While CMS has not announced any permanent policy changes, provisions to expand telehealth are likely to continue long-term, with many hospice leaders and advocates in full support. Hospices will have to work out several kinks as they navigate the telehealth landscape post-COVID-19.
During this period of national disaster, the U.S. Department of Health and Human Services has waived regulatory requirements under section 1135 of the Social Security Act, allowing the U.S. Centers for Medicare & Medicaid Services (CMS) to issue waivers relaxing conditions of participation (CoPs) for hospices and health care providers, including expanded use of telehealth for patient care. Telehealth visits have helped providers continue caring for those who need it most with continued clinical patient care and interdisciplinary services that support hospice care.
“It’s important to understand telehealth has so many advantages, and it isn’t just a backup modality until COVID-19 passes, but the center of medicine into the future,” said Brian Mistler, chief operations officer of California-based tele-palliative care provider, Resolution Care
Network, started by his business partner and CEO, Michael Fratkin, M.D.. “The risks of not using video platforms for patients who can benefit far outweigh the concerns of using them to meet with patients. The temporary guidelines recognize this, and I am confident long-term changes will support more video parity than in 2019 — not less.”
Hospice advocates like the National Hospice and Palliative Care Organization (NHPCO) and the National Association for Home Care & Hospice (NAHC) have called for the U.S. Department of Health and Human Services (HHS) to make permanent the flexibilities that allowed providers to expand telehealth services during the coronavirus pandemic. Such a move could produce lasting shifts in the hospice space.
Last week, a group of 30 U.S. senators made a similar call for making the telehealth flexibilities permanent.
“Technology has its place in hospice, just like with other areas of health care, but the pandemic has ushered us into a whole new era relative to the use of it,” said Theresa Forster, vice president for hospice policy and programs for NAHC. “Current [CMS] flexibilities have really opened the door to hospice nationwide seeing tremendous possibility with use of technology. I don’t think anyone really believes that hospice should be a totally virtual service, it’s an extremely high-touch area of care, but this experience has given everyone a flavor for how this might fit into the hospice delivery model as a real eye opener.”
Expanded telehealth utilization across multiple disciplines in hospice care has brought with it issues of patient privacy under the Health Insurance Portability and Accountability Act (HIPAA), which were partially waived for the duration of the COVID-19 pandemic. While virtual consumer platforms like Zoom or FaceTime have encryption features, speculation remains over whether these platforms measure up to HIPAA security standards that ensure protection of patient health information. Compliance concerns will be one of several areas should the current telehealth flexibilities become lasting.
“We can expect that at some point the HIPAA waiver is going to go away,” said Forster. “Hospices are going to need to be ready to invest in software and the specific products out there that meet HIPAA standards of protection of patient health information and the exchange of it. In terms of investment, providers have had a chance to see how it can provide value. Now the question is, are they ready at the moment to pre-invest in the software that’s going to allow them to carry forward these telehealth practices and make sure staff are trained not only in ensuring the safety of private health information, but also the serious importance of documenting what isn’t done in technology sessions, which CMS has specified as a requirement to measure how well they meet the laid-out goals of care for each patient.”
In addition to compliance questions, providers also contend with the hefty price tag that often comes with technology investment and maintenance, as well as ongoing staff training and system upkeep. Some hospices are in a better financial position than others, and a number of them began leveraging telehealth into service lines and care delivery even prior to the pandemic. Despite facing technology-related headwinds, providers stand to benefit from increased virtual care.
“Forcing folks to drive to an office and disrupt their lives further — or spend three times as much on transportation and other visit costs for clinical teams— just doesn’t make sense,” said Mistler. “Hospices who are able to integrate telehealth strategies into their core delivery model will be able to help the most people for the least cost. When Medicare includes a hospice and palliative benefit both, we’ll see huge health care savings and improvements for older adults. Also, we’ll see more hospices partnering and joining with independent palliative care organizations and telehealth providers as part of a larger comprehensive array of offerings to populations. Payors are coming to see the cost savings and people who understand the advantages of early and convenient care and will begin more and more to demand access where they don’t have it, pushing back against losing [the telehealth] access they’ve been given now.”
Medicare does not currently offer a community-based palliative care benefit.
Ensuring quality of care is another area of consideration when it comes to permanent telehealth policy changes. If the changes include additional CMS surveys or those from Medicare contractors, hospices will need to fulfill patient needs from a distance. Without formal direction from CMS regarding the recording of telehealth visits for quality of patient care and experience, however, it places another roadblock in the long-term trajectory of telehealth. Regardless of the potential difficulties, telehealth is anticipated to remain in the hospice space well after the pandemic eases.
“The future is digital. Six months ago, people thought you couldn’t just flip a switch and change expectations for the way medicine is done, even if telehealth works better in some situations,” Mistler told Hospice News. “Then COVID came, the country flipped a switch, and we’ve done exactly that. Individuals and organizations who have seen what telehealth can do won’t want to go back. As a field, we are counting on our government updating laws to keep us helping more people at lower cost. Providing support and parity for as many modalities as possible helps more people get care with the least risk of infectious disease transmission or disruption to their lives.”