Set to expire later this month, the public health emergency (PHE) is likely to continue, along with regulatory waivers that expanded telehealth utilization and streamlined other health care processes.
As they await word, providers are growing increasingly concerned about the future of those flexibilities, and the potential financial and operational impacts if they go away — particularly in light of the heightened regulatory scrutiny in the space.
Initially declared on Jan. 27, 2020, the U.S. Department of Health & Human Services (HHS) most recently extended the emergency status in April for an additional 90 days, expiring July 15. HHS has not made announcements whether or not another extension is coming, but signs suggest that it will.
“The COVID-19 public health emergency remains in effect,” an HHS spokesperson told Hospice News in an email. “As HHS committed to earlier, we will provide a 60-day notice to states before any possible termination or expiration.”
Additional information about PHE declarations, including frequently asked questions, will be available on the HHS website, the spokesperson indicated.
Thus far, the PHE has been prolonged roughly every three months since its initial declaration. With an extension, the emergency status could be up for renewal again in October.
Regulatory fog thickens as scrutiny intensifies
As the PHE lingers, so do questions around what it has brought to the table for hospices.
A continued federally declared emergency allows flexibilities by the U.S. Centers for Medicare & Medicaid Services (CMS) to remain intact. These include 1135 waivers of certain hospice rules that permitted use of telehealth to fulfill requirements typically done in person, such as recertification by physicians and patient visits.
Telehealth flexibilities have allowed providers to remain connected to patients and families amid waves of staffing turnover, burnout and illness, a number of hospice leaders have told Hospice News.
The future of telehealth is not the only question hanging in the balance.
CMS also temporarily waived the requirement for volunteers to provide a minimum of 5% of hospice patient care hours. Hospices often rely on volunteer support to organize educational programs, aid in fundraising efforts, perform back office work and help patients stave off loneliness and social isolation.
The need for social distancing and restricted access to patient homes and facilities challenged hospices’ ability to retain and recruit volunteers.
Though calls have grown louder among providers and health care groups to make some of these temporary flexibilities permanent in some shape or form, the results are far from certain.
“Most of us are expecting these waivers will go away, and we’ll go back to all the requirements in place before COVID,” Susan Ponder-Stansel, president and CEO of Florida-based Alivia Care, told Hospice News. “We have already seen the regulatory scrutiny and third party audits return to a pre-pandemic pace, so we expect that the flexibility given during the PHE will not become permanent.”
Regulatory scrutiny has been rising in hospice for several years running. Regulators have zeroed in on issues related to eligibility, potential False Claims Act violations, utilization of general impatient care and issues pertaining to length of stay.
The HHS Office of the Inspector General (OIG) has set plans in motion for a nationwide audit of hospice eligibility for calendar year 2023. The audit will focus on patients who did not have a hospitalization or emergency department visit prior to electing hospice.
Meanwhile, CMS and its contractors have been ramping up hospice audits. During 2021, appropriate use of general inpatient care was a key focus, which is expected to continue in 2022. These audits can be expensive and time consuming processes for hospices.
As regulatory pressure mounts amid the uncertainties, so has anxiety among providers to remain compliant, according to Michael Fratkin, CMO of ResolutionCare, a Vynca company.
“There’s a lot of anxiety about how patient and operational processes will form without crystal-clear guidance, especially in the current regulatory climate,” Fratkin told Hospice News. “I think there will be some anxiety as the pendulum continues to swing and rule makers and regulators become challenged to keep up with the impacts. We all have work to do in tracking policies very closely.”
Provider Relief Funds also in question
Beyond the shifting rules, hospices have been among those in health care wondering whether a continued PHE status would translate to further infusions of Provider Relief Funds. If so, how much of these dollars would hospices see? If not, how would a lack of federal funding affect the sustainability of hospice programs?
Some have temporarily suspended services or halted programs altogether under the weight of heavy financial pressures alongside staffing shortages.
“Provider Relief Funds would really help stabilize programs that are still dealing with a very fluid and disrupted health care system,” said Ponder-Stansel. “Many of us do not believe that CMS or Congress fully recognize all the headwinds that are hitting us simultaneously and making margins diminish or disappear — especially for smaller programs and most non-profits.”
HHS does not release data on the amounts of PRF dollars each health care setting received, a spokesperson indicated in an email to Hospice News.
COVID-19 has pummeled hospice operations and finances and exacerbated staffing shortages that have long-plagued the industry. Providers are weathering through rising costs for supplies and labor.
Other economic forces such as inflation, rising wages and increased paid sick leave for staff have thrown wrenches in hospices’ financial sustainability. Many providers also saw their revenues dip as their patient census and length of stay declined during the pandemic.
Increased costs combined with the restoration of sequestration that halted during COVID have left many hospices financially strapped. Providers have told Hospice News that the effects could be devastating.
These concerns have proliferated following the CMS proposal to raise hospice per diems by only 2.7% in 2023.
“I was shocked by the number … [CMS] is using stale data, and they’re lagging the reimbursement increase, and that’s going to exacerbate the situation that everyone has experienced in the industry,” Kevin McNamara, CEO of Chemed Corp. (NYSE: CHEM), said at the RBC Capital Markets Global Healthcare Conference. “So we are looking at a high single-digit year-over-year increase for the overall net of what we’re doing for our folks.”
Disruption on the horizon if waivers expire
Having no roadmap for a post-PHE landscape, providers are trying to gauge the level of disruption its dismissal would cause to their finances as well as their clinical processes and staff.
For example, hospices that suspended or diminished volunteer activities during the height of the pandemic have sought out ways to rebuild these programs. Elimination of the volunteer service requirement could challenge hospices that are still working to replenish their ranks.
“The waiver for the volunteer service requirement has been very helpful,” Ponder-Stansel said. “Concern is that COVID has fundamentally changed the comfort level of many of our volunteers who are predominantly older adults. None of us is sure if the lag in volunteer numbers is just a COVID impact with a long tail or a permanent change.”
Telehealth has played a crucial role in hospices’ ability to offer a safer, more convenient way for volunteers to engage and interact with patients remotely. Some hospices have seen a slow return of volunteer workforce as many continue to fear risk of exposure to COVID-19 with the virus’ continued spread.
Aside from taking away care delivery options for patients and families, eliminating the waivers would also place added pressure on “very thinly stretched” hospice clinical staff who will have to allocate more time and resources to in-person care, according to Ponder-Stansel.
Many if not most hospices had to invest in technology solutions in light of telehealth waivers. Telehealth has become an important component in serious illness and end-of-life care as more providers leverage technology to build staffing efficiencies, reduce travel times and increase touch points with patients and families.
Even before the pandemic, companies like ResolutionCare were recognizing telehealth’s value. Fratkin founded the home-based palliative care provider in 2015. The advanced planning technology company Vynca acquired Resolution Care last year.
As more patients and families embrace telehealth, it’s up to regulators to also recognize its value proposition, according to Fratkin.
“For companies like ours, we’ve seen how effective high quality digital health care can be for patients,” Fratkin told Hospice News. “This innovation is here to stay, and we’re swinging all the way out on the pendulum with it, regardless of what happens. Lessons we’ve learned during the pandemic can result in better outcomes for delivery of care. Going forward, it’s up to payers and rule makers to recognize its value.”
Previous CMS Administrator Seema Verma has stated that “the genie’s out of the bottle” on telehealth.
“It’s fair to say that the advent of telehealth has been just completely accelerated, that it’s taken this crisis to push us to a new frontier,” Verma stated in 2020. “But there’s absolutely no going back.”
However, the “jury is still out” on which regulatory waivers could become permanent, Ponder-Stansel told Hospice News, making some providers weary of investing deeper into technology.
“CMS has stated before that it doesn’t believe that a high-touch service like hospice lends itself to the use of telehealth,” said Ponder-Stansel. “If it is extended, it would probably be narrowly focused or limited, versus something we can integrate into practice as other types of health care providers have done. Hopefully they might consider allowing providers to continue doing things virtually.”
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