Re-emerging After COVID-19: Evolving Strategies for Access

Thursday, June 11, 2020 | Terri McDonald

In late February we entered an alternate universe as we listened to world leaders speak of a novel corona virus and the potential for millions of lives lost. The U.S. officially declared a Public Health Emergency (PHE) in response to the global COVID-19 pandemic on January 31, 2020, and on March 13, 2020, the Secretary of the Department of Health and Human Services announced emergency authority to waive or modify certain requirements of the Medicare/Medicaid programs. The battle had begun. The stuff of sci-fi novels and blockbuster movies, now all too real. One where healthcare providers have gained the title “superheroes,” a recognition long overdue, regrettably brought forward by one of the worst human tragedies of our lifetimes.

Fast forward to mid-May, where the concept of “access” for cardiovascular patients is radically altered. People fear hospitals and even physician clinics. Our progress toward educating the community to seek rapid care for heart attack and stroke has been set back decades by the fear of exposure to COVID-19, with patient presentation for STEMI dropping radically at the height of the pandemic. Now as we are resuming essential services our messaging to patients must offer assurance that we are taking extraordinary precautions, using Centers for Disease Control and Prevention guidelines, to mitigate the risk of COVID-19 exposure. Yet despite our best efforts the risk is there, potentially waning or worsening in the upcoming months. Shared decision-making with patients weighing the risk of exposure vs. the risk of continued deferral of preventative, diagnostic and interventional services has become a part of the informed consent.

Moving Forward

Within a two-month period traditional access and care delivery models were turned upside down, and in some cases completely interrupted. Federal aid was quickly available, providing financial support for practices and programs under the PHE. Sweeping waivers under the Coronavirus Aid, Relief, and Economic Security (CARES) Act made telehealth a financially viable option to see patients. What followed was an unprecedented response of collaboration among providers and health systems to create a safety net for access through telehealth. The cardiovascular community quickly and adeptly stepped forward and began to form the first iteration of post-pandemic care delivery models. Even among practices that were not early adopters in telehealth, the cardiovascular community has been a leader, using Centers for Medicare and Medicaid Services (CMS) waivers to implement or shore up resources for telehealth and virtual care within a very short time. Private payers quickly stepped in to implement similar waivers. Our cardiovascular community made substantial progress to mitigate massive cancellations even in advance of the guidelines for reopening issued by the Whitehouse on April 16. In an analysis done by researchers at Harvard University and Phreesia, ambulatory cardiology visits plummeted more than 60% from baseline in early April. Then, by early May, a rebound bolstered by telehealth reduced the deficit of volume from baseline to only 33%.1 Concurrently, waivers to expand the role of advanced practice providers (APPs) have enhanced the care team concept and provided expanded access to cardiovascular care.

PHE Telehealth Waivers

CMS has provided new weapons to battle the impact of COVID-19 on cardiovascular health, in the form of telehealth waivers under the CARES Act. These waivers help us mitigate the risk of spread of COVID-19 and now, in the early summer, to address the growing backlog of essential care services created by the pandemic.

Overview: Medicare Technology-Based Waivers During the PHE

Telehealth

 

  • Established the pathway for the addition of telehealth through a fast-tracked, sub-regulatory process
  • Expanded technology and HIPPA waivers permit the use of non-public facing tools (FaceTime, Skype, etc.)
  • Beneficiaries can receive Medicare telehealth and other technology-based services wherever they are located – allowing home telehealth visits
  • Telehealth visits are considered the same as in-person visits and paid at the same rate
  • Providers may reduce or waive co-pays for telehealth
  • Telehealth visits may be provided for new patients
  • A broader range of providers can use telehealth services – PT, OT, ST
  • Removal of limitations on the frequency of telehealth visits
  • An expanded range of billable codes for hospital-based care and hospitals as an originating site to reduce exposure risk

Telephone Evaluation, Management/Assessment Services

  • Time-based payment for telephone E&M visits at the same rate as office/OP visits for established patients (CPT codes 99441-99443)

Remote Evaluations, Virtual Check-ins and E-visits:

  • Brief virtual check-ins with technology-based communications may be billed for new and established patients with payment equivalent to office/OP visits (HCPCS codes G2010, G2012)
  • Coverage expanded to include services by LCSW, PT, OT, ST for e-visits (non-face-to-face communication via email HCPCS codes G2061-G2063)

Remote Patient Monitoring

 

  • May be provided for new and established patients for acute and chronic conditions
  • Under some circumstances service may be billed for shorter periods of time

 

These waivers are only in effect for the duration of the PHE, however we are hoping the changes implemented during the pandemic will lead to long term reimbursement changes to support telehealth services. Even if permanent payment relief for expanded telehealth services doesn’t happen immediately, there are several lessons learned that will help us maintain momentum in using telehealth to optimize access for cardiovascular care. Many virtual workflows for bundled services have helped to hardwire efficient, cost-effective processes to help better optimize access for the procedural care populations in the future. And the workflows created for virtual ambulatory visits have assisted a better understanding of how to implement the use of existing transitional care codes and chronic care management codes in the future.

MedAxiom Virtual Services Coding Tool

To help you remain current with the telehealth waivers and apply them to the full extent under the PHE, the MedAxiom Revenue Cycle Solutions team has created a tool to help navigate the evolving coding, documentation and reimbursement guidelines for virtual services stemming from the COVID-19 pandemic waivers. The Virtual Services Coding Tool also provides operational examples of each type of telehealth service and a flowchart for step-by-step management of telehealth visits. 

PHE Workforce Waivers – APPs

In conjunction with the telehealth waivers, CMS established Medicare waivers to assist with access to care through APPs. While state license, scope of practice, privileging, hospital bylaws, and malpractice coverage considerations are still in place, these waivers do offer strategies to bolster access for our cardiovascular population:

  • For services rendered by APPs that require direct supervision that physician supervision may be provided virtually, using real-time audiovisual technology; examples include specialty ambulatory clinics
  • APPs may order and supervise diagnostic testing
  • APPs may order home health care and review the plan of care
  • Hospitals may fully use APPs to the extent possible, including admitting patients to the care of an APP

There are still many areas of the country that had not recognized the concept and value of allowing APPs to practice at the top of license in the care team approach, which supports the full integration of APPs into the acute and ambulatory care models for cardiovascular patients. The PHE waivers expanding the scope of practice for APPs could have a lasting impact, moving the concept of team health forward and advancing the recognition of APPs as an integral part of the cardiovascular care team.

The Future of Cardiovascular Access

While telehealth and the care team model are not new concepts, the COVID-19 pandemic has moved both to the front and center of attention as high value options in planning and designing patient access models. Lessons learned through necessity will enhance our understanding of the importance for creating a culture of access, one where we can quickly and nimbly deploy assets to assure our patients get the right care, at the right time, by the right person. The resilience and vision of the cardiovascular community will keep us in our role as leaders for future challenges.

Learn more about the MedAxiom Consulting Team and how we can help you and your organization tackle issues such as patient access, effective leadership, staffing/operational efficiencies, adaptability and more.

You can also visit our COVID-19 page where we have compiled and developed resources for navigating this pandemic and the complex challenges practices and hospitals are facing.

1https://www.commonwealthfund.org/publications/2020/apr/impact-covid-19-outpatient-visits

Illustration: Lee Sauer

About the Author
Terri McDonald

Terri McDonald, RN, MBA, CPHQ is Vice President, MedAxiom Consulting. She brings extensive knowledge and experience in leading, managing and optimizing every level of the cardiovascular service line. Following a clinical career in cardiac and critical care nursing, Terri gained a diverse knowledge of administrative, operations and clinical nursing management in the acute care setting. As VP of Consulting Terri fulfills her lifelong passion for cardiology and cardiovascular care helping her clients succeed through understanding challenges and designing collaborative, practical solutions using evidence-based guidelines and emerging technologies.

To contact, email: tmcdonald@medaxiom.com



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