acute Hospital Care at Home, please visit: https://www.cms.gov/files/document/what-are-they-saying-hospital-capacity.pdf
Trump Administration Finalizes Permanent Expansion of Medicare Telehealth Services and Improved Payment for Time Doctors Spend with Patients
On December 1, CMS released the annual Physician Fee Schedule (PFS) final rule, prioritizing CMS’ investment in primary care and chronic disease management by increasing payments to physicians and other practitioners for the additional time they spend with patients, especially those with chronic conditions The rule allows non-physician practitioners to provide the care they were trained and licensed to give, cutting red tape so health care professionals can practice at the top of their license and spend more time with patients instead of on unnecessary paperwork. This final rule takes steps to further implement President Trump’s Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors including prioritizing the expansion of proven alternatives like telehealth.
“During the COVID-19 pandemic, actions by the Trump Administration have unleashed an explosion in telehealth innovation, and we’re now moving to make many of these changes permanent,” said HHS Secretary Alex Azar. “Medicare beneficiaries will now be able to receive dozens of new services via telehealth, and we’ll keep exploring ways to deliver Americans access to health care in the setting that they and their doctor decide makes sense for them.”
“Telehealth has long been a priority for the Trump Administration, which is why we started paying for short virtual visits in rural areas long before the pandemic struck,” said CMS Administrator Seema Verma. “But the pandemic accentuated just how transformative it could be, and several months in, it’s clear that the health care system has adapted seamlessly to a historic telehealth expansion that inaugurates a new era in health care delivery.”
Finalizing Telehealth Expansion and Improving Rural Health
Before the COVID-19 Public Health Emergency (PHE), only 15,000 Fee-for-Service beneficiaries each week received a Medicare telemedicine service. Since the beginning of the PHE, CMS has added 144 telehealth services, such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services, that are covered by Medicare through the end of the PHE. These services were added to allow for safe access to important health care services during the PHE. As a result, preliminary data show that between mid-March and mid-October 2020, over 24.5 million out of 63 million beneficiaries and enrollees have received a Medicare telemedicine service during the PHE.
This final rule delivers on the President’s recent Executive Order on Improving Rural Health and Telehealth Access by adding more than 60 services to the Medicare telehealth list that will continue to be covered beyond the end of the PHE, and we will continue to gather more data and evaluate whether more services should be added in the future. These additions allow beneficiaries in rural areas who are in a medical facility (like a nursing home) to continue to have access to telehealth services such as certain types of emergency department visits, therapy services, and critical care services. Medicare does not have the statutory authority to pay for telehealth to beneficiaries outside of rural areas or, with certain exceptions, allow beneficiaries to receive telehealth in their home. However, this is an important step, and as a result, Medicare beneficiaries in rural areas will have more convenient access to health care.
Additionally, CMS is announcing a commissioned study of its telehealth flexibilities provided during the COVID-19 PHE. The study will explore new opportunities for services where telehealth and virtual care supervision, and remote monitoring can be used to more efficiently bring care to patients and to enhance program integrity, whether they are being treated in the hospital or at home.
Payment for Office/Outpatient Evaluation and Management (E/M) and Comparable Visits
Last year, CMS finalized a historic increase in payment rates for office/outpatient face-to-face E/M visits that goes into effect in 2021. The Medicare population is increasing, with over 10,000 beneficiaries joining the program every day. Along with this growth in enrollment is increasing complexity of beneficiary health care needs, with more than two-thirds of Medicare beneficiaries having two or more chronic conditions. Increasing the payment rate of E/M office visits recognizes this demand and ensures clinicians are paid appropriately for the time they spend on coordinating care for patients, especially those with chronic conditions. These payment increases, informed by recommendations from the American Medical Association (AMA), support clinicians who provide crucial care for patients with dementia or manage transitions between the hospital, nursing facilities, and home.
Under this final rule, CMS continues to prioritize this investment in primary care and chronic disease management by similarly increasing the value of many services that are similar to E/M office visits, such as maternity care bundles, emergency department visits, end-stage renal disease capitated payment bundles, and physical and occupational therapy evaluation services. These adjustments ensure CMS is appropriately recognizing the kind of care where clinicians need to spend more face-to-face time with patients.
“This finalized policy marks the most significant updates to E/M codes in 30 years, reducing burden on doctors imposed by the coding system and rewarding time spent evaluating and managing their patients’ care,” Administrator Verma added. “In the past, the system has rewarded interventions and procedures over time spent with patients – time taken preventing disease and managing chronic illnesses.”
In addition to the increase in payment for E/M office visits, simplified coding and documentation changes for Medicare billing for these visits will go into effect beginning January 1, 2021. The changes modernize documentation and coding guidelines developed in the 1990s, and come after extensive stakeholder collaboration with the AMA and others. These changes will significantly reduce the burden of documentation for all clinicians, giving them greater discretion to choose the visit level based on either guidelines for medical decision-making (the process by which a clinician formulates a course of treatment based on a patient’s information, i.e., through performing a physical exam, reviewing history, conducting tests, etc.) or time dedicated with patients. These changes are expected to save clinicians 2.3 million hours per year in administrative burden so that clinicians can spend more time with their patients.
Professional Scope of Practice and Supervision
As part of the Patients Over Paperwork Initiative, the Trump Administration is cutting red tape so that health care professionals can practice at the top of their license and spend more time with patients instead of on unnecessary paperwork. The PFS final rule makes permanent several workforce flexibilities provided during the COVID-19 PHE that allow non-physician practitioners to provide the care they were trained and licensed to give, without imposing additional restrictions by the Medicare program.
Specifically, CMS is finalizing the following changes:
- Certain non-physician practitioners, such as nurse practitioners and physician assistants, can supervise the performance of diagnostic tests within their scope of practice and state law, as they maintain required statutory relationships with supervising or collaborating physicians.
- Physical and occupational therapists will be able to delegate “maintenance therapy” – the ongoing care after a therapy program is established – to a therapy assistant.
- Physical and occupational therapists, speech-language pathologists, and other clinicians who directly bill Medicare can review and verify, rather than re-document, information already entered by other members of the clinical team into a patient’s medical record. As a result, practitioners have the flexibility to delegate certain types of care, reduce duplicative documentation, and supervise certain services they could not before, increasing access to care for Medicare beneficiaries.
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