March 21, 2020
The Honorable Alex Azar II
U.S. Department of Health & Human Services
Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, DC 20201
Dear Secretary Azar:
America’s Physician Groups (APG) appreciates the opportunity to submit recommendations for changes in the Telehealth regulations for both Medicare Fee-for Service and Medicare Advantage beneficiaries for the duration of the COVID-19 emergency. With the spread of the Coronavirus, providers are quickly changing their care models to a virtual system to prevent the further spread of the virus while also providing care to their patients with chronic disease.
APG is a national professional association representing over 300 physician groups, approximately 195,000 physicians, and the nearly 45 million patients they care for. Our tagline, “Taking Responsibility for America’s Health,” represents our members’ vision and efforts to move away from the antiquated fee-for-service (FFS) reimbursement system where clinicians are paid “per click” for each service rendered rather than on the outcomes of the care provided. Instead, our members are taking responsibility for improving the health of the patients and communities they serve by holding themselves accountable for the cost and quality of care through alternative payment models (APMs).
We applaud the quick action of your teams in publishing the telehealth waiver guidance as well as the telehealth toolkit. These have been invaluable for our members and we have widely circulated them among our members. Additionally, allowing the MAOs to expand telehealth services beyond their current benefit offerings have been invaluable.
In this document, we will detail our additional recommendations regarding both Traditional Medicare and Medicare Advantage.
Summary of APG’s Comments
• Expansion of Range of Communication Methods for Telehealth: Currently, Medicare requires both audio and visual capabilities for telehealth. We would recommend an expansion of methods to include “telephone without video capability”.
• Lift requirement to have prior relationship with patient in order to utilize telehealth: APG recommends that CMS allow telehealth to be used if a prior relationship has not been established.
• Allow use of Telehealth diagnoses for Risk Adjustment: APG recommends that CMS allow the use of the telehealth encounter to populate the diagnosis for risk adjustment purposes.
• Modify the current Remote Patient Monitoring (RPM) regulations: APG recommends that CMS expand flexibility in RPM (similar to telehealth) to provide more care outside the hospital setting
• Allow licensed non-physicians to bill for telehealth visits: APM recommends that nonphysicians like NP, RN, Respiratory Therapists and PA bill for telehealth.
• Coronavirus Potential Impact: APG believes that coronavirus will impact MAOs in a variety of areas and adjustments will need to be made. We would like to propose readjusting rates this year to supplement the impact of decreased risk adjustment capture in the 2021 payment year as well as potentially increasing costs of beneficiaries. Additionally, risk adjustment will be impacted, and we recommend CMS modify the risk adjustment formula and suspend RADV audits for 2020.
Expansion of Range of Communication Methods for Telehealth:
Currently, Medicare requires both audio and visual capabilities for telehealth. We would recommend an expansion of methods to include “telephone without video capability” since many of our patients have limited internet capability. Additionally, some areas are already experiencing slow speeds due to overloading of systems.
Lift requirement to have prior relationship with patient in order to utilize telehealth:
APG recommends that CMS allow telehealth to be used if a prior relationship has not been established since we may see internal medicine physicians and other specialists be recruited into acute care hospital services thus decreasing the primary care base.
Modify the current Remote Patient Monitoring (RPM) regulations:
APG recommends that CMS expand flexibility in RPM (similar to telehealth) to provide more care outside the hospital setting. We have focused on the office visit at this early stage of the disaster response but in rapid order, we will be discharging patients from hospitals earlier than we would have done previously and they will need additional follow-up.
Allow licensed non-physicians to bill for telehealth visits:
APM recommends that non-physicians like NP, RN, Respiratory Therapists and PA bill for telehealth since our physicians will be stretched to the max.
MA is instrumental to the transformation of our nation’s health care system from volume to value. We know that MA provides better quality care for seniors, and our members’ value-based payment arrangements in MA create incentives for: (1) a team-based approach that emphasizes primary care; (2) physician organizations to provide the right care at the right time in the most appropriate setting; and (3) a care team that addresses the patient’s total care needs, including mental health, behavioral health, and home environment.
Our preferred model of capitated, delegated and coordinated care with MAOs provides high quality care and long-term engagement with the beneficiaries. Our members are truly in partnership with the MAOs that allows for physicians to provide the right care in the right setting, thus improving the health of entire populations, particularly chronically ill and fragile individuals
Allow use of Telehealth diagnoses for Risk Adjustment:
The accuracy in capturing diagnoses for risk adjustment in MA is crucial to the financial success of our members. APG recommends that CMS allow the use of the telehealth encounter to populate the diagnosis for risk adjustment purposes thus protecting MA beneficiaries’ from coming into the office setting and potentially getting infected. This modification is time sensitive since providers are currently updating the diagnoses for the March 2020 sweep deadline.
Coronavirus Potential Impact on Medicare Advantage:
With the arrival of coronavirus in the United States, the impact on the Medicare Advantage program will be seen in a variety of areas. Other programs like MSSP have policies available to readjust payment rates to address impact of extreme and uncontrollable circumstances. We believe a similar policy should be developed for MAOs.
Risk adjustment calculations depend on an annual face-to-face visit of MA patients to capture diagnoses present in the patient. Given the current concerns of COVID-19, especially in the senior population, this program has unprecedented significant risk to the stability of the MA population this year. Bringing in healthy seniors for an annual assessment, into the clinics where there may be risk of community infection, would not serve in the best interests of community health at this time. Further, these comprehensive assessment visits can be lengthy and impact physician time significantly.
In anticipation of growing impact to the clinics, due to COVID-19, we would like to propose readjusting rates this year to supplement the impact of decreased risk adjustment capture in the 2021 payment year as well as potentially increased costs. We also recommend allowing telehealth visits to be utilized for risk adjustment assessments in the 2021 PY for risk score accuracy. Even if COVID-19 is contained and does not impact our communities, due to health precautions, it is likely there will be less senior assessment visits through June 30th, 2020, of which payments in the first half of PY 2021 will be affected. This will still impact our operations significantly and decrease the stability of the Medicare Advantage program.
Thank you for your attention to the above comments. Our members have been on the “frontline” with not only screening for COVID-19 but also continuing to care for their patients with chronic disease.
We reiterate our robust support for telehealth in caring for patients and applaud your leadership in this area. It is important during this time of crisis that CMS continues to work with stakeholders to creatively redesign care to protect our Nation’s citizens. Please feel free to contact Valinda Rutledge, Senior Vice President, Federal Affairs, (firstname.lastname@example.org) if you have any questions or if America’s Physician Groups can provide any assistance as you consider these issues.
Donald H. Crane
President and CEO
America’s Physician Groups
Please click here to download a copy of the letter.