A bill before Congress would, if passed, continue COVID-era Medicare telehealth waivers until the end of 2024, while also extending the CMS Acute Hospital Care at Home program for two years.
Congress is expected to pass an omnibus spending bill this week that would extend pandemic-era Medicare telehealth waivers until the end of 2024. The bill would also keep in place the Centers for Medicare & Medicaid Services' (CMS) innovative Hospital at Home program, and continue several other programs aimed at boosting connected health access and coverage.
Among several organizations praising the news is the American Telemedicine Association, which had long warned that the elimination of these waivers and programs would seriously hinder telehealth and digital health adoption.
“The ATA and ATA Action never wavered from our appeal to Congress, to provide stability around the life-saving telehealth flexibilities that have become a relied upon and valued option for healthcare providers and patients," Kyle Zebley, senior vice president of public policy for the ATA and executive director of ATA Action, said in a press release. "Today, our Congressional telehealth champions on both sides of the aisle came through for the American people and for ATA and ATA Action members, by meeting our plea for more certainty around telehealth access for the next two years, while we continue to work with policymakers to make telehealth access a permanent part of our healthcare delivery for the future.”
"The inclusion of a two-year extension of Medicare telehealth and commercial market telehealth flexibilities will make a huge difference to so many Americans," The Alliance for Connected Care said in a separate press release. "The Alliance for Connected Care has been calling for predictability for patients and clinicians while continuing to work toward permanent telehealth authorization. This gives us both."
Generally, the bill, if passed, would:
Remove geographic requirements and expand the list of originating sites for telehealth services;
Expand the list of providers eligible to furnish telehealth services;
Expand telehealth services for federally qualified health centers (FQHCs) and rural health clinics (RHCs);
Delay in-person requirements under Medicare for mental health services furnished through telehealth and telecommunications technology;
Permit audio-only telehealth services, such as phone calls;
Allow the use of telehealth to conduct face-to-face encounters prior to recertification of eligibility for hospice care during the emergency period; and
Mandate a study on telehealth and Medicare program integrity.
The inclusion of audio-only telehealth services is a nice surprise for telehealth advocates. Federal and state regulators have long mandated that telehealth services be audio-visual, and have severely restricted any use of the telephone or an audio-only telemedicine platform for care delivery. But during the pandemic the telephone became a popular tool in regions where access to either telemedicine equipment or reliable broadband is limited. CMS has indicated it will return to those restrictions after the PHE ends, saying the platform isn't reliable enough for care delivery.
The bill would also extend for two years the waiver for the CMS Acute Hospital Care at Home program, an innovative service launched by CMS that allows health systems to shift more care for acute patients from the hospital setting to the home, through a platform that includes remote patient monitoring, telehealth services and in-person care. More than 200 health systems have signed up to take part in the program, and many had said they would be forced to curtail, drastically change, or even cancel the program once CMS support for the program ends.
“We greatly appreciate Congress including extensions the High Deductible Health Plan (HDHP) and Health Savings Account (HSA) telehealth tax provision, giving American workers continued access to needed telehealth coverage without first having to meet annual deductibles, including telemental health services," Zebley said in the ATA press release. "Further, the extension to the Acute Hospital Care at Home Program ensures continued access to this patient-centered care delivery model that is proving to effectively lower cost of care while improving patient health outcomes and satisfaction."
Not all the news was good, however. While the omnibus bill includes several measures aimed at addressing the nation's substance abuse epidemic, it does not include an extension for a waiver that currently allows healthcare providers to prescribe controlled substances via telehealth for substance abuse treatment.
Federal law bans are severely restricts prescriptions of controlled substances through telemedicine. Federal regulation is channeled primarily through the Ryan Haight Act, passed in 2008, which prohibits physicians from prescribing controlled substances electronically until they have conducted an in-person examination, or if they meet the federal definition of practicing telemedicine, which requires that the patient be treated by, and physically located in, a hospital or clinic which has a valid DEA registration; and the telemedicine practitioner is treating the patient in the usual course of professional practice.
The nation’s ongoing opioid abuse crisis is creating a groundswell of support for changes in federal law to make telemedicine and telehealth a more prominent feature in treatment. Congress has been considering bills that would, if passed, create a special registration through the US Drug Enforcement Agency to enable healthcare providers to prescribe controlled substances through telemedicine.
The bill does direct the DEA to implement that special registration process, but the DEA has been asked to start that process for several years and has yet to do so.
While the omnibus bill, if passed as expected, would extend all of these freedoms for another two years, the ATA and others are lobbying to make many of the provisions permanent, rather than just pushing the finish line farther down the road.
“The hard work continues, as we persist in pressing telehealth permanency and creating a lasting roadblock to the ‘telehealth cliff,’" Zebley said. "Additionally, we will continue to work with Congress and the Biden administration to make sure that a predictable and preventable public health crisis never occurs by giving needed certainty to the huge number of Americans relying on the clinically appropriate care achieved through the Ryan Haight in-person waiver.”
Closing gaps in care requires knowing just when a technology-powered nudge will help, rather than cause more stress.
At Ardent Health Services, physician burnout is a constant concern, and an issue that technology can address. The challenge for the Nashville-based healthcare organization, formerly known as the Behavioral Healthcare Corporation, is to find the right technology and not make things worse.
To thread that delicate needle, they're using a technology, developed in part by physicians, that identifies gaps in care and cost considerations.
Ardent deployed the IllumiCare Smart Ribbon in June and has found immediate benefits in a metric that often puts "lots of pressure" on its hospitalists, says chief medical officer FJ Campbell.
"The classic metric is discharges before 11 a.m.," Campbell says. "If you're moving your med/surg patients out by 11 a.m., then you're able to transfer your patients from your ICU to your med/surg units. We deployed IllumiCare, and discharges by 11 a.m. went up over 175%."
But reaching this level of improvement involves much more than just plopping the latest technology in front of hospitalists, Campbell says.
FJ Campbell, chief medical officer of Ardent Health Services. Photo courtesy Ardent Health Services.
Ever since he attended medical school, Campbell has been intrigued by the inefficiencies evident in the hospital setting.
"When you're a surgery resident, and you're in the hospital 100 to 110 hours a week, you take inefficiency personally," he says.
After passing his boards, Campbell pursued an MBA and entered hospital administration, initially as director of medical operations at Virtua Health. A stint at Centennial Medical Center, a flagship hospital of HCA, reinforced a notion to bring clinicians into operational decisions, one that ultimately informed his interest in tools such as Smart Ribbon.
"People who understand workflow make better products," he says. "And good workflows lead to good clinical outcomes, which lead to good financial outcomes."
Since then, Campbell says he has sought out technology defined in part by clinicians themselves, since they're the ones who ultimately have to live with that technology.
After HCA, Campbell became an equity partner and chief medical officer at an urgent care company called CareSpot. He also served as vice president of clinical services at Community Health Systems before moving to Ardent.
At Ardent Health Services, Campbell is responsible for all clinical service lines and initiatives, including hitting the health system's CMS metrics and Leapfrog scores. Nursing and case management services also report to him.
"The case management activity has been concentrating on moving patients through the continuum of care," he says. "The nursing activity has been around how do we leverage technology to overcome the staffing challenges that we have?"
Campbell also helps identify opportunities to start delivering care more effectively outside of the hospitals' four walls. That focus on workflow was intensified by the pandemic.
"We had to be conscious and cognizant of workflow," he says. "Like, how are we going to separate respiratory illness from non-respiratory illness? How are we going to turn a med/surg unit into a step-down unit? How are we going to make negative pressure rooms widely distributed now?"
Pandemic time highlighted the number of clinicians who didn't have a clear enough understanding of operations and their challenges, Campbell says.
"You had many operators with no clinical background, who had to understand clinical medicine a lot more to really appreciate how they could problem solve," he says. "COVID created a nexus and a need for it between operators and clinicians. We're going to have to be doing more to leverage technology to achieve our clinical and operational outcomes."
Clinicians want to be well-informed, but any hints or nudges from technology must be delivered in a manner that is not disruptive to their workflow, Campbell says.
"It really starts getting back to [technology] made by end-users for end-users," he says. Best practice advisories from EHR vendors such as Epic must be accurate, and IllumiCare, by populating the Epic App Orchard with its own apps, adds more important ways to inform clinicians without being intrusive.
"If you're going to give them something that is going to take their attention away from the next lab to track down or the next X-ray value to assess, your clinical decision support content had better be spot on, easy to access, easy to understand, and therefore easy to execute on," Campbell says. "Otherwise, forget it; you will be blown off in a New York minute."
Executives should focus even more on workflow as the successful path to technology adoption, he says.
"I'm going to bring you a tool that's going to make it easier for you to execute on your job," he says. "You're either going to see that very quickly, or if you won't, you're going to help position me to make modifications with the other clinical partners that we have."
Researchers at the University of Illinois and OSF HealthCar are working on a digital health app that would enable providers to better combat false rumors and malicious reports that hinder public health efforts.
Researchers at the University of Illinois are working on a digital health app that would alert providers to healthcare misinformation circulating on social media.
Kevin Leicht, PhD, a sociology professor at UI, and Mary Stapel, MD, community care lead physician for OSF HealthCare Saint Francis Medical Center and assistant program director for the combined Internal Medicine-Pediatrics Residency at the University of Illinois College of Medicine Peoria (UICOMP), are using a $100,000 grant to develop the resource, which would give users real-time alerts about rumors and malicious reports that impact public health efforts.
"What our project actually does is take not only the pre-existing fact-checked data and query it all in one place, it brings it forward in a user-friendly fashion," Leicht said in a press release from OSF Healthcare. "But then it's also trying to come up with a way of adding to this data in a way that's faster than having a human fact checker just scan the web all the time, looking for what the new piece of misinformation is."
Leicht, the science team lead at the Chicago-based Discovery Partners Institute (DPI), and Stapel are using a grant from OSF Healthcare's Jump ARCHES (Applied Research for Community Health through Engineering and Simulation) program, and building on past work, supported by the National Science Foundation, to identify the spread of misinformation about COVID-19 and other debunked medical research.
"If we can even get ahead of that – know what information is circulating and start feeding out more accurate information ahead of time through our community partners; that really could be a game changer when we're thinking about things like pandemics and infectious disease," Stapel said in the press release.
Stapel said the app would help healthcare workers, especially those in community health, to better inform patients and gain their trust at a time when public healthcare workers are struggling against false information that affects their credibility.
"Having humans curate that a little bit … you have content experts that look at that and say, 'Is this dangerous or is it not? Is this trending, is it not?' And then figuring out a way to deliver that to the final customer in a way that requires as little inner interface by them as we can possibly get away with," she added.
HealthLeaders Innovation and Technology Editor Eric Wicklund chats with Joerg, Schwarz, senior director of healthcare interoperability strategy and solutions at Infor, about how healthcare organizations should be selecting and using data platforms.
A start-up from the Mayo Clinic orbit is partnering with Pfizer to develop an AI-enhanced ECG that can detect cardiac amyloidosis, a progressive disease that's difficult to diagnose early.
A startup launched out of the Mayo Clinic Platform is partnering with Pfizer to develop AI software that can detect cardiac amyloidosis in an electrocardiogram.
Anumana, which was launched in 2021 and is part of the nference software company's portfolio, intends to develop the AI-ECG tool as a software-as-a-medical-device (SaMD) and market the algorithm in the US, Europe, and Japan.
This isn't the first time Anumana has created software addressing cardiac issues. The company has developed AI-ECG algorithms in the past through the Mayo Clinic for detection of low ejection fraction, pulmonary hypertension, and hyperkalemia, all of which have received Breakthrough Device designation from the US Food and Drug Administration (FDA).
The latest software takes aim at cardiac amyloidosis, an often undiagnosed and progressive disease characterized by the stiffening of the walls of the heart, interfering with the function of the left ventricle. Symptoms include shortness of breath, knee pain, bilateral carpal tunnel syndrome, kidney disease, and gastrointestinal issues.
Because the symptoms are so diverse, the condition is hard to diagnose. Earlier detection would give clinicians time to develop more effective treatment plans that would improve clinical outcomes over time.
“The challenge in diagnosing cardiac amyloidosis can prevent patients from getting treatment while the disease continues to progress,” David McMullin, Anumana's chief business officer, said in a press release. “We believe this collaboration [with Pfizer] will demonstrate the power of Anumana’s AI-ECG algorithms to help clinicians intervene earlier, giving them greater ability to improve patient outcomes and prolong lives.”
The project is the latest of many that aim to use AI to spot infinitesimal trends in data that might not be picked up by manual data review until much later.
“AI-ECG solutions alert clinicians to humanly imperceptible patterns in ECG signals, providing an early warning for serious occult or impending disease,” added Paul Friedman, MD, chair of the Mayo Clinic's Department of Cardiovascular Medicine and chair of Anumana’s Mayo Clinic Board of Advisors. “This stands to improve the lives of people with cardiac amyloidosis by improving the speed of triage and care of this group.”
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The Medicaid and CHIP Access to Prescription Digital Therapeutics Act, introduced this week in Congress, would create standardized coverage in Medicaid and CHIP plans for approved digital health tools and platforms.
A new bill introduced to Congress aims to improve coverage for digital therapeutics in Medicaid and state Children's Health Insurance Programs (CHIPs).
“Digital therapeutics hold particular value for Medicaid populations with convenient, accessible, and personalized treatment options to address many unmet medical needs,” Andy Molnar, chief executive officer of the Digital Therapeutics Alliance (DTA), said in a press release announcing the DTA's support for the bill. “This legislation would establish more clarity and uniformity in how prescription digital therapeutics are covered by public programs from state to state and is a critical step toward ensuring that these evidence-based treatments get into the hands of those who need them most.”
While the text of the bill wasn't yet available, supporters said it would, if passed, define 'prescription digital therapeutic' for Medicaid coverage, create standardized coverage for digital therapeutics treatments approved or cleared by the US Food and Drug Administration (FDA) in Medicaid and CHIP programs and give the Health and Human Services Secretary the ability to provide technical assistance to states considering such coverage.
The bill represents a growing interest in the use of digital health tools and platforms to treat chronic conditions and other health concerns, giving healthcare providers new options that don’t necessarily include drugs or in-patient treatments.
It also tackles one of the biggest barriers to adoption: payer coverage. Unless payers support these new treatments, providers have little incentive to prescribe them. Some health plans and private insurers have shown support for digital therapeutics, but the industry needs the backing of Medicare and Medicaid plans, who cover many of the populations that would greatly benefit from their use.
In its 2023 Standards of Care, the American Diabetes Association says technology is now a vital part of care management, and all people living with diabates should have access to those tools and platforms.
The American Diabetes Association is emphasizing the value of healthcare technology in diabetes care management in its 2023 Standards of Care.
The revised standards, issued this week, include a section devoted to technology, including continuous glucose monitoring (CGM) devices that allow people living with diabetes to check their blood glucose levels at any time, automated insulin delivery systems and digital health tools that offer coaching and access to resources.
The guidelines recommend that anyone living with diabetes have access to FDA-approved technology to manage their chronic condition, especially seniors and underserved populations. The ADA also points out that technology can be used to improve access to care and care management for those dealing with health inequity, or barriers to care caused by social determinants of health.
“ADA’s mission is to prevent and cure diabetes, a chronic illness that requires continuous medical care, and the release of ADA’s Standards of Care is a critical part of that mission,” Chuck Henderson, the organization's chief executive officer, said in a press release. “This year’s annual report provides necessary guidance that considers the role health inequities play in the development of diabetes, particularly for vulnerable communities and communities of color disproportionately impacted by the disease. This guidance will ensure healthcare teams, clinicians and researchers treat the whole person.”
Digital health technology has been a part of care management for people living with diabetes for years, though the ADA and other organizations, such as the Centers for Medicare & Medicaid Services (CMS) and US Food and Drug Administration (FDA), have been careful to support only technology that passes strict protocols and has proven to improve clinical outcomes.
The ADA's acknowledgement of the value of technology may mark an import step in the value-based care movement.
Earlier this year Kevin Sayer, CEO of digital health company Dexcom, one of the leaders in the diabetes technology space, said the industry is moving on from highlighting the next big thing and focusing more on integration and interoperability.
"Everybody wants everybody to be interoperable and talk to everybody else," he said. "The only way that these platforms are going to be successful going forward is if all the technology works with each other and people using it are engaged."
"It isn't even technological any more," he added. "What people are looking for is access."
Sayer says the diabetes care industry is now transitioning to overall health and wellness, not just tools and platforms that solely address diabetes. That's why a company like Livongo, which was launched by former Allscripts executive Glenn Tullman to help people living with diabetes like his son, has since evolved to address other chronic diseases, as well as integrating with primary care and behavioral healthcare services.
"We've come to understand that the patient's healthcare journey starts long before they were diagnosed with diabetes," Sayer said. "And it involves a lot more than just [diabetes tools and platforms]. It's all about access now, and that can be complex. We have to learn how to make access easier."
Cherry Health is using EHR technology to launch new services and view and share data with other providers as it transitions away from fee-for-service care.
Federally Qualified Health Centers (FQHCs) are a breed apart. Incorporating multispecialty practices with primary care, behavioral health, and even dental care, these 1,400 providers across the US see some 30 million Americans a year, many insured by Medicare and Medicaid.
One such FQHC, Cherry Health, covering western Michigan and headquartered in Grand Rapids, serves more than 65,000 patients annually via a network of more than 80 providers and 800 healthcare professionals. The patient population is 55% Medicaid, about 15% Medicare, perhaps 20% uninsured, and a very small percentage of commercial payer coverage.
Like many other FQHCs, Cherry Health has partnered with NextGen Healthcare for its electronic health record platform. NextGen is now leveraging the cloud to allow providers to share performance metrics and learn from each other.
This should help Cherry Health as the nation's FQHC network, supported by funding from the Health Resources and Services Administration (HRSA), continues to get squeezed, and value-based payment models are just around the corner.
"The reason that we stayed with NextGen was due to the flexibility in our different specialties," says Glenda Williams, chief information officer at Cherry Health. "We can have one integrated health record, that we don't have all these separate systems that all of our staff need to look up to be able to care for the patient."
Glenda Williams, chief information officer at Cherry Health. Photo courtesy Cherry Health.
The technology also helps with another critical issue affecting healthcare: Stress and burnout.
"Our strategy has been to talk to our providers to identify what additional technologies we can put in place to help them so that they're feeling less burned out," Williams says. "Whether or not that is from a technology standpoint, from my side, or whether or not it's from a staffing side from our CMO side, maybe they need extra help. Maybe they need a different workflow. It's really about identifying what needs they have and coming up with a solution."
Cherry Health is transitioning from fee-for-service to value-based care, says Cynthia Duncanson, the organization's chief financial officer.
"We do get paid on a fee-per-service basis, and our incentives are relatively low compared to what our program income is from the Medicaid fee-for-service payments," Duncanson says. "But we are getting ready to transition within the next year or two to an alternative payment methodology for our primary care medical population, where it will be per member per month, completely crosswalked between that fee-for-service with a little bit of incentive, all the way over to mostly incentive. Medicare's also crosswalking us in that same direction as well."
In 2022, in anticipation of this change, Cherry Health implemented NextGen's population health tool, Williams says.
"My strategy is having access to data and using the data to make our decisions," she says.
NextGen has added an extra tool in this regard, by establishing a national collaborative of FQHCs using its EHR several months ago, according to Srinivas Velamoor, executive vice president and chief growth and strategy officer at NextGen Healthcare. More than 60 have signed up so far, and NextGen expects that number to grow beyond 100.
"They all have common issues in terms of having visibility to metrics, like no-shows, and making sure they're looking at the same quality measures," Velamoor says. "They are very eager to understand how they're doing relative to others in the country that look like them, and not just focus on their own performance."
Williams says the collaborative will allow FQHCs to be more innovative in solving the clinical problems they face.
"Why reinvent the wheel if someone else has already has a solution in place?" she says.
For example, in addressing no-shows, the FQHC can separate patient populations out into groups, identifying those who don’t have e-mail addresses, or those who prefer phone calls or text messages, so as to better target its messaging and marketing campaigns.
"We're the first FQHC to have that dual designation," she says.
This will allow Cherry Health's providers, including physicians, nurses, physician assistants, and community health workers, to move from station to station within clinics while the patients remain in one place, instead of traditionally being shown into room after room, Duncanson says.
The challenge of making all these changes requires close communication between Williams, Duncanson, and the rest of the leadership team.
"We're constantly collaborating," Duncanson says.
"We're just two doors down from each other, and we've got a standing meeting to go over any issues that we may have, and we produce monthly reports that we share," Williams says.
The Weekly Wrap, HealthLeaders' new video series, brings you a quick look at what we're covering around the healthcare industry.
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