Moving Beyond COVID-19: Considerations for using PHE Flexibilities to Improve Person-Centered Care
March 3, 2023
In the early days of the pandemic, federal and state governments quickly implemented regulatory flexibilities to ensure that Medicare and Medicaid beneficiaries could receive care safely and in their own community. As policymakers prepare for the end of the COVID-19 public health emergency (PHE), federal and state policymakers will need to determine the path forward for the Medicare and Medicaid flexibilities that were implemented in response to the immediate needs of the pandemic.
This virtual public event featured a diverse panel of experts to discuss considerations for using the PHE flexibilities to improve person-centered, equitable care for older adults, as well as highlighted the background context, and high-level tradeoffs of telehealth policy that policymakers will need to contend with in the near future.
Insights from the recently produced “Leveraging COVID-19 Public Health Emergency Flexibilities to Advance Person-Centered Care for Older Adults and People with Complex Care Needs: A Roadmap for Policymakers” were highlighted during the briefing. Expert panelists underlined how this work coincides with legislative and regulatory actions done to date, including the Consolidated Appropriations Act, 2022 and the Administration’s recent declaration to end the PHE on May 11.
Speakers:
- Anne Tumlinson, M.S., Chief Executive Officer, ATI Advisory
- Stephanie Anthony, J.D., MPH Senior Advisor, Manatt Health
- Amy Bassano, M.A., Managing Director, Medicare, Health Management Associates
- Kristal Vardaman, Ph.D., MSPH, Director, Medicaid Policy and Programs, Aurrera Health Group
- Shelby Harrington, MS, RN, Principal, Quality and Clinical Strategy, Avalere Health
- Adimika Arthur, MPH, Executive Director, HealthTech 4 Medicaid
- Joanne Jee, MPH, Policy Director and Congressional Liaison, Medicaid and CHIP Payment and Access Commission
This event was organized by the Alliance for Health Policy in partnership with ATI Advisory, Health Management Associates (HMA), and Manatt Health, with generous support from The SCAN Foundation (TSF).
Presentation: Slides
Transcript
0:04
Hello, everyone. Thank you for joining today’s briefing. Moving Beyond kind of at 19 Considerations for Using PHD Flexibilities to Improve person centered care. I’m Catherine Martucci, Senior Director of Program Strategy and Management at the Alliance for Health Policy.
0:21
For those of you who are not familiar with the Alliance, welcome, We are a non partisan resource for the policy community, dedicated to advancing knowledge and understanding of policy issues.
0:33
You can join today’s conversation on Twitter, using the hashtag, all health live, and join our community Animal Health Policy, as well as on Facebook and LinkedIn.
0:44
And today’s event will have a couple of Q&A sections. And we want this to be as interactive as possible. So please get your questions ready.
0:52
You should see a dashboard on the right side of your web browser that has a speech bubble icon or a question mark. And you can use that to submit questions you have for the panelists at anytime. And you can also use that chat feature to chat any technical issues you may be experiencing, and someone will attempt to help you.
1:14
And the Lions believes a better healthcare system begins with a balanced exchange of evidence experience and multiple perspectives. So, we are so pleased to be hosting this convening today, which is the result of a year long, multi stakeholder process and has included many partners along the way, some of which are noted on this slide. And Tomlinson at HAI advisory, Amy Bassano, Jennifer … Health Management Associates and Stephanie Anthony Admin at how thank you all so much for your technical guidance and facilitation support throughout the project. Christie Gallery Read also contributed to this work by conducting a diversity, equity, and inclusion literature review to further assess the impact of DEI on T G flexibilities. And this work was woven throughout the process, and a summary of her work is available in the Roadmap document appendix. You’ll learn much more about the roadmap throughout this presentation.
2:13
And thank you to the working group members as well whose insights and feedback guided the development of the roadmap. You will also learn more about this incredible group during the event. And last but not least, the Scan Foundation.
2:25
Thank you so much for generously supporting this work and I’m so pleased to introduce doctor …, who serves as the president and chief executive officer of the Scan Foundation. She currently also is an associate professor at the Kaiser Permanente School of Medicine and a practicing internal medicine physician. She earned her MD from Boston University, her MPH from Harvard, and her MBA from UCLA. Wonderful to have you on to give some opening remarks.
2:55
Thanks, doctor Maha …, Thank you. Good morning. Good afternoon. And, hello, my name is Sarah …, and I serve as the President and CEO of the Scan Foundation.
3:07
The … Foundation is an independent public charity, and we are devoted to transforming care for older adults in ways that really preserve dignity and encourage independence.
3:19
We envision a society where every older adult has the choices and opportunity to age well.
3:26
And we pursue this vision by igniting bold and equitable changes, and how older adults age in both home and community. And we really thank the partners. And, I know many of the partners were already mentioned for their Leadership Alliance for Health Policy, Health Management Associates, Manatt Health, … Advisory, Christy Guillory, Reed, who, as I mentioned, was a Consultant for Diversity, Equity, and Inclusion. We also want to thank the working group members for their time, effort, deliberation in producing this important roadmap.
4:00
And thank the experts joining to share their really on the ground experiences with Telehealth and other flexibilities.
4:08
As we all know, the pandemic spurred innovation within Medicare and Medicaid, just when people needed it the most. And as mentioned, I’m a practicing internal medicine physician, and I continued to see patients virtually.
4:21
And I personally witnessed during the pandemic the necessity of telehealth services, which was accelerated and scaled through much needed partnership, creativity, and modernization of services.
4:34
The scan Foundation is truly proud to have supported this work to elevate the temporary Medicare and Medicaid flexibilities that most advances person centered and equitable care for older Americans.
4:48
There has been bipartisan consensus to temporarily extend several telehealth flexibilities, and I hope we can build upon that as we think about the future of these policies that will soon expire. So, I look forward to today’s discussion and I really thank everyone in attendance for your time on this really important topics. So, with that, I will turn it back to you Kathryn.
5:16
E: And and now I’m pleased to introduce our moderator for the rest of the event and Tomlinson and is Founder and CEO of … Advisory, which is a national research and consulting firm. She also founded and run …, an online and in person community that connects family caregivers with each other for support and information. And she serves on numerous other non-profit boards and advisory boards, and she spent her early career working in government first, as a Congressional staffer. and then at OMB. So, so glad we have your expertise on today to guide this conversation. I’ll turn it over to you.
5:54
Great. Thank you so much. I’m really grateful to all of you, for, especially the Alliance for Health Policy, for all of the work that you’ve done to make this possible, for letting me be part of it.
6:05
Sarah, and I, I am your moderator for today, and I will just do a little bit of setup here, by saying, and it’s, I’m sure everybody on this call is aware, ah.
6:18
Barrel.
6:18
And state governments quickly implemented, just do a wide range and large number of regulatory flexibilities in the early days of the pandemic to ensure that Medicare and Medicaid beneficiaries can receive care safely in their homes and in their community.
6:35
And we are now at a pivot point or a really important turning point, as the policymakers prepare for the …, 90, public health emergency and, you know, making some kind of really important decisions about what the path forward will be for these flexibilities.
6:52
And so, we’re really lucky to be here today, reviewing work that the scan Foundation funded with the Alliance and …
7:03
to produce essentially a roadmap for policymakers based on the discussions and deliberations of our very diverse working group.
7:11
So the first part of this event will outline the approach and insights from this roadmap and feature someone from the working group to reflect on that.
7:19
And then given that telehealth is such a top of mind priority for the policy community, we’re going to take the second portion of the event and explore tradeoffs, a telehealth policy that decision makers will need to contend with in the near future.
7:32
So, with that, let me go ahead and introduce the panel for our first section, we can get right, get right to it. Crystal Vitamin. I’m so thrilled to be able to introduce, or, I’m a huge fan, Crystal. And I have known each other since the very beginning of her career. She is now the Director of Medicaid Policy and Programs that are of Health group.
7:53
She joined the firm in about a year ago, April 20, 22.
7:58
She is almost two decades of public policy analysis, program evaluation experience, cross public and private sectors, lot of expertise and long-term services and supports dual eligibles, social tolerance of health, health equity.
8:13
So, she works closely with clients in her current role to help them and implementing programs for older adults or people with disabilities.
8:22
So, you need to sign out as a managing director at … for Medicare, at each of me.
8:29
She’s a nationally recognized health policy expert. She’s got over also my multiple decades experience, joins, H, mi, Xi Xi has recently joined Each It May, as a managing director micro services, after serving as deputy director for the Center for Medicare and Medicaid Innovation is at CMS.
8:48
And has many years of experience in the federal government, CMS, and OMB, and not. Stephanie.
8:54
Anthony is a senior advisor at Mental Health, and she’s a veteran of state and federal health care administration, with also with experience in program design implementation. So it kind of going after the key roles that she’s been in recently that I think informs a lot of her expertise that she brings in this project, was a deputy Medicaid director in Massachusetts, and also a legal advisor and policy analyst at HHS.
9:21
And now, you know who is going to be, you’re going to be hearing from and what their backgrounds are.
9:27
So I’m going to turn it over to Crystal to start off with, with her presentation.
9:35
Great, Thanks so much, Anne, for the introduction. And good afternoon, everyone.
9:40
Next slide, please.
9:44
Next slide, please.
9:45
Thank you. I’d like to begin with a reminder of where we were in those early days of the pandemic and the initial federal response.
9:52
It was January 21, 2020 when the United States had its first confirmed case of coven 19.
9:58
And a public health emergency was declared 10 days later.
10:01
I think we all vividly remember the events of March 2020 in particular.
10:05
We saw a series of congressional and administrative actions that month, including the Coronavirus, Preparedness and Response Supplemental Appropriations Act, 2020, which among its provisions waive certain Medicare restrictions around telehealth and the cares act.
10:19
We also saw that month the invocation of Section 1135 authority, which allows the Secretary of the Department of Health and Human Services to modify or waive certain Medicare, Medicaid, chip, or HIPAA requirements under international or public health emergency.
10:35
Furthermore, in March, the Centers for Medicare and Medicaid Services, or CMS, release four templates to assist states and applying for waivers of federal Medicaid requirements to respond to the pandemic.
10:46
The templates helped States leverage tools such as 915 C Appendix K Waivers, which I’ll say a bit more about in a moment.
10:53
And throughout the pandemic, we saw the enactment of a number of additional relief and recovery bills providing and extending flexibilities and funding to support the covert Response and our Healthcare Infrastructure.
11:03
Most recently in the coronavirus Appropriations Act 2020, we saw some permanent changes made to Medicare as well as some extensions of some flexibilities.
11:12
Next slide, please.
11:15
Next, I want to give you a few more details on some of the waivers CMS issued.
11:19
As of January 2021, CMS had issued over 130 Medicare blanket waivers.
11:24
These are waivers providers did not have to apply for individually.
11:28
And they also approved over 100 other Medicare waivers, use of blanket waivers included helping hospitals create surge capacity, waiving certain licensure and scope of practice requirements to increase workforce capacity, and a variety of flexibilities around telehealth.
11:44
To give you a sense of scale around the results of those telehealth flexibilities, CMS reported that before the pandemic approximately 13,000 Medicare fee for service beneficiaries had received telehealth in a week.
11:56
In April 2020, that number was almost one point seven million beneficiaries.
12:01
On the Medicaid side, CMS approved over 600 Medicaid waivers, State Plan Amendments, and other flexibilities.
12:08
In particular, these flexibilities help states are more beneficiaries in home and community based settings, which were so very important, as we all remember the concentration of kovac cases in institutions in the early months of the pandemic.
12:22
Appendix K waivers in particular help states modify their Section 915 C, Home and Community based Services or HCBS waivers to respond to the pandemic.
12:31
There was really a broad range of changes that states made to their HCBS programs and I’ll name just a few burst as of May 2020 according to an analysis by the Medicaid and chip payment access commission.
12:43
41 states had use Appendix K Waivers to temporarily expand the types of settings where services were provided, like allowing adult day centers to provide personal care.
12:53
And 32 states allowed HCBS payments to go to family members and other legally responsive relatives that hadn’t been permitted prior to expand workforce capacity and given that so many were hesitant to have workers in their home at the time.
13:06
We hear a lot today about what flexibility should be made permanent. But, hopefully, this gives you some sense of how important these flexibilities were to the pandemic response.
13:15
It took a huge and nimble effort, from federal and state partners, providers, plans, and beneficiaries, along with their families and caregivers, to adapt to the circumstances we were thrust into.
13:26
And now, looking ahead, we have the opportunity to take lessons learned and learn about how we can use them to strengthen our response to future emergencies, or, to generally strengthen our healthcare infrastructure.
13:38
And so that was our workgroups charge.
13:40
To assess the flexibilities that should go beyond the PAC, Stephanie and Amy will discuss the group’s assessment process and recommendations further.
13:48
But I want to emphasize that the university universal flexibilities we worked on were those that advanced person centered care, and also that we view these decisions with an equity lens aided by work from Krista Gallery read. I wished Kathryn mentioned is included in the final report.
14:03
And, as a former federal evaluator, I also can’t help but wonder what we can learn about the outcomes of these flexibilities.
14:09
So much had to be put in place quickly to respond to the pandemic and understandably, the priorities at the time did not include a lot of federal or formal evaluation plans, but we can still look back and learn. I use some research methods to analyze data, do qualitative work, and understand more about what the effects have been.
14:26
And looking further down the road, perhaps, that work will produce an evidence base that could inform future policy change.
14:32
So, we’re talking today, in some cases, about what states and providers should be allowed to do. But with more information on outcomes, can we start talking about what federal policy should incentivize them to do, or even require.
14:44
These are the, kind of some of the longer term questions that I have.
14:48
But, with that, I’ll close, and I will turn it over to Stephanie Anthony, and enable Sana. Thank you all.
14:55
OK, thank you, Crystal, and, and really most importantly thank you doctor Mahoney and the scan Foundation for your foresight really and about how transformative the PHD. Related flexibilities would be, and how important it would be for policymakers to think and plan strategically about how to leverage the flexibilities Once the PH was over to permanently improve the Medicare and Medicaid programs, and thank you for supporting all the partners. They’ve already been mentioned on this specific work. And, you know, that helped identify and assess the flexibilities impacts on advancing advancing person centered and equitable care, and then also their future, Amy. And I are going to highlight the findings from the Roadmap Report, the group that’s been referenced, which provides insights from national experts on the future of the PHD Flexibilities, and A Guide for Policymakers. For Advancing person Centered Care for Older Adults and People with Complex Care Needs, You Can.
15:50
Yeah. You can go to the next slide. Next slide. Can go to the next slide. I’m just going to provide some background and context You know, Crystal provided excellent background and context on the PH D the pandemic itself, and the introduction of the flexibility. So I’ll just say, I’m going to provide some background and context on the report and this work itself.
16:09
You know, again, it’s already been announced that hundreds and hundreds of flexibilities were implemented almost on a dime across Medicare and Medicaid.
16:16
There were the scale and scope of them was enormous, but all were designed really to ensure access to care, whether it’s through expanding program eligibility and enrollment, easing program, our administrative requirements, enhancing remote service delivery options, authorizing care, and alternative care sites, and much, much more.
16:34
You know, speaking to the Foundations of Foresight by spring of 2020, 2020, literally within 2 to 3 months of the pandemic starting, The Scan Foundation had engagement, an add on the Medicaid side, an HSA on the Medicare side to inventory and track implementation.
16:50
And the impacts of the flexibilities throughout 24,021.
16:54
And in March of 2022, what the expectations and hopes we all had, that the PHD. Would be ending. Soon, at that time, to elevate a subset of the flexibilities that held the most promise for making the Medicare and Medicaid programs more person centered and more equitable. And that should be considered for permanent policy change by federal and state policymakers. That work is documented in the March 2022 issue Brief and Policymaker Playbook highlighted here.
17:20
And then last summer, the scan Foundation supported all of the partners that you’ve met today so far to convene a small and diverse group of experts and key stakeholders to provide insights and advice on the future of these flexibilities. These insights are documented in the Roadmap, which just came out in January of this year. Last month, in February of 2023, the Biden Administration announced that the PHC would finally be ending on May 11th of this year, a couple more months.
17:48
While some telehealth related Medicare and Medicaid flexibilities have already been extended, on the Medicare side are made permanent by some states on the Medicaid side.
17:57
Without further action, most of the other flexibilities are going to end at the end of the PHD or shortly thereafter. This is where the Roadmap Report is a vital tool that provides expert perspectives and a potential path for federal and state policy makers to consider as they assess the future of the pandemic era flexibilities.
18:16
You can go to the next slide.
18:19
This is a list of October 19, … flexibility, working group members, including Crystal, who met several times over the course of last summer, to discuss and assess the future of the flexibilities and to determine which one should be made permanent based on specific considerations that Amy and I are gonna talk about a little bit. The workgroup members brought diverse perspectives on are really the true authors of the roadmap. We just want to thank them for their time, their contributions, and their insights.
18:45
If we go to the next slide, please.
18:49
So, the working group analyzed 21 of the hundreds of Medicare and Medicaid flexibilities that were selected for their propensity to further person centered care and equitable care and come to consensus on continuing or just continuing their use.
19:02
Based on this decision making framework, you see here flexibilities that the working group reached a broad consensus on making permanent were categorized as green flexibilities that the workgroup felt required, further study, or further modifications were categorized as yellow.
19:18
Flexibilities on which no consensus was able to be obtained, would be categorized as bread. However, the Working group group didn’t find any other flexibilities to fall into that category. And flexibilities that the working group felt were useful in current or potential future emergencies, but should not be made permanent right now. As you know, permanent parts of the Medicare and Medicaid programs were categorized as blue.
19:42
An important point on the slide is that the vote on each flexibility did not have to be unanimous. These were consensus driven, vote, voting, and recommendations.
19:51
And now, I’m going to turn it to Amy who’s gonna talk through some of the principles that guided the group’s work and then also talk about the medical Care flexibilities assessment before I pick up again and talk about the Medicaid flexibilities. So, Amy.
20:05
Great.
20:05
Thanks, Stephanie, and echoing your thanks to the Scan Foundation, and are other supporters in working group members in this process. So, next slide, please.
20:16
So, as the working group got together to think about these flexibilities, and just to emphasize, again, this was a subset of all the hundreds of flexibilities that, uh, Medicare and Medicaid put into place.
20:30
They were looking at ones that were really trying to, they focus on person centered care.
20:36
And, as they were going through their deliberations, they went through the, they determined they came up with these six principles. And the first one is to prioritize maintaining and Medicare flexibilities that enable that person centered care and that health care that is guided by the individual’s personal values and preferences, and designed to help people achieve that matters the most.
20:55
So, this really was that, The number one thing they, they thought about, and then coming from, you know, along with that, was Health equity in programs and Policies. Looking to achieve the highest level of Health. For all then, Recognizing this. This report, was going to be talking to federal and state policymakers, looking at the data collection. Monitoring, oversight, and transparent reporting. In order to make those decisions, and to continue the looking at access quality of care, and respect, and making sure they’re looking at the perspective of the people who are impacted by the policies. And so, you must use those things to inform the process of thinking about you know, what would be worthy of being continuing continued.
21:41
Equitable access to health care, regardless of the type of coverage or insurance status, yes, these are Medicare and Medicaid flexibilities, but the extent that the Flexibilities could could impact more than that, looking at, looking at that issue, as well. And then, on the state side, states differ. Medicaid programs are all different across the country and that they’re going to be looking at the flexibilities in different ways, but that the, making sure that the, but just keeping this in mind, that there could be differences, but also could affect the way the federal federal flexibilities are implemented across the states.
22:19
And then, the recognizing that these are decisions not need in a vacuum, that the policymakers should be considering the person centered and equitable care. But there’s other goals that go along with policymakers making decisions, such as beneficiary protections, program integrity, and other budgetary constraints. And, so, that, this is, this is, this was a lot to take on. A lot of things to be considering, but the working group, you know, kept coming back to these principles as they were making their determinations. So, next slide, please.
22:51
Then, of the flexibility is that they were looking at, they really fell into three broad categories. The first was demanding Telehealth Benefits, which we’ll spend most of our time talking about today.
23:03
And then, there’s also modifying the scope of practice and other related requirements, because there were quite a few flexibilities on provider licensure, scope of practice, practicing across state lines, and then qualifications, and then the payment amounts given to the new, you know, whether you’re expanding the workforce, or, you know, using she looking to use the workforce in different ways as a result of the flexibilities.
23:27
And the third was other flexibilities, other things, such as a three day stay for Hospitalizations, for Skilled Nursing Facilities in Medicare, or Medicaid Side, self directed home and community based services, and other financial eligibility rules.
23:42
And so, they broke down that way and you will see when, as Stephanie and I walk through the specifics of some of these examples of the flexibilities, how they, how they came into those categories. Next slide, please.
23:58
And go to the next one.
23:59
So, I’ll now pivot from talking about the broader working group and how they were thinking about things in the big picture, to talk about some of the key Medicare weaver’s that they were considering.
24:11
And so, when they were looking at Medicare, there was, in addition to the six guiding principles, they were very much interested. The working group was in the operational feasibility of these flexibilities. The waivers themselves were designed They really waived or modify the way Medicare providers and suppliers can deliver care and services. And so, there’s sometimes, you know, thinking about how that connects back to the person centered care aspect of it.
24:41
They wanted, you know, added some additional points in their deliberations and that the, the existing, you know, the programmatic structure that existed pre public health emergency was not necessarily equipped to deliver this new type of care through the flexibilities like sustainable sustainably, a long term basis, or at scale. Really fun thing that all providers were going to be using. So, there needed to be some additional changes to programs, or guardrails in place to think about, if you were taking these flexibilities from using an emergency situation and used only with me potentially, a subset of the Medicare population to how this work, when it’s really done on a permanent thesis, and, you know, applicable to anyone.
25:27
So, the workgroup members wanted to see conforming changes to operational issues, provider enrollment for payment and beneficiary protections, and other changes that would need to be done to really go back to thinking about things in the broader context.
25:41
Also, in terms of the broader context, there’s a lot of other debate going on around Medicare are discussions about financing, movement to value based care, workforce initiatives, and other initiatives to improve health equity. And then, the role of Medicare Advantage is that, you know, as Medicare beneficiaries approach, 50% of enrollment in Medicare Advantage.
26:03
You know, there’s other conversations about the plan, financing, risk adjustment, But then, thinking about what this would look like for a greater population in Medicare Advantage.
26:12
Then, despite all this complexity, you know, focus on how to achieve harmony in person centered, person centered care, both across Medicare and Medicaid, you know, themes that they came back to on a regular basis.
26:27
And so, with that, this next slide, Please, is, is shows. It’s a little hard to read here, but, you know, shows the different flexibilities that were evaluated and their particular working group recommendations. And you will see the green ones, they’re, they’re all telehealth related.
26:48
And so, just to be sort of talked about a little bit, but just for further context, before, the public health emergency, Medicare had a very limited telehealth benefit.
26:57
It had to be delivered from rural locations only in certain very specific locations, not including a patient’s home, only for very limited types of services, and only certain types of providers.
27:11
And so, you know, one of the big lessons learned from this was that, you know, this was, you know, the flexibility, additional flexibility in telehealth, both in a patient’s home, in any geographic area, and notably in urban areas.
27:25
And others, you know, allows, you know, was deemed successful, and really to keep, keep the The incentives, or that really improvement in person centered care, and so that is how the, the working group came to those recommendations on the green.
27:42
The other ones, though, I would say, you know, just a note in terms of telehealth, the the there were the yellows about the payment rates, because it wasn’t clear. you know, what the rate should be. So there was some more conversation about potentially further study. And then other other things here, you can see, you know, where the blue ones were about thinking about scope of practice laws or other facilities that may be appropriate in future emergencies. But not really ready yet to say that. That’s something should be a permanent part of the Medicare program. And so, I’ll give a couple, go into detail a couple more examples on the next, next slide.
28:25
Um, oh, and this was just something about the Medicare policies are changing in the coming time, and I think we’ll hear more about the consolidation appropriate approves, Consolidated Appropriations Act at the end of last year where it did decouple many of the Medicare Telehealth Flexibilities from the public health emergency. And the working group supported the continuation of these flexibilities, as we said about the green boats, and that some of the others are going to sunset in May. And just thinking about those operational issues that the working group had noted about, you know, what that will look like, when some flexibilities continue and some have sunset it. But, you know, that, though, the word to the Policymakers is, you know, think about that, how to make sure that those are operating smoothly and next slide, please.
29:14
And so, here’s an example of one where it was yellow, and that was sitting the payment rates for M visits equal for Telehealth or in person, Medicare. Absent the public health emergency does not pay equal, pays at a lesser setting, lesser amount for the telehealth services. And so thinking about you.
29:34
What is, what are the resources necessary to provide telehealth services versus in person services, and looking for additional study on that and think, you know, evaluation of what those resources be?
29:46
And then thinking about how to set those payment rates at a point in the future to make sure that they are correct. Next slide, please.
29:57
Then, this is one that was blue and are talking about the waving a three day stay for skilled nursing, physician admissions. So, right now, I mean, if your beneficiary has to be an inpatient hospital, inpatient for three days before Medicare will pay for their stay in the skilled nursing facility.
30:17
This is one that’s been, you know, a subject of conversation for many years, even prior to the public health emergency and the flexibilities there about whether this is a good policy or not.
30:28
But this is one in particular, wanted to highlight because the working group was particularly concerned about the health equity issues and disparity issues associated with this policy.
30:38
And if it really was feasible or equitable to continue this policy to require those new time in the inpatient when no clinical care is moving away from that. And then, you know, having to have, you know, access to other services. And is it equitably offered? And so, you know, who would have access to the different alternatives, in, are there disparities there? And so another area for the groups very much interested in, but wanted to have a little bit more study on this to see how it could be applied.
31:13
I think with that, I’m going to turn it back to Stephanie to talk about Medicaid. So I think you flip to that yet to flip to the next slide, and Stephanie will take that. And I think we have time for questions after the Medicaid on on our entire section.
31:29
Great. Thank you, Amy. Here I am, OK. So, I’m gonna. You can quickly check through the Medicaid how the group approach the Medicaid flexibility. So like the Medicare flexibilities, the Medicaid side of the house, you know, the flexibilities here were also designed to expand remote service delivery options.
31:46
You know, stabilize and bolster the workforce.
31:48
Providers maintain continuity of care and seamless access to care and provide home care to new populations and services. But right away like really right from the beginning, the co-worker realized that the Medicaid flexibilities are a little different and should be assessed first separately, but also with a little bit different approach that I’m gonna talk about and that we embedded or the group imbedded in guiding principle number five that Amy had walked through earlier. The scan Foundation.
32:15
You know, do their focus on complex care populations, the Medicaid flexibilities, the group assess for focused on those that enhance access to long term services and supports in home and community based services for older adults and people with disabilities. That was one way the group recognized. There was a kind of uniqueness here with respect to the Medicaid flexibilities, also, unlike most of the Medicare flexibility, states could pursue these reforms, are flexibilities and the absence of a public health emergency under existing Medicaid waiver or state plan authorities. And the future of the Medicaid flexibilities may not be a one size fits all approach, Because there’s wide variation in State, Medicaid program characteristics covered, populations, benefits, and programmatic goals. So, you know, right from the start, the group took a little bit of a different lens on the Medicaid flexibilities and the consensus recommendations related to how state should consider.
33:04
So, you should consider the flexibilities as part of their Medicaid policy toolkit. You know, if the goal is to advance person centered and equitable healthcare and recognize that going forward, individual state circumstances will guide policy decisions and modifications related to the PHD flexibility. So, some of the considerations that the group looked at in their assessment of the Medicaid flexibilities are highlighted on this slide. You know, they were really assessing the flexibilities based on their ability to address persistent challenges in the Medicaid program for accessing person centered care, whether it’s chronic workforce shortages or disparate access to telehealth. You know, they looked at whether policies are the future of the flexibilities would minimize or support alignment between the Medicare and Medicaid programs, particularly for the 12 million dually eligible individuals and their providers.
33:57
You know, Amy just talked about how, you know, in some places on telehealth, for example, Medicare was not doing things that states in some states were doing around originating sites and other uses of telehealth.
34:08
So, you know, to the extent, you know, the return to pre covert policies on the Medicare side could perpetuate existing misalignments. So, the group looked at it with an eye towards, A, better aligning the Medicare and Medicaid programs.
34:22
Um, then, to the extent that states avail themselves of these flexibilities, there was recognition that the states and the federal government, you know, the CMS is jointly funds Medicaid That they have a role in this. They have a role in evaluating what states are doing.
34:38
They all have a role in sharing best practices on the Medicaid side and state side, You know, to the extent that they avail themselves of these long term services and supports related flexibilities. They should think about their broader applicability to other services in the Medicaid program. So that’s generally how this group decided to approach the Medicaid flexibilities. You can go to the next slide.
35:01
So, the roadmap on the Medicaid side focused on eight Medicaid flexibilities of the subset of 21 that were identified in prior work as best promoting and advancing person centered and equitable care.
35:13
There’s a lot of nuances and considerations underlying each of these votes that are, you know, spelled out in the report in more detail. But you can see the consensus votes here.
35:21
If the group landed on five greens to lose and one yellow, I’ll go, I’m going to give examples of a couple of these on the next slides before we wrap up.
35:30
I do want to call out on this slide the asterix flexibility that allowed on the Medicaid side out of state providers to provide services and receive payment for long term services and supports through expedited licensing rules or other special circumstances. This one of the group debated for awhile because there were similar flexibilities on the Medicare side. But, because the Medicare flexibilities in this area tended to authorize the flexibility to, you know, really quote, to the extent allowed, under state law, the group decided to capture this as a Medicaid flexibility. And additionally, because the Medicaid flexibilities that we focused on in the roadmap report were long term services and supports at home and community based services focused, they, you know, they’re often services not typically covered by Medicare.
36:15
The workgroup recommended that if a state implements this authority for out of state Medicaid providers that are also covered by Medicare, then CMS should enable Medicare to reimburse those providers to the, to the extent a state allows.
36:31
You can go to the next slide.
36:33
Quick examples of a green. A balloon, a yellow, telehealth. We’re going to talk a lot more about it.
36:38
We talked earlier about crystaline a lot of facts about what a game changer it was in both the Medicare and Medicaid space and preserving access to services, including for people who use long term services and supports some on a daily basis.
36:50
The group felt that Telehealth will and should play a key role in Medicaid programs going forward. And in fact, about half of states have already expanded telehealth parity permanently, including a few very early in the pandemic. by early of 20 or late 2021 I think Massachusetts and Pennsylvania had started to make these reforms more permanent states expanded telehealth in many ways. Crystal talked about those. So, to the extent that states expand, Telehealth has a modality of service delivery.
37:18
The group felt strongly that states do it carefully and thoughtfully balancing appropriate use of telehealth and in person visits and other considerations and monitor the impacts of expanded telehealth on the workforce. Is it helping or hurting shortages and the impacts on equitable access to broadband and telehealth enabling equipment?
37:38
Go to the next slide.
37:40
This is an example of flexibility. It’s blue. I call them toggle on, toggle off flexibilities on.
37:46
This one is under abroad the broad category of modify, provider, scope of practice but it’s really about provider financial preservation and sustainability.
37:54
Particularly early in the pandemic when no providers were shut down and people were more locked in their houses and it was about increasing provider rates to sustain and bolster the workforce specifically through time, limited retainer payments to providers of personal care services.
38:11
For this one, the group suggested that states could develop health plan contract clauses or an addendum that they could have on the ready, or develop a PHD playbooks with lists of potential flexibilities that they can quickly deploy, and future public health emergencies, and based on the specific type, is a natural disaster, or is it, an infectious disease pandemic.
38:30
States with histories of natural disaster related public Health emergencies, like North Carolina and Florida with floods and hurricanes do, or are considering this type of approach.
38:40
And finally, you can go to the last slide.
38:44
This Medicaid flexibility, eased program requirements by temporarily changing the financial eligibility rules for Medicaid covered long term services and supports through eliminating acid or reset resource tests for populations or excluding certain income or assets from what is counted in determining one’s financial eligibility for Medicaid long term services and supports.
39:06
The workgroup did not come to consensus that this specific flexibility should be made permanent and voted. It yellow are promising.
39:14
Primarily because they felt that states need to balance competing goals here, such as expanding access to Medicaid, long term services, and supports in a way that enables people to keep or preserve more of their assets for other life expenses that could help them remain in the community and avoid or delay institutional care and acknowledging state resource constraints. And that the need to meet, and, you know, states. Have a need to meet state balanced budget requirements.
39:38
And so, for those reasons, they realize that different states may come down, you know, in different places on that equation and that, you know, it’s a promising strategy, but a lot of considerations need to be factored in and they voted. Yes.
39:52
I think with that, Amy and I are happy to take any questions about the roadmap report, the Medicare and Medicaid accessibility questions. And Crystal, also, obviously, she was a member of the workgroup before hearing from our excellent panelists. On Telehealth, some more.
40:08
Great, Thanks so much. All right, Let me just see.
40:13
So we’re, we’re going to take just maybe a couple of minutes to do, a couple of questions, and then we’re going to move along pretty quickly, because we have so many other people we want to hear from.
40:24
But I think a question that’s come up is, what do we think about the future evidenced base.
40:35
I think, in other words, how do we develop an evidence base?
40:40
It seems. I will just say, personally, I feel like it seems too overwhelming.
40:44
You know, research is hard. It takes a long time.
40:48
We need to move quickly, Like, it’s nice to say that we need to have an evidence base, but, just practically speaking, What are some things that policymakers could consider doing, Um, you know, relatively quickly, to build up an evidence base on some of these flexibilities in there, and their efficacy and their cost effectiveness that would help support additional policy change or make policymakers more comfortable was moving forward with more flexibilities?
41:20
Here’s the big one, I think. Yes.
41:24
Good question on that.
41:26
I mean, one of the things that I really grabbed onto in the discussion was flexibilities around a self direction. And particular disbanding, the family caregivers that can be paid to provide HTTPS. I think a lot of, you know, thinking about building the evidence base is going to be around like prioritizing which areas we really want to focus on. And I think that’s one way or prior to the pandemic, there was a lot of interests and giving people with disabilities, you know, more control over the care they receive and managing their care. And so, I think that’s one where, it’s going to be a lot of qualitative work, probably, which is certainly, you know, intense and and difficult. But I think there’s a lot to be learned there. And there’s already so much work underway. I think that’s one way, or maybe it’s further along than some others and figuring out what we can do next.
42:12
OK, super.
42:14
Alright, I’m gonna have one more question, so I’m gonna pop over to Diana, and I know we talk about thank you, Crystal and then we can talk about evidence for, oh, this could be a whole, could be a whole hour on that.
42:24
But, um, so we had a question, how did the mechanics of reaching a consensus on the green, yellow, blue recommendations work?
42:35
Um, no, Amy or Stephanie, do you wanna take a stab at that?
42:43
I’ll start and Amy should jump in.
42:46
And I will start with a lot of honestly, there were great discussions with each other, The group was very engaged, very active, there were a lot of back and forth on nuances considerations. I’m coming from this perspective. I’m coming from this perspective, you know, listening to each other, hearing each other.
43:02
And then, there were, I can’t remember the exact step because I think there was some like straw vote since I’m talking, you know, more final notes.
43:10
But I think that we know it was very smooth, the group was fantastic and, you know, collegial got along. Great and really listen to each other. So, a little bit of it was just hearing each other in their perspectives because people were coming for different perspectives.
43:24
Amy, I don’t know if you want to add more, Kristal, who was involved directly.
43:28
Yeah, and I would say as the conversations, when people would like circle back to other ideas and that’s where some of the principles came from or some of the ideas about the refinements in terms of these were really complex things to be considering. Can’t be done in a vacuum need, to think about how you would scale them. So, I think the things that Stephanie, I both sort of talked about, like, specific to Medicare and Medicaid also. Like, once you’ve got those down, that helps you make it easier to get to consensus, Because you had enough other things to say, like, what you need to think about it. Within this, is not just like in a vacuum that, we all agreed to it. And, so, it really was a great process, and some really interesting, and very robust policy discussions, And so gotten, you know, great working group members who were really thoughtful.
44:09
So, made it easy.
44:12
And I’ll just add that we had a really great mixture of viewpoints. And so, I think with the facilitation that it was remarkable that we came to so much agreement, but it was great because everyone brought their different perspectives, and to inform the discussion.
44:25
And I think that, that those guiding principles made a really big difference, because we were definitely, I will say, just transparently Like we were getting pretty hung up on some of those things, like, you know, how do we, know, you know, everybody acknowledges that We have to be conscious about costs.
44:42
And if it, until we could sort of establish that as a guiding principle.
44:46
I think we were, we were circling around that quite a bit and then having those guiding principles really helped us move on. So.
44:55
You guys, thank you so much.
44:57
This has been great.
44:58
We’re going to move on to the next, Um, So, um, so we’re going to keep our conversation moving, and maybe I’ll ask, I think the way this works is we lose you all and we at the next panel.
45:22
Great. And can you see the presentation I’m sharing right now with the speakers?
45:26
I cannot, just yours up here. OK, great, I’ll just keep going. Thank you, I appreciate that. So, apologies, it might look like my, my video is a little bit delayed as it, as it turns out, so. Oh, great, there we go. Now, I’m seeing everything that somebody OK, So we are, we’re moving on to our next set of panelists who will dive in deeper on considerations for telehealth policy. And I’m really excited about this. We’re going to hear from …, who is the policy director and Congressional liaison at Math.
46:03
And before joining backpack, she was the Program Director at the National Academy for State Health Policy, focusing on children’s coverage issues. She’s been senior Analyst at …, Program Manager at the lewin Group.
46:14
Legislative Analyst in the HHS Office of Legislation has a Master’s of Public Health from you, ever see of California and Los Angeles, UCLA, and a Bachelor of Science from UC Davis.
46:25
So we also have I’d Amica Arthur, who serves as the founding Executive Director for Health Tack for Medicaid. And she brings a population health public health expertise and focus on improving health equity and access to quality care for vulnerable populations. She has a BS in Biochemistry from Clark, Atlanta University and a Master’s Degree in Public Health and Epidemiology and Health Systems for your State of Washington and has spent time at Boston University School of Medicine.
46:59
And we have Shelby Harrington, who works with client support clients and navigating transition to value based care, focused on clinical quality strategy and digital transformation at Adler Health.
47:10
She has helped Life sciences manufacturers develop value based care strategies, and before joining …, Lead, Clinical product and strategy at …, a direct to consumer telemedicine startup.
47:22
Shelby holds a bachelor’s degree in Public Policy from University of North Carolina at Chapel Hill, and Bachelor’s and Master’s degrees in Nursing from Virginia, Commonwealth University. So, we have a you can see we have an incredible panel. Let’s go ahead and get started with Joanna.
47:41
OK, all right, hi everybody, Thank you for that introduction. Really appreciate that.
47:47
So, my job today is to help set the Medicaid context for our thinking about telehealth. Next slide, please.
47:57
I’m just gonna go over some general contextual points, talk a little bit about Medicaid and telehealth before the PHD and during the PHD, and then close out with some thoughts on the evolving policy context. Next slide, please.
48:14
This is just a slide about map path to Medicaid and chip Payment Access Commission. I won’t read it, I just wanted to provide it for those who are unfamiliar with our agency.
48:24
Next slide, please.
48:25
Alright, so foundational to the Medicaid policy context. Is how States and CMS really think about telehealth?
48:34
So this definition is from the CMS medicaid dot gov website, and you can see that the definition is rather expansive and encompasses different types of modalities for for telehealth, as well as the different kinds of technologies that could be used to provide telehealth services. And although we often hear and talk about telehealth as a benefit for purposes of Medicaid, it’s, you know, it’s really not a benefit, per se. It’s really a way of delivering covered services.
49:13
So it’s just like a, an important, but an important distinction there.
49:18
With respect to federal rules, I think the biggest take home in, with respect to Medicaid is that states really have had and continue to have substantial flexibility to design their telehealth policies.
49:37
That means that they can decide whether to cover telehealth, which specialties, which providers, which modalities can be covered with, or can be can occur over telehealth, as well as payment.
49:53
And we know, of course, that payment is an important issue. There are certain requirements and Medicaid that don’t really apply. These include, for example, comparability and state rightness.
50:07
However, states that limit telehealth availability to certain providers or regions must ensure that those services are otherwise available to beneficiaries through in person visits.
50:25
In addition, State Plan Amendments or spa’s are not always required for states that want to use Telehealth in their Medicaid programs. There are some circumstances in which they are required, but as a general matter, states don’t need to submit them in order to provide telehealth.
50:47
And lastly, on this slide here, you’ll see that State Scope of Practice rules apply. And these are rules that CMS has articulated on its website and in other guidances that it has issued.
51:02
Next slide, please.
51:04
So taking a quick look at Medicaid telehealth prior to the PH E As I said, states have always enjoyed a lot of flexibility to design their telehealth policies.
51:17
So this could mean that states could choose to cover different modalities, synchronous or asynchronous telehealth, again, different services or specialties, providers and payment.
51:30
Before 20 20, when the pandemic struck, we do know that nearly all states allow for at least some form of telehealth.
51:39
And, as you can imagine, there was great variability in what that coverage looked like.
51:46
Um, prior to 2020, all states, pretty much, I think it was all, but one covered some form of synchronous or live telehealth. About 21 states covered remote patient monitoring, and about 15 or so covered, store and forward, health.
52:07
Let’s see here, and so, as you can imagine, there are a number of considerations in state decisions for covering telehealth.
52:18
I think that probably many of these aren’t new to you.
52:22
There’s a couple of examples on the slide, connectivity and broadband, access to technology, licensure, privacy, et cetera.
52:33
In the times before the public health emergency, there’s really relatively little known about the level of utilization of telehealth in Medicaid. There was little Medicaid specific research on the use of telehealth as well.
52:49
Um, this includes on spending utilization outcomes and importantly, beneficiary and provider experience. Next slide, please.
53:02
Alright, so turning to the P H E era, again, just sticking with the theme here, federal rules remain flexible.
53:11
I think one sort of important development was that CMS really spent a lot of time and issued several pieces of guidance specific to telehealth, as well as a really helpful toolkit.
53:27
States, in this time, as you know, we’re trying to protect access to coverage for the beneficiaries, So they really leveraged the flexibility in the federal rules, as well as the guidance coming out of CMS and implemented rapid and broad expansions of telehealth coverage.
53:47
In fact, I recall hearing several states saying that they basically threw open the doors to Telehealth to cover, you know, pretty much any Medicaid comfortable service in their state. They really expanded to a wide range of providers and took advantage of as many modalities as they as they could in particular the synchronous telehealth.
54:10
And of course, with that, there was unprecedented growth in use of telehealth.
54:16
There were states that use telehealth, of course, as was alluded to, to provide HCBS related services. But also, I just wanted to flag behavioral health services, where there was really just tremendous use in telehealth during the PHC. Next slide, please.
54:35
So, just a few weeks ago, actually, it was actually just a week ago, I think CMS published its most recent preliminary data snapshot, which is a great treasure trove of data.
54:46
Using administrative data, CMS displays the trend in telehealth use among Medicaid beneficiaries from the beginning of the PH. E 2 July 2022, which is the most recent data that are available. And you can see that sort of bumpy line, that, that purple line, or blue line.
55:08
And you’ll see that telehealth use really peaked in April 2020, plateaued in the months after that. And then, since then, has really started to decline a little bit.
55:21
But if you can see that line, sort of along the X axis there, it’s the purple, lighter purple line, it’s actually dotted. It’s a little hard to see.
55:31
That represents telehealth utilization, in the months in the years prior to the PAC.
55:38
So you can see that, although Telehealth uses declined a little bit or has declined since 20 20, April, it still remains substantially higher than the months before the PHD.
55:51
Next slide, please.
55:54
Alright, so with the end of the PHD, on the horizon I think it’s safe to assume that the policy contexts will continue to evolve quite a bit and as we have discussed already today, states are really thinking about what to do with their pandemic era policies for future.
56:14
With respect to telehealth, you know, states are considering have considered which of these which of their pandemic era telehealth policies to keep.
56:25
Um, as was mentioned before, some states have already made permanent.
56:31
Some of these policies, other states are continue to consider and deliberate on on their policies, and many states have state legislation in process.
56:44
Um, there are some states that are looking at these policies and thinking about certain of them, such as like audio only and payment parity and really thinking about whether those are policies that they might want to key.
56:58
Which, you know, suggests to me that there might be some contraction it’s policies.
57:05
There’s also a number of considerations, I mean, this slide says emerging considerations. I think they were always considerations, but, well, I think they’ve really come to the forefront as we think about future telehealth policies.
57:19
So, how do we ensure equitable access to telehealth for all of Medicaid beneficiaries?
57:26
Particularly when we, when we know that there are disparities in access to reliable broadband service or technologies that are needed to sustain telehealth services.
57:37
How do we think about telehealth in the context of network addicts?
57:43
What are program integrity concerns? Are we seeing anything emerging? And what can be done about them? And, lastly, what about quality? How do we think about quality of services delivered over telehealth?
57:58
Are the measures that we have in play right now and available? Are those the right measures, or do we need to think about measures in a slightly different way? These are all sort of open questions.
58:09
And lastly, you know, as we, as we look to future the future, I think that there is just a tremendous opportunity for additional learning data analysis to really understand the effects of telehealth on access, cost quality, outcomes.
58:28
And, again, really wanted to sort of lift out this idea of understanding the beneficiary experience with telehealth is, and, of course, the providers who are serving members using telehealth.
58:44
So, that’s it. That’s my presentation.
58:49
I thank you and I’m going to pass the mic to at amica in case so much Joanna or Joanne.
59:03
Next slide is fine.
59:05
Good afternoon, my name is … there, and I run a non-profit called Health Tech for Medicaid, and next slide.
59:13
A little bit about … for Medicaid, we’re convening body and we’re dedicated to supporting innovation in Medicaid. So most of my remarks today are really going to be on behalf of the recipients of Medicaid, their caregivers, and families, which ultimately make up more than a fifth of our communities in America. And our purpose that Health Tech for Medicaid is to further improve the quality, equity, and access to care for Medicaid recipients. And we call ourselves a mission based market enabler, because we really are trying to get cross-section.
59:46
Cross sectoral, collaborative partnerships really across building better infrastructure and ecosystem development where health, technology and health equity and and tech equity kind of come together. And so we do a lot of issue and policy advocacy and a lot of insights, which I’ll be sharing today. Next slide.
1:00:08
So, today, just to frame my conversation, and I really want to make sure that we’ve talked a lot about the public health emergency, but I really want to focus on this from a patient provider, consumer, and an individual people perspective. And in order to do that, you have to think about the perception, the language, we’re using, the voice, and the narrative, that we’re using it in, and also how disaggregated this can be, and in confusion, across.
1:00:38
Folks here: care and system barriers and affordability and a lot of that doesn’t really mean much when you’re just trying to get basic care for your health and your family. Next slide.
1:00:49
So, the untangled, tethering of Medicaid I mean, we all know what essentially occurred in the decoupling. What I want to unpack here today is really, you know, the ninety one point three million people that are on Medicaid. And what that really no makes up, we know there was significant growth during coven, and we have to ask ourselves, who are these new enrollees, right? We know that economic conditions were spurred by the pandemic.
1:01:18
We also know there was newly adopted Medicaid expansion specifically in three states we want to probably highlight, which is Nebraska, Missouri, and Oklahoma, But, really, this is a life preserver for many people to continue their coverage. And I think, as we go through this enrollment process, we really need to think about what that means. Next slide.
1:01:40
Great. So in-between these slides, I’m actually showing some of the things that we have done as a part of our larger campaign around showing Medicaid recipients and the larger ecosystem, what actually Medicaid redetermination is. Next slide.
1:01:57
So, this is also a follow the money pathway. And, I think, as we know, we’ve started with, you know, F map got increased by 6.2%, which has really helped in some cases. And there’s lots of different data out there that says it’s either balanced state cost, or help states actually get some surplus.
1:02:16
And as the April first deadline happens, we’re going to see a phase down of F map. And even as of this morning, we’re seeing States that are trying to super accelerate their ability to do their redetermination because after December you know, we go down to below 2.5% of F map. And so, a lot of states, we’re seeing this rapid cycle.
1:02:37
I think, unfortunately, and we will talk about this in a few slides, our rapidity with trying to get people read determined, we, hope, is not a cliff. That gets people to just drop off of coverage altogether. Next, slide.
1:02:52
So, some of the lessons that we’ve learned from the PHD is really, we learned a lot about churn. And many of us who’ve been in Medicaid for a long, long time, have talked a lot about churn burn, which is really that learned temporary loss of coverage. That is common when Medicaid is stopped and we know a lot about the fits and starts of that. It’s typically due to two things, short-term changes in income and also circumstances that suddenly make you ineligible for Medicaid.
1:03:18
So, while we learned a lot about churn burn because we were halted.
1:03:22
And so, we didn’t have as many access problems, barriers, to, or, or, you know, the cost of really unnecessarily administrative costs. a third with churn. Now the risk we have is pretty significant. As we know, there are currently already about twenty two point five million people who qualify for Medicaid today and have not, will not know, or will never get on the program. And some of that is due to a myriad of examples and things. Some people don’t want the government in their business. Some people can’t find the documentation. Some individuals are estranged from their families, and don’t have anyone who can help them do some of the work. Some people are institutionalized.
1:04:03
There’s lots of reasons why what we hope is that we’re not increasing the burden of having more people without coverage significantly.
1:04:10
And we know there are lots of barriers to coverage around renewal processes from periodic eligibility checks, not being able to read or understand the notices that are coming to them, needing additional forms that are requested, and where those things go to either via mail or sometimes electronically. Some states don’t send things electronically. And also really unreasonable timeframe. Sometimes when people have other traumatic life events, remember that many caregivers who help individuals on Medicaid often die before their individual, who they’re caring for. So we’ve got a lot of parents that are helping young insect children. We’ve got a lot of individuals who are helping the disabled, and I think that those are some of the considerations we need to think about. Next slide.
1:04:55
So, what did we already know? We already knew that if you are a full benefit beneficiary, we’re very accustomed to certain populations of people having gaps in coverage. So we knew.
1:05:07
And almost 10.5% of people had gaps that were less than a year. And we had many people that went back and forth.
1:05:15
There was about 9.1% that were that had gaps within six months, and then, you know. I think we saw lots of people who were enrolled in … enrolled and re-enrolled within three months as well.
1:05:28
And I think chip is something to really consider. We’ve seen case studies and horror stories. I don’t know if many people remember many years ago, I’m in Texas in 20 19 when 900,000 kids got Doctor Chip because of a computer error. So I think we really need to think about chip and we also need to think about where our states with their operational plans. A lot of them didn’t have to turn them in until recently. And there’s really, not a fact checker, or, or an ability for us to, to humanize them. Have they been co-designed with communities, et cetera? Next slide.
1:06:01
And believe me, remember that there’s about 56 of these state plans that are coming in. So, who’s at risk? I just wanna give an illustration of who we’re talking about here, who’s truly at risk from a patient perspective.
1:06:12
It could be anyone who’s moved in state and across state during the pandemic.
1:06:17
People who do not have adequate or accurate data, and the system, individuals with limited English proficiency are those people who rely on caregivers, or family members, or neighbors, or others to assist them with their Medicaid information, Individuals with disabilities, people with traditional mistrust of the government, and people with poor loyalty relationships to their MCOs, caregivers, or other kind of government representatives. Next slide.
1:06:44
So, I wanted to pause there and had us really think about how many of those types of individuals do you know, and then you push that out to 91 million people.
1:06:54
I really want us to really think about, what does this mean and what do Medicaid enrollees need to do under this time period? Next slide.
1:07:03
Where we are now? I think the big elephant in the room is outreach. How our MCOs and non-profit and safety plans. Working, along with our commercial plans, how are we working with community health centers, whether it’d be federally qualified health centers, Indian health centers, or others? And how are our public hospitals, or the America Central Hospital Network hospitals engaged? Are we looking at Navigators? Or Promotoras or other marketplaces sisters?
1:07:31
How are our CBOs connected?
1:07:33
Oftentimes, we don’t think of our Volunteers of America, United Way friends, and what other partners are untraditional that could actually help us in our convening power, and our ability to get the message out.
1:07:44
Next slide.
1:07:50
And just one more slide, I think I’m almost at time here.
1:07:54
Gregg, I want to talk a little bit about patient consumer outcomes. Those digitally reported a non digitally reported, we’re seeing a lot of pros and cons.
1:08:01
So 1, 1 of the challenges with patient reported outcomes is we don’t have a lot of methodologies that help us with really understanding how patients feel, right. There’s issues with data collection harmonizing the data across different ecosystems.
1:08:17
A lot of individuals are worried about data sharing and I think we have to think about consistence and consent, transparency, consumer oversight, and also where does our data go if we want to delete it and re give you new information? And I think that we’re also starting to see, and even as of this morning, many novel models, I think Maryland came out with something this morning with HIES, how our State Designated Health Information Exchanges helping us, with this redetermination notification, how can we leverage them as a powerhouse as well? Next slide.
1:08:52
So I think I want to end today with just really reminding us that people are on this program. And 91.5 million people is a lot of people in this country. And so oftentimes when we’re reading legislation, or we’re thinking about things, we’re often thinking about it from, from our lens. And I would just really want you to think about moving out to thinking about individuals who work in factories and are in fields every single day, as to how this really impacts their quality and duration of life.
1:09:22
Thank you very much, and I am going to pass it along to Shelby.
1:09:29
Thanks, that I make, I appreciate it. Next slide, please.
1:09:34
I will go for the next slide. I’m going to focus on telehealth. And I know many of you on the line, our policy folks know we’re going to touch on policy issues.
1:09:42
But, I am a nurse. And I’ve spent most of my career working in quality and value based care.
1:09:47
So, as we go through these next slide, I’m going to ask you to think about the implications of these things through the lens of a provider organization at what this means to them, and how they operationalized care delivery model.
1:10:05
I want you to think about it through the lens of its impact to advancing value based care and value based payment model.
1:10:13
And through the lens, of course, of patients. And how these policies and other considerations impact patient centered care.
1:10:21
And we’ve talked a lot about Medicaid coverage and the variation at the state level. We’re seeing across the board within and between states so much so many differences and how telehealth is covered.
1:10:35
And operationalized, which introduces a lot of complexity. You think about from the provider organization perspective, the policy or the coverage implications in Medicaid. And how much that different differs between states and the modalities of telehealth.
1:10:54
Within states, the commercial market requirements, where commercial payers are given the flexibilities to offer more telehealth services. But their limitation may come back, and he’s going to differ by specific payer. And there’s not necessarily a requirement for payment parity, and also, payers can have separate network when you think about the complexity of managing an in network versus out of network considerations.
1:11:22
And, of course, the common refrain and concern around licensure of care providers, physicians, and nurses to be able to deliver Telehealth.
1:11:32
I was actually just having this conversation last night with my good friend who’s an oncologist here in Baltimore about, she had a patient yesterday that had to drive all the way up here and drive a few hours for a routine visit. that could have been done via Telehealth, which she and a patient would have been, would have preferred.
1:11:51
But because she wasn’t licensed in his home state, he had to make that, that drive.
1:11:56
And, of course, that is not a very patient centered way of delivering care. And so licensure standards and a lack of a national compact can really introduce a lot of complexities that inhibit that patient centered care.
1:12:11
A lot of these considerations really need to be the focus and will be the state legislators as they come into session this year.
1:12:20
Next slide, please.
1:12:23
And I’m going to focus on this middle column around telehealth. And what we look at happening at the Medicare level.
1:12:30
And a lot of these new flexibilities that have been introduced throughout the pandemic has been given an extension ongoing through the end of 2024 and this is really crucial from an evidence perspective, from a research perspective and from a quality perspective.
1:12:46
So, if we go to the next slide.
1:12:50
Policymakers.
1:12:53
I’m sorry, I can keep going to the next slide, We’ll skip ahead to this one, policymakers and payer and really, even provider networks as well. They need the evidence for telehealth optimal position in the care continuum.
1:13:07
The details of how and when telehealth is delivered can have a major impact on outcomes.
1:13:13
If you think about it like with a medication, um, we passed and we research and regenerate evidence to understand which specific dosage and administration method of medication are optimal and when to use them for different clinical population.
1:13:32
We do similar things for services, for surgery, For, for therapy, if we match and generate evidence, Cassie, what is the specific way of delivering care that matches to an appropriate patient population? And a lot of that data and evidence on telehealth just isn’t quite there yet. And so we’re trying to make the decision and the absence of strong evidence, as we’ve seen many of the previous speakers have mentioned, we saw a lot of the recommendations from that consensus group, there were still in yellow paint that we need more information.
1:14:07
And so, there’s this balance between giving a provider or giving researchers giving any of them policymakers time to leverage the flexibility of Telehealth to generate that evidence.
1:14:22
But also being mindful of, we don’t want to do any harm to patients along the way and have negative consequences quickly.
1:14:30
We think about telehealth impact, and potential impact and equity.
1:14:36
It seems pretty clear that if we’re going to deliver patient centric care, that we need to consider patient preferences balanced by quality and safety by thinking about what are their preferences for telehealth versus in person care.
1:14:50
We know there are concerns around equity based on Internet access, but then we also see from studies that are showing, many of the traditionally underserved populations have widespread access to smartphones.
1:15:03
Now, going back to we need better evidence on what modalities and telehealth are most effective and what clinical situation.
1:15:11
We heard a lot from previous speakers about the need for understanding the quality of telehealth care, and even defining what is quality and telehealth care?
1:15:22
Clinical practice guidelines are a key evidence piece that are used by payers and policymakers to decide how telehealth should be cover it, covered health services should be covered, but also how to measure outcome in these areas.
1:15:39
And so, this is something where we’re starting to see these societies issue these guidelines, Best practices toolkit, But we need more, we need to really gather that evidence and have clear and concise guidelines on, what are the optimal care pathways, what are the optimal clinical scenarios, and the optimal population that benefit from telehealth. And then, how do we measure quality? How do we improve quality? How do we improve value?
1:16:07
Taking into consideration the potential risks and benefits of telehealth.
1:16:12
And then operationally And I asked you to put on your, your provider organization.
1:16:18
And think about the fact of that.
1:16:21
It is operationally burdensome and difficult, sometimes, a complete barrier, for providers when can’t have a clear and consistent care pathway, as it relates to telehealth.
1:16:37
If they have the evidence and they’ve designed care pathway as when they use telehealth in their practice, but it, it’s, they’re limited by the patient I see at 10 0 AM does not have telehealth coverage in a patient I see at 10 15 does have telehealth coverage and so on. It makes that burdensome to establish and hard wire best practices within an organization.
1:17:00
So that’s something to consider and both a barrier to generating evidence and also a need for generating evidence to understand how optimal evidence based care can be delivered.
1:17:12
And then looking to organizations that are engaged and value based care, like those that are in Medicare ACOs, the wrentham, some of the bundled payment models. And they really stand to gain the most from the cost savings that could potentially be achieved through Telehealth.
1:17:30
But they need to figure out what are the best care pathway. And by design of their payment models, they’re incentivized to lower costs and improve quality, So it’s an optimal scenario for them to test out and learn and generate evidence from somebody’s telehealth modality.
1:17:46
And just a consideration, as we think about a holistic view of the role of Telehealth, and our care system is ensuring that the workforce models and how we staff and deliver telehealth optimize quality and efficiency, but also minimize the risk of burnout.
1:18:03
We’re seeing that being a tremendous problem in our care providers where they are just burned out, and they’re leaving the profession, and we need to think about using telehealth as a way to make their work more efficient, bringing joy back to work, and reducing their overall workload, and not being additive to that.
1:18:24
And so with that, I think we still have a little bit of time for questions, so I’m going to turn it back over.
1:18:33
Thank you so much. That was all all of you.
1:18:36
That was great, I’m going to ask all of the panelists now, to reach wane.
1:18:43
Let me just check our Question section, and maybe I’m Shelby. I might just go ahead and start with you as we’re waiting for everybody to rejoin because I loved the last slide that you just presented. And it was really helpful for me to get my mind organized around some of these things. Where do you see the most progress happening on some of the care pathways?
1:19:05
In other words, the organizations that, in, I’ll just give you my bias, which is that, I guess, traditional providers who have that, who are very used to practicing in a traditional kind of office based in person, and are trying to kind of mixed methods, so to speak, in real time, struggle, as opposed to, kind of the start, you know, build from scratch.
1:19:26
A virtual environment, you know, I’m thinking of Amazon, you know, in the tech space.
1:19:33
The thing that they’ve just rolled out labor there, they’re obviously not kinda trying to compete across modalities and interested in your thoughts about sort of, does this put traditional providers at a disadvantage?
1:19:45
Are there things that policymakers need to be thinking about with respect to ensuring kind of an even playing field, or that was a lot of questions in one, but just interested? Yeah, yeah. The flow, OK, we’ll take that apart a little bit.
1:20:00
I think in many ways, this touches on the payment parity component and also touches on technology, and what the Office of the National co-ordinator is doing to certified health IT, the HIE for making sure providers have enough information available.
1:20:19
You know, when we, when we think about some of the things, we’re learning, one thing that’s becoming clear: As that no one patient is going to be able to receive all of their necessary health care for any significant period period of time, purely through Telehealth.
1:20:40
And no one clinical population is going to all be able to receive care through Telehealth, and so telehealth only.
1:20:49
And any wide-scale format is going to be pretty limited, where we’re really seeing a balanced darger form, as, and when what impact are calling a bricks and click model. Hybrid consideration, being able to fluidly, move it, move back between in person care and telehealth care.
1:21:12
That, for patient and kind of patient centered way, that can mean, and I’m going to different provider organization and have enough flexibility to do that.
1:21:21
From a provider side, when you think about your strategy and your organization, organizational model, it could mean having the flexibility to offer all of those different methods of reaching patients.
1:21:33
And telehealth is such a big topic, like, Yeah.
1:21:36
We’re talking about live, face-to-face visit, or live virtual, very survey, Whether We’re talking about phone calls, we’re talking about asynchronous messaging.
1:21:48
There’s so much variation there. It is, but I think we’re learning there.
1:21:54
There’s a there’s a right place for all of those things.
1:22:00
So letting the policies have that be set in a way that providers have the flexibility to find what works best for their clinical populations? What really optimizes quality, what lower total cost of care, and what is extremely patient centered.
1:22:18
No.
1:22:18
But again, putting some incentives out there and calling on researchers to really dig in and get us the data on what works.
1:22:27
Thank you. Yeah. I appreciate that. And we did have a question.
1:22:29
Come in earlier about, I think, some of the things that you, you touched on, and I invite Joanne, and I can’t Sue, I apologize, y’all.
1:22:39
I only see Joanne and Shelby on the screen is it’s not available at the moment, OK, all right, all right, guys, she was so kind as to jump in and present her really, really, really helpful presentation, and I know she’s in motion, So.
1:22:56
Maybe can I ask Amy and Stephanie and Crystal to rejoin?
1:23:06
It’s like.
1:23:10
All right, I only see shelving in Japan, But I’ll just, I’ll keep going with this next question, because I think this next 1 is 1 that everybody enjoyed. Really, very much. Welcome your input on as well and then, and then we’ll wrap up. And if anybody has any additional questions, please, we’re gonna, I’m gonna pivot in a minute and hand it back over to Catherine. But we’re going to have us, there’s gonna be a survey feedback survey that you receive. And you can submit questions through that if you, if you have something that you are just burning desire to get to get answered.
1:23:41
So, I think, just, kind of, Um, the other question that came up had to do with, without, you know, our recommendations in the roadmap, But, but something that, that everybody has touched on, which is, which is access to technology, You know, and the implications of that for, you know, equity and inclusion, and, And, and she’ll be, I think, you even written about this.
1:24:13
And so, I think that, I think the question was whether or not our recommendations in the in the workgroup and for the roadmap, you can give some consideration.
1:24:24
So that maybe My answer would be that we did very much have one of our It’s our guiding principles That? That we’re making sort of an underlying assumption.
1:24:33
That that’s something that policymakers need to make sure that they addressed, But I don’t know that there was. We certainly had a conversation about it, But it was there and a lot of Christie’s work. I think centered on some of this. Is there anything you all want to add in terms of what we did as a work group?
1:24:50
With respect to making sure that the Telehealth and As we move forward with allowing for more flexibility around telehealth that we’re taking into consideration limited access and ability.
1:25:10
Oh, I can’t hear you, Stephanie, my webcam, so I’ll actually sorry. I mean, it was definitely a consideration.
1:25:17
This was something that we talked about a lot And it was, you know, kind of, You’ll see it more on the detailed report, but there was a lot of considerations around the true implications of expanding telehealth. And you know, I think I said it when I was talking, but you know on the Medicaid side, it was really thinking.
1:25:35
Barry, like slowly the right word, but deliberately insightfully about downstream implications and impacts that you might not consider at first. So, really, you know, even during the pandemic, I know some states were already exploring and doing studies and surveys and evaluations about broadband access across their states. You, know, things like that have to continue.
1:26:01
I think we’re, again, you know, we’ve talked about this a little bit, but with respect to all people who use long-term services and supports are people with disabilities using all services?
1:26:11
Really thinking about person centered ness and person, people’s preference, and what their appropriate role and a balance between in person visits and telehealth visits or it is one, come, first, you know, telehealth for triaging or does in person come first two, know, assess people’s needs and think about appropriate and, you know, appropriate cadence for telehealth and other visits. So, it was discussed a lot, I think there’s more nuanced thinking on it in the report, and it really kind of fell into our considerations bucket. These were, you know, I think we all know that telehealth is out of the bag.
1:26:49
I think it, I think it has done wonders for many, many people, particularly with behavioral health needs, but, But, But, everybody, and it’s really just thinking about, I think, thoughtful expansion of it and making sure that people can access it equitably and then a person centered way.
1:27:10
Thank you, Stephanie.
1:27:13
Taking on a hard thing.
1:27:15
And I think she’ll be you have a, I think, some research or publication about, I saw in your footnotes on one of your slides, it looked like, you’ve done some research, actually on that.
1:27:28
On the, you know, kind of the limited sort of, the access.
1:27:34
Yeah.
1:27:35
Yeah, it’s interesting, because you do see, um, to two different sides of the coin, we can think of telehealth being something that really opened up access, particularly when you’re looking at rural areas.
1:27:50
And areas and health professional shortages are even some areas where just, transportation is a barrier, which can happen right in the middle of a city.
1:28:02
And when you But when you compare that to, if broadband Internet access as a requirement, those are the same places and populations that struggle to have access to broadband Internet.
1:28:16
So, when we think about doing what is best for the patient, and thinking about how can we really realize telehealth potential for increasing equity and access?
1:28:27
You know, we looked at some other studies that found most of your folks actually do have access to a smartphone.
1:28:34
And so, can we optimize the telehealth, the ways in which we deliver telehealth and access to care, through the technology that they do have in hand, and the things that they do, have access to?
1:28:45
And really using those tools, as effectively as possible.
1:28:50
You know, I made my prior company, or there’s a great example where we had a migraine, certified, and evidence based clinical guidelines for migraines. There’s actually pretty straightforward.
1:29:03
It can be safely and effectively delivered through asynchronous telehealth care, just through messaging, And we guide. And because we had providers dedicated to that, but they did nothing but migrate all day, every day, They were certified in it, they were excellent. Care quality.
1:29:20
You know, we were increasing access for so many people. And I remember a quote we got specifically from a patient that said, I live in a rural part of a day and there’s one neurologists here and a year long. Wait.
1:29:32
And you have made my life so much better, just by giving me that I can get me the medications I need. So we need to think about those stories and how we consider our policy implications. and then again, in designing our care model and what are the potential? And optimize.
1:29:49
That’s great. I know real life stories. I must feel like we maybe there is such a thing, but we need a place where like these stories can start to go to limb.
1:29:56
So we can sometimes it’s the real life stories that teach you exactly where the micro problems are that you can address and you’re just going to be think of my arm.
1:30:06
It’s a very intensive caregiving phase for my father towards the end of his life.
1:30:10
And his direct care worker needed to talk to her psychiatrist.
1:30:16
And we were at the hospital with my dad, and she was able to just, no, go to another room with her smartphone and have her mental health appointment.
1:30:27
And, you know, like, if it was very convenient for her was it was lifesaving for us at that time because we needed her help and you know, that’s like a good story and then a bad story is, you know, we all have those as well where we have an appointment with the doctor. We wait on line for the Zoom thing for like, you know, 30 minutes, because nobody knows. Because they’re having trouble knowing. Yeah.
1:30:55
Yeah, Yeah.
1:30:56
So, anyway, OK, well, we’re very much at time, And just, thank you all so much. Amy and Stephanie.
1:31:03
It’s been a huge pleasure to work with both of you who did an incredible job with this project long before I joined, and certainly, after I joined in to the team at HP, Kathryn and Sarah. It’s been just a huge pleasure work for you in, Crystal. Thanks for being the representative of the working group on this call. It’s wonderful to see you, as always, and Joanne and Shelby, for for joining at this stage. Just adding more voices. More expertise to the discussion has been incredibly valuable. So I think everybody who’s still on and everybody who attended, we’ll have we’ll just ask you to please complete a brief evaluation survey that you will receive immediately after. We’re done and a recording of the webinar additional materials will be available on the Alliance website.
1:31:50
So this concludes today’s webinar Moving Beyond Coburn 19 Considerations for Using P&G Flexibilities to improve person centered care.
1:31:58
So, thanks very much, and everybody have a great rest of your day.
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