Operators, Telehealth Providers See Skilled Nursing Promise in New CMS Proposal

While they don’t represent broad-based coverage for skilled nursing facilities, new proposed telehealth guidelines from the Centers for Medicare & Medicaid Services (CMS) have drawn praise from providers and groups that see the news as a sign of even wider coverage on the horizon.

Under the proposed rule issued earlier this month, CMS would expand physician coverage to include remote check-ins on patients — with the goal of determining whether an in-person doctor visit is really necessary — while also covering a wider swath of preventative telehealth interventions.

“Getting to the doctor can be a challenge for some beneficiaries, whether they live in rural or urban areas,” CMS said in a statement announcing the proposed rule, which would take effect on New Year’s Day 2019. “Innovative technology that enables remote services can expand access to care and create more opportunities for patients to access personalized care management as well as connect with their physicians quickly.”

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The federal government currently only covers telemedicine services in rural skilled nursing facilities — which, according to Tapestry Telehealth COO Mordy Eisenberg, only equates to about a third of the more than 15,000 SNFs that operate in the United States. But Eisenberg indicated that further expansion of those services is likely over the coming years.

“I really think that as CMS starts to see the results of the telemedicine outcomes, and that it’s really practically the same as being there in person, I think they’re going to expand it to non-rural markets,” he told Skilled Nursing News.

The current proposal would have some direct benefits for nursing home residents, according to Majd Alwan, executive director of the Center for Aging Services Technologies (CAST) at LeadingAge, an association that represents non-profit long-term care providers.

“This is certainly a step in the right direction,” Alwan told SNN via e-mail.

The proposed rule would cover “virtual check-ins” — which would include phone conversations, e-mail, or texts sent through a patient portal — with nursing home medical directors, primary care physicians, and other doctors or nurse practitioners, Alwan said.

“These types of providers, physicians, can now take or return calls initiated by nursing home, AL [assisted living], or CCRC staff on behalf of patients to talk to them about their medical concerns, including management of opioid medications,” he said.

Telemedicine promise

Founded by David Chess, the doctor who also founded telemedicine provider TripleCare, Tapestry first started seeing patients in January and currently operates in 23 rural nursing homes. The company’s offerings take the form of virtual rounds, with nurse practitioners preforming routine checks on skilled nursing residents remotely.

Under its arrangements with individual nursing operators, the company doesn’t charge an ongoing rate for its services, instead billing Medicare directly for the nurse practitioner visits. Providers are on the hook for a nominal monthly administrative fee, but Eisenberg noted that the facilities can also receive Medicare reimbursements of about $25 per telemedicine encounter — with one building in particular ending up about $2,000 per month in the black.

Using telemedicine also has benefits outside of potentially making money by providing digital rounds: With the SNF Value-Based Purchasing Program taking effect this fall, preventing rehospitalizations could determine whether or not a particular building earns back its automatic 2% reduction in Medicare, and Eisenberg emphasized the importance of using virtual visits to avoid a costly hospital trip.

When providers do a post-hospitalization analysis, Eisenberg said, many times doctors and nurses conclude that the acute care stay was inevitable — but it didn’t have to be if someone had noticed the warning signs a few days earlier.

“At that point, they probably did have to go back to the hospital. If you look back three, four days before that, there were so many things that were missed along the way … If there’s a change in their ADL status, something different about the way they’re eating, they’ll try to flag that so they can see those patients earlier and hopefully mitigate any problems,” he said.

I-SNP benefits

Right now, the stakes are even higher for rural facilities, which may not have access to private ambulette services — forcing them to use more expensive municipal ambulance rides to transport residents the long distances to area hospitals. In addition to the Medicare hit, sending patients to faraway acute-care facilities also represents a census issue for rural skilled nursing facilities, according to Eisenberg: If a given town doesn’t have a hospital, the patient may have to travel 100 miles or more to receive acute care. Once it’s time for him or her to be discharged back into a SNF, it’s likely the hospital or surgical center will pick a facility in its immediate vicinity.

“They’ll never come back home,” Eisenberg said. “What we’re finding as we partner with these facilities, they’re able to say: We can actually handle this stuff now. We have an NP on staff.”

Going forward, expanded telemedicine coverage could help attract the attention of Institutional Special Needs Plans (I-SNPs), special Medicare Advantage plans for nursing home residents.

Eisenberg gave the example of a 30-building chain that used telemedicine services in its eight rural locations, but not the urban and suburban buildings where Medicare doesn’t cover it. If the operator elected to deploy telemedicine across the entire spectrum, it could help create the kind of consistent medical model that would lend itself to an I-SNP — either a third-party plan or one created internally, as some skilled nursing operators have already done.

“The real goal is, once you have your 30 buildings being managed effectively, now you can take risk surrounding those buildings. Now you can start thinking about I-SNPs or even bundled payments,” Eisenberg said.

Written by Alex Spanko

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