FOR IMMEDIATE RELEASE
August 3, 2020
Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries
Trump Administration Proposes to Expand Telehealth Benefits Permanently for Medicare Beneficiaries Beyond the COVID-19 Public Health Emergency and Advances Access to Care in Rural Areas
The Centers for Medicare & Medicaid Services (CMS) is proposing changes to expand telehealth permanently, consistent with the Executive Order on Improving Rural and Telehealth Access that President Trump signed today. The Executive Order and proposed rule advance our efforts to improve access and convenience of care for Medicare beneficiaries, particularly those living in rural areas. Additionally, the proposed rule implements a multi-year effort to reduce clinician burden under our Patients Over Paperwork initiative and to ensure appropriate reimbursement for time spent with patients. This proposed rule also takes steps to implement President Trump's Executive Order on Protecting and Improving Medicare for our Nation's Seniors and continues our commitment to ensure that the Medicare program is sustainable for future generations.
Expanding Beneficiary Access to Care through Telehealth
Over the last three years, as part of the Fostering Innovation and Rethinking Rural Health strategic initiatives CMS has been working to modernize Medicare by unleashing private sector innovations and improve beneficiary access to services furnished via telecommunications technology. Starting in 2019, Medicare began paying for virtual check-ins, meaning patients across the country can briefly connect with doctors by phone or video chat to see whether they need to come in for a visit. In response to the COVID-19 pandemic, CMS moved swiftly to significantly expand payment for telehealth services and implement other flexibilities so that Medicare beneficiaries living in all areas of the country can get convenient and high-quality care from the comfort of their home while avoiding unnecessary exposure to the virus. Before the public health emergency (PHE), only 14,000 beneficiaries received a Medicare telehealth service in a week while over 10.1 million beneficiaries have received a Medicare telehealth service during the public health emergency from mid-March through early-July. For more information on Medicare's unprecedented increases in telemedicine and its impact on the health care delivery system, visit the CMS Health Affairs blog here.
As directed by President Trump's Executive Order on Improving Rural and Telehealth Access, through this rule, CMS is taking steps to extend the availability of certain telemedicine services after the PHE ends, giving Medicare beneficiaries more convenient ways to access healthcare particularly in rural areas where access to healthcare providers may otherwise be limited Improving Rural and Telehealth Access.
"Telemedicine can never fully replace in-person care, but it can complement and enhance in-person care by furnishing one more powerful clinical tool to increase access and choices for Americas seniors," said CMS Administrator Seema Verma. "The Trump Administration's unprecedented expansion of telemedicine during the pandemic represents a revolution in healthcare delivery, one to which the healthcare system has adapted quickly and effectively. Never one merely to tinker around the edges when it comes to patient-centered care, President Trump will not let this opportunity slip through our fingers."
During the public health emergency, CMS added 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. CMS is proposing to permanently allow some of those services to be done by telehealth including home visits for the evaluation and management of a patient (in the case where the law allows telehealth services in the patient's home), and certain types of visits for patients with cognitive impairments. CMS is seeking public input on other services to permanently add to the telehealth list beyond the PHE in order to give clinicians and patients time as they get ready to provide in-person care again. CMS is also proposing to temporarily extend payment for other telehealth services such as emergency department visits, for a specific time period, through the calendar year in which the PHE ends. This will also give the community time to consider whether these services should be delivered permanently through telehealth outside of the PHE.
Prioritizing Investment in Preventive Care and Chronic Disease Management
Under our Patients Over Paperwork initiative, the Trump Administration has taken steps to eliminate burdensome billing and coding requirements for Evaluation and Management (E/M) (or office/outpatient visits) that make up 20 percent of the spending under the Physician Fee Schedule. These billing and documentation requirements for E/M codes were established 20 years ago and have been subject to longstanding criticism from clinicians that they do not reflect current care practices and needs. After extensive stakeholder collaboration with the American Medical Association and others, simplified coding and billing requirements for E/M visits will go into effect January 1, 2021, saving clinicians 2.3 million hours per year in burden reduction. As a result of this change, clinicians will be able to make better use of their time and restore the doctor-patient relationship by spending less time on documenting visits and more time on treating their patients.
Additionally, last year, the Trump Administration finalized historic changes to increase payment rates for office/outpatient E/M visits beginning in 2021. The higher payment for E/M visits takes into account the changes in the practice of medicine, recognizing that additional resources are required of clinicians to take care of the Medicare patients, of which two-thirds have multiple chronic conditions. The prevalence of certain chronic conditions in the Medicare population is growing. For example, as of 2018, 68.9% of beneficiaries have 2 or more chronic conditions. In addition, between 2014 and 2018, the percent of beneficiaries with 6 or more chronic conditions has grown from 14.3% to 17.7%.
In this rule, CMS is proposing to similarly increase the value of many services that are comparable to or include office/outpatient E/M visits such as maternity care bundles, emergency department visits, end-stage renal disease capitated payment bundles, physical and occupational therapy evaluation services and others. The proposed adjustments, which implement recommendations from the American Medical Association, help to ensure that CMS is appropriately recognizing the kind of care where clinicians need to spend more face-to-face time with patients, like primary care and complex or chronic disease management.
Bolstering the Healthcare Workforce/Patients Over Paperwork
CMS is also taking steps to ensure that healthcare professionals can practice at the top of their professional training. During the COVID-19 public health emergency, CMS announced several temporary changes to expand workforce capacity and reduce clinician burden so that staffing levels remain high in response to the pandemic. As part of its Patients over Paperwork initiative to reduce regulatory burden for providers, CMS is proposing to make some of these temporary changes permanent following the PHE. Such proposed changes include nurse practitioners, clinical nurse specialists, physician assistants, and certified nurse-midwives (instead of only physicians) to supervise others performing diagnostic tests consistent with state law and licensure, providing that they maintain the required relationships with supervising/collaborating physicians as required by state law; clarifying that pharmacists can provide services as part of the professional services of a practitioner who bills Medicare; allowing physical andoccupational therapy assistants (instead of only physical and occupational therapists) to provide maintenance therapy in outpatient settings; and allowing physical or occupational therapists, speech-language pathologists and other clinicians who directly bill Medicare to review and verify (sign and date), rather than re-document, information already entered by other members of the clinical team into a patient's medical record.
Public comments on the proposed rules are due by October 5, 2020.
For a fact sheet on the CY 2021 Physician Fee Schedule proposed rule, please visit: https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-4
For a fact sheet on the CY 2021 Quality Payment Program proposed rule, please visit: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/1100/2021%20QPP%20Proposed%20Rule%20Fact%20Sheet.pdf
For a fact sheet Medicare Diabetes Prevention Program- https://www.cms.gov/newsroom/fact-sheets/proposed-policies-medicare-diabetes-prevention-program-expanded-model-mdpp-calendar-year-2021
To view the CY 2021 Physician Fee Schedule and Quality Payment Program proposed rule, please visit: https://www.cms.gov/files/document/cms-1734-p-pdf.pdf
Chuck IngogliaPresident & CEONational Council for Behavioral HealthDirect: (202) 684-3749ChuckI@TheNationalCouncil.org
CMS Releases Proposed Updates to Physician Fee Schedule, Quality Payment Program for FY 2021
· The proposed rule will make permanent or extend many of the telehealth flexibilities implemented during the coronavirus public health emergency.
· The administration proposed significant changes to E/M reimbursement, resulting in significant cuts among many physician subspecialties - while increasing overall reimbursement for others.
· CMS also strongly encourages adoption of electronic prescribing even as it works to finalizes its regulations.
Last night, the Centers for Medicare and Medicaid Services (CMS) released its proposed fiscal year (FY) 2021 updates for the Medicare Physician Fee Schedule and Quality Payment Program (proposed rule, Physician Fee Schedule fact sheet; Quality Payment Program fact sheet; Medicare Diabetes Prevention Program fact sheet), including several policies to permanently expand telehealth services. The rule, released concurrently with the President's Executive Order (EO) to expand rural telehealth access, seeks to advance efforts to improve access and convenience of care for Medicare beneficiaries through telehealth, particularly for those living in rural areas.
Other major changes in this year's proposed rule include: (1) redistributing physician pay as result of the budget neutrality requirements linked to an increase in pay for evaluation and management (E/M) visits; (2) implementing President Trump's EO on Protecting and Improving Medicare for our Nation's Seniors and aims to ensure sustainability of the Medicare program; and (3) strongly encouraging adoption of electronic prescribing of controlled substances (EPCS). Comments on the proposed rules are due by October 5, 2020.
· Background. Since 1992, CMS has used the Physician Fee Schedule to update reimbursement for physician and supplier services within the Medicare program annually, and payments are based on the relative resources typically used to furnish the service. President Trump issued an executive order on May 19, 2020, directing agency heads to examine regulations issued in response to the COVID-19 pandemic and to identify those that should be kept in place going forward. CMS Administrator Verma has been particularly focused on the telehealth flexibilities introduced since January, and has hinted for weeks the administration would look to use rulemaking to make permanent many of the telehealth flexibilities expanded during the pandemic.
Among the key policies changes outlined in the proposed Medicare Physician Fee Schedule:
· Telehealth - As directed by President Trump's Executive Order on Improving Rural and Telehealth Access, CMS will take steps through the proposed rule to extend the availability of certain telemedicine services after the public health emergency (PHE) ends. During the public health emergency, CMS has added 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. CMS is proposing to permanently incorporate some of the PHE expanded telehealth services, including home visits for the evaluation and management of a patient (in the case where the law allows telehealth services in the patient's home), and certain types of visits for patients with cognitive impairments. CMS is seeking public input on other services to permanently add to the telehealth list beyond the PHE in order to give clinicians and patients time as they get ready to provide in-person care again. CMS is also proposing to temporarily extend payment for other telehealth services - such as emergency department visits - through the calendar year in which the PHE ends in order to allow the community time to consider whether these services should be delivered permanently through telehealth outside of the PHE.
· E/M Updates and Impact - Under the Patients Over Paperwork initiative, the administration has increased payment for evaluation and management (E/M) visits - which make up 20 percent of the spending under the Physician Fee Schedule - while reducing pay for other services due to budget neutrality requirements. CMS noted that the administration collaborated with the American Medical Association to simplify the coding and billing requirements, and reported it is expected to save clinicians 2.3 million hours per year once it goes into effect January 1, 2021. Although some specialties saw big bumps in reimbursement in this year's proposed physician fee schedule, many others fell victim to large cuts due to the "redistributive effects" of CMS's E/M policy. The administration explained that the changes are averages, and "may not necessarily be representative of what is happening to the particular services furnished by a single practitioner within any given specialty." The substantial changes in reimbursement are likely to renew calls from stakeholders for Congress to waive budget neutrality requirements, as many argue that they lead to significant disparities in impact among physician subspecialties - as seen in this chart included in the proposed rule. Additionally, advocates have warned that many of the specialties impacted are providing critical care during the pandemic and the decrease in reimbursement will limit patient access. Under the proposed rule, radiologists faced the largest cuts, as well as physical and occupational therapy, pathology, anesthesiology, and critical care, among others.
· Additionally in the proposed rule, CMS proposes to increase the value of many services that are comparable to or include office, outpatient, and E/M visits, such as maternity care bundles, emergency department visits, end-stage renal disease capitated payment bundles, physical and occupational therapy evaluation services and others. In justifying the proposed adjustments, which the agency notes are based on recommendations from the American Medical Association, CMS says they aim to "ensure that [Medicare] is appropriately recognizing the kind of care where clinicians need to spend more face-to-face time with patients," and take into account "the changes in the practice of medicine, recognizing that additional resources are required of clinicians to take care of the Medicare patients, of which two-thirds have multiple chronic conditions."
· Permanent PHE Flexibilities - CMS is proposing to make permanent several flexibilities enacted during the PHE to ease clinician burden and expand the health workforce capacity. Such proposed changes include:
· Allowing nurse practitioners, clinical nurse specialists, physician assistants, and certified nurse-midwives (instead of only physicians) to supervise others performing diagnostic tests consistent with state law and licensure, provided that they maintain the required relationships with supervising or collaborating physicians as required by state law;
· Clarifying that pharmacists can provide services as part of the professional services of a practitioner who bills Medicare;
· Allowing physical and occupational therapy assistants (instead of only physical and occupational therapists) to provide maintenance therapy in outpatient settings; and
· Allowing physical or occupational therapists, speech-language pathologists and other clinicians who directly bill Medicare to review and verify (sign and date), rather than re-document, information already entered by other members of the clinical team into a patient's medical record.
· Electronic Prescribing of Controlled Substances (EPCS) - The proposed rule begins to implement Section 2003 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT Act) which requires that prescribing of certain controlled substances under Medicare Part D be done electronically. While CMS strongly encourages adoption of EPCS, the agency also states "it is sympathetic to the unique challenges faced by prescribers during this PHE for the COVID–19 pandemic." Accordingly, the agency is proposing to balance these competing priorities by requiring EPCS by January 1, 2022. According to CMS, allowing time to solicit and consider feedback from the recently issued Request for Information is necessary for implementation of the EPCS requirements for waivers from the requirements and penalties.
· Communication Technology-based Services (CTBS) - CMS discusses the recent changes it has made allowing separate payment for several services that use telecommunications technology but are not considered Medicare telehealth services. These communication technology-based services (CTBS) include certain kinds of remote patient monitoring (RPM), a virtual check-in, and a remote asynchronous service. CMS writes that these services are different than the kinds of services specified in section 1834(m) of the Act, which describes telehealth services, and therefore are not subject to the same restrictions.
· The agency is seeking comments on whether there are additional services that fall outside the scope of telehealth services under section 1834(m) of the Act where it would be helpful for them to clarify that the services are inherently non-face-to-face, so do not need to be on the Medicare telehealth services list in order to be billed and paid when furnished using telecommunications technology rather than in person with the patient present.
· CMS is also seeking comment on physicians' services that use evolving technologies to improve patient care that may not be fully recognized by current PFS coding and payment, for example, additional or more specific coding for care management services.
· Substance Use Disorder Payment Updates - CMS proposes several updates to the Medicare Part B benefit category for OUD treatment services furnished by opioid treatment providers (OTPs) as established by Section 2005 of the SUPPORT Act as of January 1, 2020. In the CY 2020 PFS final rule CMS implemented coverage requirements and established new codes describing the bundled payments for episodes of care for the treatment of OUD furnished by OTPs. The agency also proposes to extend the definition of OUD treatment services to include opioid antagonist medications, such as naloxone, that are approved by FDA under section 505 of the FFDCA for emergency treatment of opioid overdose. Further, for CY 2021, CMS is proposing several refinements, including modifications to facilitate initiation of medication assisted treatment (MAT) and the potential for either referral or follow-up care during an emergency room visit. In response to earlier feedback, CMS also proposes to expand its bundled payment program to be inclusive of other substance use disorders, not just opioid use disorder (OUD). The agency writes that doing so could expand access to needed care.