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Transcription:

Angel: Hello and welcome to episode 10, part 2 in the Avalere Health Essential Voice series focused on the COVID-19 pandemic. Today’s episode will focus on the healthcare provider exemptions and waivers due to the COVID-19 pandemic. My name is Angel Valladares, a consultant in the Center for Healthcare Transformation at Avalere, and I will be discussing these notable impacts to providers with two my colleagues here at Avalere. My background is in population health research, measure development, and data infrastructure and strategy. I am joined today by Sura Edmonds and Penelope Solis, two of my colleagues who are also in the Center for Healthcare Transformation. Sura is an obstetrician/gynecologist (OB/GYN) by training and Penelope has a legal background, also spending more than 15 years working with specialty provider practices in cardiovascular disease (CVD) and diabetes care on the development of their clinical registries and quality measures.

In the previous episode we discussed some of the impacts on providers, but what about the response to some of those impacts? Do we know if providers will be shielded or protected from some of the impacts of not just having COVID-19 patients and changes that need to happen in practice to facilitate that care, but also some of the market wide impacts around declining visits and declining revenue. All of these will impact providers’ ability to keep doors open. It is pretty clear that there will be a number of measurable impacts to performance across many specialties and practice types. What we have tried to investigate is an understanding of what exemptions and waivers for providers participating in performance-based programs could exist. Up to now, from my knowledge, the Centers for Medicare & Medicaid Services (CMS) has mostly given additional funding and flexibilities towards hospitals. Hospitals are likely providing the majority of COVID-19 care. But the guidance from Public Health organizations and departments, as well as many professionals around the country, including the federal government, have directed patients to monitor their symptoms and if they experience specific symptoms of COVID-19 that could indicate a likely exacerbation of a condition, then in that situation they would be able to go to the emergency room if necessary. But much of that care would happen prior to a hospitalization. What we are seeing in terms of places where there is this wave of patients going to the hospital, there is a need to triage as much as possible. Telehealth coverage has been a part of that to expand opportunities for hospitals to provide telehealth, so they are not significantly impacted by a wave of patients. We have seen many examples where hospitals have set up a telehealth infrastructure to be able to filter and triage patients before they reach the emergency room to reduce the wave and crowding of the emergency room. Many of the flexibilities that CMS has provided or has reported have been temporary relaxations to regulations. A larger number of providers can provide telehealth services; this also applies non-hospital providers. So, telehealth is certainly an option to mitigate some of the obstacles that patients encounter in terms of seeking physical in-person care. There doesn’t seem to be existing policies to support severely impacted outpatient providers, specifically those that have been on the front-line areas where you perhaps do not think of large volumes of patients. An example that comes to mind is rural health providers or federally qualified healthcare centers. Those practices are large enough to accommodate multiple types of practitioners and other potential types of clinical practices that are not necessarily thought of at first. CMS is waiving telehealth requirements for a lot of those practices. However, there has not been a lot of policy making to shield the providers from some of these impacts related to volume reduction.

So, when we think of the exemptions and waivers there is a hope that those will be put in place to reduce any of the financial impact or harms the providers are likely to experience regardless, due to significant losses in revenue. What will be interesting to understand is how the provider performance issues described in Part 1 of this episode translate to performance incentives and value-based payments.

Starting with Penelope, from your perspective in CVD care and diabetes care, what are some of the impacts you think are likely to occur in terms of payment, translated from the performance issues you previously shared?

Penelope: When it comes to CVD patients, who require laboratory data such as having their low-density lipoprotein (LDL) levels taken to determine if they need statin medications or having a blood pressure (BP) test performed or having an Estimated Glomerular Filtration Rate (eGFR) tests analyzed, there is a barrier created for the clinician to be able to do what they need to do to comply with those measures. There are potentially two strings that might happen when it comes to those sets of measures.

• Clinicians may decide not to report them and choose alternative measures if they are able to collect the data and have significant data by which to be gauged on those performance measures.
• Others might choose to submit those measures, but what will be interesting is that compared to previous years they will have a smaller population size that they are grappling with for those measures.

So, the benchmarking quality even within the same physician may be different. But when you are talking nationally for those that submit the data, the population size will be lower, and the benchmarking will vary significantly. Which means there will be an impact on performance in quality reporting for the Merit-based Incentive Payment System (MIPS), accounting for 40% of performance for this payment period. Additionally, there is an interesting factor that will trigger potential discussions among measure developers in CMS, surrounding existing measures currently being used. While some may allow for telemedicine to be leveraged, there are some measures that require an in-person consultation, and there is no strategy for whether or not there should be an allowance during a pandemic for data reporting that can be collected by the patient at home, using something like a blood pressure cuff that records readings that could be then transmitted to the physician. It will be interesting to see how this pandemic will necessitate a need to look at existing measures and spur additional thoughts and innovations, especially for home monitoring devices.

Angel: Those were really great examples. And brings up the question for me, in terms of strategy for the payers, specifically CMS, who we have mostly talked about regarding opportunities to adapt for measures supporting telehealth. Specifically, including telehealth codes as a covered encounter or explore a blanket waiver or blanket exemption for unreliable data. When thinking long-term, MIPS is focused on improvement year over year, so that does factor into scoring and payment. This is not only how you improve to the benchmark, which is the performance threshold set for all providers participating in the program, but also your own performance. With year over year performance improvements, this year is significantly impacted especially with patients at-risk and those who have had to delay care. Also compounded by the reduction in volume of visits which limits the pool for incentive payments. The pool of funds that goes for paying for providers that incentive payment is going to be reduced significantly as many providers unfortunately will have not seen enough patients to participate in the program. Sura, I am curious if you have any thoughts on the payment impacts for specialists in OB/GYN?

Sura: Sure! We have to acknowledge that there will be delays in the recommended preventive women’s health screenings like breast cancer screenings and cervical screenings, including Pap tests. Anecdotally, I have heard from my colleagues that some providers are not getting proper payment from insurers for their telehealth services that have been rendered during this time. I do not know if this is temporary as something new. Hopefully, this is something that will be worked out and not happening across the board. From a specialty perspective, I think those tied to performance-based payment are likely gynecologic oncologists. These are OB/GYNs with special training in cancers that affect female patients. And these are the physicians in this field that are most likely to participate in MIPS, due to the Medicare age group that they primarily serve. In addition, there are some providers in Medicaid programs who are providing maternal care to women with Medicaid coverage who could be managed in a managed care setting. And in this area the impacts will vary depending on the state that the provider is currently practicing within.

Angel: Great. Across the 3 groups we have hit on many common and also interesting and unique threads, particularly the impacts specialty providers and primary care and general practitioners. The programs that are managed by CMS and potentially some of the private payers, who have performance-based incentive programs have their work cut out for them. There are several impacts that participating providers and their respective patients have and will continue experiencing throughout the COVID-19 pandemic.

Thank you, Penelope and Sura for joining me today. Your insights are invaluable to our listeners. Thank you all for tuning in to Avalere Health Essential Voice. Stay tuned for part 3 of this episode, where we will discuss the impacts on provider performance-based payment incentives. If you would like to learn more please visit to our COVID-19 Intel Center. Thanks again!