National Association for the Support of Long Term Care July 17, 2020 VIA Electronic Submission Dear Commissioners: We are writing on behalf of the National Association for the Support of Long Term Care (NASL), which represents the providers of ancillary care and services and products to the long term and post-acute care (LTPAC) sector. NASL members include rehabilitation therapy companies; providers of clinical laboratory services and portable x-ray; suppliers of complex medical equipment and other specialized supplies; and health information technology (health IT) companies that develop and distribute full clinical electronic medical records (EMRs), billing and point-of-care health IT systems and other software solutions that serve the majority of LTPAC providers (i.e., assisted living, home health, inpatient rehabilitation facilities, long term care hospitals and skilled nursing facilities). We at NASL appreciate your willingness to serve on the Coronavirus Commission for Safety & Quality in Nursing Homes (“Commission”). Several of you know first-hand what it takes to put critical patient protections in place, to care for staff who are doing the hard work of caring for our most vulnerable citizens and to maintain all of the myriad components that comprise nursing facility care and operations. Our members are true heroes. Despite significant risk, they have endeavored every day to meet the care needs of their patients and the providers they serve. We have been fortunate to know and work with some of the most dedicated of caregivers. We also know that nursing facility providers have one of the most challenging of jobs in our nation’s healthcare system. The pandemic has tested our sector and we know that we have a long way to go with the virus but based on what we have experienced so far, there are many changes we could make. The recommendations we provide today are in the spirit of changes that we could make based on our experience thus far. We appreciate that you are keeping America’s seniors foremost in your thoughts and deliberations.
1444 I Street, NW Suite 301 Washington, DC 20005
202-803-2385 www.NASL.org @NASLdc
Recommendation: Prioritize Nursing Facility Patients, the Services and Providers Who Serve Them Including the Ancillary Services We believe that nursing facility patients and the staff who provide services to them should be prioritized for assistance in terms of resources and policy changes that would help to provide protection of patients and safer care by their providers. Supplies of personal protective equipment (PPE) were very difficult to obtain at the beginning of the pandemic. PPE supplies are still at various points of scarcity and or the cost to procure these are high. Given that nursing facilities will be battling COVID for many months to come, there will continue to be a significant need for PPE for the months to come. All providers that are involved in providing services to the nursing facility should be prioritized to obtain PPE.A coordinated approach to sourcing PPE items of adequate quality and a reliable means to place orders should exist rather than leaving each provider to ‘fend for themselves’ amid what has been a chaotic market. Also, funding should be provided directly to all providers to meet the new costs of care including PPE costs and mandatory COVID testing. Providers such as rehabilitation therapists are part of the patient’s care team and that care team relies on results from lab tests and radiological studies in order to make clinical decisions for the patient. Yet, these types of ancillary providers were overlooked for assistance and resources likely because of contractual arrangements between the provider and the facility or the type of policy governing payment, for example consolidated billing. Federal funding that is directed primarily to the nursing facility, which we fully support and agree is needed, has not been fully accessible to the ancillary services, yet our services are just as critical to patients. The corona virus does not discriminate between different members of the care team and availability of relief funds should not discriminate either.
Recommendation: Update and Modernize Medicare Telehealth Policies Perhaps one of the silver linings of this horrific pandemic is the realization of the value of telehealth. We believe telehealth is an important tool that enhances patient care and can provide efficiency in health care delivery. While telehealth may not be able to replace all inperson care, we believe it should continue to be an option to meet individual care needs. We appreciate that CMS acted quickly to issue multiple policy waivers and allowed providers a range of flexibilities through blanket and 1135 waivers. NASL and our colleagues pressed hard to have rehabilitation therapists included as “qualified telehealth practitioners” under CMS Waiver 1135. The ability to utilize various telecommunications technologies to treat patients was and is crucial to patient access to care. This is because guidance from the CDC and CMS recommended and required that nursing facilities decrease the number of healthcare personnel NASL Comments to Coronavirus Nursing Home Commission July 17, 2020 Page 2 of 4
entering facilities. Often therapists must serve patients at multiple facilities and we needed an ability to provide care while reducing potential exposure and keeping patients and clinicians safe and healthy. Telehealth has been a lifeline to patients and their providers during the COVID-19 pandemic. For patients, telehealth has provided continuity of care, allowing them to access care without exposing themselves or their providers to the risk of a COVID-19 infection. For providers, telehealth has maintained safe access to patients and extended the ability of staff to provide therapy to their patients when COVID risk kept the clinician from entering the facility. While face to face therapy is the first choice, many of NASL’s member companies report leveraging some form of telecommunications to meet patients’ and residents’ needs through tele-consultation, tele-supervision and assisted tele-health visits.
Medicare Part B telehealth statute and regulation is the most restrictive in terms of where it can be used and the clinicians who can use it. Because COVID was and is most rampant with vulnerable nursing facility patients, it is a crucial, obvious tool to provide therapy. It was disappointing that what seemed the most obvious use case for waiving Medicare’s restrictions on telehealth services – i.e., providing rehab therapy to patients isolated in their rooms in part due to CMS visitor restrictions – was not waived until almost June. Additionally, because telehealth policy – like many regulations in nursing facilities – is completely different if the patient is under a Part A stay or a Part B stay. There was confusion as to whether the new waiver authority on telehealth applied to all patients in the facility. From a patient-centered approach, why would you deny some patients the benefit of continuing their therapy just because they are under a particular payor? Additionally, because nursing facility policy is handled by many different offices at CMS, especially with respect to Part A or Part B, this probably greatly slowed down the consideration of the ability for rehab therapists to be qualified health care providers under the telehealth waiver. CMS has waived the restrictions on Medicare coverage of telehealth services to allow rehabilitation therapists to furnish services via telehealth in all institutional settings. We urge CMS to work with Congress to make this change permanent so that after the public health emergency, rehabilitation therapy providers can utilize telehealth to provide services when safety and reducing spread of infection are paramount so that patients can maintain access to the medically necessary services they need. We see a place for this mode of practice to be a permanent option for rehabilitation therapy in skilled nursing facilities – but one that would not replace face-to-face care when practical. Implementing this mode of practice beyond the Public Health Emergency (PHE) should be done thoughtfully. We must consider the competency necessary to deliver therapy via telehealth, the use of technology and insuring privacy, patient access beyond the current geographic limitation emphasis as well as billing and payment that NASL Comments to Coronavirus Nursing Home Commission July 17, 2020 Page 3 of 4
accounts for the cost of delivering the service. In many cases, the cost of providing therapy via telehealth technology exceeded what the reimbursement for the particular service delivered. This is because to provide a service to a patient in a nursing facility, often there has to be an additional clinician with the patient as a type of guide to help the patient with the service. Telehealth is not a one size policy fits all and a thoughtful process should be commenced to ensure the policy fits the clinicians who use it and that it can be deployed quickly.
Thank you for your consideration of these items. We welcome any questions you may have and to working with you as our sector – and our nation – recovers from this most extraordinary time. If you have any questions regarding our comments, please contact
[email protected] or 202-213-0289. Sincerely,
Martha Schram, PT President, Board of Directors
Cynthia K. Morton, MPA Executive Vice President
NASL Comments to Coronavirus Nursing Home Commission July 17, 2020 Page 4 of 4
