The federal government implemented sweeping waivers to broaden access to telemedicine for Medicare beneficiaries at the start of the COVID-19 national emergency. And now that skilled nursing facilities have gotten a chance to see the benefits over several months, it will be difficult to take them back when the pandemic ends.
“Telemedicine in the 1135 [waivers], it’s kind of like toothpaste that’s now out of the tube,” Dr. Waseem Ghannam, the founder of the telemedicine company Telehealth Solution, told Skilled Nursing News in a June 24 interview. “It’s going to be really tough to put it back in.”
His company, which provides telehealth services to SNFs in 23 states, provides hardware that includes a cart, tablet, stethoscope, electrocardiogram, pulse oximeter, and two-way video and audio, with other modalities that it can add. The firm also has an application that allows nursing homes to put out a page for physicians.
On March 30, the Centers for Medicare & Medicaid Services (CMS) announced a raft of waivers aimed helping health care providers navigate the storm of COVID-19, which included provisions to expand the use of telehealth.
CMS allowed providers to remotely perform initial and discharge services, and waived a requirement that SNF telehealth visits only occur every 30 days; earlier in March, the Department of Health and Human Services Office for Civil Rights (OCR) waived penalties for violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). That allowed providers to use technologies like FaceTime or Skype during the COVID-19 emergency.
That last provision is one that Ghannam believes will be cut when the pandemic is over.
“We will inevitably revert back to HIPAA compliance, meaning your FaceTime and WhatsApps of the world will not longer be acceptable — I don’t think that’s going to stay forever,” he predicted.
But even with that change, the experience of COVID-19 has put digital medicine front and center in the minds of post-acute providers, even more than before, Ghannam argued.
The question for the future will be whether CMS takes meaningful steps to “fully embrace telemedicine as a viable option, post-COVID-19,” Alexi Alizadeh, the founder of the medical services platform Adviise, which connects patients with providers in real time, told SNN on June 22.
“On the regulatory side, CMS needs to broaden their fee schedule,” she argued. “Every physician is paid based on Medicare or Medicaid, but for Medicare specifically, they’re paid on a fee schedule where they’re paid this much for this procedure, and so on. So they need to actually code into their payer fee schedules the telemedicine visits in the same way that they would a real visit, and they haven’t done that in the past. That’s something that needs to change.”
Adviise, which charges physicians a flat subscription fee of $99 a month for full access to the platform and unlimited patients, has seen a jump in the number of SNFs using its platform since the start of the pandemic. The firm works with providers; for SNFs, the facilities arrange the visits between patients and doctors, with the doctors billing Medicare for the visits.
Before COVID-19, around half a dozen SNFs in the New York metropolitan area were using Adviise. Since the pandemic, that number has more than doubled, with about 15 now using the platform, Alizadeh told SNN.
There were benefits to using the platform even before COVID-19, she argued. Patients in the SNF setting typically require ambulatory transport and escorts for visits to a physician’s office. In the case of one common injury, the hip fracture, imaging will often be necessary, but the procedure could involve even more risks for a fall-prone SNF patient — and costs that can add up fast, with a visit to the physician’s office and then an imaging facility, Alizadeh pointed out.
“With telemedicine, you can be seen immediately after the injury; your only visit needs to be to the imaging facility,” she said. “Braces or other DME [durable medical equipment] can be delivered directly to the SNF, eliminating a lot of the costs and struggles related to getting immediate care.”
In the case of COVID-19, that can also eliminate many potential vectors for infection, while allowing residents to get the care that they need. The use of telehealth hasn’t come without challenges, but by allowing clinicians to experience telemedicine, at least one physician group is expecting permanent change.
“One of the things that is true with clinicians in the community that have not had the experience of telemedicine — I’m hearing from many of my colleagues they never want to go back,” Dr. Grace Terrell, CEO of the skilled nursing-focused physician group Eventus WholeHealth, told SNN in March. “They’re enjoying it.”
Ghannam argued that in the post-acute sector, the arrival of the Patient-Driven Payment Model (PDPM) system of reimbursement for Medicare, helped build momentum for telemedicine.
PDPM’s reimbursement mechanism is designed to be driven by a patient’s care needs, so those with more complex care needs would draw higher reimbursement. Telemedicine allows facilities to care for more complex patients, Ghannam said, and when the COVID-19 waivers were implemented, the reimbursement barriers to telemedicine were eliminated.
Alizadeh saw a similar phenomenon to Terrell, with physicians accelerating their adaptation process in the face of COVID-19 — which is why she’s concerned about CMS keeping the broad access even once the COVID-19 national emergency is over.
“They need to classify it as a real visit,” she said, referring to CMS. “It’s not something that’s like a luxury or a fringe practice. It’s a necessity, and they need to recognize that, especially for the elderly population. And on the physician side, they’re not going to work for free. So the regulatory side has to change for physicians to adopt this.”