University of Michigan Hospitals & Health Centers Issues Public Comment on Centers for Medicare & Medicaid Services Rule

WASHINGTON, July 7 -- Margie Andreae, chief medical officer, and David Spahlinger, president, of the University of Michigan Hospitals and Health Centers, Ann Arbor, have issued a public comment on the Centers for Medicare and Medicaid Services' rule entitled "Medicare and Medicaid Programs, Basic Health Program, and Exchanges: Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program". The comment was written on June 30, 2020, and posted on July 6, 2020:

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On behalf of the University of Michigan Health System (UMHS) known nationally for excellence in patient care, education and research, composed of the University of Michigan Hospitals and Health Centers and the University of Michigan Medical School which includes more than 1,800 physician faculty members performing over 46,000 inpatient discharges and 2,000,000 outpatient visits annually, we appreciate the opportunity to provide comments on the Centers for Medicare and Medicaid Services (CMS) Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-- 19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program interim final rule with comment period published in the May 8 th, 2020 Federal Register.

The UMHS welcomes and strongly supports the steps taken by CMS to broaden access to care delivered via telehealth and other communication technology-based services. Expanding access to telehealth services not only provides the necessary tools for beneficiaries to access healthcare, but also acknowledges the growing importance of using cost effective care delivery models to enable healthcare organizations and providers to better serve their communities. There has been a national surge in telehealth activity in response to the COVID-19 pandemic. The UMHS has leveraged many virtual modalities and rapid telehealth deployment to care for patients who otherwise would have visited the hospital, clinics or the emergency department. Telehealth services not only prevented exposure to COVID-19 for those patients who were able to receive care at home but served as a mechanism to deter the spread of a highly infectious disease and allowed patients who were afraid of getting sick while visiting the medical center to still access much needed care. However, widespread access to telehealth services remains restricted, and extending coverage for these services will serve to mitigate patient access issues while also enabling the delivery of more cost-effective care beyond the current public health emergency (PHE). Both our patients and our clinicians have expressed a strong desire to continue with telehealth services into the future.

Furnishing Outpatient Services in Temporary Expansion Locations of a Hospital or a Community Mental Health Center (Including the Patient's Home)

Hospital Services Accompanying a Professional Service Furnished Via Telehealth

The UMHS commends CMS for recognizing that the majority of hospital services are provided in conjunction with professional services of physicians and other practitioners and that the hospital continues to provide administrative and clinical support for these services when delivered via telehealth. Employed physicians and other qualified health care professionals (QHPs) at the UMHS ordinarily practice in provider-based clinics where the hospital receives separate payment for overhead, equipment, and staff labor to support the delivery of care. To address these costs, CMS is allowing the hospital to report Q3014--the originating site fee--for remote services furnished by hospital-based clinicians to patients in the hospital including temporary expansion site such as patients home. Expanding the ability of physicians and QHPs to deliver care via telehealth requires investment in critical technology and software infrastructure over and above the normal equipment costs associated with care delivery not covered by the originating site fee. During and after the COVID-19 PHE, telehealth services should continue to be provided by physicians and other QHPs in the provider-based facilities to patients located in their homes or other appropriate locations. We strongly recommend permitting the hospital facility to report the same facility fee G0463 for telehealth services to patients in their home that is allowed for in-person visits to allow for appropriate coverage of the costs of these services and true parity.

Payment tor Audio-Only Telephone Evaluation and Management Services

The UMHS is encouraged by CMS's decision to allow audio-only communication between patients and practitioners when clinically appropriate during the PHE, although these services were previously not covered under the Physician Fee Schedule (PFS). This is especially critical for those patients for whom the two-way audio and visual technology required to furnish telehealth services per Medicare's definition is prohibitive. During the PHE, clinicians at the UMHS have leveraged telephone calls in place of in-person evaluation and management (E/M) services often due to patient hardship. The technological or connectivity limitations experienced by some beneficiaries will not be mitigated or eliminated following the PHE. Access to video-enabled communication technology from patient homes, or entire communities in some remote geographic areas, may still not be available even if the practitioner would otherwise have used telehealth to evaluate and manage the patient's medical concerns.

The UMHS is pleased that CMS recognizes the substitution of office and outpatient telehealth visits with audio-only services for beneficiaries who cannot access video-enabled telecommunications technology and applauds the establishment of RVUs for telephone E/M services analogous to office visit E/M codes and based on time. This is consistent with the experience of clinicians at the UMHS, that have seen an unexpectedly high increase in telephone visit utilization to deliver E/M services. The UMHS also supports CMS's addition of audio-only services to the list of Medicare telehealth services for the duration of the PHE. In addition, the UMHS strongly advocates for extension beyond the PHE for the above-mentioned reasons with respect to beneficiaries' lack of access to video-enabled communication remaining, regardless of the PHE ending. Discontinuation of coverage for these services will leave significant care gaps for beneficiaries. The UMHS strongly advocates for continued payment for E/M services delivered by audio-only communication in cases where beneficiaries do not have access to two-way audio-video communications technology.

Updating the Medicare Telehealth List

The UMHS commends CMS for adding many services to the list of eligible Medicare telehealth services, eliminating frequency limitations and other requirements associated with particular telehealth services and for establishing a subregulatory process to add services to the Medicare telehealth list. In addition, the UMHS would advocate for the continued inclusion of expanded services as eligible Medicare telehealth services beyond the duration of the PHE.

Payment for Remote Physiologic Monitoring (RPM) Services Furnished During the COVID-19 Public Health Emergency

The UMHS applauds CMS's recognition of RPM services' ability to increase access to care, improve patient outcomes and avoid unnecessarily emergency department visits and admissions/readmissions. Faculty physicians and practitioners at the UMHS have used RPM services just as described in the interim final rule, including to follow patients with acute respiratory symptoms to monitor pulse and oxygen saturation levels using pulse oximetry. Physicians, nurses and other staff have partnered to monitor patient data, check in with patients as needed, and determine whether the patient can remain at home and engage in self-care.

The UMHS strongly supports allowing RPM services to be provided to new patients in addition to established patients, and by auxiliary personnel performing monitoring under general supervision. The UMHS also commends CMS for establishing a policy to allow RPM services to be reported for periods of time that are fewer than 16 (CPT code 99454) or 30 (CPT codes 99091, 99453, 99457, 99458) days. The UMHS advocates for continuing to allow this reporting beyond the duration of the PHE as clinicians will continue enrolling suspected and symptomatic COVID-19 patients in these protocols.

Payment for Equipment Essential to Providing Remote Telehealth Services to Patients in their Home

The UMHS has identified cases where care can be safely provided to patients in their home using audio-visual technology but where the patient requires equipment such as a blood pressure machine to complete the care. These cases do not meet remote monitoring service definitions and so patients that do not have access to the equipment in their home are not able to receive this care. An example is prenatal care visits which occur on a periodic basis and require blood pressure checks at these visits but not between visits. Patients who do not have a blood pressure machine at home must be seen in-person for these visits increasing the risk of disease transmission to the pregnant mother and her unborn child. The UMHS recommends that CMS provide a mechanism for patients to purchase required monitoring equipment for in-home care.

The UMHS appreciates the opportunity to provide comments on the interim final rule and looks forward to working with CMS to ensure that Medicare beneficiaries have the same access to telehealth services that they have benefited from during the PHE.

Sincerely,

Margie Andreae, MD, Chief Medical Officer, Revenue Cycle, University of Michigan Hospitals and Health Centers, and University of Michigan Medical Group and Professor of Pediatrics

David Spahlinger, MD, President, University of Michigan Hospitals and Health Centers, and University of Michigan Medical Group and Executive Vice Dean for Clinical Affairs and Professor of Internal Medicine

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The rule can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0047-0001

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