Much has been said about how COVID-19 has acted as an accelerant for telehealth and remote patient monitoring. Since March 2020, the U.S. has probably cut 5-10 years off the normal time frame to bring telehealth and RPM into patient/consumer accepted, mainstream care, thanks in no small part to policy and reimbursement rule changes from the Centers for Medicare and Medicaid Services.
Nothing like a global pandemic to get people into fast action. That said, there has been one notable (and inexplicable, in my mind) exception: telehealth and Remote Physiologic Monitoring reimbursement for home health agencies.
The CMS Offered Conditional, Limited Approval
In its latest Final Rule, which was issued at the end of October 2020, CMS did state that HHAs "can utilize telecommunications technologies in providing care to beneficiaries under the Medicare home health benefit, as long as any provisions of remote patient monitoring or other services furnished via a telecommunications system or audio-only technology are included on the plan of care." In other words, telehealth may be used if the patient's physician approves.
The Final Rule also states that "the use of such telecommunications technology or audio-only technology must be tied to the patient-specific needs as identified in the comprehensive assessment." In plain language, telehealth can only be used for issues that have already been identified.
So far it all sounds positive and makes sense. Limiting telehealth use to known issues, essentially as a substitute for an in-person visit for the same issues, is a logical first step in expanding its use, especially for patients who have high risk of developing severe or fatal symptoms should they be exposed to COVID-19 or other easily transmissible health issues.
Still No Reimbursement
However, here is the problem with the rule as it currently exists While HHAs may take the time and effort to speak with and monitor patients via telehealth, CMS states these visits will not be reimbursed. Furthermore, telehealth visits do not count against Low-Utilization Payment Adjustment thresholds.
In fact, the Health and Human Services Department's Office of the Inspector General recently announced plans to "evaluate home health services provided by agencies during the COVID-19 public health emergency to determine which types of skilled services were furnished via telehealth, and whether those services were administered and billed in accordance with Medicare requirements."
This makes no sense!
HHAs have a huge responsibility for keeping the sickest among us as healthy as they can be so they can avoid costly inpatient stays and emergency department visits, helping bring down the cost of care for all of us.
This charter makes them one of the linchpins of the transition to value-based care, which healthcare still plans to do once the pandemic is fully behind us. So why would CMS not want to pay for a solution that helps them perform this mission more efficiently and effectively?
Just think of the time involved. Let's say that HHA nurses can visit six patients in an urban setting per day because those patients are clumped together in a fairly small geographic area.
As they spread out to the suburbs and exurbs, that number goes down to five, or four, because of the greater distance between patients. By the time you get to rural areas, where patients are often at greater risk for having poor health outcomes in addition to being spread even further apart, that number may go down even more.
Telehealth takes the distance factor out of the equation, enabling greater efficiencies in human and other resources so more patients can be seen on a more regular basis. As a result, the HHA can intervene on a developing health issue before it rises to the level of a crisis, possibly an expensive one.
Remote Physiologic Monitoring (RPM) is a synergistic adjunct to telehealth in managing chronic and acute patients at home. In the past, HHAs are also not allowed to bill for these services, and unfortunately, that continues for 2021. The best an HHA can do is have their clinical staff provide remote care management services incident to the general supervision of the billing Physician or Qualified Health Professional (QHP), under contract, with the Physician or QHB billing Medicare for the applicable RPM Codes.
In addition, improving staff efficiency and the timeliness of patient care will not happen if HHAs are not being compensated for the time they are expending in telehealth and RPM. That is just business. Instead, they will likely use telehealth to manage more emergent needs when they can't get someone on-site immediately, which will likely lead to an ED visit or hospital stay.
There is still hope
Fortunately, there is some recognition within the government of the significant deficiency in care created by this lack of reimbursement for telehealth care delivered by HHAs. In October 2020, Senator Susan Collins (R-ME), along with co-sponsors Senators Benjamin Cardin (D-MD) and Jeanne Shaheen (D-NH) introduced the bipartisan Home Health Emergency Access to Telehealth (HEAT) Act (S.4854) calling for reimbursement of HHAs for telehealth services delivered during the current public health emergency.
A similar bipartisan bill, H.R.8677, was introduced at the same time in the House by Representative Roger Marshall (R-KS), with co-sponsors including Terri Sewell (D-AL), Jodey Arrington (R-TX) and Mike Thompson (D-CA).
Unfortunately, neither bill has moved very far yet. The Senate bill was referred to the Finance Committee, where it has languished since, while the House bill has been referred to the Committee on Ways and Means as well as the Committee on Energy and Commerce, meeting a similar fate. Hopefully, now that the election and inauguration are behind us and the new administration is in place, Congress will take a closer look at this important matter.
All Hands on Deck
What can you do? To start, you can contact your Senators and Representatives to let them know you want these bills to move forward so money can be freed to initiate reimbursement to HHAs for telehealth services. You can contact Ron Wyden (D-OR), Chair of the Senate Finance Committee, and Richard Neal (D-MA), Chair of the House Ways and Means committee to ask them to move forward with these bills as well.
Enabling this reimbursement as quickly as possible matters. Right now, telehealth and RPM are being proven in the crucible of the pandemic. The more they can demonstrate their value, the more likely it is that reimbursement for these solutions will continue once the pandemic is over.
HHAs need this opportunity as well. Telehealth and RPM make as much sense, if not more, in the home health setting as they do anywhere else.
Being able to closely monitor and communicate with the sickest and most invalid among us on a regular basis while fitting within sound business practices is critical to helping Americans lead better, more satisfying lives while reducing the cost of care. Reimbursing them now, within the context of the pandemic, offers the ideal opportunity to demonstrate just how important that is.
One day, hopefully soon, the COVID-19 pandemic will be a distant memory and the healthcare industry will once again turn its attention to moving from a fee-for-service approach to value-based care. Offering reimbursement to HHAs for delivering telehealth services will help accelerate that transition.