- Joint Principles from Center for Medicare Advocacy and Medicare Rights Center: Medicare Expansion of Telehealth Helps Beneficiaries Access Care During the Pandemic – But Caution is Needed Before Making These Changes Permanent
- Center for Medicare Advocacy Submits Recommendations to the Nursing Home Commission
- Medicare Home Health Case Settled with Full Coverage for Beneficiary with Chronic Conditions
- COVID Does Not Have to Lead to Deaths in Nursing Homes
- Cinnamon St. John joins the Center for Medicare Advocacy as a 2019-2020 Health and Aging Policy Fellow through the American Political Science Association (APSA)
Joint Principles from Center for Medicare Advocacy and Medicare Rights Center: Medicare Expansion of Telehealth Helps Beneficiaries Access Care During the Pandemic – But Caution is Needed Before Making These Changes Permanent
Note: the Center for Medicare Advocacy issued a version of these principles in last week’s CMA Alert. They have been updated, and are now issued jointly with the Medicare Rights Center.
During the COVID-19 public health emergency, legislative mandates and administrative authorities have allowed the Centers for Medicare & Medicaid Services (CMS) to issue temporary Medicare waivers and rules. Combined, these policies have let beneficiaries receive a wider range of health services from home, from a broader array of providers, and using more types of technology.
Although the country is still in the midst of the COVID-19 crisis, some stakeholders are already pushing to permanently extend many of these new flexibilities. Concurrently, CMS has signaled a willingness to do so through rulemaking, and there is bipartisan support in Congress for legislative action.
We recognize the recent expansion of Medicare-covered telehealth services has helped beneficiaries and their families safely and responsibly obtain needed care during this unprecedented time—likely leading to improved outcomes and reduced transmission of the COVID-19 virus. We applaud these successes and understand the impulse to keep many of the underlying policies in place. However, doing so would risk reflexively locking in an unexamined expansion of services that was developed for and during a crisis. Instead, we urge Congress and the Administration to move forward deliberately. Any policy changes should be directly informed by the current experience with telehealth and made through existing legislative and regulatory processes that allow for public comment and stakeholder input.
We are concerned that without careful study and evaluation concerning the expansions—including the types of services being provided; consumer participation and utilization barriers; changes in program and beneficiary spending; quality measures, including patient satisfaction; as well as impacts on beneficiary health and any disparities—calls for and steps toward permanence are premature. Further, policy decisions made without this critical information could fundamentally change the care delivery landscape for people with Medicare in unanticipated, and potentially unwelcome, ways.
While telehealth’s potential may not yet be fully realized, neither are its pitfalls. An intentional and aware approach to post-pandemic expansion is needed to safeguard and advance beneficiary health and well-being.
The following principles are intended to aid such a process. When making decisions about whether and how to expand Medicare coverage for telehealth, we urge policymakers to:
- Ensure any covered telehealth services are clinically appropriate;
- Ensure that telehealth options supplement, rather than replace, in-person care—and ensure that payment incentives align with this goal;
- Promote behavioral health parity to help address the unmet needs of current and future beneficiaries in both urban and rural settings;
- Ensure that any expansion of telehealth does not exacerbate health, racial, or income disparities, and that actions and expenditures are authorized to meaningfully address the digital divide many Medicare beneficiaries face—including lack of or limited access to digital literacy training, reliable broadband, and remote technologies;
- Ensure equitable access to telehealth for underserved communities, including Black Americans and people of color, individuals with disabilities, and people with limited English proficiency; purposefully collect data on such access; and ensure compliance with all existing civil rights laws, including rules requiring the use of interpreters and the provision of materials in alternative formats and non-English languages;
- Require providers to accurately disclose beneficiary cost-sharing obligations prior to service, and to fully document such disclosures; connect beneficiaries and providers with the resources they need to understand their financial responsibilities; and carefully monitor to ensure that any waivers of cost-sharing are not happening in a discriminatory or otherwise problematic way;
- Ensure that any expansion of telehealth protects patient privacy and data security for personal health information. HIPAA privacy protections must apply to telehealth interactions between the patient and provider and personal health data must also be kept secure;
- Ensure any expansion of telehealth is identical in traditional Medicare and private Medicare Advantage, and that the services and necessary equipment to access telehealth are equally available to all beneficiaries, regardless of the coverage pathway they choose;
- Ensure that telehealth does not weaken Medicare Advantage network adequacy standards, including by prohibiting telehealth providers from satisfying network adequacy requirements;
- Require public release of data concerning Medicare-covered telehealth, including the type of services provided, beneficiary experience and preferences, programmatic and beneficiary spending, health outcomes, and quality measurements; ensure monitoring, oversight, data collection, and evaluation continues ongoingly so as to best inform future telehealth policymaking; and
- Provide an extended phase-out period for the temporary COVID telehealth waivers and rules in order to minimize interruptions in care and prevent rushed policy development.
In comments to the Commission on Safety and Quality in Nursing Homes addressing the coronavirus pandemic, submitted July 17, the Center for Medicare Advocacy (Center) calls for a national solution to the national coronavirus crisis. The Center asks for immediate reinstatement of resident protections that the Administration has unilaterally waived during the pandemic, including residents’ rights, nurse aide training rules, and comprehensive surveys and enforcement, as well as new COVID-based protections, including weekly testing of all residents and staff and establishment of COVID-only facilities meeting national standards.
For the longer term, the Center makes four broad recommendations: (1) strengthening staffing, to include registered nurses around the clock and federal requirements that direct care workers receive a living wage and paid sick leave; (2) strengthening the survey and enforcement systems, to include corporate-wide enforcement; (3) meaningful standards for state licensure and federal certification of nursing facilities; and (4) better accountability for reimbursement, including audits and medical loss ratios.
- To read the full statement, go to: https://medicareadvocacy.org/recommendations-of-the-center-for-medicare-advocacy-to-the-commission-on-safety-and-quality-in-nursing-homes/
Vermont Legal Aid and the Center for Medicare Advocacy are pleased to announce the settlement of McKee v. Azar, a case that was brought in federal court to ensure proper coverage of home health care services for a Medicare beneficiary with multiple chronic conditions. Ms. McKee, a Vermont resident, required skilled nursing visits to assess and treat her serious medical conditions, which included difficulty breathing, digestive problems, and significant swelling in her legs with a continuing need for leg wound care.
Medicare denied coverage, concluding that her condition was “stable” and therefore did not require skilled care. This was erroneous under the standard clarified in the Jimmo v. Sebelius settlement. In her lawsuit, Ms. McKee challenged the notion that her supposedly “stable” condition meant that the care she received was not skilled. She argued that she was eligible for home health coverage based on skilled observation and assessment as well as patient education services. Ms. McKee was at risk for complications, and the knowledge and judgment of skilled nurses were key to identifying when she needed additional or modified care. In addition, Ms. McKee challenged Medicare’s failure to afford appropriate weight to the opinion of her treating physician about her need for skilled care.
Under the terms of a settlement agreement filed on July 21, 2020, Medicare agreed to pay Ms. McKee’s home health claim in full.
Advocates should continue to be alert for inappropriate denials of coverage based on lack of improvement or on “stability” – particularly for individuals with chronic conditions. Jimmo requires Medicare coverage determinations to be based on individuals’ need for skilled care, not on their potential for improvement or on their stability. Skilled nursing, or physical, occupational, or speech therapy may be required to maintain a person’s condition or to prevent or slow deterioration. For more information about Jimmo and the “Improvement Standard,” see the webpages of the Center for Medicare Advocacy and CMS.
With nearly 4 million confirmed cases of COVID-19 in the United States, the nation braces as the disease surges in the Sun Belt, where Arizona, Florida, and Texas are now considered the epicenters of the illness. A recent article in The Atlantic contends that despite the fact that one in five nursing homes around the country has at least one death, we do not have to repeat the same mistakes which have contributed to almost 60,000 residents and nursing home staff losing their lives.
The article, written by Olga Khazan, highlights the fact that Hong Kong was able to learn from its 2003 outbreak of the severe acute respiratory syndrome (SARS) and has now reported no deaths from COVID-19, despite its population of 7.5 million. In contrast, one nursing home in New Jersey has reported 82 deaths. Hong Kong’s learnings include having a designated, government-trained infection control officer at nursing homes, and maintaining at least a one-month supply of face masks and other PPE in each facility. Meanwhile, according to CMS data, 11 percent of nursing homes in Arizona, Florida, and Texas currently don’t have a one-week supply of N95 masks on hand.
Ms. St. John is also Associate Director of the Hartford Institute for Geriatric Nursing (HIGN) at NYU Rory Meyers College of Nursing. She designs and manages programs that focus on ensuring optimal health and quality of life for older adults through interprofessional and patient education. Her work at HIGN has helped train over 2,000 Bronx seniors on wellness and disease self-management, has strengthened collaboration between a major NYC health system and community-based organizations, and has driven the national and international dissemination of elder care training modules. Prior to this placement, she was with the U.S. Senate Special Committee on Aging in the office of Chairman Susan Collins (R-Maine). For the Committee, Ms. St. John helped inform policy and drive the oversight of legislation focused on improving the support infrastructure for older Americans, with a particular focus on Alzheimer’s Disease.
As a former journalist, Cinnamon is passionate about increasing public awareness of the needs of older adults, the challenges that our society is facing in addressing those needs, and the opportunities we have to improve how we care for our aging population. Ms. St. John received a Master’s of Public Administration from the NYU Wagner Graduate School of Public Service and an MA in International Peace and Security from King’s College London.
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