Apr 24, 2020
By Farlyn Lucas
Most Americans do not remember when the last global pandemic was. If you weren’t in one of the only five American states that were hit by the H1N1 (Swine Flu) virus, you may not even remember the panic that spread in April of 2009. There were. 60.8 million cases in one year that resulted in 12,469 American deaths. H1N1 infected approximately 24% of the world’s population. That was the flu.
The global pandemic we are now in the throes of is not the flu. This is COVID-19. On December 31, 2019; a pneumonia strain of unknown cause was reported to the World Health Organization in Wuhan, China. At the rate this respiratory virus is spreading across the world, the statistics show that it won’t be long before the confirmed Coronavirus cases reach a million. By March 11th, less than two months from the first reported cases, the WHO declared a global pandemic. On that day, there were 118,000 confirmed cases. As of March 27, 2020; there are over half a million cases.
The immediate question at hand is: how will the most susceptible American population receive care without being exposed to the virus, who decides who these patients are, and how will physicians get reimbursed for treatment when the PGDM just took effect the day after the virus was reported in Wuhan?
Defining High Risk Patients
Foremost, any human of any stage in life can contract COVID-19. No one should assume they are impervious. There are, indeed, parts of our population that are at a higher risk than others of contracting the virus. Based on medical expertise anyone over the age of 65 (especially if cancer, diabetes, or any other immunosuppressive conditions exist). Addition risks exist for:
● Residents of nursing homes or long-term post-acute facilities
● Other conditions that create susceptibility are:
o Patients with chronic lung diseases such as asthma, emphysema, or COPD
o Cardiac patients
o The wide range of patients who are immunocompromised including
▪ Cancer patients
▪ Renal failure
▪ Liver disease
▪ Chronic wound patients
o Pregnant women
o Any patient that has been on prolonged corticosteroid treatment
The question at hand stands to be, how do the already medically frail population of our nation get the healthcare they need without being exposed to the symptomatic and the asymptomatic?
Telemedicine. Where technology and medicine meet miraculously just in time.
Telemedicine is a subset of telehealth. Telemedicine connects the patient to the doctor for the provision of clinical care from a distance by way of telecommunications technology. Patients receive treatment via the internet or a telephone. Video visits, emails secured through a patient portal, and the monitoring of a patient’s vitals are possible with telemedicine.
Telehealth also includes the non-clinical methods of utilizing telecommunications by patient education sent to a patient regarding management conditions, education on a new diagnosis, self-monitoring, and medical record management. Telemedicine is private and secure, conducted only on an encrypted platform designed specifically for this purpose. Consumer applications such as Facetime are not secure enough to guarantee privacy.
Telemedicine has been used for healthcare delivery since the 1960s when NASA began utilizing it to provide healthcare to astronauts. Telemedicine is safe, it is cost-effective, and most of all it keeps at risk patients in their homes rather than going to a facility where COVID-19 exposure risk is heightened.
Telemedicine has been a viable solution for patients to receive care from their provider for some time, but as of 2020 it is a necessity for many patients. The risk of exposure to COVID-19 and any other communicable illnesses is eliminated, and their outcomes increase in quality partially because the patient becomes more involved with their own care and treatment. Additionally, providers can protect themselves and their staff as well.
Up until 2020, reimbursements for telemedicine and home health care came by way of HH PPS (home health prospective payment system) which reimbursed agencies for all covered services with payouts in 60-day increments.
The Affordable Care Act came along and gave way to a new payment system: PDGM (Patient-Driven Groupings Model). Section 3131(d) – the Report to Congress identified that the HH PPS produced lower margins for patients such as:
● Those with traumatic wounds or ulcers
● Those who require substantial assistance with bathing
● Those admitted to home health as a transition from post-acute stays
● Those with poorly controlled clinical conditions
In 2018 MedPac recommended a 5% home health payment rate reduction, but CMS announced in October of 2018 that there would be a 2.2% home health payment increase. It was determined that HH payments should not be based on the number of visits but determined by the patient's characteristics instead.
The reform of payment was solidified by the Bipartisan Budget Act of 2018. The act eliminated therapy thresholds and payment episodes transitioned from sixty days to thirty. The PGDM is based on five main case-mix variables which are:
● Admission source and timing
o Community early
o Community late
o Institutional early
o Institutional late
● Clinical grouping
o Neuro rehab
o Wound care
o Complex nursing intervention
o MS rehab
o Behavioral health
▪ Surgical aftercare
▪ Infectious disease/neoplasms/blood forming diseases
● Functional impairment level
● Comorbidity adjustment
One of the most frequent clinical groupings of the PGDM is wound care. According to the CMS wound care utilizes the most resources with the average reimbursement being $2,090.83. With federal and state officials urging Americans (especially older adults) to stay at home to limit the spread of the Coronavirus, President Trump has made it easier to utilize telehealth options for Medicare and Medicaid patients.
Medicare recipients are now able to visit with any physician by either phone or video conference and there will be no additional costs. All providers should have received the most recent federal health privacy laws which have been relaxed to include FaceTime and Skype as tools for telehealth. This step gives clinicians that are on the frontlines of this battle against COVID-19 the flexibility and freedom to provide treatment to their patients while preventing exposure for their patients and themselves.
This transition will allow beneficiaries to visit their doctors remotely for check-up and to monitor chronic conditions (such as wound care) that would usually take place in person at the clinician’s office. This does not apply only to patients that are at home, skilled nursing facility residents also can have telehealth consultations with their team of doctors. Regular Medicare copays will still be charged, but clinicians can reduce or waive cost-sharing for telemedicine.
There have already been a number of Medicare Advantage and Medicare Part D benefits that have been changed in order to influence the impact of the outbreak on the healthcare system and make care readily available to recipients (especially for those who are in the high-risk category).
The changes include:
● Waiver of cost-sharing for testing for COVID-19
● Waiver of cost-sharing for treatments delivered by telemedicine
● Prior authorization requirements removed
● Limits on prescription refills waived
● Restrictions on delivery of medications relaxed
Coronavirus may have Changed the Definition of Healthcare Delivery Permanently
No one can say how long it will take before the Coronavirus is not a global pandemic. The United States has now surprised China and Italy in cases, therefore it has not even peaked yet. Is it possible that delivery healthcare may have been redefined? Will patients with compromised immunity be able to see their physicians via telemedicine even after the outbreak has flatlined and we see a downward curve in the data? This all remains to be seen. For now, we must focus on following the guidelines of the CDC and WHO to impact the spread of this nightmarish disease.
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