The COVID-19 pandemic presents complex challenges for the US health care system and social safety net programs. In our latest blog post series, IMPAQ experts bring you timely updates and informed insights on the intersection of COVID-19 and pressing policy issues.
Every facet of life will be irrevocably changed as a result of the COVID-19 pandemic. Its sweeping impact on our collective values, institutions, and industries cannot be understated nor fully understood. Undoubtedly, we’ve already seen pillars of US health care policy and infrastructure respond in myriad ways.
With the shift toward telehealth, the Centers for Medicare & Medicaid Services (CMS) has temporarily changed Medicare telehealth payment and delivery policy. In this blog post, we’ll review Medicare telehealth payment rules prior to COVID-19, summarize the temporary changes, and explore how these actions could (or arguably should) influence certain aspects of the Quality Payment Program (QPP). The potential ways in which the pandemic generally, and the temporary Medicare telehealth expansion specifically, may impact programmatic elements of the QPP and its Merit-based Incentive Payment System (MIPS) are vast. To illustrate, we’ll focus on one cost measure’s attribution method, telehealth improvement activities, and quality measurement.
What were Medicare’s Telehealth Payment Rules prior to COVID-19?
Prior to pandemic-initiated changes, Medicare paid practitioners for services furnished through telehealth under very specific and limited circumstances. First, and perhaps most notably, a Medicare beneficiary receiving services had to be located in a rural area and in a medical facility such as a rural health clinic, skilled nursing facility, physician’s office, or critical access hospital when receiving Medicare telehealth services. The site at which a patient receives telehealth services is referred to as an “eligible originating site.” Prior to COVID-19, the beneficiary’s home was generally not an eligible originating site.
Second, only certain practitioners, located at a “distant site,” could provide services and receive payment for a defined set of covered telehealth services. Any changes to this defined set are historically made using the annual physician fee schedule proposed rule published in the summer and the final rule published by November 1 each year.
Lastly, distant site practitioners had to use an interactive audio and video telecommunications system to allow for real-time communication between the practitioner at the distant site and the beneficiary at the originating site.
In summary, pre-pandemic Medicare telehealth policy limited the use and applicability of telehealth for many Medicare providers and patients.
How has Medicare Temporarily Expanded Its Telehealth Policy during COVID-19?
The Secretary of the U.S. Department of Health and Human Services authorized additional telehealth waivers through authority granted under the CARES Act. As a result, beginning March 6, 2020, and for the duration of the COVID-19 public health emergency, CMS will pay for Medicare telehealth services furnished to beneficiaries in any healthcare facility and in their home, in any area of the country.
Medicare will pay for more than 80 additional services delivered via telehealth as if those services were provided in person for both new and established patients (including virtual check-ins). The types of health care professionals who can furnish distant site telehealth services have been expanded to include physical therapists, occupational therapists, and speech language pathologists. Further, CMS is temporarily permitting use of audio-only telephone equipment to furnish certain evaluation and management services.
How will Telehealth Expansion Impact the Quality Payment Program?
The temporary expansion of Medicare telehealth will have both immediate and longer-term impacts on the QPP and MIPS. To illustrate, we focus on three elements of MIPS—attribution for one cost measure, telehealth improvement activities, and quality measurement.
MIPS Cost Measure Attribution
In order for CMS to evaluate costs, claims-based measures must be calculated by attributing patients costs to clinicians. A re-evaluated version of the Total Per Capita Cost (TPCC) Measure is one of 20 claims-based measures to be used to evaluate cost performance in the 2020 MIPS performance year (PY). The TPCC measures the overall cost of care delivered to a beneficiary with a focus on primary care received.
The 2020 PY TPCC attribution methodology is intended to identify a patient’s primary care relationships by establishing “risk windows,” a year-long period of time beginning at the onset of a candidate event. A candidate event identifies the start of a primary care relationship and is defined by the occurrence of an eligible evaluation and management (E/M) service paired with additional services that are indicative of general primary care. Clinicians “who would not reasonably be responsible for providing primary care are excluded from attribution of the TPCC measure.” The 56 excluded specialties include physical therapists and occupational therapists in private practice, hospitalists, emergency medicine, psychiatry, licensed clinical social workers, clinical psychologists, and more.
It’s becoming apparent that “typical” practice patterns for certain clinicians are changing substantially in response to the pandemic. Providers are answering a collective call to action and practicing in sites and settings that they otherwise wouldn’t under normal conditions. Providers are also utilizing telehealth delivery technology to prevent viral transmission, maintain social-distancing measures when possible and medically indicated, and to free up limited medical equipment and resources. As a result, clinicians in specialties who are not usually seen as responsible for providing primary care to patients may in fact be providing primary care services to Medicare beneficiaries. Moreover, these clinicians may be delivering these services via telehealth technologies as permitted by expanded telehealth rules. In light of marked shifts in practice realities, CMS should consider whether current cost measure attribution methodologies remain relevant.
Promoting and Expanding Telehealth Improvement Activities
The MIPS Improvement Activity performance category measures participation in activities that improve clinical practice. Each improvement activity is weighted medium or high based on its alignment with public health priorities. The weight corresponds to a score; high-weighted activities earn 20 points and medium-weighted activities earn 10 points. To earn full credit in this performance category, MIPS eligible clinicians must generally submit two high-weighted activities, one high-weighted activity and two medium-weighted activities, or four medium-weighted activities.
Two improvement activities for 2020 PY are related to telehealth:
- The use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults or teleaudiology pilots that assess ability to deliver quality care to patients. This activity falls under the Expanded Practice Access subcategory and has a medium weight.
- MIPS eligible clinicians prescribing the blood thinner warfarin must attest that 60 percent or more of their ambulatory care patients receiving the medication are managed by one or more clinical practice improvement activities One of these activities includes telehealth that involves systematic and coordinated care for rural or remote beneficiaries. This activity aligns with the population management subcategory and has a high weight.
In response to the current public health emergency, clinicians are increasing adoption of telehealth services. Surveys show that nearly half of all physicians in the United States are now using telehealth to treat patients. In 2018, only 18 percent of physicians used telehealth. This represents a 178 percent increase.
The recent acceleration in telehealth use, as well as insights gained from providers through IMPAQ’s work to support CMS with the implementation of MIPS, present an important opportunity to consider ways to align improvement activities with providers’ priorities and realities. For example, CMS should consider changing the improvement activity titled “Use of telehealth services that expand practice access” from a medium to high-weighted activity. Further, CMS may also consider promoting telehealth by expanding current care coordination and care management-focused improvement activities to include integration and assessment of telehealth practice improvements.
Prioritizing the Development of Telehealth Quality Measures
Though CMS has not announced pandemic-related 2020 MIPS program updates at the time of this posting, quality measure reporting will likely be impacted. The expanded list of covered telehealth services means that more MIPS-eligible clinicians may be measured on the quality of care delivered through telehealth for the Quality Performance Category, which constitutes nearly half of a participant’s final score in PY 2020. However, measurement of telehealth quality lags behind practice.
Telehealth offers significant potential to meaningfully transform the way care is delivered to Medicare patients by overcoming geographical distance, improving access, and building efficiencies. For example, the use of telehealth for chronic disease care management has been shown to reduce hospitalizations, readmissions, and lengths of stay, as well as improve some physiologic measures such as pulmonary function and body temperature. The impact of expanded use of telehealth services within the Medicare population could be significant considering that more than two-thirds of Medicare beneficiaries have a chronic condition.
The post-pandemic realities of care delivery present an important opportunity for development and incorporation of quality measures that focus on telehealth following the framework outlined by the National Quality Forum’s Telehealth Committee. Such measures might assess timeliness of care, patient empowerment, added value of telehealth to provide evidence-based base practices, and care coordination.
As illustrated by the QPP MIPS examples discussed here, the health care delivery system and its supporting policies will be significantly impacted by the current pandemic. With the temporary expansion of Medicare telehealth, a close examination of MIPS policy shows opportunities to align cost measure attribution, improvement activities, and quality measurement with providers’ increased use of telehealth services.
IMPAQ has significant expertise in the QPP MIPS. Our experts in value-based care—including Dr. Mai Hubbard, Kevin Van Dyke, Dr. Brandy Farrar, Sarah Pedersen, and Leah Nash—will continue to work with CMS, providers, vendors, and other stakeholders to analyze how COVID-19 will impact the program going forward and consult with CMS on program improvements.
Leah Nash, Research Associate, IMPAQ Health
Sarah Pedersen, Senior Research Associate, IMPAQ Health