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Transcription:

Fred: Hello and welcome to Avalere’s seventh podcast in our series on COVID-19. My name is Fred Bentley, and I am the Managing Director for our Health Plans and Providers practice. I am joined by my colleague, Heather Flynn, a Consultant on our team who specializes in the post-acute care (PAC) space. The focus for our conversation today is on the implications of PAC for providers in the near-term and long-term, as a result of COVID-19. To dive in, Heather, a lot has been released by the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS) related to PAC and long-term care facilities (LTCFs) at lightning speed for our industry. In your opinion, what are the big changes that have happened?

Heather: There are a few things happening at the federal level. Last week, CMS released additional guidance specifically for LTCFs. In this guidance, CMS along with the Centers for Disease Control and Prevention (CDC) strengthened previous recommendations to cover what facilities should be immediately adopting. This includes that any person in a LTCF should be screened for symptoms and temperature checks, including visitors, staff, as well as daily checks on residents. Other items that were strengthened were that every personnel should be wearing personal protective equipment (PPE) and that facilities should be designating separate locations and staff to care for patients that are either diagnosed or suspected of having COVID-19.

Fred: Right, and even as there is a lot going on at the federal level from CMS and CDC, states are also active here. Can you give us a sense of what some of the more advanced states or states who have gotten out ahead of this are doing, pertaining to PAC?

Heather: States are doing a few things. States are taking these general guidelines from CMS and CDC and making them into strict orders. An example would be Governor Hogan in Maryland, who recently ordered an emergency order after they saw a spike in COVID-19 cases in nursing homes across the state. That emergency order not only gave nursing home residents expedited COVID-19 tests, but also strictly ordered staff to wear PPE and require nursing homes to separate patients who tested positive for COVID-19. So, the purpose of issuing that emergency order redirected supplies and tests to nursing homes in that state. This is a redirection of equipment that other states are not seeing. Some other states are going in the opposite direction, where they are directing nursing homes to specifically care for COVID-19 patients. For example, New York specifically directed nursing homes to accept patients affected by COVID-19, who were discharged from the hospital but are still actively recovering, to free up hospital beds and open room for more severe patients that need to be in those in-patient beds. In Massachusetts, we see similar actions, where they are designating specific nursing facilities to care for positive COVID-19 patients.

Fred: That is helpful! It is interesting, going back to the emergency order that my governor [Larry Hogan] issued – I am in Bethesda, Maryland holed up in a home office – which had requirements around gear and testing. It is great and I think we would all probably agree that it is important to do. It is one thing to say it, and another to have the tests and equipment. Anybody who has not been living under a rock knows that this is a massive challenge. Not that you may have all the answers, but do you have any insights or thoughts on how this gets resolved or gets addressed?

Heather: Yes, and that is a good point! I think this is what nursing facilities are struggling with. Of course, they would love to have all their staff wear PPE, but as we know, there is a huge shortage of masks, gloves, gowns and the like. The American Health Care Association (AHCA) responded to the guidelines laid out by CMS and the CDC, agreeing with the recommendations noted, but also noting that it is not possible for many nursing facilities to comply with these recommendations because there are so many shortages of PPE. While CMS is urging states to consider nursing facilities and the high need of these patients in the nursing facilities to have tests and staff with equipment, many are noting the shortages and it is just not possible currently.

Fred: It is also worth noting that even as some of the states are imposing specific requirements, and CMS and CDC are getting more prescriptive, CMS has also introduced some sweeping flexibilities to the healthcare industry broadly and particularly for PAC providers. Heather, I would love to hear your perspective on what is most significant?

Heather: Yeah, absolutely. CMS has issued quite a few rounds of flexibilities. I will say there are 3 that have targeted PAC more specifically.

• The first, which is also wide reaching, is expanding reimbursement for Medicare telehealth. CMS has done a few things here. For example, CMS is temporarily removing frequency limitations on how often you can use telehealth visits and be reimbursed for it under Medicare. CMS is also more flexible with provider-specific considerations. For example, for inpatient rehab, they are allowing the required 3 visits per week to be done virtually. In hospice they are allowing recertification to be done through telehealth. There is a lot of telehealth expansion during this time.
• The second is the use of skilled nursing facilities (SNFs) and waivers. Generally, there is a required 3-day patient stay before you can get covered for an inpatient SNF under Medicare. They are temporarily waiving that, as well as allowing for SNF coverage to continue, even if you do not have that “break in spell of illness” that is generally required for Medicare coverage.
• Lastly, for home health, CMS has also issued an interim final rule that expands the definition of what they define as homebound, so that more patients can qualify for Medicare homebound health coverage and recover in their home with this care. This is specific to patients who are confirmed or suspected of COVID-19. It gives home health agencies flexibilities to use telehealth and remote patient monitoring to care for these patients. Additionally, with any drug infusions that might be necessary, there are some flexibilities added to give physicians more flexibility in terms of any clinical conditions of coverage in home infusion and related oversight that was required.

Fred: I want to circle back to those sweeping new flexibilities. Especially for the long-term implications for how care is delivered and managed in the post-acute setting, as a result to some of these changes. In terms of the here and now, I would like to get your take on what is going on from a business standpoint for our clients that span the post-acute continuum, from home health to SNFs to LTAFs?

Heather: Yeah, to your point of the here and now Fred, I think there are 2 big pieces that are impacting these facilities both from a financial perspective and an operational perspective in terms of patient mix and volume.

• From a financial aspect, there is going to be some relief for these facilities as CMS has temporarily lifted the Medicare sequester, which reduced payments to these providers by 2%. So, these providers will get that 2% and have the sequester lifted until the end of 2020. This will boost payments to hospitals, physicians, nursing homes, home health and the like.
• From the operational perspective, I think there will be a noticeable shift in patient mix and volume as we get through this crisis. As elective procedures and surgeries are suspended or postponed, these providers will see fewer of those cases and more COVID-19 patients, especially in states where they are specifically directing COVID-19 patients to a SNF.

Fred: Got it. As we close out this conversation, what are your thoughts in terms of the long-term changes in PAC and long-term care as a result of COVID-19? When we look back 2-3 years from now, what are the big changes that will be obvious to us?

Heather: There have been a few things that I have thought about.

• First to note, that goes without saying, is that there will be an increased focus on infection control and processes used by these facilities to contain infections, like COVID-19 or novel viruses. This is done not only to prevent but also assist if there is a recurrence of COVID-19. But in general, there will be a focus on how facilities would handle these types of situations, to be determined somewhat informally through guidance or more formally through CMS or individual states.
• Also, I think this crisis will highlight the value of telehealth and remote patient care. I imagine the use of technology will continue to be a focus not only through this crisis but beyond. We may see CMS maintain some of these flexibilities during this time, as we note its value and as providers become more familiar with implementing. This situation has forced us to adapt.

Going forward, this might shift how the industry thinks about PAC and the opportunities that the industry must use PAC to shift patients out of the inpatient setting and ensure a higher acuity level of care. This could have a lasting impact on how PAC is used and how other hospitals and organizations partner with these providers moving forward.

Fred: Great! I think we covered a lot of ground here in a short amount of time. Heather, I want to thank you for your insights. Thank you to everyone who tuned in. Feel free to visit our COVID-19 intel center at www.avalere.com/covid-19 for more episodes. As always, do not hesitate to reach out to us.