Riley Children's Health, Indiana University Health Issue Public Comment on Centers for Medicare & Medicaid Services Proposed Rule

WASHINGTON, June 10 -- Matt Cook, president of Riley Children's Health, Indianapolis, Indiana, and chief strategy officer of the Indiana University Health, Indianapolis, has issued a public comment on the Centers for Medicare and Medicaid Services' proposed rule entitled "Coordinating Care from Out-of-State Providers for Medicaid Eligible Children with Medically Complex Conditions". The comment was written and posted on June 3, 2020:

* * *

On behalf of Indiana University Health ("IU Health"), we appreciate the opportunity to comment on the request for information for CMS-2324-NC, Request for Information on Coordinating Care from Out-of-State Providers ("RFI"). We appreciate CMS' efforts to collect additional information and your ongoing dialogue on this important issue.

IU Health is Indiana's largest and most comprehensive health system and one of the busiest hospital systems in the United States. Based in Indianapolis, IU Health is comprised of 16 hospitals, including Riley Hospital for Children at IU Health ("Riley"). Riley is Indiana's largest and most skilled pediatric system, with over 50 care locations across the state. As one of the nation's leading healthcare networks specifically for children, Riley's multidisciplinary team of pediatric primary care and specialists have expertise in all areas of pediatric health. Riley is also the only pediatric research hospital in the state of Indiana and is ranked among the top hospitals in the nation in ten categories of specialized healthcare for children.

The team at Riley cares not only for some of the most medically complex cases in Indiana, but we are often called to care for patients outside of our state who are in need of specialized care and expertise whether on an emergency or non-emergency basis. Unfortunately, in recent years, Riley has been forced to make the difficult decision to not accept for treatment children with out-of-state Medicaid due to the inability to secure a reliable source of reimbursement from these states' Medicaid programs. (EMTALA scenarios being the obvious exclusion to this practice.) This has been a difficult decision for our care team as we believe strongly in being able to provide care to all children regardless of geographic region given the unique and specialized services Riley has to offer.

Issues Faced with Out-of-State Care

An estimated two-thirds of children with complex medical conditions have health insurance through Medicaid. There are frequent challenges in securing payment from Medicaid and private payers that providers face when treating a child that has traveled out-of-state for care. This unnecessarily burdens the already complex care that is being provided to pediatric cases. Approval for care involves coordination with the patient's out-of-state Medicaid office, and states often have varied processes for review and, if denied, appeals of the denial. Delays can also arise when seeking authorization of coverage under the individual health plans. Some states have accepted the providers' home state enrollment or enrollment in Medicare as an acceptable process, but this is not universal. These challenges in the ability to access care add stress on families already facing many challenges in their daily lives. This stress is further exacerbated when risk to health status is escalated due to access delays.

Families face many out-of-pocket costs when traveling outside their home state for care--including lodging and other travel costs, daycare expenses for children who remain at home, lost wages for missed work, and are also separated from their typical community support systems. These issues can be financially and emotionally taxing for families and add to the significant stress created by caring for a child with specialized healthcare needs. Furthermore, there can be access and referral issues when children, who return home, require follow up services and support needed post-discharge whether because these services and supports are either not available back home or very difficult for an out-of-state provider to order for the child. Ordering durable medical equipment, prescriptions from outside the state, obtaining needed respite care for families, or securing private duty nursing or other home care can all be complicated when providing out of state care. Some states require in-state providers to order prescriptions or durable medical equipment, but the in-state provider is often not the provider most familiar with the child's condition or care.

Areas of Opportunity to Improve Access to Care

We do believe, however, there are opportunities to create a more seamless system of care for this population of children by creating consistent policies and support across states. Support for change from CMS and federal policymakers can help foster better coordinated care across states for this population of children enrolled in Medicaid.

Support and Strengthen Foundational Medicaid Policies Critical for All Children. Ensuring continued coverage for all children, but importantly those children with medically complex conditions, is important to their ability to receive the care they need to live their best quality of life. Allowing them access to the full array of medically necessary benefits that reflect the child's unique needs, and limiting their out-ofpocket costs is also important to their care, regardless of whether the care is provided in their home state or across state lines. Altering the eligibility processes and procedures as new policies and regulations are enacted should be minimized to the greatest extent possible to prevent loss of coverage. This is true whether the care is provided in their home state or across state lines. We ask CMS to uphold these important protections and ensure they are not inadvertently diminished and protect Medicaid program funding as new policies are proposed or implemented to ensure children's health and ability to receive needed health care services outside their home state continue.

Further Implement the ACE Kids Act. Another opportunity to better coordinate out-of-state care for children with medically complex conditions is implementation of the Advancing Care for Exceptional Kids Act ("ACE Kids Act"). The ACE Kids Act establishes more consistency across states for this small group of children with very complex medical needs to begin to address the challenges they face accessing care outside their home states. For states that opt in, we expect the health homes tailored to this population will provide better coordinated care across state lines, better supporting families as they deal with administrative and other burdens associated with traveling for care. In addition, having a consistent framework for implementation to support states, providers and children who participate in ACE Kids-- including guidance on how best to operationalize the ACE Kid eligible child definition and consistent quality metrics tailored to this population--will be important to delivering on the legislative intent to streamline and better support care across state lines. A consistent way of operationalizing across states will also enable better national data to identify care patterns, gaps, costs and quality improvement opportunities for this population of children. More consistency for accessing and coordinating care across state lines and better data on children's needs will best enable states and providers when providing the best quality care for children with complex medical conditions, no matter where needed care is provided.

Encourage consistent approaches that work across states. As discussed above, the inconsistent approaches among states creates regulatory burdens and puts paperwork ahead of patient care. Although we understand that, as a joint federal/state program, Medicaid programs will have some variability among states, care could be improved with standardization for this small, but very complex (and therefore very expensive) population that must cross state lines for care. More consistency in policies like credentialing, payment and telehealth rules would greatly help both in Medicaid managed care and in fee-for-service Medicaid.

Specific Policy Recommendations

Building on the foundational concepts outlined above, we recommend the following specific policies that CMS could implement to increase consistency between states and reduce challenges for children requiring out-of-state care:

* Undertake an examination of this population of children, their care patterns, reimbursement and quality of care to do a better job of supporting care across states and fast tracking patient access to out-of-state care when needed. This is a known population of children and through such an examination we should be able to identify where we can do a better job of supporting this care and streamlining policies and procedures. There should be clear guidelines and processes across states to better support care for this very medically vulnerable population of children.

* Streamline out-of-state Medicaid provider enrollment and screening. CMS should strongly encourage states to streamline their enrollment and screening requirements for out-of-state Medicaid providers. Several states already accept the home state enrollment of the provider and/or providers' Medicare enrollment. If more states used this approach, it would cut back significantly on the administrative burden on providers and result in more timely care for children. We support legislation introduced in the House--Accelerating Kids' Access to Care Act (H.R. 5900)-- that would allow a streamlined pathway to enrollment and screening similar to some states' current policies to ensure this approach is adopted more consistently across states.

* Provide support and guidance on telehealth. We ask CMS to provide guidance on the use of telehealth, outlining current authority and rules around use and payment under Medicaid-- particularly for this population of children. Robust telehealth networks with appropriate reimbursement for provider-to-provider (primary care to complex clinic care) communication while a child is in an exam room or after a child returns to their home state would help significantly. Supporting this critical communication between the specialty provider and community providers will help ensure children stay as close to home as possible and only travel when necessary to specialty clinics or children's hospitals.

* Support more consistency in the out-of-state care administrative processes, including the following:

- Develop a template for a single case agreement and encourage state/health plan use.

- Provide guidance and best practices to states on approving out-of-state care to streamline the process, make the process more transparent for children and families and establish appropriate timelines/criteria for decisions.

- Encourage states to have consistent policies on out-of-state care for all their Medicaid managed care plans, including consistent provisions in Medicaid managed care contracts on out-of-state care.

- Encourage states to ensure that, if health plans include providers in children's care plans, then the provider should be included in their provider network or have an agreement in place for that care.

- Explore how best to identify the specific pediatric services children within a state will need to obtain out-of-state care in their Medicaid state plan amendments.

* Additional support for families. The sharing of best practices on how to support families requiring out- of-state care should be a key element of guidance to states. There is a need for additional support/training provided to family organizations to help support children and families as they access care outside the state and for identification of resources available to help with additional costs related to out-of-state travel for care. In addition, encouraging states to pay for family navigators to better support families who need to access care outside of their home state should be included in CMS' guidance to states.

* Explore and address the current state of Medicaid payment for out-of-state care. We ask CMS to conduct a review of Medicaid out-of-state payment, related opportunities and related challenges, including the fact that out-of-state costs are often not reflected in in-state base rates or supplemental payments. We also ask CMS to explore a CMMI demonstration project to test new and creative approaches to payment, including allowing Medicaid funds to more clearly and seamlessly follow the child across state lines.

* Use of non-face-to-face encounters and chronic condition management codes. States that have reimbursed for non-face-to-face encounters and used chronic care management codes for payment have more effectively supported out-of-state care. CMS should explore how best to share these best practices and encourage other states to adopt this approach.

* Support additional sharing of information across care settings. As interoperability is rolled out, CMS should keep front of mind the need for consistent, reliable flow of clinic notes to out-of-state primary care providers and secure e-communications between state agencies and interstate providers.

Once again, we thank you for the opportunity to provide comment on this RFI. If you have any questions regarding the aforementioned, please feel free to contact me via email at [email protected].

Sincerely,

Matt Cook

President, Riley Children's Health

Chief Strategy Officer, Indiana University Health

* * *

The proposed rule can be viewed at: https://beta.regulations.gov/document/CMS-2020-0006-0001

TARGETED NEWS SERVICE (founded 2004) features non-partisan 'edited journalism' news briefs and information for news organizations, public policy groups and individuals; as well as 'gathered' public policy information, including news releases, reports, speeches. For more information contact MYRON STRUCK, editor, [email protected], Springfield, Virginia; 703/304-1897; https://targetednews.com