Traditionally a supplementary and underutilized form of health care delivery, telehealth is now one of the frontline pillars of defense against the COVID-19 pandemic. In April 2020, a Morning Consult poll found that 23% of adults have used telemedicine services since the outbreak of COVID-19, and virtual visits surged 50% in March 2020, compared to February. By keeping patients away from busy hospitals, telehealth is helping to reduce the burden on overwhelmed care centers and the risk of infections. However, the potential applications of telehealth extend far beyond this crisis. It could help ease longstanding problems with health care costs and accessibility, particularly in underserved communities. Today, New Center policy analyst Olive Morris checks in with Mei Kwong with the Center for Connected Health Policy to explore the potential of telehealth during and after the crisis.
In a new podcast, Craig Settles explains how underserved populations can gain access to telehealth and other resources through the development of community broadband programs.
By – The key to telehealth expansion in underserved communities, says Craig Settles, may very well be the development of community broadband programs.
Settles, a broadband and telehealth consultant, says both urban and rural areas struggle to access reliable broadband, the foundation on which connected health programs are built. With that access controlled in large part by corporations, it’s important to develop community partnerships that give underserved residents an opportunity to schooling, library services and healthcare.
“There are segments of the country that (broadband providers) do not consider worth their time,” he says. But a community broadband program will pool resources and create access points, and “having all those access points enables them to provide services” to people at home, or at alternative locations.
Settles, who says telehealth saved his life when he suffered a stroke on a weekend several years ago, was a recent guest of Xtelligent Healthcare Media’s Healthcare Strategies podcast series. His support for community broadband is evidenced in a pilot telehealth program he recently launched in Cleveland and 10 other cities.
In that program, Settles is organizing partnerships between healthcare providers and barbershops or hair salons (his Cleveland sites are partnering with the Cleveland Clinic). While getting their hair done, customers are encouraged to have their blood pressure checked via an mHealth device, and are given information on high blood pressure or referred directly to a care provider based on the results.
“The barbershop represents getting people comfortable with the idea” of telehealth, he says. “People who don’t normally go see a doctor, be it because of insurance or whatever,” are intrigued by the idea of virtual care if introduced to it in a community setting.
Settles sees his pilot program in three stages. The first focuses on mHealth testing, and the second will explore how other telehealth services could be introduced in a barbershop, salon or similar community gathering.
And the third focuses on developing community broadband programs that extend high-speed access to these and other locations – locations where access is limited due to cost, excessive data caps or a lack of resources or infrastructure.
To develop these programs, he says, communities need to look at federal and state funding opportunities, such as those offered by the Federal Communications Commission, and pool together businesses, schools, libraries and healthcare providers who would benefit from reliable access to broadband services. This, in turn, would make that community more robust.
“That’s what incites people to build these broadband networks in the first place,” he says. “If I can deliver economic development by making the local healthcare system more robust, people are going to go for that.”
A bill before the Senate would extend telehealth coverage for substance abuse disorder treatment, including MAT therapy and Medicare reimbursement for audio-only phone calls, beyond the COVID-19 emergency.
– A new bill before the Senate aims to expand the telehealth platform for substance abuse treatment.
Introduced last week by Senators Rob Portman (R-OH) and Sheldon Whitehouse (D-RI), the Telehealth Response for E-prescribing Addiction Therapy Services (TREATS) Act would make permanent certain emergency actions passed during the coronavirus pandemic to boost telehealth access for substance use disorder (SUD) treatment.
While the bill’s text hasn’t yet been made public, it would reportedly include allowing care providers to skip the in-person exam requirement and prescribe controlled substances in Medicated Assistant Treatment (MAT) therapy programs via connected health. It would also expand Medicare coverage for mHealth services to include audio-only phone calls.
“The COVID-19 pandemic has affected every aspect of our lives and the increase in overdoses we’re seeing only increases the need for additional flexibility to help those suffering from addiction,” Portman said in a press release. “The roll out of telehealth waivers has both helped patients maintain access to care safely at home and increased access to care for those that didn’t otherwise have access to in-person treatment. As we move forward and look to life beyond this pandemic, we must make sure that the advances to care and access that telehealth is currently providing is not lost and that’s exactly what this bill will do.”
Mental health and substance abuse treatment providers have long lobbied the federal government to remove restrictions on virtual care for SUD treatment, clashing with those who argue that online prescribing needs to be tightly regulated. With substance abuse issues skyrocketing during the ongoing pandemic, federal officials have taken action to loosen those restrictions.
Under the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, certain healthcare providers are allowed to prescribe controlled substances for treatment as long as they first conduct an in-person examination with the patient. That law offers several instances in which the in-person requirement could be waived. On March 16, the US Drug Enforcement Agency (DEA) waived that requirement by invoking the public health emergency exception caused by the COVID-19 crisis.
In addition, on March 19, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued separate guidance allowing Opioid Treatment Programs and certified care providers to use prescribed drugs and conduct treatments over the phone without first meeting in person. Shortly thereafter, the DEA joined SAMHSA in issuing a letter allowing “’authorized practitioners’ to prescribe buprenorphine to new and existing OUD patients for maintenance or detoxification treatment on the basis of telehealth examination, which may include a telephone voice-only evaluation – without the need for a prior in-person exam.”
“The DEA Letter allows authorized practitioners the added flexibility of using audio-only modalities (i.e., telephone) – instead of audio-visual, real-time, two-way interactive communication system – which is required to prescribe controlled substances via telemedicine, pursuant to the aforementioned emergency exception to the federal Ryan Haight Act,” Sunny J. Levine and Emily H. Wein of the Foley & Lardner law firm wrote in a recent blog summarizing the government’s actions.
Those emergency actions will end with the public health emergency, and telehealth advocates have been working at both the state and national level to extend many of these waivers indefinitely.
Among those supporting the TREATS Act are the American Society for Addiction Medicine, American College of Medical Toxicology, Kennedy Forum, National Association of Addiction Treatment Providers, National Association of Behavioral Health, National Safety Council, Shatterproof and the Well Being Trust.
During a panel session at the American Telemedicine Association’s recent virtual conference, experts from two large health systems explained how telehealth improves care for complex patients no matter where they are.
– As healthcare providers launch telehealth programs to improve critical care management and coordination, they’re seeing value far beyond the ICU.
Indeed, as the coronavirus pandemic taxes hospital resources and a growing shortage of critical care doctors becomes more apparent, hospitals and health systems are deploying telemedicine technology to treat patients wherever they’re located.
“This is telehealth at a different level,” said Jeff Guy, MD, MSc, MMHC, FACS, vice president of Emergency and Critical Care Services with HCA Healthcare, a Nashville-based network of some 186 hospitals and more than 2,000 care locations in both the US and UK.
Guy was part of a panel session at the American Telemedicine Association’s weeklong virtual conference last week. Titled “Implementing TeleCritical Care in a Healthcare Platform,” the discussion centered on how the concept of using telehealth to improve care is evolving, to focus more on delivering quality care than where that care is delivered.
A platform that began with a focus on improving care for stroke victims is now much more complex, with networks that allow large hospitals with specialists to reach out to smaller, rural hospitals that treat critical care patients regardless of whether they have an ICU. Through this platform, the large hospital at the center of the network can manage care across the enterprise, delivering specialized care and cutting down on transfers and traffic, while the smaller hospitals can keep and care for their patients on-site.
READ MORE: ATA Leaders Define the Value of Telehealth – And How to Measure It
The concept of connected critical care has led to large networks like HCA, Providence Health in the Pacific Northwest, St. Louis-based Mercy Virtual and Utah’s Intermountain Healthcare, whose medical director for critical care telehealth, William Beninati, MD, was part of the panel.
Beninati pointed out the telecritical care platforms have become a means of standardizing critical care across the health system, giving the tiny hospital in a rural community that same access to care as the big-city hospital. This gives the small hospital the tools to care for more complex patients.
That point is being proven with the COVID-19 crisis. With a telecritical care platform, the large hospital is the hub of a hub-and-spoke network, using a dedicated facility or specialized call center to manage care in the spokes. It can help to balance the patient populations at all hospitals, reducing the need for costly and potentially dangerous transfers, while also helping to cut down on ICU traffic, provider exposure to the virus and even PPE use.
Both Beninati and Guy pointed out that today’s telecritical care platforms are purposefully built to be flexible, as each hospital in the system (and those outside the system who might be able to join the platform) has different needs and capabilities. The telemedicine platform should also be easy enough that a hospital with only the most basic resources can connect.
To that end, Beninati noted that Intermountain has added an asynchronous telehealth program to its roster of services, allowing those with limited access to or need of an audio-visual platform to connect through an online portal.
READ MORE: UMass Memorial Ready to Launch Telehealth Program for NICU Care
This also requires the coordinating hospital to train its specialists to be adept at virtual care.
“This is a very unique skillset,” Guy said. “Because you’re a critical care physician doesn’t mean that, by default, you’re a telecritical care physician.”
Among the challenges to launching and expanding such a platform, Beninati said, is the fear among smaller providers that the telehealth platform “sucks patients out of a community.” In contrast, he said, the services does the opposite, giving those small providers the resources they need to keep patients in the community – not only for in-patient care but also for post-discharge care, including virtual visits with specialists and rehab care providers.
Other challenges include EMR integration – Beninati says Intermountain’s network has to content with several different EMR platforms – and interstate licensure and credentialing, which can be a hassle for health systems spanning several states.
The benefits, meanwhile, include reduced ER traffic at the hub hospital, a steadier care environment at the spoke hospitals, reduced transports (and the clinical and financial toll that they exact), and certain clinical benchmarks like improved sepsis detection and ventilator care, reduced length of stay and a reduced risk-adjusted mortality rate.
READ MORE: Telemedicine in the ICU: How One Hospital Improved Care Management
Guy also pointed out the value in making sure the hub hospitals have a rapport with the care providers, especially the nurses, in outlying hospitals.
Last week the Centers for Medicare and Medicaid Services (CMS) issued their proposed rule for the Calendar Year 2021 Home Health Prospective Payment System. The rule proposes to permanently finalize the allowances made during the COVID-19 public health emergency (PHE) for use of telecommunications technology by Home Health Agencies (HHAs). Although the Social Security Act specifies that telecommunications technology cannot substitute for in-person home health services, CMS acknowledges ways in which technology can be used to improve patient care, especially during the COVID-19 PHE. The rule includes an example of a circumstance in which virtual visits can be added to a patient’s plan of care, not as a substitute but as an additional measure in the context of the COVID-19 PHE. CMS states that they believe the provision of in-person visits and encounters using telecommunications technology can also apply outside of the PHE.
The specific changes CMS is seeking to finalize that were originally included in the first COVID PHE interim final rule (IFC) include:
- Allowing HHAs to continue to report the costs of telehealth/telemedicine as an allowable administrative cost on their cost report. The instructions would be modified to reflect a broader use of telecommunications technology.
- Provide for the use of remote patient monitoring and other communications or monitoring services, consistent with a patient’s plan of care. The plan of care should describe how the use of the technology is tied to the patient-specific needs and goals as identified in a comprehensive assessment.
Comments are requested on both of these proposals. CMS notes that finalizing these interim policies would be fulfilling an element of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) which requires the Secretary to consider ways to encourage the use of telecommunications systems, including remote patient monitoring and other communications or monitoring services for home health services. The rule also indicates that finalizing these policies would allow HHAs who may have been unsure whether or not to invest in telecommunications systems, to do so confidently knowing the policies will be in place to support those expansions. CMS also makes a point of reminding stakeholders that telecommunications technology must be inclusive and made accessible for patients who have disabilities that may make utilizing the technology a challenge.
To read the full CMS proposed rule on the CY 2021 home health prospective payment system or submit comments, visit its listing on the Federal Register.
School may not be in session, but telehealth programs across the nation are busy addressing the needs of students stuck at home during the pandemic – including a growing number in need of mental health counseling.
– School may not be in session because of the coronavirus pandemic, but that doesn’t mean school-based telehealth programs are shuttered. In many cases, they’re busier than ever.
While originally designed to treat non-acute health concerns and keep students in school, connected health platforms have evolved to handle a variety of issues, including chronic care management and behavioral health concerns. Those concerns haven’t gone away during the COVID-19 emergency, and are often exacerbated because students are stuck at home, with perhaps even less access to healthcare than at school.
(For more coronavirus updates, visit our resource page, updated twice daily by Xtelligent Healthcare Media.)
In Massachusetts, a telemental health program run through Athol Hospital for students in two high schools pivoted to a home-based program in mid-March, when the schools closed. Maureen Donovan, the hospital’s program manager, said counselors had to transition from seeing students via telehealth in a room at school to connecting wherever and whenever a student could find the time and space at home to talk.
“Now that we’re at home, we’ve seen things that we’ve never seen before,” Donovan said during a recent virtual session hosted by the Northeast Regional Telehealth Resource Center and Mid-Atlantic Telehealth Resource Center.
READ MORE: School-Based Telehealth Makes Health a Priority for Teachers, Providers
Donovan said the program – based in rural region of the Bay State – had to find ways to ensure access for students who didn’t have access to telemedicine technology or broadband at home. In addition, counselors often had to deal with a noisy home environment that often intruded on a student’s privacy.
“We’re trying – we’re trying to have family support and sibling support,” she said, noting students would sometimes call in from their car or another remote location, or text-message or e-mail counselors to keep the lines of communication going.
“They’re all doing what they need to do to have sessions,” she said.
Donovan expects that the program, currently serving more than 100 students, will remain home-based if and when schools reopen this fall. She said school districts will place a heavy emphasis on academic activities during whatever becomes of the school day, to make up for time lost to the pandemic, and programs like the telemental health platform will need to work around the edges.
“School is going to be very different,” she said, and a telemedicine platform “will allow us to be flexible” in meeting student needs.
READ MORE: Lawmakers Seek Funding for Home, School Telehealth Services for Children
In some areas, particularly rural and underserved regions, the school nurse may be a student’s only access to healthcare. School districts have often partnered with local health systems to make sure primary care needs were being met.
When these schools shifted from in-person education to virtual education, they had to make sure their healthcare services were virtual as well.
“A lot of folks don’t realize that school nurses are still working full time,” says Josh Golomb, CEO for Hazel Health, a national provider of telehealth services for schools. “What those nurses quickly asked us to do is offer Hazel at home. Students still need healthcare.”
Robert Darzynkiewicz, Hazel’s chief medical officer, points out that the COVID-19 crisis not only sent students home from school – it closed or severely limited access to primary care providers. Parents stopped going to the doctor’s office with their children.
With that in mind, school districts, local health systems and providers like Hazel Health worked to emphasize telehealth as an option. They pushed services out to the home not as a means of replacing what was lost when schools closed, but to make sure people were able to access care.
READ MORE: Can an mHealth Wearable Help College Students Deal With Stress?
Golomb, noting his business has increased significantly over the past two months, says school districts are now learning the value of a telehealth platform.
“This has heightened the realization that they need to be offering more services,” he says. “The simple part of healthcare is what we actually see during the school day … but there’s a lot more” that goes into a school health program.
With re-opening on the horizon, Golomb and Darzynkiewicz say school districts are now scrambling to prepare for what will be a much different environment – and they’re peppering healthcare providers with questions about how to set things up. How should schools handle COVID-19 testing for both staff and students, and what do they do when someone tests positive? And how will traditional healthcare services still be made available?
Like Donovan, Golomb says school districts will rely more heavily on telehealth platforms that can offer services at home – particularly services like chronic care management and behavioral health. They’re looking at more wrap-around services, he says, that complement the academic program while offering better and more convenient access to care.
“Our goal is to be where the kids are,” Darzynkiewicz says.
In colleges and universities, the telehealth platform is just as important, if not more so. Campus health centers are, in many cases, the sole source of healthcare for students during the school year. And being stuck at home doesn’t make things any easier.
“There’s a strong need for psychiatric services and counseling no matter where they are,” says Anne Fisher, a clinical psychiatrist and head of the wellness center at the New College of Florida, which “went from 100 percent in-person to 100 percent online” in March.
Fisher says students face a wide variety of behavioral health concerns and stresses in a college setting, ranging from sex and gender identity issues to the challenges of coping with classes and social life away from home. Those issues are still there even when the student is home, and they can’t walk over to the health center to chat with a counselor.
“This is a crucial time in their life,” she says, noting that her center sees roughly 40 percent of the college’s 800-student population. One moment they’re living on or near the campus, she says, “and the next moment they’re back at home. Suddenly they’re a kid in the house again.”
Fisher says her department’s telehealth platform is more important now than ever, but the challenges are daunting. Privacy and security issues abound with virtual care, and there’s the added difficulty of making sure that out-of-state students can access the service.
“These things get trickier when you’re remote,” she says.
As well, while the school will re-open, perhaps this fall, the campus will be decidedly different. COVID-19 protocols will affect how many students live in a dorm, how meals are delivered, even how students interact with elderly faculty and staff who are more susceptible to the virus. Older buildings will have to be thoroughly cleaned, maybe even reconfigured.
“Generally, counseling centers are stuck wherever they can be stuck,” Fisher says. “Old offices in older buildings, or converted spaces with poor ventilation.”
With an emphasis on healthcare, or healthier activities, that will change. And in an effort to reduce the need for major construction and renovation projects, as many programs as possible will be transitioned to telemedicine platforms, giving providers and students more freedom to connect when and where they can find the time and space. As well, there will be more emphasis on pushing resources out to students through virtual platforms, including mHealth apps.
“I think this is going to change (campus) healthcare a lot … especially mental healthcare,” she says.
Today, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule [CMS-1730-P] that proposes routine updates to the home health payment rates for calendar year (CY) 2021, in accordance with existing statutory and regulatory requirements. This proposed rule also includes a proposal to make permanent the regulatory changes related to telecommunications technologies in providing care under the Medicare home health benefit beyond the expiration of the public health emergency (PHE) for the Coronavirus Disease 2019 (COVID-19) pandemic.
This rule includes a proposal to adopt the revised Office of Management and Budget (OMB) statistical area delineations as described in OMB Bulletin 18-04 and proposes to apply a 5 percent cap on wage index decreases in CY 2021. Finally, this rule proposes Medicare enrollment policies for qualified home infusion therapy suppliers and updates the home infusion therapy services payment rates for CY 2021.
The proposed rule can be downloaded from the Federal Register at: https://www.federalregister.gov/documents/2020/06/30/2020-13792/medicare-and-medicaid-programs-cy-2021-home-health-prospective-payment-system-rate-update-home
Strengthening Medicare – Further Promoting Telecommunications Technology in Medicare
In an effort to promote efficiencies, this rule proposes to permanently finalize, beginning January 1, 2021, the amendment to the home health regulations outlined in the March 30, 2020 Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency Interim Final Rule (85 FR 19230). This would mean that home health agencies (HHAs) can continue to utilize telecommunications technologies in providing care to beneficiaries under the Medicare home health benefit beyond the COVID-19 PHE, as long as the telecommunications technology is related to the skilled services being furnished, is outlined on the plan of care, and is tied to a specific goal indicating how such use would facilitate treatment outcomes.
The use of technology may not substitute for an in-person home visit that is ordered on the plan of care and cannot be considered a visit for the purpose of patient eligibility or payment; however, the use of technology may result in changes to the frequencies and types of in-person visits as ordered on the plan of care. This rule also proposes to allow HHAs to continue to report the costs of telecommunications technology as allowable administrative costs on the home health agency cost report beyond the PHE for the COVID-19 pandemic. These proposed changes are one of the first flexibilities provided during the COVID-19 PHE that CMS is proposing to make a permanent part of the Medicare program. These proposals would ensure patient access to the latest technology and give home health agencies predictability that they can continue to use telecommunications technology as part of patient care beyond the PHE.
Updates to the Home Health Prospective Payment System (HH PPS) rates for CY 2021
This rule proposes routine, statutorily-required updates to the home health payment rates for CY 2021. CMS estimates that Medicare payments to HHAs in CY 2021 would increase in the aggregate by 2.6 percent, or $540 million, based on the proposed policies. This increase reflects the effects of the proposed 2.7 percent home health payment update percentage ($560 million increase) and a 0.1 percent decrease in payments due to reductions made in the rural add-on percentages mandated by the Bipartisan Budget Act of 2018 for CY 2021 ($20 million decrease). This rule also proposes to update the home health wage index including the adoption of revised Office of Management and Budget (OMB) statistical area delineations and limiting any decreases in a geographic area’s wage index value to no more than 5 percent in CY 2021.
Proposals and Updates to the Home Infusion Therapy Benefit for CY 2021
This rule proposes to implement Medicare enrollment policies for qualified home infusion therapy suppliers and proposes updates to the CY 2021 home infusion therapy services payment rates using the CY 2021 Physician Fee Schedule amounts.
For additional information about the Home Health Prospective Payment System, visit https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/HomeHealthPPS/index.html and https://www.cms.gov/center/provider-Type/home- Health-Agency-HHA-Center.html.
For additional information about the Home Health Patient-Driven Groupings Model, visit https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/HH-PDGM.html.
For additional information about the Home Infusion Therapy Services benefit, visit – https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Home-Infusion- Therapy/Overview.html.
About Palmetto Care Connections
Palmetto Care Connections (PCC) is the telehealth network for South Carolina that offers telehealth support services to rural and underserved health care providers.
