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CMS delays controversial E/M changes in final rule
After a torrent of criticism from the physician community, .
The agency’s final 2019 Physician Fee Schedule, announced Nov. 1, rescinds a proposal that would have blended payments for new and established patients for office/outpatient E/M levels 2 through 5 into single payments. Instead, the agency will continue to hear perspective on the proposal with plans to collapse E/M code levels 2 through 4 into single payments beginning in 2021, while maintaining level 5.
CMS also pulled back its proposal to apply a multiple procedure payment reduction to E/M visits furnished on the same day as a procedure. Payment rates for the less expensive of the two will be maintained, rather than cut in half as initially proposed.
The final rule released is much different than the one proposed, which shows that CMS heeded concerns by physicians and took time to craft a more realistic fee schedule, said Orly Avitzur, MD, chair of the American Academy of Neurology’s Medical Economics and Management Committee. The proposed collapsed E/M levels would have likely led to shorter visit times, negatively impacting the doctor-patient relationship and patient care, she said.
As part of its final rule, CMS moved forward with several other changes to coding and documentation, including eliminating the need to document the medical necessity of a home visit in lieu of an office visit, and allowing physicians to skip documentation of changes since a prior patient visit when relevant information is already contained in the record.
Additionally, the final rule clarifies that for E/M office/outpatient visits physicians do not need to re-enter information on the patient’s chief complaint and history that has already been entered by ancillary staff or the patient. The physician may just indicate in the medical record that he or she has reviewed and verified the information.
In a statement, CMS administrator Seema Verma said the final rule cements dramatic improvements for clinicians and patients and reflects extensive input from the medical community.
“Addressing clinician burnout is critical to keeping doctors in the workforce to meet the growing needs of America’s seniors,” Ms. Verma said in the statement. “[The] rule offers immediate relief from onerous requirements that contribute to burnout in the medical profession and detract from patient care. It also delays even more significant changes to give clinicians the time they need for implementation and provides time for us to continue to work with the medical community on this effort.”
“In the final rule, CMS acknowledges concerns from physicians regarding many aspects of the proposed rule,” said Anton Decker, MD, chair of the American Gastroenterological Association’s Practice Management and Economics Committee. “In particular, proposed revisions to E/M services would have negatively impacted the doctor-patient relationship and patient care, especially for the most complex patients,” he said.
“Overall, the AGA is pleased that CMS listened to concerns and reversed certain proposals such as the multiple procedure payment reduction for E/M visits furnished on the same day as a procedure,” Dr. Decker said. “We are also pleased that CMS is giving stakeholders an additional 2 years to provide input on how best to refine E/M documentation and coding.”
Shivan Mehta, MD, MBA, AGA’s advisor to the AMA Relative-value Update Committee (RUC), the body that provides code value recommendations to CMS, noted, “Although CMS heeded concerns from physicians on many aspects on the proposed rule, in a surprise move, CMS took direction from Anthem Inc., a large health insurance company, and recommended two endoscopy services be revalued by the AMA’s RUC. Private health insurers don’t typically influence the appropriateness of Medicare payment amounts, and we question Anthem’s motivation as commercial payers frequently link their payment rates to a percentage of Medicare payment amounts or use those amounts as benchmarks when negotiating physician contracts.”
CMS finalized a number of proposals to pay doctors separately for communication technology services. This includes HCPCS code G2012 for brief communication technology-based services, such as virtual check-ins and HCPCS code G2010 for remote evaluation of a recorded video and/or images submitted by an established patient, also known as store and forward.
Additionally, CMS will pay separately for new codes that describe chronic care remote physiologic monitoring (CPT codes 99453, 99454, and 99457) and interprofessional Internet consultation (CPT codes 99451, 99452, 99446, 99447, 99448, and 99449). Also new to the list of reimbursable telehealth services are HCPCS codes G0513 and G0514 for prolonged preventive services.
Telehealth physicians who treat opioid use disorder received more flexibility under the CMS 2019 fee schedule through the agency’s removal of originating site geographic requirements. CMS will now allow a patient’s home to be an originating site for telehealth services for substance use disorder treatment or co-occurring mental health disorder. The agency is also accepting comments on a new Medicare benefit category for opioid use disorder treatment furnished by opioid treatment programs under Part B beginning on or after Jan. 1, 2020.
CMS also approved updates to its Medicare Shared Savings Program, including finalizing time-sensitive program policy changes for currently participating Accountable Care Organizations (ACOs). These changes include:
- A voluntary 6-month extension for existing ACOs whose participation agreements expire on Dec. 31, 2018, and the methodology for determining financial and quality performance for the 6-month performance year from Jan. 1 to June 30, 2019.
- Revising the definition of primary care services used in beneficiary assignment.
- Providing relief for ACOs and their clinicians impacted by extreme and uncontrollable circumstances in 2018 and subsequent years.
After a torrent of criticism from the physician community, .
The agency’s final 2019 Physician Fee Schedule, announced Nov. 1, rescinds a proposal that would have blended payments for new and established patients for office/outpatient E/M levels 2 through 5 into single payments. Instead, the agency will continue to hear perspective on the proposal with plans to collapse E/M code levels 2 through 4 into single payments beginning in 2021, while maintaining level 5.
CMS also pulled back its proposal to apply a multiple procedure payment reduction to E/M visits furnished on the same day as a procedure. Payment rates for the less expensive of the two will be maintained, rather than cut in half as initially proposed.
The final rule released is much different than the one proposed, which shows that CMS heeded concerns by physicians and took time to craft a more realistic fee schedule, said Orly Avitzur, MD, chair of the American Academy of Neurology’s Medical Economics and Management Committee. The proposed collapsed E/M levels would have likely led to shorter visit times, negatively impacting the doctor-patient relationship and patient care, she said.
As part of its final rule, CMS moved forward with several other changes to coding and documentation, including eliminating the need to document the medical necessity of a home visit in lieu of an office visit, and allowing physicians to skip documentation of changes since a prior patient visit when relevant information is already contained in the record.
Additionally, the final rule clarifies that for E/M office/outpatient visits physicians do not need to re-enter information on the patient’s chief complaint and history that has already been entered by ancillary staff or the patient. The physician may just indicate in the medical record that he or she has reviewed and verified the information.
In a statement, CMS administrator Seema Verma said the final rule cements dramatic improvements for clinicians and patients and reflects extensive input from the medical community.
“Addressing clinician burnout is critical to keeping doctors in the workforce to meet the growing needs of America’s seniors,” Ms. Verma said in the statement. “[The] rule offers immediate relief from onerous requirements that contribute to burnout in the medical profession and detract from patient care. It also delays even more significant changes to give clinicians the time they need for implementation and provides time for us to continue to work with the medical community on this effort.”
“In the final rule, CMS acknowledges concerns from physicians regarding many aspects of the proposed rule,” said Anton Decker, MD, chair of the American Gastroenterological Association’s Practice Management and Economics Committee. “In particular, proposed revisions to E/M services would have negatively impacted the doctor-patient relationship and patient care, especially for the most complex patients,” he said.
“Overall, the AGA is pleased that CMS listened to concerns and reversed certain proposals such as the multiple procedure payment reduction for E/M visits furnished on the same day as a procedure,” Dr. Decker said. “We are also pleased that CMS is giving stakeholders an additional 2 years to provide input on how best to refine E/M documentation and coding.”
Shivan Mehta, MD, MBA, AGA’s advisor to the AMA Relative-value Update Committee (RUC), the body that provides code value recommendations to CMS, noted, “Although CMS heeded concerns from physicians on many aspects on the proposed rule, in a surprise move, CMS took direction from Anthem Inc., a large health insurance company, and recommended two endoscopy services be revalued by the AMA’s RUC. Private health insurers don’t typically influence the appropriateness of Medicare payment amounts, and we question Anthem’s motivation as commercial payers frequently link their payment rates to a percentage of Medicare payment amounts or use those amounts as benchmarks when negotiating physician contracts.”
CMS finalized a number of proposals to pay doctors separately for communication technology services. This includes HCPCS code G2012 for brief communication technology-based services, such as virtual check-ins and HCPCS code G2010 for remote evaluation of a recorded video and/or images submitted by an established patient, also known as store and forward.
Additionally, CMS will pay separately for new codes that describe chronic care remote physiologic monitoring (CPT codes 99453, 99454, and 99457) and interprofessional Internet consultation (CPT codes 99451, 99452, 99446, 99447, 99448, and 99449). Also new to the list of reimbursable telehealth services are HCPCS codes G0513 and G0514 for prolonged preventive services.
Telehealth physicians who treat opioid use disorder received more flexibility under the CMS 2019 fee schedule through the agency’s removal of originating site geographic requirements. CMS will now allow a patient’s home to be an originating site for telehealth services for substance use disorder treatment or co-occurring mental health disorder. The agency is also accepting comments on a new Medicare benefit category for opioid use disorder treatment furnished by opioid treatment programs under Part B beginning on or after Jan. 1, 2020.
CMS also approved updates to its Medicare Shared Savings Program, including finalizing time-sensitive program policy changes for currently participating Accountable Care Organizations (ACOs). These changes include:
- A voluntary 6-month extension for existing ACOs whose participation agreements expire on Dec. 31, 2018, and the methodology for determining financial and quality performance for the 6-month performance year from Jan. 1 to June 30, 2019.
- Revising the definition of primary care services used in beneficiary assignment.
- Providing relief for ACOs and their clinicians impacted by extreme and uncontrollable circumstances in 2018 and subsequent years.
After a torrent of criticism from the physician community, .
The agency’s final 2019 Physician Fee Schedule, announced Nov. 1, rescinds a proposal that would have blended payments for new and established patients for office/outpatient E/M levels 2 through 5 into single payments. Instead, the agency will continue to hear perspective on the proposal with plans to collapse E/M code levels 2 through 4 into single payments beginning in 2021, while maintaining level 5.
CMS also pulled back its proposal to apply a multiple procedure payment reduction to E/M visits furnished on the same day as a procedure. Payment rates for the less expensive of the two will be maintained, rather than cut in half as initially proposed.
The final rule released is much different than the one proposed, which shows that CMS heeded concerns by physicians and took time to craft a more realistic fee schedule, said Orly Avitzur, MD, chair of the American Academy of Neurology’s Medical Economics and Management Committee. The proposed collapsed E/M levels would have likely led to shorter visit times, negatively impacting the doctor-patient relationship and patient care, she said.
As part of its final rule, CMS moved forward with several other changes to coding and documentation, including eliminating the need to document the medical necessity of a home visit in lieu of an office visit, and allowing physicians to skip documentation of changes since a prior patient visit when relevant information is already contained in the record.
Additionally, the final rule clarifies that for E/M office/outpatient visits physicians do not need to re-enter information on the patient’s chief complaint and history that has already been entered by ancillary staff or the patient. The physician may just indicate in the medical record that he or she has reviewed and verified the information.
In a statement, CMS administrator Seema Verma said the final rule cements dramatic improvements for clinicians and patients and reflects extensive input from the medical community.
“Addressing clinician burnout is critical to keeping doctors in the workforce to meet the growing needs of America’s seniors,” Ms. Verma said in the statement. “[The] rule offers immediate relief from onerous requirements that contribute to burnout in the medical profession and detract from patient care. It also delays even more significant changes to give clinicians the time they need for implementation and provides time for us to continue to work with the medical community on this effort.”
“In the final rule, CMS acknowledges concerns from physicians regarding many aspects of the proposed rule,” said Anton Decker, MD, chair of the American Gastroenterological Association’s Practice Management and Economics Committee. “In particular, proposed revisions to E/M services would have negatively impacted the doctor-patient relationship and patient care, especially for the most complex patients,” he said.
“Overall, the AGA is pleased that CMS listened to concerns and reversed certain proposals such as the multiple procedure payment reduction for E/M visits furnished on the same day as a procedure,” Dr. Decker said. “We are also pleased that CMS is giving stakeholders an additional 2 years to provide input on how best to refine E/M documentation and coding.”
Shivan Mehta, MD, MBA, AGA’s advisor to the AMA Relative-value Update Committee (RUC), the body that provides code value recommendations to CMS, noted, “Although CMS heeded concerns from physicians on many aspects on the proposed rule, in a surprise move, CMS took direction from Anthem Inc., a large health insurance company, and recommended two endoscopy services be revalued by the AMA’s RUC. Private health insurers don’t typically influence the appropriateness of Medicare payment amounts, and we question Anthem’s motivation as commercial payers frequently link their payment rates to a percentage of Medicare payment amounts or use those amounts as benchmarks when negotiating physician contracts.”
CMS finalized a number of proposals to pay doctors separately for communication technology services. This includes HCPCS code G2012 for brief communication technology-based services, such as virtual check-ins and HCPCS code G2010 for remote evaluation of a recorded video and/or images submitted by an established patient, also known as store and forward.
Additionally, CMS will pay separately for new codes that describe chronic care remote physiologic monitoring (CPT codes 99453, 99454, and 99457) and interprofessional Internet consultation (CPT codes 99451, 99452, 99446, 99447, 99448, and 99449). Also new to the list of reimbursable telehealth services are HCPCS codes G0513 and G0514 for prolonged preventive services.
Telehealth physicians who treat opioid use disorder received more flexibility under the CMS 2019 fee schedule through the agency’s removal of originating site geographic requirements. CMS will now allow a patient’s home to be an originating site for telehealth services for substance use disorder treatment or co-occurring mental health disorder. The agency is also accepting comments on a new Medicare benefit category for opioid use disorder treatment furnished by opioid treatment programs under Part B beginning on or after Jan. 1, 2020.
CMS also approved updates to its Medicare Shared Savings Program, including finalizing time-sensitive program policy changes for currently participating Accountable Care Organizations (ACOs). These changes include:
- A voluntary 6-month extension for existing ACOs whose participation agreements expire on Dec. 31, 2018, and the methodology for determining financial and quality performance for the 6-month performance year from Jan. 1 to June 30, 2019.
- Revising the definition of primary care services used in beneficiary assignment.
- Providing relief for ACOs and their clinicians impacted by extreme and uncontrollable circumstances in 2018 and subsequent years.
Trump administration rule erodes ACA contraceptive mandate
More employers can opt out of providing contraception coverage to their employees under final regulations from the Trump administration that narrow the Affordable Care Act’s contraceptive mandate.
The two regulations, released Nov. 7, allow an expanded group of employers and insurers to get out of covering contraception methods by objecting on either religious or moral grounds.
The first rule broadens exemptions to the ACA’s contraceptive mandate to entities that object to services covered by the mandate on the basis of sincerely held religious beliefs. The second rule protects nonprofit organizations and small businesses that have nonreligious moral convictions that oppose services covered by the mandate. The religious and moral exemptions apply to institutions of education, issuers, and individuals, but not to governmental entities.
When first proposed in 2017, Trump administration officials said the new policies would “better balance the government’s interest in promoting coverage for contraceptive and sterilization services with the government’s interests in providing conscience protections for entities with sincerely held moral convictions.” The U.S. Department of Health & Human Services estimates that the rules, which take effect in January 2019, will affect no more than 200 employers.
The American College of Obstetricians and Gynecologists expressed concern that the final rules will restrict patient access to meaningful contraceptive methods and will erode decades of progress in increasing women’s reproductive autonomy and restrict patient access to contraception.
“Women, families and our nation all benefit from seamless, affordable access to contraception,” ACOG President Lisa M. Hollier, MD, said in a statement. “Contraception improves women’s health and well-being, reduces unintended pregnancy, enables pregnancy spacing for safer pregnancies and deliveries, and empowers women’s engagement in the workforce and economic self-sufficiency. A woman’s employer should not determine whether or not she has this access.”
Marjorie Dannenfelser, president of Susan B. Anthony List, an anti-abortion group, praised the final rules, calling them needed protections from the burdensome Obama-era ACA abortifacient drug mandate.
“President Trump and HHS Secretary Azar delivered a huge victory for conscience rights and religious liberty in America,” Ms. Dannenfelser said in a statement. “No longer will Catholic nuns who care for the elderly poor be forced by the government to provide abortion-inducing drugs in their health care plans. Not only that, moral objectors such as Susan B. Anthony List, will also no longer have to pay for life-ending drugs that are antithetical to their mission and for which we have argued there is certainly no compelling state interest.”
The ACA initially required all employers to cover birth control for employees with no copayments, except for group health plans of religious employers, which were deemed exempt. Those religious employers were primarily churches and other houses of worship. After a number of complaints and legal challenges, the Obama administration created a workaround for nonprofit religious employers to opt out of the mandate.
However, critics argued the process itself was a violation of their religious freedom. The issue led to the case of Zubik v. Burwell, a legal challenge over the mandate exemption that went before the U.S. Supreme Court in March 2016. The issue was never resolved. In May 2016, the Supreme Court vacated the lower court rulings related to Zubik v. Burwell and remanded the case back to the four appeals courts that had originally ruled on the issue.
Under the approved regulations, employers or insurers can stop their coverage of contraceptive services if they have religious beliefs or moral convictions against covering birth control. Exempted entities and individuals also can choose to cover some, but not all, contraceptive services, depending on their specific religious or moral objection, according to an HHS fact sheet.
The agency emphasized that the regulations leave in place government programs that provide free or subsidized contraceptive coverage to low-income women, such as through community health centers, and that the rules do not ban any employer from covering contraceptives.
The regulations become effective 60 days after they are published in the Federal Register.
More employers can opt out of providing contraception coverage to their employees under final regulations from the Trump administration that narrow the Affordable Care Act’s contraceptive mandate.
The two regulations, released Nov. 7, allow an expanded group of employers and insurers to get out of covering contraception methods by objecting on either religious or moral grounds.
The first rule broadens exemptions to the ACA’s contraceptive mandate to entities that object to services covered by the mandate on the basis of sincerely held religious beliefs. The second rule protects nonprofit organizations and small businesses that have nonreligious moral convictions that oppose services covered by the mandate. The religious and moral exemptions apply to institutions of education, issuers, and individuals, but not to governmental entities.
When first proposed in 2017, Trump administration officials said the new policies would “better balance the government’s interest in promoting coverage for contraceptive and sterilization services with the government’s interests in providing conscience protections for entities with sincerely held moral convictions.” The U.S. Department of Health & Human Services estimates that the rules, which take effect in January 2019, will affect no more than 200 employers.
The American College of Obstetricians and Gynecologists expressed concern that the final rules will restrict patient access to meaningful contraceptive methods and will erode decades of progress in increasing women’s reproductive autonomy and restrict patient access to contraception.
“Women, families and our nation all benefit from seamless, affordable access to contraception,” ACOG President Lisa M. Hollier, MD, said in a statement. “Contraception improves women’s health and well-being, reduces unintended pregnancy, enables pregnancy spacing for safer pregnancies and deliveries, and empowers women’s engagement in the workforce and economic self-sufficiency. A woman’s employer should not determine whether or not she has this access.”
Marjorie Dannenfelser, president of Susan B. Anthony List, an anti-abortion group, praised the final rules, calling them needed protections from the burdensome Obama-era ACA abortifacient drug mandate.
“President Trump and HHS Secretary Azar delivered a huge victory for conscience rights and religious liberty in America,” Ms. Dannenfelser said in a statement. “No longer will Catholic nuns who care for the elderly poor be forced by the government to provide abortion-inducing drugs in their health care plans. Not only that, moral objectors such as Susan B. Anthony List, will also no longer have to pay for life-ending drugs that are antithetical to their mission and for which we have argued there is certainly no compelling state interest.”
The ACA initially required all employers to cover birth control for employees with no copayments, except for group health plans of religious employers, which were deemed exempt. Those religious employers were primarily churches and other houses of worship. After a number of complaints and legal challenges, the Obama administration created a workaround for nonprofit religious employers to opt out of the mandate.
However, critics argued the process itself was a violation of their religious freedom. The issue led to the case of Zubik v. Burwell, a legal challenge over the mandate exemption that went before the U.S. Supreme Court in March 2016. The issue was never resolved. In May 2016, the Supreme Court vacated the lower court rulings related to Zubik v. Burwell and remanded the case back to the four appeals courts that had originally ruled on the issue.
Under the approved regulations, employers or insurers can stop their coverage of contraceptive services if they have religious beliefs or moral convictions against covering birth control. Exempted entities and individuals also can choose to cover some, but not all, contraceptive services, depending on their specific religious or moral objection, according to an HHS fact sheet.
The agency emphasized that the regulations leave in place government programs that provide free or subsidized contraceptive coverage to low-income women, such as through community health centers, and that the rules do not ban any employer from covering contraceptives.
The regulations become effective 60 days after they are published in the Federal Register.
More employers can opt out of providing contraception coverage to their employees under final regulations from the Trump administration that narrow the Affordable Care Act’s contraceptive mandate.
The two regulations, released Nov. 7, allow an expanded group of employers and insurers to get out of covering contraception methods by objecting on either religious or moral grounds.
The first rule broadens exemptions to the ACA’s contraceptive mandate to entities that object to services covered by the mandate on the basis of sincerely held religious beliefs. The second rule protects nonprofit organizations and small businesses that have nonreligious moral convictions that oppose services covered by the mandate. The religious and moral exemptions apply to institutions of education, issuers, and individuals, but not to governmental entities.
When first proposed in 2017, Trump administration officials said the new policies would “better balance the government’s interest in promoting coverage for contraceptive and sterilization services with the government’s interests in providing conscience protections for entities with sincerely held moral convictions.” The U.S. Department of Health & Human Services estimates that the rules, which take effect in January 2019, will affect no more than 200 employers.
The American College of Obstetricians and Gynecologists expressed concern that the final rules will restrict patient access to meaningful contraceptive methods and will erode decades of progress in increasing women’s reproductive autonomy and restrict patient access to contraception.
“Women, families and our nation all benefit from seamless, affordable access to contraception,” ACOG President Lisa M. Hollier, MD, said in a statement. “Contraception improves women’s health and well-being, reduces unintended pregnancy, enables pregnancy spacing for safer pregnancies and deliveries, and empowers women’s engagement in the workforce and economic self-sufficiency. A woman’s employer should not determine whether or not she has this access.”
Marjorie Dannenfelser, president of Susan B. Anthony List, an anti-abortion group, praised the final rules, calling them needed protections from the burdensome Obama-era ACA abortifacient drug mandate.
“President Trump and HHS Secretary Azar delivered a huge victory for conscience rights and religious liberty in America,” Ms. Dannenfelser said in a statement. “No longer will Catholic nuns who care for the elderly poor be forced by the government to provide abortion-inducing drugs in their health care plans. Not only that, moral objectors such as Susan B. Anthony List, will also no longer have to pay for life-ending drugs that are antithetical to their mission and for which we have argued there is certainly no compelling state interest.”
The ACA initially required all employers to cover birth control for employees with no copayments, except for group health plans of religious employers, which were deemed exempt. Those religious employers were primarily churches and other houses of worship. After a number of complaints and legal challenges, the Obama administration created a workaround for nonprofit religious employers to opt out of the mandate.
However, critics argued the process itself was a violation of their religious freedom. The issue led to the case of Zubik v. Burwell, a legal challenge over the mandate exemption that went before the U.S. Supreme Court in March 2016. The issue was never resolved. In May 2016, the Supreme Court vacated the lower court rulings related to Zubik v. Burwell and remanded the case back to the four appeals courts that had originally ruled on the issue.
Under the approved regulations, employers or insurers can stop their coverage of contraceptive services if they have religious beliefs or moral convictions against covering birth control. Exempted entities and individuals also can choose to cover some, but not all, contraceptive services, depending on their specific religious or moral objection, according to an HHS fact sheet.
The agency emphasized that the regulations leave in place government programs that provide free or subsidized contraceptive coverage to low-income women, such as through community health centers, and that the rules do not ban any employer from covering contraceptives.
The regulations become effective 60 days after they are published in the Federal Register.
AAP: Pediatricians can mitigate conflict effects on children
Pediatricians have a central role in addressing the impact to children caused by armed conflict, including diagnosing and managing health conditions resulting from exposure to associated violence, according to a new American Academy of Pediatrics policy statement.
The recommendation, published in Pediatrics, emphasizes the need for child health professionals to understand the prevalence of armed conflict and its pervasive effects on children and to respond both domestically and globally to the problem. The AAP defines armed conflict as any organized dispute that involves the use of weapons, violence, or force, such as international wars, civil wars, ethnic conflicts, and violence associated with gangs and drug trafficking. Children effected by armed conflict may include refugees forcibly displaced from their countries, unaccompanied immigrant children, and former child combatants, known as child soldiers.
The policy details the various health effects triggered by armed conflict, including physical, mental, developmental, and behavioral health conditions in children as well as indirect effects through deprivation and toxic stress. Children affected by armed conflict, for example, are at increased risk for PTSD, depression, anxiety, and behavioral and psychosomatic problems, which can continue well into adulthood, according to the policy statement.
To address these effects, pediatricians should receive training on trauma-informed care that enables them to recognize the dynamics of traumatic life experiences among children exposed to armed conflict and provide optimal responses, the policy advises.
and can work to mitigate the effects of trauma, according to the policy. The AAP recommends that child health professionals be prepared to diagnose and offer initial management for conditions associated with exposure to armed conflict as well as partner with community mental and behavioral health providers to establish collaborative care networks, when possible. Other AAP recommendations in the policy statement include that child health professionals:
- Be trained to provide “culturally effective care,” defined as “the delivery of care within the context of appropriate physician knowledge, understanding, and appreciation of all cultural distinctions, leading to optimal health outcomes.”
- Collaborate with local refugee resettlement groups and other public and private sector organizations, such as schools, health systems, and social services, to “facilitate the integration of children and families into their communities and to help families meet unmet needs.”
- Receive special preparation before working with refugees in camps or in conflict settings to become familiar with recognized standards for child protection and to better manage the physical, sexual, and psychological injuries caused by armed conflict.
The policy statement goes on to offer recommendations for systems that serve children exposed to armed conflict, advising that such systems should protect exposed children from abuse and exploitation, and offer access to physical, mental, behavioral, developmental, oral, and rehabilitation health services.
Finally, the AAP stressed its support of policies that advance the health, development, well-being, and rights of children affected by armed conflict and displacement. The AAP states that children should not be separated from their families during displacement and resettlement, emphasizing that “an intact family is the optimal environment for children’s health and well-being” and that “in the event of separation, family reunification should be prioritized.”
In addition, the AAP strongly advocates that children affected by armed conflict have access to educational opportunities, noting that pediatricians can act as a voice toward this end.
“There is strong evidence to suggest that education for boys and girls at all levels reduces most forms of political violence,” the authors wrote. “However, education currently receives less than 2% of all humanitarian funding, and girls are more likely than boys to be excluded from education. Because education is a priority for many children and essential for their well-being, child health providers may advocate for their educational rights and access, especially during humanitarian emergencies.”
SOURCE: Shenoda S et al. Pediatrics. 2018 Nov 5. doi: 10.1542/peds.2018.2586.
The new policy by the American Academy of Pediatrics regarding the effects of armed conflict on children is an important and interesting statement. At first look, someone reading statements like “children should be protected from land mines” might easily conclude that what is contained here is simply common sense guidelines.
On an individual level, the statement also urges individual child health professionals to consider getting out of their comfort zone and become more involved in community organizations, advocacy, and public policy. It also directly states that child health professionals should be prepared to diagnose and treat several mental health conditions that many might not consider in their current scope of practice. This is an important point, especially considering that stigma surrounding mental health treatment in many developing countries is even worse than it is in the United States – which means that primary care plays a crucial role in identification and treatment of these conditions.
David C. Rettew, MD , is an associate professor of psychiatry and pediatrics and director of child and adolescent psychiatry at the University of Vermont’s Center for Children, Youth, and Families in Burlington, Vt. These comments were taken from an interview with Dr. Rettew for this article.
The new policy by the American Academy of Pediatrics regarding the effects of armed conflict on children is an important and interesting statement. At first look, someone reading statements like “children should be protected from land mines” might easily conclude that what is contained here is simply common sense guidelines.
On an individual level, the statement also urges individual child health professionals to consider getting out of their comfort zone and become more involved in community organizations, advocacy, and public policy. It also directly states that child health professionals should be prepared to diagnose and treat several mental health conditions that many might not consider in their current scope of practice. This is an important point, especially considering that stigma surrounding mental health treatment in many developing countries is even worse than it is in the United States – which means that primary care plays a crucial role in identification and treatment of these conditions.
David C. Rettew, MD , is an associate professor of psychiatry and pediatrics and director of child and adolescent psychiatry at the University of Vermont’s Center for Children, Youth, and Families in Burlington, Vt. These comments were taken from an interview with Dr. Rettew for this article.
The new policy by the American Academy of Pediatrics regarding the effects of armed conflict on children is an important and interesting statement. At first look, someone reading statements like “children should be protected from land mines” might easily conclude that what is contained here is simply common sense guidelines.
On an individual level, the statement also urges individual child health professionals to consider getting out of their comfort zone and become more involved in community organizations, advocacy, and public policy. It also directly states that child health professionals should be prepared to diagnose and treat several mental health conditions that many might not consider in their current scope of practice. This is an important point, especially considering that stigma surrounding mental health treatment in many developing countries is even worse than it is in the United States – which means that primary care plays a crucial role in identification and treatment of these conditions.
David C. Rettew, MD , is an associate professor of psychiatry and pediatrics and director of child and adolescent psychiatry at the University of Vermont’s Center for Children, Youth, and Families in Burlington, Vt. These comments were taken from an interview with Dr. Rettew for this article.
Pediatricians have a central role in addressing the impact to children caused by armed conflict, including diagnosing and managing health conditions resulting from exposure to associated violence, according to a new American Academy of Pediatrics policy statement.
The recommendation, published in Pediatrics, emphasizes the need for child health professionals to understand the prevalence of armed conflict and its pervasive effects on children and to respond both domestically and globally to the problem. The AAP defines armed conflict as any organized dispute that involves the use of weapons, violence, or force, such as international wars, civil wars, ethnic conflicts, and violence associated with gangs and drug trafficking. Children effected by armed conflict may include refugees forcibly displaced from their countries, unaccompanied immigrant children, and former child combatants, known as child soldiers.
The policy details the various health effects triggered by armed conflict, including physical, mental, developmental, and behavioral health conditions in children as well as indirect effects through deprivation and toxic stress. Children affected by armed conflict, for example, are at increased risk for PTSD, depression, anxiety, and behavioral and psychosomatic problems, which can continue well into adulthood, according to the policy statement.
To address these effects, pediatricians should receive training on trauma-informed care that enables them to recognize the dynamics of traumatic life experiences among children exposed to armed conflict and provide optimal responses, the policy advises.
and can work to mitigate the effects of trauma, according to the policy. The AAP recommends that child health professionals be prepared to diagnose and offer initial management for conditions associated with exposure to armed conflict as well as partner with community mental and behavioral health providers to establish collaborative care networks, when possible. Other AAP recommendations in the policy statement include that child health professionals:
- Be trained to provide “culturally effective care,” defined as “the delivery of care within the context of appropriate physician knowledge, understanding, and appreciation of all cultural distinctions, leading to optimal health outcomes.”
- Collaborate with local refugee resettlement groups and other public and private sector organizations, such as schools, health systems, and social services, to “facilitate the integration of children and families into their communities and to help families meet unmet needs.”
- Receive special preparation before working with refugees in camps or in conflict settings to become familiar with recognized standards for child protection and to better manage the physical, sexual, and psychological injuries caused by armed conflict.
The policy statement goes on to offer recommendations for systems that serve children exposed to armed conflict, advising that such systems should protect exposed children from abuse and exploitation, and offer access to physical, mental, behavioral, developmental, oral, and rehabilitation health services.
Finally, the AAP stressed its support of policies that advance the health, development, well-being, and rights of children affected by armed conflict and displacement. The AAP states that children should not be separated from their families during displacement and resettlement, emphasizing that “an intact family is the optimal environment for children’s health and well-being” and that “in the event of separation, family reunification should be prioritized.”
In addition, the AAP strongly advocates that children affected by armed conflict have access to educational opportunities, noting that pediatricians can act as a voice toward this end.
“There is strong evidence to suggest that education for boys and girls at all levels reduces most forms of political violence,” the authors wrote. “However, education currently receives less than 2% of all humanitarian funding, and girls are more likely than boys to be excluded from education. Because education is a priority for many children and essential for their well-being, child health providers may advocate for their educational rights and access, especially during humanitarian emergencies.”
SOURCE: Shenoda S et al. Pediatrics. 2018 Nov 5. doi: 10.1542/peds.2018.2586.
Pediatricians have a central role in addressing the impact to children caused by armed conflict, including diagnosing and managing health conditions resulting from exposure to associated violence, according to a new American Academy of Pediatrics policy statement.
The recommendation, published in Pediatrics, emphasizes the need for child health professionals to understand the prevalence of armed conflict and its pervasive effects on children and to respond both domestically and globally to the problem. The AAP defines armed conflict as any organized dispute that involves the use of weapons, violence, or force, such as international wars, civil wars, ethnic conflicts, and violence associated with gangs and drug trafficking. Children effected by armed conflict may include refugees forcibly displaced from their countries, unaccompanied immigrant children, and former child combatants, known as child soldiers.
The policy details the various health effects triggered by armed conflict, including physical, mental, developmental, and behavioral health conditions in children as well as indirect effects through deprivation and toxic stress. Children affected by armed conflict, for example, are at increased risk for PTSD, depression, anxiety, and behavioral and psychosomatic problems, which can continue well into adulthood, according to the policy statement.
To address these effects, pediatricians should receive training on trauma-informed care that enables them to recognize the dynamics of traumatic life experiences among children exposed to armed conflict and provide optimal responses, the policy advises.
and can work to mitigate the effects of trauma, according to the policy. The AAP recommends that child health professionals be prepared to diagnose and offer initial management for conditions associated with exposure to armed conflict as well as partner with community mental and behavioral health providers to establish collaborative care networks, when possible. Other AAP recommendations in the policy statement include that child health professionals:
- Be trained to provide “culturally effective care,” defined as “the delivery of care within the context of appropriate physician knowledge, understanding, and appreciation of all cultural distinctions, leading to optimal health outcomes.”
- Collaborate with local refugee resettlement groups and other public and private sector organizations, such as schools, health systems, and social services, to “facilitate the integration of children and families into their communities and to help families meet unmet needs.”
- Receive special preparation before working with refugees in camps or in conflict settings to become familiar with recognized standards for child protection and to better manage the physical, sexual, and psychological injuries caused by armed conflict.
The policy statement goes on to offer recommendations for systems that serve children exposed to armed conflict, advising that such systems should protect exposed children from abuse and exploitation, and offer access to physical, mental, behavioral, developmental, oral, and rehabilitation health services.
Finally, the AAP stressed its support of policies that advance the health, development, well-being, and rights of children affected by armed conflict and displacement. The AAP states that children should not be separated from their families during displacement and resettlement, emphasizing that “an intact family is the optimal environment for children’s health and well-being” and that “in the event of separation, family reunification should be prioritized.”
In addition, the AAP strongly advocates that children affected by armed conflict have access to educational opportunities, noting that pediatricians can act as a voice toward this end.
“There is strong evidence to suggest that education for boys and girls at all levels reduces most forms of political violence,” the authors wrote. “However, education currently receives less than 2% of all humanitarian funding, and girls are more likely than boys to be excluded from education. Because education is a priority for many children and essential for their well-being, child health providers may advocate for their educational rights and access, especially during humanitarian emergencies.”
SOURCE: Shenoda S et al. Pediatrics. 2018 Nov 5. doi: 10.1542/peds.2018.2586.
FROM PEDIATRICS
CMS delays controversial E/M changes in final rule
After a torrent of criticism from the physician community, .
The agency’s final 2019 Physician Fee Schedule, announced Nov. 1, rescinds a proposal that would have blended payments for new and established patients for office/outpatient E/M levels 2 through 5 into single payments. Instead, the agency will continue to hear perspective on the proposal with plans to collapse E/M code levels 2 through 4 into single payments beginning in 2021, while maintaining level 5.
CMS also pulled back its proposal to apply a multiple procedure payment reduction to E/M visits furnished on the same day as a procedure. Payment rates for the less expensive of the two will be maintained, rather than cut in half as initially proposed.
The American Academy of Dermatology Association (AADA) expressed appreciation that CMS took feedback from the physician community seriously and that the agency took steps to eliminate some of its proposals.
“The AADA appreciates the effort and willingness of key decision makers at CMS, at HHS, and on Capitol Hill to hear the concerns of dermatologists and other physicians, and to take them into consideration in developing this final rule,” George J. Hruza, MD, president-elect of the AADA said in an interview. “We appreciate that CMS decided against moving forward with the proposal to make aggressive changes to payment associated with modifier 25 – when an office visit and one or more procedures are provided to a patient on the same day. We are also pleased that CMS made the decision to delay its larger proposal to collapse E/M codes for two years to 2021; this delay gives physicians of different perspectives the opportunity to come together, through the RUC/CPT Workgroup, and work toward developing a solution and a path forward in payment reform.”
Dr. Hruza noted that the AADA worked closely with the American Medical Association and other medical specialty groups to convey their concerns to CMS about the proposed rule, and that they look forward to working with policymakers on further refinements.
The final rule released is much different than the one proposed, which shows that CMS heeded concerns by physicians and took time to craft a more realistic fee schedule, said Orly Avitzur, MD, chair of the American Academy of Neurology’s Medical Economics and Management Committee. The proposed collapsed E/M levels would have likely led to shorter visit times, negatively impacting the doctor-patient relationship and patient care, she said.
“Overall, the American Academy of Neurology was extremely pleased that CMS made several reversals to the proposed rule that indicated that they really listened to our concerns and tried to address them,” Dr. Avitzur said in an interview. “We are very pleased they are giving us an additional 2 years to help us and other stakeholders to give them feedback about how to refine their decision to collapse levels 2, 3, and 4 codes.”
As part of its final rule, CMS moved forward with several other changes to coding and documentation, including eliminating the need to document the medical necessity of a home visit in lieu of an office visit, and allowing physicians to skip documentation of changes since a prior patient visit when relevant information is already contained in the record.
Additionally, the final rule clarifies that for E/M office/outpatient visits physicians do not need to re-enter information on the patient’s chief complaint and history that has already been entered by ancillary staff or the patient. The physician may just indicate in the medical record that he or she has reviewed and verified the information.
In a statement, CMS administrator Seema Verma said the final rule cements dramatic improvements for clinicians and patients and reflects extensive input from the medical community.
“Addressing clinician burnout is critical to keeping doctors in the workforce to meet the growing needs of America’s seniors,” Ms. Verma said in the statement. “[The] rule offers immediate relief from onerous requirements that contribute to burnout in the medical profession and detract from patient care. It also delays even more significant changes to give clinicians the time they need for implementation and provides time for us to continue to work with the medical community on this effort.”
With physicians facing excessive documentation requirements in their practices, it is a relief to see that the administration not only understands the problem of regulatory burden but is taking concrete steps to address it, said Barbara L. McAneny, MD, president of the American Medical Association.
“Patients are likely to see the effect as their physicians will have more time to spend with them and be able to more quickly locate relevant information in medical records,” Dr. McAneny said in a statement. “Implementation of these policies will streamline documentation requirements, reducing paperwork burdens that interfere with a meaningful patient-physician relationship.”
CMS finalized a number of proposals to pay doctors separately for communication technology services. This includes HCPCS code G2012 for brief communication technology-based services, such as virtual check-ins and HCPCS code G2010 for remote evaluation of a recorded video and/or images submitted by an established patient, also known as store and forward.
Additionally, CMS will pay separately for new codes that describe chronic care remote physiologic monitoring (CPT codes 99453, 99454, and 99457) and interprofessional Internet consultation (CPT codes 99451, 99452, 99446, 99447, 99448, and 99449). Also new to the list of reimbursable telehealth services are HCPCS codes G0513 and G0514 for prolonged preventive services.
Telehealth physicians who treat opioid use disorder received more flexibility under the CMS 2019 fee schedule through the agency’s removal of originating site geographic requirements. CMS will now allow a patient’s home to be an originating site for telehealth services for substance use disorder treatment or co-occurring mental health disorder. The agency is also accepting comments on a new Medicare benefit category for opioid use disorder treatment furnished by opioid treatment programs under Part B beginning on or after Jan. 1, 2020.
CMS also approved updates to its Medicare Shared Savings Program, including finalizing time-sensitive program policy changes for currently participating Accountable Care Organizations (ACOs). These changes include:
- A voluntary 6-month extension for existing ACOs whose participation agreements expire on Dec. 31, 2018, and the methodology for determining financial and quality performance for the 6-month performance year from Jan. 1 to June 30, 2019.
- Revising the definition of primary care services used in beneficiary assignment.
- Providing relief for ACOs and their clinicians impacted by extreme and uncontrollable circumstances in 2018 and subsequent years.
After a torrent of criticism from the physician community, .
The agency’s final 2019 Physician Fee Schedule, announced Nov. 1, rescinds a proposal that would have blended payments for new and established patients for office/outpatient E/M levels 2 through 5 into single payments. Instead, the agency will continue to hear perspective on the proposal with plans to collapse E/M code levels 2 through 4 into single payments beginning in 2021, while maintaining level 5.
CMS also pulled back its proposal to apply a multiple procedure payment reduction to E/M visits furnished on the same day as a procedure. Payment rates for the less expensive of the two will be maintained, rather than cut in half as initially proposed.
The American Academy of Dermatology Association (AADA) expressed appreciation that CMS took feedback from the physician community seriously and that the agency took steps to eliminate some of its proposals.
“The AADA appreciates the effort and willingness of key decision makers at CMS, at HHS, and on Capitol Hill to hear the concerns of dermatologists and other physicians, and to take them into consideration in developing this final rule,” George J. Hruza, MD, president-elect of the AADA said in an interview. “We appreciate that CMS decided against moving forward with the proposal to make aggressive changes to payment associated with modifier 25 – when an office visit and one or more procedures are provided to a patient on the same day. We are also pleased that CMS made the decision to delay its larger proposal to collapse E/M codes for two years to 2021; this delay gives physicians of different perspectives the opportunity to come together, through the RUC/CPT Workgroup, and work toward developing a solution and a path forward in payment reform.”
Dr. Hruza noted that the AADA worked closely with the American Medical Association and other medical specialty groups to convey their concerns to CMS about the proposed rule, and that they look forward to working with policymakers on further refinements.
The final rule released is much different than the one proposed, which shows that CMS heeded concerns by physicians and took time to craft a more realistic fee schedule, said Orly Avitzur, MD, chair of the American Academy of Neurology’s Medical Economics and Management Committee. The proposed collapsed E/M levels would have likely led to shorter visit times, negatively impacting the doctor-patient relationship and patient care, she said.
“Overall, the American Academy of Neurology was extremely pleased that CMS made several reversals to the proposed rule that indicated that they really listened to our concerns and tried to address them,” Dr. Avitzur said in an interview. “We are very pleased they are giving us an additional 2 years to help us and other stakeholders to give them feedback about how to refine their decision to collapse levels 2, 3, and 4 codes.”
As part of its final rule, CMS moved forward with several other changes to coding and documentation, including eliminating the need to document the medical necessity of a home visit in lieu of an office visit, and allowing physicians to skip documentation of changes since a prior patient visit when relevant information is already contained in the record.
Additionally, the final rule clarifies that for E/M office/outpatient visits physicians do not need to re-enter information on the patient’s chief complaint and history that has already been entered by ancillary staff or the patient. The physician may just indicate in the medical record that he or she has reviewed and verified the information.
In a statement, CMS administrator Seema Verma said the final rule cements dramatic improvements for clinicians and patients and reflects extensive input from the medical community.
“Addressing clinician burnout is critical to keeping doctors in the workforce to meet the growing needs of America’s seniors,” Ms. Verma said in the statement. “[The] rule offers immediate relief from onerous requirements that contribute to burnout in the medical profession and detract from patient care. It also delays even more significant changes to give clinicians the time they need for implementation and provides time for us to continue to work with the medical community on this effort.”
With physicians facing excessive documentation requirements in their practices, it is a relief to see that the administration not only understands the problem of regulatory burden but is taking concrete steps to address it, said Barbara L. McAneny, MD, president of the American Medical Association.
“Patients are likely to see the effect as their physicians will have more time to spend with them and be able to more quickly locate relevant information in medical records,” Dr. McAneny said in a statement. “Implementation of these policies will streamline documentation requirements, reducing paperwork burdens that interfere with a meaningful patient-physician relationship.”
CMS finalized a number of proposals to pay doctors separately for communication technology services. This includes HCPCS code G2012 for brief communication technology-based services, such as virtual check-ins and HCPCS code G2010 for remote evaluation of a recorded video and/or images submitted by an established patient, also known as store and forward.
Additionally, CMS will pay separately for new codes that describe chronic care remote physiologic monitoring (CPT codes 99453, 99454, and 99457) and interprofessional Internet consultation (CPT codes 99451, 99452, 99446, 99447, 99448, and 99449). Also new to the list of reimbursable telehealth services are HCPCS codes G0513 and G0514 for prolonged preventive services.
Telehealth physicians who treat opioid use disorder received more flexibility under the CMS 2019 fee schedule through the agency’s removal of originating site geographic requirements. CMS will now allow a patient’s home to be an originating site for telehealth services for substance use disorder treatment or co-occurring mental health disorder. The agency is also accepting comments on a new Medicare benefit category for opioid use disorder treatment furnished by opioid treatment programs under Part B beginning on or after Jan. 1, 2020.
CMS also approved updates to its Medicare Shared Savings Program, including finalizing time-sensitive program policy changes for currently participating Accountable Care Organizations (ACOs). These changes include:
- A voluntary 6-month extension for existing ACOs whose participation agreements expire on Dec. 31, 2018, and the methodology for determining financial and quality performance for the 6-month performance year from Jan. 1 to June 30, 2019.
- Revising the definition of primary care services used in beneficiary assignment.
- Providing relief for ACOs and their clinicians impacted by extreme and uncontrollable circumstances in 2018 and subsequent years.
After a torrent of criticism from the physician community, .
The agency’s final 2019 Physician Fee Schedule, announced Nov. 1, rescinds a proposal that would have blended payments for new and established patients for office/outpatient E/M levels 2 through 5 into single payments. Instead, the agency will continue to hear perspective on the proposal with plans to collapse E/M code levels 2 through 4 into single payments beginning in 2021, while maintaining level 5.
CMS also pulled back its proposal to apply a multiple procedure payment reduction to E/M visits furnished on the same day as a procedure. Payment rates for the less expensive of the two will be maintained, rather than cut in half as initially proposed.
The American Academy of Dermatology Association (AADA) expressed appreciation that CMS took feedback from the physician community seriously and that the agency took steps to eliminate some of its proposals.
“The AADA appreciates the effort and willingness of key decision makers at CMS, at HHS, and on Capitol Hill to hear the concerns of dermatologists and other physicians, and to take them into consideration in developing this final rule,” George J. Hruza, MD, president-elect of the AADA said in an interview. “We appreciate that CMS decided against moving forward with the proposal to make aggressive changes to payment associated with modifier 25 – when an office visit and one or more procedures are provided to a patient on the same day. We are also pleased that CMS made the decision to delay its larger proposal to collapse E/M codes for two years to 2021; this delay gives physicians of different perspectives the opportunity to come together, through the RUC/CPT Workgroup, and work toward developing a solution and a path forward in payment reform.”
Dr. Hruza noted that the AADA worked closely with the American Medical Association and other medical specialty groups to convey their concerns to CMS about the proposed rule, and that they look forward to working with policymakers on further refinements.
The final rule released is much different than the one proposed, which shows that CMS heeded concerns by physicians and took time to craft a more realistic fee schedule, said Orly Avitzur, MD, chair of the American Academy of Neurology’s Medical Economics and Management Committee. The proposed collapsed E/M levels would have likely led to shorter visit times, negatively impacting the doctor-patient relationship and patient care, she said.
“Overall, the American Academy of Neurology was extremely pleased that CMS made several reversals to the proposed rule that indicated that they really listened to our concerns and tried to address them,” Dr. Avitzur said in an interview. “We are very pleased they are giving us an additional 2 years to help us and other stakeholders to give them feedback about how to refine their decision to collapse levels 2, 3, and 4 codes.”
As part of its final rule, CMS moved forward with several other changes to coding and documentation, including eliminating the need to document the medical necessity of a home visit in lieu of an office visit, and allowing physicians to skip documentation of changes since a prior patient visit when relevant information is already contained in the record.
Additionally, the final rule clarifies that for E/M office/outpatient visits physicians do not need to re-enter information on the patient’s chief complaint and history that has already been entered by ancillary staff or the patient. The physician may just indicate in the medical record that he or she has reviewed and verified the information.
In a statement, CMS administrator Seema Verma said the final rule cements dramatic improvements for clinicians and patients and reflects extensive input from the medical community.
“Addressing clinician burnout is critical to keeping doctors in the workforce to meet the growing needs of America’s seniors,” Ms. Verma said in the statement. “[The] rule offers immediate relief from onerous requirements that contribute to burnout in the medical profession and detract from patient care. It also delays even more significant changes to give clinicians the time they need for implementation and provides time for us to continue to work with the medical community on this effort.”
With physicians facing excessive documentation requirements in their practices, it is a relief to see that the administration not only understands the problem of regulatory burden but is taking concrete steps to address it, said Barbara L. McAneny, MD, president of the American Medical Association.
“Patients are likely to see the effect as their physicians will have more time to spend with them and be able to more quickly locate relevant information in medical records,” Dr. McAneny said in a statement. “Implementation of these policies will streamline documentation requirements, reducing paperwork burdens that interfere with a meaningful patient-physician relationship.”
CMS finalized a number of proposals to pay doctors separately for communication technology services. This includes HCPCS code G2012 for brief communication technology-based services, such as virtual check-ins and HCPCS code G2010 for remote evaluation of a recorded video and/or images submitted by an established patient, also known as store and forward.
Additionally, CMS will pay separately for new codes that describe chronic care remote physiologic monitoring (CPT codes 99453, 99454, and 99457) and interprofessional Internet consultation (CPT codes 99451, 99452, 99446, 99447, 99448, and 99449). Also new to the list of reimbursable telehealth services are HCPCS codes G0513 and G0514 for prolonged preventive services.
Telehealth physicians who treat opioid use disorder received more flexibility under the CMS 2019 fee schedule through the agency’s removal of originating site geographic requirements. CMS will now allow a patient’s home to be an originating site for telehealth services for substance use disorder treatment or co-occurring mental health disorder. The agency is also accepting comments on a new Medicare benefit category for opioid use disorder treatment furnished by opioid treatment programs under Part B beginning on or after Jan. 1, 2020.
CMS also approved updates to its Medicare Shared Savings Program, including finalizing time-sensitive program policy changes for currently participating Accountable Care Organizations (ACOs). These changes include:
- A voluntary 6-month extension for existing ACOs whose participation agreements expire on Dec. 31, 2018, and the methodology for determining financial and quality performance for the 6-month performance year from Jan. 1 to June 30, 2019.
- Revising the definition of primary care services used in beneficiary assignment.
- Providing relief for ACOs and their clinicians impacted by extreme and uncontrollable circumstances in 2018 and subsequent years.
Neurologists to lose money under CMS E/M proposal
Neurologists can expect decreased reimbursement under a proposal by the Centers for Medicare & Medicaid Services that would change how the agency pays for evaluation and management services (E/M), according to an analysis published in JAMA Neurology.
The CMS recommendation, issued as part of the agency’s 2019 proposed Physician Fee Schedule, would collapse payments for new and established patients for office/outpatient E/M levels 2-5 (currently between $45 and $211) into single payments. The proposed single payments (return visits $93; new patients $135) are between current rates for levels 3-4. In its proposal, CMS officials said the change would improve payment accuracy and simplify documentation.
If approved, neurologists stand to lose the most money under the payment scheme since the majority of their Medicare payments stem from these services, while specialists who use the services less often would benefit from the modification. Specifically, neurologists would lose a median of $3,226 annually under the CMS proposal and cardiologists would lose a median of $3,203 per year, while dermatologists would gain an annual median of $16,655 and orthopedists would gain a median of $6,239, according to the study.
Lead author Brian C. Callaghan, MD, of the University of Michigan, Ann Arbor, and colleagues evaluated the 2013 Medicare Physician and Other Supplier File to determine the distribution of outpatient E/M codes for levels 2-5 used by different specialists and the proportion of total payments for all physician services attributable to these outpatient codes. Investigators estimated the financial impact of collapsed payments by calculating the difference of actual annual payments for outpatient E/M work and the projected annual payments with the proposed policy change.
Results showed that in 2013 the proportion of outpatient E/M codes billed at levels 4-5 varied widely by specialty. Neurologists for example, billed 70% of their outpatient physician E/M codes under levels 4-5, the highest of any specialty. Cardiologists were also high utilizers of the codes with 65% of their outpatient E/M codes falling between levels 4 and 5. The lowest users for levels 4-5 were dermatologists (11%), orthopedists (22%), and otolaryngologists (25%). Taking into account the distribution and volumes of E/M services, the investigators concluded that CMS’ proposed payment change would be most favorable for surgical specialists, neutral for generalists, and most unfavorable for neurologists.
Dr. Callaghan and colleagues wrote that collapsing E/M payments would likely incentivize all physicians to shorten visit times, which could negatively impact doctor-patient relationships and patient care.
“Given that longer visit times are associated with higher patient satisfaction and important elements of care, the CMS proposal would likely have negative consequence,” Dr. Callaghan and his coauthors wrote. “Current E/M payments strongly undervalue the cognitive work of physicians, compared with procedural-based payments. Based on our data, the recent proposal to collapse E/M payment levels would further undervalue these important services, particularly for neurologists.”
The authors reported receiving grants and fees from organizations, companies, and government agencies outside the published study.
SOURCE: Callaghan B et al. JAMA Neurol. 2018 Oct 31. doi: 10.1001/jamaneurol.2018.3794.
Neurologists can expect decreased reimbursement under a proposal by the Centers for Medicare & Medicaid Services that would change how the agency pays for evaluation and management services (E/M), according to an analysis published in JAMA Neurology.
The CMS recommendation, issued as part of the agency’s 2019 proposed Physician Fee Schedule, would collapse payments for new and established patients for office/outpatient E/M levels 2-5 (currently between $45 and $211) into single payments. The proposed single payments (return visits $93; new patients $135) are between current rates for levels 3-4. In its proposal, CMS officials said the change would improve payment accuracy and simplify documentation.
If approved, neurologists stand to lose the most money under the payment scheme since the majority of their Medicare payments stem from these services, while specialists who use the services less often would benefit from the modification. Specifically, neurologists would lose a median of $3,226 annually under the CMS proposal and cardiologists would lose a median of $3,203 per year, while dermatologists would gain an annual median of $16,655 and orthopedists would gain a median of $6,239, according to the study.
Lead author Brian C. Callaghan, MD, of the University of Michigan, Ann Arbor, and colleagues evaluated the 2013 Medicare Physician and Other Supplier File to determine the distribution of outpatient E/M codes for levels 2-5 used by different specialists and the proportion of total payments for all physician services attributable to these outpatient codes. Investigators estimated the financial impact of collapsed payments by calculating the difference of actual annual payments for outpatient E/M work and the projected annual payments with the proposed policy change.
Results showed that in 2013 the proportion of outpatient E/M codes billed at levels 4-5 varied widely by specialty. Neurologists for example, billed 70% of their outpatient physician E/M codes under levels 4-5, the highest of any specialty. Cardiologists were also high utilizers of the codes with 65% of their outpatient E/M codes falling between levels 4 and 5. The lowest users for levels 4-5 were dermatologists (11%), orthopedists (22%), and otolaryngologists (25%). Taking into account the distribution and volumes of E/M services, the investigators concluded that CMS’ proposed payment change would be most favorable for surgical specialists, neutral for generalists, and most unfavorable for neurologists.
Dr. Callaghan and colleagues wrote that collapsing E/M payments would likely incentivize all physicians to shorten visit times, which could negatively impact doctor-patient relationships and patient care.
“Given that longer visit times are associated with higher patient satisfaction and important elements of care, the CMS proposal would likely have negative consequence,” Dr. Callaghan and his coauthors wrote. “Current E/M payments strongly undervalue the cognitive work of physicians, compared with procedural-based payments. Based on our data, the recent proposal to collapse E/M payment levels would further undervalue these important services, particularly for neurologists.”
The authors reported receiving grants and fees from organizations, companies, and government agencies outside the published study.
SOURCE: Callaghan B et al. JAMA Neurol. 2018 Oct 31. doi: 10.1001/jamaneurol.2018.3794.
Neurologists can expect decreased reimbursement under a proposal by the Centers for Medicare & Medicaid Services that would change how the agency pays for evaluation and management services (E/M), according to an analysis published in JAMA Neurology.
The CMS recommendation, issued as part of the agency’s 2019 proposed Physician Fee Schedule, would collapse payments for new and established patients for office/outpatient E/M levels 2-5 (currently between $45 and $211) into single payments. The proposed single payments (return visits $93; new patients $135) are between current rates for levels 3-4. In its proposal, CMS officials said the change would improve payment accuracy and simplify documentation.
If approved, neurologists stand to lose the most money under the payment scheme since the majority of their Medicare payments stem from these services, while specialists who use the services less often would benefit from the modification. Specifically, neurologists would lose a median of $3,226 annually under the CMS proposal and cardiologists would lose a median of $3,203 per year, while dermatologists would gain an annual median of $16,655 and orthopedists would gain a median of $6,239, according to the study.
Lead author Brian C. Callaghan, MD, of the University of Michigan, Ann Arbor, and colleagues evaluated the 2013 Medicare Physician and Other Supplier File to determine the distribution of outpatient E/M codes for levels 2-5 used by different specialists and the proportion of total payments for all physician services attributable to these outpatient codes. Investigators estimated the financial impact of collapsed payments by calculating the difference of actual annual payments for outpatient E/M work and the projected annual payments with the proposed policy change.
Results showed that in 2013 the proportion of outpatient E/M codes billed at levels 4-5 varied widely by specialty. Neurologists for example, billed 70% of their outpatient physician E/M codes under levels 4-5, the highest of any specialty. Cardiologists were also high utilizers of the codes with 65% of their outpatient E/M codes falling between levels 4 and 5. The lowest users for levels 4-5 were dermatologists (11%), orthopedists (22%), and otolaryngologists (25%). Taking into account the distribution and volumes of E/M services, the investigators concluded that CMS’ proposed payment change would be most favorable for surgical specialists, neutral for generalists, and most unfavorable for neurologists.
Dr. Callaghan and colleagues wrote that collapsing E/M payments would likely incentivize all physicians to shorten visit times, which could negatively impact doctor-patient relationships and patient care.
“Given that longer visit times are associated with higher patient satisfaction and important elements of care, the CMS proposal would likely have negative consequence,” Dr. Callaghan and his coauthors wrote. “Current E/M payments strongly undervalue the cognitive work of physicians, compared with procedural-based payments. Based on our data, the recent proposal to collapse E/M payment levels would further undervalue these important services, particularly for neurologists.”
The authors reported receiving grants and fees from organizations, companies, and government agencies outside the published study.
SOURCE: Callaghan B et al. JAMA Neurol. 2018 Oct 31. doi: 10.1001/jamaneurol.2018.3794.
FROM JAMA NEUROLOGY
Key clinical point: Neurologists would lose reimbursement under a coding proposal by the Centers for Medicare & Medicaid Services.
Major finding: Neurologists would lose a median of $3,226 annually under the new CMS E/M coding proposal.
Study details: Investigators analyzed the 2013 Medicare Physician and Other Supplier File to determine the distribution of outpatient E/M codes for levels 2-5 used by different specialists and the proportion of total payments for all physician services attributable to these outpatient codes.
Disclosures: The authors reported receiving grants and fees from organizations, companies, and government agencies outside the published study.
Source: Callaghan B et al. JAMA Neurol. 2018 Oct 31. doi: 10.1001/jamaneurol.2018.3794.
ACOG: First gynecologist visit between ages 13 and 15
The American College of Obstetricians and Gynecologists (ACOG) recommends that girls receive their first reproductive health visit between the ages of 13 and 15 years to discuss healthy relationships in addition to general reproductive health, according to a new committee opinion.
The recommendation, published online Oct. 24, emphasizes that such early visits provide opportunities for ob.gyns. to educate teenage girls and their guardians about age-appropriate health issues, such as sexual relationships, dating violence, and sexual coercion. Between the ages of 13 years and 15 years is an ideal window because middle school is a time that some adolescents develop their first romantic and sexual relationships (Obstet Gynecol. 2018; 132[5]:1317-18 doi: 10.1097/AOG.0000000000002946).
“Creating a nonjudgmental environment and educating staff on the unique concerns of adolescents are helpful ways to provide effective and appropriate care to this group of patients,” the authors wrote.
Ob.gyns. can use the early meeting to discuss key aspects of a healthy relationship with patients, including communication, self-respect, and mutual respect, while helping adolescents identify the characteristics of an unhealthy relationships such as dishonesty, intimidation, disrespect, and abuse, according to the opinion. As part of the discussion, ob.gyns. also may counsel patients to define their current relationship and their expectations for future relationships. Both relationships with and without sexual intimacy should be discussed, the opinion advises.
The recommendation reminds health care professionals to be mindful of federal and state confidentiality laws and that they be aware of mandatory reporting laws when intimate partner violence, teen dating violence, or statutory rape is suspected. In addition, the opinion notes that pregnant and parenting adolescents; lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ) individuals; and adolescents with physical and mental disabilities are at particular risk of disparities in the health care system.
“The promotion of healthy relationships in these groups requires the obstetrician-gynecologist to be aware of the unique barriers and hurdles to sexual and nonsexual expression, as well as to health care,” the opinion states. “Interventions to promote healthy relationships and a strong sexual health framework are more effective when started early and can affect indicators of long-term individual health and public health.”
The American College of Obstetricians and Gynecologists recommends that the first reproductive health visit occur between the ages of 13 and 15, and I agree with them. Often patients attending this appointment don’t have physical complaints, and we can focus on prevention and education. The visit can be about building the provider-patient relationship and may serve to ease fears and develop trust before visits for problem management.
There are a number of important health education topics to cover from puberty and menses to confidentiality and minor-access laws. Because many young people will begin to initiate romantic relationships during middle school, the topic of healthy relationships is critical. Unhealthy relationships, in their many forms, can have far reaching impacts on a young person’s health and wellness. For years, we’ve been talking with young people about preventing STIs or preventing unwanted pregnancy, but we’ve spent less energy working towards something.
I’m excited to see these recommendations and look forward to helping my younger patients think through relationships as important aspects of life and health, what they want from them, and how they can work towards them.
Melissa Kottke , MD is an obstetrician-gynecologist specializing in family planning and adolescent reproductive health at Emory University in Atlanta.
The American College of Obstetricians and Gynecologists recommends that the first reproductive health visit occur between the ages of 13 and 15, and I agree with them. Often patients attending this appointment don’t have physical complaints, and we can focus on prevention and education. The visit can be about building the provider-patient relationship and may serve to ease fears and develop trust before visits for problem management.
There are a number of important health education topics to cover from puberty and menses to confidentiality and minor-access laws. Because many young people will begin to initiate romantic relationships during middle school, the topic of healthy relationships is critical. Unhealthy relationships, in their many forms, can have far reaching impacts on a young person’s health and wellness. For years, we’ve been talking with young people about preventing STIs or preventing unwanted pregnancy, but we’ve spent less energy working towards something.
I’m excited to see these recommendations and look forward to helping my younger patients think through relationships as important aspects of life and health, what they want from them, and how they can work towards them.
Melissa Kottke , MD is an obstetrician-gynecologist specializing in family planning and adolescent reproductive health at Emory University in Atlanta.
The American College of Obstetricians and Gynecologists recommends that the first reproductive health visit occur between the ages of 13 and 15, and I agree with them. Often patients attending this appointment don’t have physical complaints, and we can focus on prevention and education. The visit can be about building the provider-patient relationship and may serve to ease fears and develop trust before visits for problem management.
There are a number of important health education topics to cover from puberty and menses to confidentiality and minor-access laws. Because many young people will begin to initiate romantic relationships during middle school, the topic of healthy relationships is critical. Unhealthy relationships, in their many forms, can have far reaching impacts on a young person’s health and wellness. For years, we’ve been talking with young people about preventing STIs or preventing unwanted pregnancy, but we’ve spent less energy working towards something.
I’m excited to see these recommendations and look forward to helping my younger patients think through relationships as important aspects of life and health, what they want from them, and how they can work towards them.
Melissa Kottke , MD is an obstetrician-gynecologist specializing in family planning and adolescent reproductive health at Emory University in Atlanta.
The American College of Obstetricians and Gynecologists (ACOG) recommends that girls receive their first reproductive health visit between the ages of 13 and 15 years to discuss healthy relationships in addition to general reproductive health, according to a new committee opinion.
The recommendation, published online Oct. 24, emphasizes that such early visits provide opportunities for ob.gyns. to educate teenage girls and their guardians about age-appropriate health issues, such as sexual relationships, dating violence, and sexual coercion. Between the ages of 13 years and 15 years is an ideal window because middle school is a time that some adolescents develop their first romantic and sexual relationships (Obstet Gynecol. 2018; 132[5]:1317-18 doi: 10.1097/AOG.0000000000002946).
“Creating a nonjudgmental environment and educating staff on the unique concerns of adolescents are helpful ways to provide effective and appropriate care to this group of patients,” the authors wrote.
Ob.gyns. can use the early meeting to discuss key aspects of a healthy relationship with patients, including communication, self-respect, and mutual respect, while helping adolescents identify the characteristics of an unhealthy relationships such as dishonesty, intimidation, disrespect, and abuse, according to the opinion. As part of the discussion, ob.gyns. also may counsel patients to define their current relationship and their expectations for future relationships. Both relationships with and without sexual intimacy should be discussed, the opinion advises.
The recommendation reminds health care professionals to be mindful of federal and state confidentiality laws and that they be aware of mandatory reporting laws when intimate partner violence, teen dating violence, or statutory rape is suspected. In addition, the opinion notes that pregnant and parenting adolescents; lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ) individuals; and adolescents with physical and mental disabilities are at particular risk of disparities in the health care system.
“The promotion of healthy relationships in these groups requires the obstetrician-gynecologist to be aware of the unique barriers and hurdles to sexual and nonsexual expression, as well as to health care,” the opinion states. “Interventions to promote healthy relationships and a strong sexual health framework are more effective when started early and can affect indicators of long-term individual health and public health.”
The American College of Obstetricians and Gynecologists (ACOG) recommends that girls receive their first reproductive health visit between the ages of 13 and 15 years to discuss healthy relationships in addition to general reproductive health, according to a new committee opinion.
The recommendation, published online Oct. 24, emphasizes that such early visits provide opportunities for ob.gyns. to educate teenage girls and their guardians about age-appropriate health issues, such as sexual relationships, dating violence, and sexual coercion. Between the ages of 13 years and 15 years is an ideal window because middle school is a time that some adolescents develop their first romantic and sexual relationships (Obstet Gynecol. 2018; 132[5]:1317-18 doi: 10.1097/AOG.0000000000002946).
“Creating a nonjudgmental environment and educating staff on the unique concerns of adolescents are helpful ways to provide effective and appropriate care to this group of patients,” the authors wrote.
Ob.gyns. can use the early meeting to discuss key aspects of a healthy relationship with patients, including communication, self-respect, and mutual respect, while helping adolescents identify the characteristics of an unhealthy relationships such as dishonesty, intimidation, disrespect, and abuse, according to the opinion. As part of the discussion, ob.gyns. also may counsel patients to define their current relationship and their expectations for future relationships. Both relationships with and without sexual intimacy should be discussed, the opinion advises.
The recommendation reminds health care professionals to be mindful of federal and state confidentiality laws and that they be aware of mandatory reporting laws when intimate partner violence, teen dating violence, or statutory rape is suspected. In addition, the opinion notes that pregnant and parenting adolescents; lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ) individuals; and adolescents with physical and mental disabilities are at particular risk of disparities in the health care system.
“The promotion of healthy relationships in these groups requires the obstetrician-gynecologist to be aware of the unique barriers and hurdles to sexual and nonsexual expression, as well as to health care,” the opinion states. “Interventions to promote healthy relationships and a strong sexual health framework are more effective when started early and can affect indicators of long-term individual health and public health.”
FROM OBSTETRICS & GYNECOLOGY
Experts: Kavanaugh may have lasting impact on health care
As the Supreme Court sits for its second session on Oct. 29, legal analysts question what impact its newest Associate Justice, Brett M. Kavanaugh, may have on health care cases that might come before the court.
The addition of Justice Kavanaugh cements a conservative majority on the high court, said Eric J. Segall, a constitutional law professor at Georgia State University in Atlanta.
“Where Justice Kennedy was moderate or liberal, Justice Kavanaugh will move the court dramatically to the right in most areas of law,” Mr. Segall said in an interview.
One area drawing considerable attention is abortion, with abortion rights advocates raising concerns that Justice Kavanaugh’s appointment may mean the reversal of Roe v. Wade. Legal analysts, however, say fall of the momentous ruling is not probable.
Based on his decisions written while he sat on the Court of Appeals for the District of Columbia Circuit, it’s more likely that Justice Kavanaugh would attempt to narrow the instances in which state abortion restrictions are considered to impede a woman’s constitutional right to an abortion, according to Timothy S. Jost, a legal analyst and retired health law professor at Washington and Lee University in Lexington, Va.
In Garza v. Hargan for example, then-Judge Kavanaugh dissented from a majority decision which ultimately allowed a teenage immigrant in U.S. custody to have an abortion. Judge Kavanaugh argued that it was wrong for unlawful immigrant minors in U.S. detention to obtain “immediate abortion on demand.” However, his dissent was not as far-reaching as that of another judge who argued that a minor undocumented immigrant had no constitutional right to an abortion.
“[Justice] Kavanaugh certainly could vote to overturn Roe v. Wade, but based on his past opinions, I think it much more likely that he would simply expand Roe’s undue burden exception on a case by case basis until it was meaningless,” Mr. Jost said in an interview. “He doesn’t have to overturn Roe v. Wade to allow states that want to effectively bar abortion [to succeed].”
Mr. Segall agrees that Justice Kavanaugh will likely water down the undue burden test for abortion and through this softening, essentially dismantle Roe and return the issue of abortion to states.
As for the fate of the Affordable Care Act, legal experts foresee a restrained stance by Justice Kavanaugh, rather than a strong rejection of the entire law. In 2011, Judge Kavanaugh wrote a dissenting opinion in Seven-Sky v. Holder, a case that challenged the constitutionality of the health law’s individual mandate. While his fellow judges ruled that Congress had the authority to enact the mandate, Judge Kavanaugh argued the mandate was a tax and thus, it was too early for the court to hear the case since the tax had not yet been levied.
The dissent by Judge Kavanaugh in this case amounted to a “procedural cop-out,” according to Thomas P. Miller, a resident fellow at the conservative American Enterprise Institute and a health care policy scholar.
“That tells you he is a relatively cautious judge as opposed to going right to the metal because other circuit court of appeals judges were able to say this is an unconstitutional mandate,” Mr. Miller said in an interview. “That suggests a degree of tactical caution on these issues, very similar to [Supreme Court Chief Justice John] Roberts.”
Justice Kavanaugh may get his first chance to rule on the ACA’s future through Texas v. United States. The case centers on a challenge by 20 Republican state attorneys general over the constitutionality of the health law’s individual mandate. The Trump administration has reduced the penalty for failing to have health insurance to $0 starting in 2019. The plaintiffs allege that the mandate cannot be severed from the rest of the ACA and that if the mandate is eliminated, the rest of the law should fall. Because the Trump administration has opted not to protect the ACA, Democratic state attorneys general in 16 states have intervened to defend the health law. Arguments were heard before the federal district court in the Northern District of Texas in September and a decision is expected any day.
If appealed, the Fifth Circuit would next take on the case, but the challenge could eventually reach the Supreme Court, Mr. Jost said.
“Chief Justice Roberts could save [the ACA] one more time, but I could see [Justice] Kavanaugh voting to uphold the ACA as the question would likely be a question of severability of the individual mandate from the rest of the ACA, and I can see [Kavanaugh] holding it severable,” he said.
Justice Kavanaugh may also weigh in on a handful of Medicaid cases that could go before the Supreme Court. The first case involves how much deference the federal government should have in allowing states to impose work requirements on Medicaid patients. In June, a federal judge in Washington D.C. struck down the federal government’s approval of a Kentucky Medicaid waiver that would have imposed work requirements and other rules for eligibility. That judge ruled that the Centers for Medicare & Medicaid Services did not adequately evaluate whether Kentucky’s requirements were consistent with federal Medicaid law.
Mr. Miller said it is too early to tell which way Justice Kavanaugh would vote on a Medicaid work requirements case, and that the decision depends on the context of the case and the reading of the law involved.
“[Justice] Kavanaugh has a less predictable record in this more narrow area of administrative law,” Mr. Miller said. “I doubt he alone is going to drive the court anywhere on this issue it doesn’t otherwise want to go – or at least drift.”
Two other Medicaid cases pending before the Supreme Court revolve around the right of a private Medicaid patient to sue a state over the exclusion of Planned Parenthood in its Medicaid program. Gee v. Planned Parenthood of Gulf Coast Inc. and its sister case, Anderson v. Planned Parenthood of Kansas and Mid-Missouri, stem from separate efforts by Kansas and Louisiana to remove Planned Parenthood from their Medicaid programs. The question is whether the Medicaid patients have a right to challenge the exclusions.
If the Supreme Court accepts the cases, Mr. Jost said it’s likely that Justice Kavanaugh would side with the states and bar the patients from suing.
“I could see him holding that Medicaid recipients can’t sue if a state violates federal law, which would effectively end Medicaid as an entitlement,” Mr. Jost said. “This would have disastrous consequences for low-income Americans.”
Justice Kavanaugh also could make an impact on gun control, Mr. Segall noted. The Supreme Court has not taken a Second Amendment case in several years; in the past, there was uncertainty about how Justice Kennedy would vote on a gun control case. Not so with Justice Kavanaugh, Mr. Segall said. In Heller v. District of Columbia (known as Heller II), Judge Kavanaugh dissented from the majority, writing that the District’s ban on semiautomatic rifles and its requirement that handguns be registered were unconstitutional.
“[The dissent] gave the Second Amendment as broad a reading as any judge has ever given,” Mr. Segall said. “Gun control, gun reform, and gun limits ... this is where [Kavanaugh] is going to make the biggest difference.”
As the Supreme Court sits for its second session on Oct. 29, legal analysts question what impact its newest Associate Justice, Brett M. Kavanaugh, may have on health care cases that might come before the court.
The addition of Justice Kavanaugh cements a conservative majority on the high court, said Eric J. Segall, a constitutional law professor at Georgia State University in Atlanta.
“Where Justice Kennedy was moderate or liberal, Justice Kavanaugh will move the court dramatically to the right in most areas of law,” Mr. Segall said in an interview.
One area drawing considerable attention is abortion, with abortion rights advocates raising concerns that Justice Kavanaugh’s appointment may mean the reversal of Roe v. Wade. Legal analysts, however, say fall of the momentous ruling is not probable.
Based on his decisions written while he sat on the Court of Appeals for the District of Columbia Circuit, it’s more likely that Justice Kavanaugh would attempt to narrow the instances in which state abortion restrictions are considered to impede a woman’s constitutional right to an abortion, according to Timothy S. Jost, a legal analyst and retired health law professor at Washington and Lee University in Lexington, Va.
In Garza v. Hargan for example, then-Judge Kavanaugh dissented from a majority decision which ultimately allowed a teenage immigrant in U.S. custody to have an abortion. Judge Kavanaugh argued that it was wrong for unlawful immigrant minors in U.S. detention to obtain “immediate abortion on demand.” However, his dissent was not as far-reaching as that of another judge who argued that a minor undocumented immigrant had no constitutional right to an abortion.
“[Justice] Kavanaugh certainly could vote to overturn Roe v. Wade, but based on his past opinions, I think it much more likely that he would simply expand Roe’s undue burden exception on a case by case basis until it was meaningless,” Mr. Jost said in an interview. “He doesn’t have to overturn Roe v. Wade to allow states that want to effectively bar abortion [to succeed].”
Mr. Segall agrees that Justice Kavanaugh will likely water down the undue burden test for abortion and through this softening, essentially dismantle Roe and return the issue of abortion to states.
As for the fate of the Affordable Care Act, legal experts foresee a restrained stance by Justice Kavanaugh, rather than a strong rejection of the entire law. In 2011, Judge Kavanaugh wrote a dissenting opinion in Seven-Sky v. Holder, a case that challenged the constitutionality of the health law’s individual mandate. While his fellow judges ruled that Congress had the authority to enact the mandate, Judge Kavanaugh argued the mandate was a tax and thus, it was too early for the court to hear the case since the tax had not yet been levied.
The dissent by Judge Kavanaugh in this case amounted to a “procedural cop-out,” according to Thomas P. Miller, a resident fellow at the conservative American Enterprise Institute and a health care policy scholar.
“That tells you he is a relatively cautious judge as opposed to going right to the metal because other circuit court of appeals judges were able to say this is an unconstitutional mandate,” Mr. Miller said in an interview. “That suggests a degree of tactical caution on these issues, very similar to [Supreme Court Chief Justice John] Roberts.”
Justice Kavanaugh may get his first chance to rule on the ACA’s future through Texas v. United States. The case centers on a challenge by 20 Republican state attorneys general over the constitutionality of the health law’s individual mandate. The Trump administration has reduced the penalty for failing to have health insurance to $0 starting in 2019. The plaintiffs allege that the mandate cannot be severed from the rest of the ACA and that if the mandate is eliminated, the rest of the law should fall. Because the Trump administration has opted not to protect the ACA, Democratic state attorneys general in 16 states have intervened to defend the health law. Arguments were heard before the federal district court in the Northern District of Texas in September and a decision is expected any day.
If appealed, the Fifth Circuit would next take on the case, but the challenge could eventually reach the Supreme Court, Mr. Jost said.
“Chief Justice Roberts could save [the ACA] one more time, but I could see [Justice] Kavanaugh voting to uphold the ACA as the question would likely be a question of severability of the individual mandate from the rest of the ACA, and I can see [Kavanaugh] holding it severable,” he said.
Justice Kavanaugh may also weigh in on a handful of Medicaid cases that could go before the Supreme Court. The first case involves how much deference the federal government should have in allowing states to impose work requirements on Medicaid patients. In June, a federal judge in Washington D.C. struck down the federal government’s approval of a Kentucky Medicaid waiver that would have imposed work requirements and other rules for eligibility. That judge ruled that the Centers for Medicare & Medicaid Services did not adequately evaluate whether Kentucky’s requirements were consistent with federal Medicaid law.
Mr. Miller said it is too early to tell which way Justice Kavanaugh would vote on a Medicaid work requirements case, and that the decision depends on the context of the case and the reading of the law involved.
“[Justice] Kavanaugh has a less predictable record in this more narrow area of administrative law,” Mr. Miller said. “I doubt he alone is going to drive the court anywhere on this issue it doesn’t otherwise want to go – or at least drift.”
Two other Medicaid cases pending before the Supreme Court revolve around the right of a private Medicaid patient to sue a state over the exclusion of Planned Parenthood in its Medicaid program. Gee v. Planned Parenthood of Gulf Coast Inc. and its sister case, Anderson v. Planned Parenthood of Kansas and Mid-Missouri, stem from separate efforts by Kansas and Louisiana to remove Planned Parenthood from their Medicaid programs. The question is whether the Medicaid patients have a right to challenge the exclusions.
If the Supreme Court accepts the cases, Mr. Jost said it’s likely that Justice Kavanaugh would side with the states and bar the patients from suing.
“I could see him holding that Medicaid recipients can’t sue if a state violates federal law, which would effectively end Medicaid as an entitlement,” Mr. Jost said. “This would have disastrous consequences for low-income Americans.”
Justice Kavanaugh also could make an impact on gun control, Mr. Segall noted. The Supreme Court has not taken a Second Amendment case in several years; in the past, there was uncertainty about how Justice Kennedy would vote on a gun control case. Not so with Justice Kavanaugh, Mr. Segall said. In Heller v. District of Columbia (known as Heller II), Judge Kavanaugh dissented from the majority, writing that the District’s ban on semiautomatic rifles and its requirement that handguns be registered were unconstitutional.
“[The dissent] gave the Second Amendment as broad a reading as any judge has ever given,” Mr. Segall said. “Gun control, gun reform, and gun limits ... this is where [Kavanaugh] is going to make the biggest difference.”
As the Supreme Court sits for its second session on Oct. 29, legal analysts question what impact its newest Associate Justice, Brett M. Kavanaugh, may have on health care cases that might come before the court.
The addition of Justice Kavanaugh cements a conservative majority on the high court, said Eric J. Segall, a constitutional law professor at Georgia State University in Atlanta.
“Where Justice Kennedy was moderate or liberal, Justice Kavanaugh will move the court dramatically to the right in most areas of law,” Mr. Segall said in an interview.
One area drawing considerable attention is abortion, with abortion rights advocates raising concerns that Justice Kavanaugh’s appointment may mean the reversal of Roe v. Wade. Legal analysts, however, say fall of the momentous ruling is not probable.
Based on his decisions written while he sat on the Court of Appeals for the District of Columbia Circuit, it’s more likely that Justice Kavanaugh would attempt to narrow the instances in which state abortion restrictions are considered to impede a woman’s constitutional right to an abortion, according to Timothy S. Jost, a legal analyst and retired health law professor at Washington and Lee University in Lexington, Va.
In Garza v. Hargan for example, then-Judge Kavanaugh dissented from a majority decision which ultimately allowed a teenage immigrant in U.S. custody to have an abortion. Judge Kavanaugh argued that it was wrong for unlawful immigrant minors in U.S. detention to obtain “immediate abortion on demand.” However, his dissent was not as far-reaching as that of another judge who argued that a minor undocumented immigrant had no constitutional right to an abortion.
“[Justice] Kavanaugh certainly could vote to overturn Roe v. Wade, but based on his past opinions, I think it much more likely that he would simply expand Roe’s undue burden exception on a case by case basis until it was meaningless,” Mr. Jost said in an interview. “He doesn’t have to overturn Roe v. Wade to allow states that want to effectively bar abortion [to succeed].”
Mr. Segall agrees that Justice Kavanaugh will likely water down the undue burden test for abortion and through this softening, essentially dismantle Roe and return the issue of abortion to states.
As for the fate of the Affordable Care Act, legal experts foresee a restrained stance by Justice Kavanaugh, rather than a strong rejection of the entire law. In 2011, Judge Kavanaugh wrote a dissenting opinion in Seven-Sky v. Holder, a case that challenged the constitutionality of the health law’s individual mandate. While his fellow judges ruled that Congress had the authority to enact the mandate, Judge Kavanaugh argued the mandate was a tax and thus, it was too early for the court to hear the case since the tax had not yet been levied.
The dissent by Judge Kavanaugh in this case amounted to a “procedural cop-out,” according to Thomas P. Miller, a resident fellow at the conservative American Enterprise Institute and a health care policy scholar.
“That tells you he is a relatively cautious judge as opposed to going right to the metal because other circuit court of appeals judges were able to say this is an unconstitutional mandate,” Mr. Miller said in an interview. “That suggests a degree of tactical caution on these issues, very similar to [Supreme Court Chief Justice John] Roberts.”
Justice Kavanaugh may get his first chance to rule on the ACA’s future through Texas v. United States. The case centers on a challenge by 20 Republican state attorneys general over the constitutionality of the health law’s individual mandate. The Trump administration has reduced the penalty for failing to have health insurance to $0 starting in 2019. The plaintiffs allege that the mandate cannot be severed from the rest of the ACA and that if the mandate is eliminated, the rest of the law should fall. Because the Trump administration has opted not to protect the ACA, Democratic state attorneys general in 16 states have intervened to defend the health law. Arguments were heard before the federal district court in the Northern District of Texas in September and a decision is expected any day.
If appealed, the Fifth Circuit would next take on the case, but the challenge could eventually reach the Supreme Court, Mr. Jost said.
“Chief Justice Roberts could save [the ACA] one more time, but I could see [Justice] Kavanaugh voting to uphold the ACA as the question would likely be a question of severability of the individual mandate from the rest of the ACA, and I can see [Kavanaugh] holding it severable,” he said.
Justice Kavanaugh may also weigh in on a handful of Medicaid cases that could go before the Supreme Court. The first case involves how much deference the federal government should have in allowing states to impose work requirements on Medicaid patients. In June, a federal judge in Washington D.C. struck down the federal government’s approval of a Kentucky Medicaid waiver that would have imposed work requirements and other rules for eligibility. That judge ruled that the Centers for Medicare & Medicaid Services did not adequately evaluate whether Kentucky’s requirements were consistent with federal Medicaid law.
Mr. Miller said it is too early to tell which way Justice Kavanaugh would vote on a Medicaid work requirements case, and that the decision depends on the context of the case and the reading of the law involved.
“[Justice] Kavanaugh has a less predictable record in this more narrow area of administrative law,” Mr. Miller said. “I doubt he alone is going to drive the court anywhere on this issue it doesn’t otherwise want to go – or at least drift.”
Two other Medicaid cases pending before the Supreme Court revolve around the right of a private Medicaid patient to sue a state over the exclusion of Planned Parenthood in its Medicaid program. Gee v. Planned Parenthood of Gulf Coast Inc. and its sister case, Anderson v. Planned Parenthood of Kansas and Mid-Missouri, stem from separate efforts by Kansas and Louisiana to remove Planned Parenthood from their Medicaid programs. The question is whether the Medicaid patients have a right to challenge the exclusions.
If the Supreme Court accepts the cases, Mr. Jost said it’s likely that Justice Kavanaugh would side with the states and bar the patients from suing.
“I could see him holding that Medicaid recipients can’t sue if a state violates federal law, which would effectively end Medicaid as an entitlement,” Mr. Jost said. “This would have disastrous consequences for low-income Americans.”
Justice Kavanaugh also could make an impact on gun control, Mr. Segall noted. The Supreme Court has not taken a Second Amendment case in several years; in the past, there was uncertainty about how Justice Kennedy would vote on a gun control case. Not so with Justice Kavanaugh, Mr. Segall said. In Heller v. District of Columbia (known as Heller II), Judge Kavanaugh dissented from the majority, writing that the District’s ban on semiautomatic rifles and its requirement that handguns be registered were unconstitutional.
“[The dissent] gave the Second Amendment as broad a reading as any judge has ever given,” Mr. Segall said. “Gun control, gun reform, and gun limits ... this is where [Kavanaugh] is going to make the biggest difference.”
Tech-based cancer company raises access concerns
Oncologists are raising concerns about care access after the launch of a new company that links patients to cancer care options and clinical trials through mobile technology.
Driver, which began in September in the U.S. and China, is a global technology platform that allows patients to access treatment options across a broad network of cancer centers without leaving home. Cancer patients join the platform using a mobile app, through which Driver obtains the required consent to acquire medical records and tumor samples, and the company uses the information to recommend treatment options and clinical trials.
A separate app called Driver for Clinic enables oncologists who belong to Driver’s partner hospitals to manage their institution’s clinical trial information and quickly filter that information based on patients’ medical history to determine the patient’s eligibility for treatments.
Driver’s mission is to connect more patients to the best cancer treatments, regardless of location, said Will Polkinghorn, MD, Driver cofounder and CEO.
“Driver’s cofounders met at Harvard Medical School [in Boston] and saw firsthand the challenges of patients getting access to the latest, cutting-edge treatments available,” Dr. Polkinghorn said in an interview. “As doctors, [we] also witnessed how difficult it was for doctors to manage information in clinic and know about all the treatments that become available all around the world. Driver was created as a platform, with an app for the patient and an app for the doctor, to solve this broken marketplace.”
As part of the model, patients can review their recommended treatment options through video with an expert oncologist and select a hospital within Driver’s network for further evaluation. The company’s global network includes more than 30 leading U.S. cancer centers, including the Cleveland Clinic; multiple locations of the Mayo Clinic; the University of California, San Francisco; and Massachusetts General Hospital, Boston. The U.S. National Cancer Institute (NCI) and the Chinese National Cancer Center are founding members of Driver’s global network, according to the company.
Making more information and treatment options available is a positive for patients, said Walter Stadler, MD, chief of hematology/oncology and director of the genitourinary oncology program at the University of Chicago. However, he noted that the cost for patients to use Driver is prohibitive for many patients. Driver charges patients $3,000 up front and then a $20 monthly fee to use its service. Insurance does not subsidize the cost, nor does Driver help with travel or treatment costs, according to its website.
“It’s inequality of access,” Dr. Stadler said in an interview. “Many of us are very concerned that the clinical trials currently being conducted do not represent the general population well because they don’t represent patients with disparities … Here, we further exacerbate the problem by saying, ‘Okay, we’ll take the 5% of patients who can afford the service and expand their access, and the others, well, that’s not our problem.’ ”
Kashyap Patel, MD, secretary for the Community Oncology Alliance and CEO for the Carolina Blood and Cancer Care in Rock Hill, S.C., also sees positives and negatives about the business model. Using technology to link patients with care and clinical trials can help speed treatment and accelerate drug development, he said. But Driver’s network of large tertiary care centers in metropolitan areas poses challenges for rural cancer patients, he said.
“Access to clinical trials for patients residing in rural areas, as well as those getting their treatment in community based clinics, would not change,” Dr. Patel said in an interview. “Hence, challenges of social and demographic disparities and inequalities in clinical trial access and participation would be altered minimally. There is much greater need for such [platforms to include] community cancer clinics that would be more inclusive and encompass larger geographic areas where the majority of patients receive their care.”
Disadvantaged populations with limited access are not being overlooked by the company, according to Driver leaders. A branch of the company called Driver for All aims to increase access to optimal treatments for free through partnerships with local communities, Dr. Polkinghorn said. Driver for All has thus far partnered with Howard University Hospital in Washington to connect Howard patients to clinical trials at NCI. A partnership with Beijing Children’s Hospital and the Futang Research Center of Pediatric Development, meanwhile, is working to connect patients with rare-disease experts. Driver has funded 100% of the cost of these projects to date, according to its website.
Outside of Driver for All, Dr. Polkinghorn acknowledges that patients must bear the cost of Driver’s consumer products; however, the price should be viewed in context, he said.
“It’s important to remember that today, in order to be evaluated by 30 [plus] centers for treatment options, patients would need to fly to these centers, make appointments, and be seen by a doctor – this would require both time and resources for flights/hotels, which would cost much more than our sticker price,” he said. “So while $3,000 is a lot of money for some patients, Driver’s product is ultimately able to provide more visibility to options that simply would not be realistic today.”
James Gulley, MD, of the National Cancer Institute Center for Cancer Research, said any platform that can efficiently provide access to clinical trial options yields another source of information for patients to utilize in decision making with their health provider. Dr. Gulley, who heads the center’s genitourinary malignancies branch, declined to comment about access-to-care concerns with Driver’s model. He emphasized that patients who participate in NIH research studies are treated without charge.
“The key to finding better [cancer] treatment is to perform science-driven clinical trials,” Dr. Gulley said in an interview. “However, there are many barriers for enrollment in clinical trials. … As a government agency, NCI is open to partnering with any organization that seeks to improve access to clinical trials for cancer patients.”
NCI and Driver recently conducted a study to validate Driver’s platform; it showed that Driver’s technology successfully predicted the eligibility of patients in NCI Center for Cancer Research clinical trials. The study, presented at a recent American Society of Clinical Oncology meeting, evaluated Driver’s processing of 21 metastatic prostate cancer patients enrolled in a therapeutic NCI clinical trial within the last five years. Results showed Driver correctly predicted that 20 of the patients were “potentially eligible” for the trial in which they were enrolled, and that one was ineligible. Based on the study, a protocol is now in development for a new clinical study, which will seek to further determine the efficiency and accuracy of the clinical trial access program created by Driver, according to Dr. Gulley.
Charles Ryan, MD, director of the division of hematology, oncology, and transplantation for the University of Minnesota, Minneapolis, views Driver’s platform as a way to eliminate geographical barriers, which often keep patients from care, while at the same time enabling researchers to find the right patients for clinical trials.
“We need breakthrough technologies and opportunities for patients to be able to access the most successful and promising cancer treatments, regardless of where they live,” Dr. Ryan said in an interview. “Companies like Driver are attempting to bridge that gap by connecting patients to doctors at world class cancer institutes and direct them toward the best care for their particular condition.”
Driver’s model also allows researchers the opportunity to develop specific, unique treatment for less common cancers and remain optimistic that they can attract patients to receive such treatments as they are developed, Dr. Ryan said.
Dr. Stadler, however, worries that Driver may be giving patients the wrong perception that all it takes is a computer and medical records to determine their best treatment route.
“There’s a lot more subtlety to treatment decisions than most people would like to admit,” Dr. Stadler said. “It’s more than just a bunch of data from sophisticated laboratory tests and the written medical record. Obtaining objective information is the first step, but it’s far from the only step.”
Patients may have significant limitations in functional status that is apparent only during an in-person assessment, for example, he said. In other cases, family members may be essential in conveying information about a patient’s cognitive disabilities. Even when such information is documented, it is sometimes difficult to extract the full picture from the record alone, he said. Dr. Stadler is also bothered that the model requires physicians and hospitals to provide their skilled analyses to a for-profit company, which in turn, charges patients to review the information.
“This is our work,” he said. “I agree that patients should have the information, and I don’t mind sharing anything I have with patients, but now I’m going to share it with another business that essentially is competing with me in terms of providing guidance to patients.”
Oncologists are raising concerns about care access after the launch of a new company that links patients to cancer care options and clinical trials through mobile technology.
Driver, which began in September in the U.S. and China, is a global technology platform that allows patients to access treatment options across a broad network of cancer centers without leaving home. Cancer patients join the platform using a mobile app, through which Driver obtains the required consent to acquire medical records and tumor samples, and the company uses the information to recommend treatment options and clinical trials.
A separate app called Driver for Clinic enables oncologists who belong to Driver’s partner hospitals to manage their institution’s clinical trial information and quickly filter that information based on patients’ medical history to determine the patient’s eligibility for treatments.
Driver’s mission is to connect more patients to the best cancer treatments, regardless of location, said Will Polkinghorn, MD, Driver cofounder and CEO.
“Driver’s cofounders met at Harvard Medical School [in Boston] and saw firsthand the challenges of patients getting access to the latest, cutting-edge treatments available,” Dr. Polkinghorn said in an interview. “As doctors, [we] also witnessed how difficult it was for doctors to manage information in clinic and know about all the treatments that become available all around the world. Driver was created as a platform, with an app for the patient and an app for the doctor, to solve this broken marketplace.”
As part of the model, patients can review their recommended treatment options through video with an expert oncologist and select a hospital within Driver’s network for further evaluation. The company’s global network includes more than 30 leading U.S. cancer centers, including the Cleveland Clinic; multiple locations of the Mayo Clinic; the University of California, San Francisco; and Massachusetts General Hospital, Boston. The U.S. National Cancer Institute (NCI) and the Chinese National Cancer Center are founding members of Driver’s global network, according to the company.
Making more information and treatment options available is a positive for patients, said Walter Stadler, MD, chief of hematology/oncology and director of the genitourinary oncology program at the University of Chicago. However, he noted that the cost for patients to use Driver is prohibitive for many patients. Driver charges patients $3,000 up front and then a $20 monthly fee to use its service. Insurance does not subsidize the cost, nor does Driver help with travel or treatment costs, according to its website.
“It’s inequality of access,” Dr. Stadler said in an interview. “Many of us are very concerned that the clinical trials currently being conducted do not represent the general population well because they don’t represent patients with disparities … Here, we further exacerbate the problem by saying, ‘Okay, we’ll take the 5% of patients who can afford the service and expand their access, and the others, well, that’s not our problem.’ ”
Kashyap Patel, MD, secretary for the Community Oncology Alliance and CEO for the Carolina Blood and Cancer Care in Rock Hill, S.C., also sees positives and negatives about the business model. Using technology to link patients with care and clinical trials can help speed treatment and accelerate drug development, he said. But Driver’s network of large tertiary care centers in metropolitan areas poses challenges for rural cancer patients, he said.
“Access to clinical trials for patients residing in rural areas, as well as those getting their treatment in community based clinics, would not change,” Dr. Patel said in an interview. “Hence, challenges of social and demographic disparities and inequalities in clinical trial access and participation would be altered minimally. There is much greater need for such [platforms to include] community cancer clinics that would be more inclusive and encompass larger geographic areas where the majority of patients receive their care.”
Disadvantaged populations with limited access are not being overlooked by the company, according to Driver leaders. A branch of the company called Driver for All aims to increase access to optimal treatments for free through partnerships with local communities, Dr. Polkinghorn said. Driver for All has thus far partnered with Howard University Hospital in Washington to connect Howard patients to clinical trials at NCI. A partnership with Beijing Children’s Hospital and the Futang Research Center of Pediatric Development, meanwhile, is working to connect patients with rare-disease experts. Driver has funded 100% of the cost of these projects to date, according to its website.
Outside of Driver for All, Dr. Polkinghorn acknowledges that patients must bear the cost of Driver’s consumer products; however, the price should be viewed in context, he said.
“It’s important to remember that today, in order to be evaluated by 30 [plus] centers for treatment options, patients would need to fly to these centers, make appointments, and be seen by a doctor – this would require both time and resources for flights/hotels, which would cost much more than our sticker price,” he said. “So while $3,000 is a lot of money for some patients, Driver’s product is ultimately able to provide more visibility to options that simply would not be realistic today.”
James Gulley, MD, of the National Cancer Institute Center for Cancer Research, said any platform that can efficiently provide access to clinical trial options yields another source of information for patients to utilize in decision making with their health provider. Dr. Gulley, who heads the center’s genitourinary malignancies branch, declined to comment about access-to-care concerns with Driver’s model. He emphasized that patients who participate in NIH research studies are treated without charge.
“The key to finding better [cancer] treatment is to perform science-driven clinical trials,” Dr. Gulley said in an interview. “However, there are many barriers for enrollment in clinical trials. … As a government agency, NCI is open to partnering with any organization that seeks to improve access to clinical trials for cancer patients.”
NCI and Driver recently conducted a study to validate Driver’s platform; it showed that Driver’s technology successfully predicted the eligibility of patients in NCI Center for Cancer Research clinical trials. The study, presented at a recent American Society of Clinical Oncology meeting, evaluated Driver’s processing of 21 metastatic prostate cancer patients enrolled in a therapeutic NCI clinical trial within the last five years. Results showed Driver correctly predicted that 20 of the patients were “potentially eligible” for the trial in which they were enrolled, and that one was ineligible. Based on the study, a protocol is now in development for a new clinical study, which will seek to further determine the efficiency and accuracy of the clinical trial access program created by Driver, according to Dr. Gulley.
Charles Ryan, MD, director of the division of hematology, oncology, and transplantation for the University of Minnesota, Minneapolis, views Driver’s platform as a way to eliminate geographical barriers, which often keep patients from care, while at the same time enabling researchers to find the right patients for clinical trials.
“We need breakthrough technologies and opportunities for patients to be able to access the most successful and promising cancer treatments, regardless of where they live,” Dr. Ryan said in an interview. “Companies like Driver are attempting to bridge that gap by connecting patients to doctors at world class cancer institutes and direct them toward the best care for their particular condition.”
Driver’s model also allows researchers the opportunity to develop specific, unique treatment for less common cancers and remain optimistic that they can attract patients to receive such treatments as they are developed, Dr. Ryan said.
Dr. Stadler, however, worries that Driver may be giving patients the wrong perception that all it takes is a computer and medical records to determine their best treatment route.
“There’s a lot more subtlety to treatment decisions than most people would like to admit,” Dr. Stadler said. “It’s more than just a bunch of data from sophisticated laboratory tests and the written medical record. Obtaining objective information is the first step, but it’s far from the only step.”
Patients may have significant limitations in functional status that is apparent only during an in-person assessment, for example, he said. In other cases, family members may be essential in conveying information about a patient’s cognitive disabilities. Even when such information is documented, it is sometimes difficult to extract the full picture from the record alone, he said. Dr. Stadler is also bothered that the model requires physicians and hospitals to provide their skilled analyses to a for-profit company, which in turn, charges patients to review the information.
“This is our work,” he said. “I agree that patients should have the information, and I don’t mind sharing anything I have with patients, but now I’m going to share it with another business that essentially is competing with me in terms of providing guidance to patients.”
Oncologists are raising concerns about care access after the launch of a new company that links patients to cancer care options and clinical trials through mobile technology.
Driver, which began in September in the U.S. and China, is a global technology platform that allows patients to access treatment options across a broad network of cancer centers without leaving home. Cancer patients join the platform using a mobile app, through which Driver obtains the required consent to acquire medical records and tumor samples, and the company uses the information to recommend treatment options and clinical trials.
A separate app called Driver for Clinic enables oncologists who belong to Driver’s partner hospitals to manage their institution’s clinical trial information and quickly filter that information based on patients’ medical history to determine the patient’s eligibility for treatments.
Driver’s mission is to connect more patients to the best cancer treatments, regardless of location, said Will Polkinghorn, MD, Driver cofounder and CEO.
“Driver’s cofounders met at Harvard Medical School [in Boston] and saw firsthand the challenges of patients getting access to the latest, cutting-edge treatments available,” Dr. Polkinghorn said in an interview. “As doctors, [we] also witnessed how difficult it was for doctors to manage information in clinic and know about all the treatments that become available all around the world. Driver was created as a platform, with an app for the patient and an app for the doctor, to solve this broken marketplace.”
As part of the model, patients can review their recommended treatment options through video with an expert oncologist and select a hospital within Driver’s network for further evaluation. The company’s global network includes more than 30 leading U.S. cancer centers, including the Cleveland Clinic; multiple locations of the Mayo Clinic; the University of California, San Francisco; and Massachusetts General Hospital, Boston. The U.S. National Cancer Institute (NCI) and the Chinese National Cancer Center are founding members of Driver’s global network, according to the company.
Making more information and treatment options available is a positive for patients, said Walter Stadler, MD, chief of hematology/oncology and director of the genitourinary oncology program at the University of Chicago. However, he noted that the cost for patients to use Driver is prohibitive for many patients. Driver charges patients $3,000 up front and then a $20 monthly fee to use its service. Insurance does not subsidize the cost, nor does Driver help with travel or treatment costs, according to its website.
“It’s inequality of access,” Dr. Stadler said in an interview. “Many of us are very concerned that the clinical trials currently being conducted do not represent the general population well because they don’t represent patients with disparities … Here, we further exacerbate the problem by saying, ‘Okay, we’ll take the 5% of patients who can afford the service and expand their access, and the others, well, that’s not our problem.’ ”
Kashyap Patel, MD, secretary for the Community Oncology Alliance and CEO for the Carolina Blood and Cancer Care in Rock Hill, S.C., also sees positives and negatives about the business model. Using technology to link patients with care and clinical trials can help speed treatment and accelerate drug development, he said. But Driver’s network of large tertiary care centers in metropolitan areas poses challenges for rural cancer patients, he said.
“Access to clinical trials for patients residing in rural areas, as well as those getting their treatment in community based clinics, would not change,” Dr. Patel said in an interview. “Hence, challenges of social and demographic disparities and inequalities in clinical trial access and participation would be altered minimally. There is much greater need for such [platforms to include] community cancer clinics that would be more inclusive and encompass larger geographic areas where the majority of patients receive their care.”
Disadvantaged populations with limited access are not being overlooked by the company, according to Driver leaders. A branch of the company called Driver for All aims to increase access to optimal treatments for free through partnerships with local communities, Dr. Polkinghorn said. Driver for All has thus far partnered with Howard University Hospital in Washington to connect Howard patients to clinical trials at NCI. A partnership with Beijing Children’s Hospital and the Futang Research Center of Pediatric Development, meanwhile, is working to connect patients with rare-disease experts. Driver has funded 100% of the cost of these projects to date, according to its website.
Outside of Driver for All, Dr. Polkinghorn acknowledges that patients must bear the cost of Driver’s consumer products; however, the price should be viewed in context, he said.
“It’s important to remember that today, in order to be evaluated by 30 [plus] centers for treatment options, patients would need to fly to these centers, make appointments, and be seen by a doctor – this would require both time and resources for flights/hotels, which would cost much more than our sticker price,” he said. “So while $3,000 is a lot of money for some patients, Driver’s product is ultimately able to provide more visibility to options that simply would not be realistic today.”
James Gulley, MD, of the National Cancer Institute Center for Cancer Research, said any platform that can efficiently provide access to clinical trial options yields another source of information for patients to utilize in decision making with their health provider. Dr. Gulley, who heads the center’s genitourinary malignancies branch, declined to comment about access-to-care concerns with Driver’s model. He emphasized that patients who participate in NIH research studies are treated without charge.
“The key to finding better [cancer] treatment is to perform science-driven clinical trials,” Dr. Gulley said in an interview. “However, there are many barriers for enrollment in clinical trials. … As a government agency, NCI is open to partnering with any organization that seeks to improve access to clinical trials for cancer patients.”
NCI and Driver recently conducted a study to validate Driver’s platform; it showed that Driver’s technology successfully predicted the eligibility of patients in NCI Center for Cancer Research clinical trials. The study, presented at a recent American Society of Clinical Oncology meeting, evaluated Driver’s processing of 21 metastatic prostate cancer patients enrolled in a therapeutic NCI clinical trial within the last five years. Results showed Driver correctly predicted that 20 of the patients were “potentially eligible” for the trial in which they were enrolled, and that one was ineligible. Based on the study, a protocol is now in development for a new clinical study, which will seek to further determine the efficiency and accuracy of the clinical trial access program created by Driver, according to Dr. Gulley.
Charles Ryan, MD, director of the division of hematology, oncology, and transplantation for the University of Minnesota, Minneapolis, views Driver’s platform as a way to eliminate geographical barriers, which often keep patients from care, while at the same time enabling researchers to find the right patients for clinical trials.
“We need breakthrough technologies and opportunities for patients to be able to access the most successful and promising cancer treatments, regardless of where they live,” Dr. Ryan said in an interview. “Companies like Driver are attempting to bridge that gap by connecting patients to doctors at world class cancer institutes and direct them toward the best care for their particular condition.”
Driver’s model also allows researchers the opportunity to develop specific, unique treatment for less common cancers and remain optimistic that they can attract patients to receive such treatments as they are developed, Dr. Ryan said.
Dr. Stadler, however, worries that Driver may be giving patients the wrong perception that all it takes is a computer and medical records to determine their best treatment route.
“There’s a lot more subtlety to treatment decisions than most people would like to admit,” Dr. Stadler said. “It’s more than just a bunch of data from sophisticated laboratory tests and the written medical record. Obtaining objective information is the first step, but it’s far from the only step.”
Patients may have significant limitations in functional status that is apparent only during an in-person assessment, for example, he said. In other cases, family members may be essential in conveying information about a patient’s cognitive disabilities. Even when such information is documented, it is sometimes difficult to extract the full picture from the record alone, he said. Dr. Stadler is also bothered that the model requires physicians and hospitals to provide their skilled analyses to a for-profit company, which in turn, charges patients to review the information.
“This is our work,” he said. “I agree that patients should have the information, and I don’t mind sharing anything I have with patients, but now I’m going to share it with another business that essentially is competing with me in terms of providing guidance to patients.”
Telehealth: States broaden options for locations, providers
More states are expanding their telehealth policies to reach patients, and pulling back on rigid in-person requirements.
Several state Medicaid programs now explicitly allow the home to serve as an originating site for telehealth, with 10 states – Delaware, Colorado, Maryland, Michigan, Minnesota, Montana, New York, Texas, Washington, and Wyoming – adding the home as an approved site since 2016.
In addition, 16 jurisdictions now allow schools to serve as originating sites for telehealth, although some have restrictions about when the sites are acceptable, said Mei Kwong, an attorney and executive director for the Center for Connected Health Policy and the author of the center’s Spring 2018 report on telehealth trends.
At the same time, nearly all states have now dropped Medicaid restrictions that limited reimbursable telehealth services to rural or underserved areas. Colorado, Idaho, Nebraska, New Hampshire, Nevada, and Missouri are the most recent states to remove such geographic restrictions.
“[The expanded locations are] extremely helpful in providing greater access for patients to needed services,” Ms. Kwong said in an interview. “For example, a person who has difficulty leaving his or her home for a physical or other reason, they can get care, [or] a child having a rough time in school, can seek out a mental health counselor while at school.”
More telehealth providers
In addition to expanding teleheath sites, states are increasing acceptance for telehealth providers beyond physicians. Most recently, New Jersey enacted a broad telemedicine law that includes doctors, nurses, psychologists, social workers, physician assistants, counselors, respiratory therapists, speech pathologists, and optometrists, among others. The New Jersey law addresses telemedicine practice standards, prescribing, patient consent, privacy, and other requirements for providers.
In addition, more states are carving out telehealth regulations. Since 2016, 11 states have revised or adopted new scope of practice restrictions for counselors providing telemedicine, according to a state telehealth analysis published in July 2018 by law firm Epstein, Becker, Green.
Arkansas, Idaho, Maine, New Jersey, and Rhode Island recently imposed regulations for the practice of telepsychology. In addition, seven states have new or revised scope of practice restrictions for advanced practice registered nurses (APRN) providing telehealth services, while eight states have new licensing requirements specific to telehealth practice by APRNs, according to the Epstein analysis.
A telehealth compact that would allow APRNs to practice nursing via telemedicine across state lines is also in the works. Similar to the physician Interstate Medical Licensure Compact, the APRN Compact would establish an interstate commission and guidelines for uniform licensing requirements and criminal background checks. The compact will become effective when 10 states enact the compact legislation. So far, three states – Wyoming, North Dakota, and Idaho – have enacted the model legislation.
Another telemedicine compact for psychologists is getting ready to launch. In August, Illinois became the seventh state to join the Psychology Interjurisdictional Compact (PSYPACT). The pact requires seven states to enact compact legislation to become effective, however Illinois law does not go into effect until 2020.
The developments highlight the rise in more mid- and lower-level providers practicing telemedicine, said Anjali B. Dooley, an attorney and chief legal and compliance officer for Forefront Telecare, a telehealth platform for behavioral health services. While the increase allows greater care access, the expansion also poses scope of practice challenges, she notes.
“Increasing scope of practice extensions also increases risk if physician extenders are not trained properly in telehealth technology use and protocols,” Ms. Dooley said in an interview. “Providers and provider extenders need to be educated and learned in human factors such as communication, empathy, and etiquette.”
A greater number of nonphysician telemedicine providers is beneficial as long as the providers are adhering to appropriate standards of care and consulting with supervising physicians when necessary, adds Jean R. Sumner, MD, dean of the School of Medicine at Mercer University in Macon, Georgia, and a telemedicine internist.
“The standard should always be equal to an in-person visit,” she said in an interview. “The patient has a right to know who is seeing them, too, to understand [their credentials]. They need to know the person on the telehealth unit is qualified to provide the care.”
Responding to the opioid crisis
The need for increased access to mental health care is a primary driver behind state efforts to expand the pool of telemedicine providers, adds Amy Lerman, an attorney at Epstein, Becker, Green and lead author of her firm’s report.
“The reason it is important for states to continue expanding the scope of health professionals, other than physicians, who can provide behavioral health telemedicine services, is not only to address an overall nationwide shortage of behavioral health providers, but also to expand access to behavioral health services because a wider range of providers are equipped to provide these services,” she said in an interview.
In the same vein, more states are using telehealth to address the opioid crisis, according to both the Epstein report and the Center for Connected Health Policy analysis.
In September, California enacted a law that would allow Medicaid reimbursement for certified substance use disorder counselors who provide treatment via telehealth. In August, Illinois approved a similar law that mandates reimbursement for behavioral and mental health experts who treat Medicaid patients through telehealth technologies.
The laws come after a June 2018 letter from the Centers for Medicare & Medicaid Services that encouraged states to utilize health technology efforts to address the opioid crisis, including through telemedicine and telepsychiatry, said Daniel Kim, an attorney with Epstein, Becker, Green and a coauthor of his firm’s report.
At the same time, a number of states have expanded their controlled substance laws to allow remote prescribing through telehealth for the treatment of psychiatric or substance use disorders. Connecticut’s law, for instance, allows providers to prescribe Schedule I-III controlled substances through telehealth platforms, while banning opioid prescribing. In Indiana, 2017 legislation expanded the types of controlled medications that providers can prescribe through telehealth platforms, primarily drugs used to treat or manage opioid dependence. The states join an increasing number that have enacted laws allowing the remote prescribing of controlled substances, including Delaware, Florida, Indiana, Michigan, New Hampshire, Ohio, and West Virginia.
The new laws will enhance the availability of behavioral health services, while allowing more treatment flexibility and privacy for patients, said Ms. Dooley.
“Treatment in one’s own environment where the addiction takes place is often more effective,” she said. People with addiction disorders “can also receive treatment without having to drive long distances.”
The disappearing in-person requirement
As states define their telehealth policies, they are fading out a once-prevalent requirement – the in-person visit. There is no longer a single state that requires physicians to meet with patients in-person before providing telemedicine services, according to the Epstein report.
States realized that requiring in-person visits before doctors can provide telemedicine creates a barrier to care, said Mr. Kim. A move to eliminate the requirement in Texas influenced other states in phasing out the common regulation. In the widely publicized Teladoc case, the national telemedicine company sued the Texas Medical Board in 2011 over its rule requiring Texas physicians to conduct a face-to-face evaluation before treating a patient via telemedicine. The legal battle continued for years, until Teladoc voluntarily dropped its lawsuit in 2017 after Texas adopted a new law that allowed doctors to treat first-time patients through telemedicine.
“The medical board [understood] that the in-person requirement wasn’t really a benefit to patients,” Mr. Kim said in an interview. “Once they changed it, a lot of other states have recognized the same and have moved toward getting rid of the requirement.”
In some states, midlevel providers still must see patients face-to-face before providing telehealth care. Arkansas for instance, requires that psychologists, counselors, and APRNs conduct an in-person exam before rendering telehealth. Professional boards in Colorado and Massachusetts recommend a face-to-face visit by midlevel providers as a best practice.
Reimbursement growing, but restrictions remain
Forty-nine states and the District of Columbia reimburse for some form of telehealth, mainly live video services. At least 20 states now pay providers for remote payment monitoring (RPM), according to the Center for Connected Health Policy report. The reimbursement is often restricted, however, to certain clinical conditions and/or rules that limit the type of monitoring device allowed. Colorado, for instance, only reimburses RPM for patients with congestive heart failure, chronic obstructive pulmonary disease, asthma, or diabetes and requires that the patient was hospitalized at least twice in the last 12 months for reasons associated with one of the conditions. Missouri has similar RPM criteria associated with hospitalizations, but allows for a greater number of conditions including pregnancy, stroke, and cancer.
Most states have yet to pay for store-and-forward services, technologies that enable the electronic transfer of photos, prerecorded videos, or documents. Only about 14 states reimburse for such technology, and many policies include limitations. California, for example, only reimburses for store-and-forward services in teledermatology, teledentistry, and teleophthalmology. Connecticut allows for store-and-forward payment between physicians through email. Missouri allows for store-and-forward services in orthopedics, dermatology, optometry, ophthalmology, and in cases of retinopathy, burn and wound care, dental services, and maternal-fetal ultrasounds.
Reimbursement for telehealth is still a challenge for many physicians, Dr. Sumner said. Part of the problem is the wide discrepancy in how telehealth is defined among states, she said. Some states only consider live or interactive two-way technology as telehealth, excluding services such as store-and-forward and RPM. Other states reimburse for certain technology-based services, but they do not consider them telehealth. Maryland’s Medicaid program for example, does not reimburse for store and forward under its telehealth policy. However, store and forward used in dermatology, radiology, and ophthalmology is reimbursed by Maryland under an alternate billing code, though not considered telehealth.
Establishing best practices in telehealth through careful evaluation and research would improve reimbursement, said S. David McSwain, MD, interim chief medical information officer at the Medical University of South Carolina, Charleston, and medical director for telehealth optimization.
“We can use that evidence to reduce the variation in telehealth payment policies across the states,” Dr. McSwain said in an interview. “By leveraging reimbursement models to promote best practices, we can encourage the spread of telehealth services that have the greatest impacts on patients, their families, and the health care system.”
More states are expanding their telehealth policies to reach patients, and pulling back on rigid in-person requirements.
Several state Medicaid programs now explicitly allow the home to serve as an originating site for telehealth, with 10 states – Delaware, Colorado, Maryland, Michigan, Minnesota, Montana, New York, Texas, Washington, and Wyoming – adding the home as an approved site since 2016.
In addition, 16 jurisdictions now allow schools to serve as originating sites for telehealth, although some have restrictions about when the sites are acceptable, said Mei Kwong, an attorney and executive director for the Center for Connected Health Policy and the author of the center’s Spring 2018 report on telehealth trends.
At the same time, nearly all states have now dropped Medicaid restrictions that limited reimbursable telehealth services to rural or underserved areas. Colorado, Idaho, Nebraska, New Hampshire, Nevada, and Missouri are the most recent states to remove such geographic restrictions.
“[The expanded locations are] extremely helpful in providing greater access for patients to needed services,” Ms. Kwong said in an interview. “For example, a person who has difficulty leaving his or her home for a physical or other reason, they can get care, [or] a child having a rough time in school, can seek out a mental health counselor while at school.”
More telehealth providers
In addition to expanding teleheath sites, states are increasing acceptance for telehealth providers beyond physicians. Most recently, New Jersey enacted a broad telemedicine law that includes doctors, nurses, psychologists, social workers, physician assistants, counselors, respiratory therapists, speech pathologists, and optometrists, among others. The New Jersey law addresses telemedicine practice standards, prescribing, patient consent, privacy, and other requirements for providers.
In addition, more states are carving out telehealth regulations. Since 2016, 11 states have revised or adopted new scope of practice restrictions for counselors providing telemedicine, according to a state telehealth analysis published in July 2018 by law firm Epstein, Becker, Green.
Arkansas, Idaho, Maine, New Jersey, and Rhode Island recently imposed regulations for the practice of telepsychology. In addition, seven states have new or revised scope of practice restrictions for advanced practice registered nurses (APRN) providing telehealth services, while eight states have new licensing requirements specific to telehealth practice by APRNs, according to the Epstein analysis.
A telehealth compact that would allow APRNs to practice nursing via telemedicine across state lines is also in the works. Similar to the physician Interstate Medical Licensure Compact, the APRN Compact would establish an interstate commission and guidelines for uniform licensing requirements and criminal background checks. The compact will become effective when 10 states enact the compact legislation. So far, three states – Wyoming, North Dakota, and Idaho – have enacted the model legislation.
Another telemedicine compact for psychologists is getting ready to launch. In August, Illinois became the seventh state to join the Psychology Interjurisdictional Compact (PSYPACT). The pact requires seven states to enact compact legislation to become effective, however Illinois law does not go into effect until 2020.
The developments highlight the rise in more mid- and lower-level providers practicing telemedicine, said Anjali B. Dooley, an attorney and chief legal and compliance officer for Forefront Telecare, a telehealth platform for behavioral health services. While the increase allows greater care access, the expansion also poses scope of practice challenges, she notes.
“Increasing scope of practice extensions also increases risk if physician extenders are not trained properly in telehealth technology use and protocols,” Ms. Dooley said in an interview. “Providers and provider extenders need to be educated and learned in human factors such as communication, empathy, and etiquette.”
A greater number of nonphysician telemedicine providers is beneficial as long as the providers are adhering to appropriate standards of care and consulting with supervising physicians when necessary, adds Jean R. Sumner, MD, dean of the School of Medicine at Mercer University in Macon, Georgia, and a telemedicine internist.
“The standard should always be equal to an in-person visit,” she said in an interview. “The patient has a right to know who is seeing them, too, to understand [their credentials]. They need to know the person on the telehealth unit is qualified to provide the care.”
Responding to the opioid crisis
The need for increased access to mental health care is a primary driver behind state efforts to expand the pool of telemedicine providers, adds Amy Lerman, an attorney at Epstein, Becker, Green and lead author of her firm’s report.
“The reason it is important for states to continue expanding the scope of health professionals, other than physicians, who can provide behavioral health telemedicine services, is not only to address an overall nationwide shortage of behavioral health providers, but also to expand access to behavioral health services because a wider range of providers are equipped to provide these services,” she said in an interview.
In the same vein, more states are using telehealth to address the opioid crisis, according to both the Epstein report and the Center for Connected Health Policy analysis.
In September, California enacted a law that would allow Medicaid reimbursement for certified substance use disorder counselors who provide treatment via telehealth. In August, Illinois approved a similar law that mandates reimbursement for behavioral and mental health experts who treat Medicaid patients through telehealth technologies.
The laws come after a June 2018 letter from the Centers for Medicare & Medicaid Services that encouraged states to utilize health technology efforts to address the opioid crisis, including through telemedicine and telepsychiatry, said Daniel Kim, an attorney with Epstein, Becker, Green and a coauthor of his firm’s report.
At the same time, a number of states have expanded their controlled substance laws to allow remote prescribing through telehealth for the treatment of psychiatric or substance use disorders. Connecticut’s law, for instance, allows providers to prescribe Schedule I-III controlled substances through telehealth platforms, while banning opioid prescribing. In Indiana, 2017 legislation expanded the types of controlled medications that providers can prescribe through telehealth platforms, primarily drugs used to treat or manage opioid dependence. The states join an increasing number that have enacted laws allowing the remote prescribing of controlled substances, including Delaware, Florida, Indiana, Michigan, New Hampshire, Ohio, and West Virginia.
The new laws will enhance the availability of behavioral health services, while allowing more treatment flexibility and privacy for patients, said Ms. Dooley.
“Treatment in one’s own environment where the addiction takes place is often more effective,” she said. People with addiction disorders “can also receive treatment without having to drive long distances.”
The disappearing in-person requirement
As states define their telehealth policies, they are fading out a once-prevalent requirement – the in-person visit. There is no longer a single state that requires physicians to meet with patients in-person before providing telemedicine services, according to the Epstein report.
States realized that requiring in-person visits before doctors can provide telemedicine creates a barrier to care, said Mr. Kim. A move to eliminate the requirement in Texas influenced other states in phasing out the common regulation. In the widely publicized Teladoc case, the national telemedicine company sued the Texas Medical Board in 2011 over its rule requiring Texas physicians to conduct a face-to-face evaluation before treating a patient via telemedicine. The legal battle continued for years, until Teladoc voluntarily dropped its lawsuit in 2017 after Texas adopted a new law that allowed doctors to treat first-time patients through telemedicine.
“The medical board [understood] that the in-person requirement wasn’t really a benefit to patients,” Mr. Kim said in an interview. “Once they changed it, a lot of other states have recognized the same and have moved toward getting rid of the requirement.”
In some states, midlevel providers still must see patients face-to-face before providing telehealth care. Arkansas for instance, requires that psychologists, counselors, and APRNs conduct an in-person exam before rendering telehealth. Professional boards in Colorado and Massachusetts recommend a face-to-face visit by midlevel providers as a best practice.
Reimbursement growing, but restrictions remain
Forty-nine states and the District of Columbia reimburse for some form of telehealth, mainly live video services. At least 20 states now pay providers for remote payment monitoring (RPM), according to the Center for Connected Health Policy report. The reimbursement is often restricted, however, to certain clinical conditions and/or rules that limit the type of monitoring device allowed. Colorado, for instance, only reimburses RPM for patients with congestive heart failure, chronic obstructive pulmonary disease, asthma, or diabetes and requires that the patient was hospitalized at least twice in the last 12 months for reasons associated with one of the conditions. Missouri has similar RPM criteria associated with hospitalizations, but allows for a greater number of conditions including pregnancy, stroke, and cancer.
Most states have yet to pay for store-and-forward services, technologies that enable the electronic transfer of photos, prerecorded videos, or documents. Only about 14 states reimburse for such technology, and many policies include limitations. California, for example, only reimburses for store-and-forward services in teledermatology, teledentistry, and teleophthalmology. Connecticut allows for store-and-forward payment between physicians through email. Missouri allows for store-and-forward services in orthopedics, dermatology, optometry, ophthalmology, and in cases of retinopathy, burn and wound care, dental services, and maternal-fetal ultrasounds.
Reimbursement for telehealth is still a challenge for many physicians, Dr. Sumner said. Part of the problem is the wide discrepancy in how telehealth is defined among states, she said. Some states only consider live or interactive two-way technology as telehealth, excluding services such as store-and-forward and RPM. Other states reimburse for certain technology-based services, but they do not consider them telehealth. Maryland’s Medicaid program for example, does not reimburse for store and forward under its telehealth policy. However, store and forward used in dermatology, radiology, and ophthalmology is reimbursed by Maryland under an alternate billing code, though not considered telehealth.
Establishing best practices in telehealth through careful evaluation and research would improve reimbursement, said S. David McSwain, MD, interim chief medical information officer at the Medical University of South Carolina, Charleston, and medical director for telehealth optimization.
“We can use that evidence to reduce the variation in telehealth payment policies across the states,” Dr. McSwain said in an interview. “By leveraging reimbursement models to promote best practices, we can encourage the spread of telehealth services that have the greatest impacts on patients, their families, and the health care system.”
More states are expanding their telehealth policies to reach patients, and pulling back on rigid in-person requirements.
Several state Medicaid programs now explicitly allow the home to serve as an originating site for telehealth, with 10 states – Delaware, Colorado, Maryland, Michigan, Minnesota, Montana, New York, Texas, Washington, and Wyoming – adding the home as an approved site since 2016.
In addition, 16 jurisdictions now allow schools to serve as originating sites for telehealth, although some have restrictions about when the sites are acceptable, said Mei Kwong, an attorney and executive director for the Center for Connected Health Policy and the author of the center’s Spring 2018 report on telehealth trends.
At the same time, nearly all states have now dropped Medicaid restrictions that limited reimbursable telehealth services to rural or underserved areas. Colorado, Idaho, Nebraska, New Hampshire, Nevada, and Missouri are the most recent states to remove such geographic restrictions.
“[The expanded locations are] extremely helpful in providing greater access for patients to needed services,” Ms. Kwong said in an interview. “For example, a person who has difficulty leaving his or her home for a physical or other reason, they can get care, [or] a child having a rough time in school, can seek out a mental health counselor while at school.”
More telehealth providers
In addition to expanding teleheath sites, states are increasing acceptance for telehealth providers beyond physicians. Most recently, New Jersey enacted a broad telemedicine law that includes doctors, nurses, psychologists, social workers, physician assistants, counselors, respiratory therapists, speech pathologists, and optometrists, among others. The New Jersey law addresses telemedicine practice standards, prescribing, patient consent, privacy, and other requirements for providers.
In addition, more states are carving out telehealth regulations. Since 2016, 11 states have revised or adopted new scope of practice restrictions for counselors providing telemedicine, according to a state telehealth analysis published in July 2018 by law firm Epstein, Becker, Green.
Arkansas, Idaho, Maine, New Jersey, and Rhode Island recently imposed regulations for the practice of telepsychology. In addition, seven states have new or revised scope of practice restrictions for advanced practice registered nurses (APRN) providing telehealth services, while eight states have new licensing requirements specific to telehealth practice by APRNs, according to the Epstein analysis.
A telehealth compact that would allow APRNs to practice nursing via telemedicine across state lines is also in the works. Similar to the physician Interstate Medical Licensure Compact, the APRN Compact would establish an interstate commission and guidelines for uniform licensing requirements and criminal background checks. The compact will become effective when 10 states enact the compact legislation. So far, three states – Wyoming, North Dakota, and Idaho – have enacted the model legislation.
Another telemedicine compact for psychologists is getting ready to launch. In August, Illinois became the seventh state to join the Psychology Interjurisdictional Compact (PSYPACT). The pact requires seven states to enact compact legislation to become effective, however Illinois law does not go into effect until 2020.
The developments highlight the rise in more mid- and lower-level providers practicing telemedicine, said Anjali B. Dooley, an attorney and chief legal and compliance officer for Forefront Telecare, a telehealth platform for behavioral health services. While the increase allows greater care access, the expansion also poses scope of practice challenges, she notes.
“Increasing scope of practice extensions also increases risk if physician extenders are not trained properly in telehealth technology use and protocols,” Ms. Dooley said in an interview. “Providers and provider extenders need to be educated and learned in human factors such as communication, empathy, and etiquette.”
A greater number of nonphysician telemedicine providers is beneficial as long as the providers are adhering to appropriate standards of care and consulting with supervising physicians when necessary, adds Jean R. Sumner, MD, dean of the School of Medicine at Mercer University in Macon, Georgia, and a telemedicine internist.
“The standard should always be equal to an in-person visit,” she said in an interview. “The patient has a right to know who is seeing them, too, to understand [their credentials]. They need to know the person on the telehealth unit is qualified to provide the care.”
Responding to the opioid crisis
The need for increased access to mental health care is a primary driver behind state efforts to expand the pool of telemedicine providers, adds Amy Lerman, an attorney at Epstein, Becker, Green and lead author of her firm’s report.
“The reason it is important for states to continue expanding the scope of health professionals, other than physicians, who can provide behavioral health telemedicine services, is not only to address an overall nationwide shortage of behavioral health providers, but also to expand access to behavioral health services because a wider range of providers are equipped to provide these services,” she said in an interview.
In the same vein, more states are using telehealth to address the opioid crisis, according to both the Epstein report and the Center for Connected Health Policy analysis.
In September, California enacted a law that would allow Medicaid reimbursement for certified substance use disorder counselors who provide treatment via telehealth. In August, Illinois approved a similar law that mandates reimbursement for behavioral and mental health experts who treat Medicaid patients through telehealth technologies.
The laws come after a June 2018 letter from the Centers for Medicare & Medicaid Services that encouraged states to utilize health technology efforts to address the opioid crisis, including through telemedicine and telepsychiatry, said Daniel Kim, an attorney with Epstein, Becker, Green and a coauthor of his firm’s report.
At the same time, a number of states have expanded their controlled substance laws to allow remote prescribing through telehealth for the treatment of psychiatric or substance use disorders. Connecticut’s law, for instance, allows providers to prescribe Schedule I-III controlled substances through telehealth platforms, while banning opioid prescribing. In Indiana, 2017 legislation expanded the types of controlled medications that providers can prescribe through telehealth platforms, primarily drugs used to treat or manage opioid dependence. The states join an increasing number that have enacted laws allowing the remote prescribing of controlled substances, including Delaware, Florida, Indiana, Michigan, New Hampshire, Ohio, and West Virginia.
The new laws will enhance the availability of behavioral health services, while allowing more treatment flexibility and privacy for patients, said Ms. Dooley.
“Treatment in one’s own environment where the addiction takes place is often more effective,” she said. People with addiction disorders “can also receive treatment without having to drive long distances.”
The disappearing in-person requirement
As states define their telehealth policies, they are fading out a once-prevalent requirement – the in-person visit. There is no longer a single state that requires physicians to meet with patients in-person before providing telemedicine services, according to the Epstein report.
States realized that requiring in-person visits before doctors can provide telemedicine creates a barrier to care, said Mr. Kim. A move to eliminate the requirement in Texas influenced other states in phasing out the common regulation. In the widely publicized Teladoc case, the national telemedicine company sued the Texas Medical Board in 2011 over its rule requiring Texas physicians to conduct a face-to-face evaluation before treating a patient via telemedicine. The legal battle continued for years, until Teladoc voluntarily dropped its lawsuit in 2017 after Texas adopted a new law that allowed doctors to treat first-time patients through telemedicine.
“The medical board [understood] that the in-person requirement wasn’t really a benefit to patients,” Mr. Kim said in an interview. “Once they changed it, a lot of other states have recognized the same and have moved toward getting rid of the requirement.”
In some states, midlevel providers still must see patients face-to-face before providing telehealth care. Arkansas for instance, requires that psychologists, counselors, and APRNs conduct an in-person exam before rendering telehealth. Professional boards in Colorado and Massachusetts recommend a face-to-face visit by midlevel providers as a best practice.
Reimbursement growing, but restrictions remain
Forty-nine states and the District of Columbia reimburse for some form of telehealth, mainly live video services. At least 20 states now pay providers for remote payment monitoring (RPM), according to the Center for Connected Health Policy report. The reimbursement is often restricted, however, to certain clinical conditions and/or rules that limit the type of monitoring device allowed. Colorado, for instance, only reimburses RPM for patients with congestive heart failure, chronic obstructive pulmonary disease, asthma, or diabetes and requires that the patient was hospitalized at least twice in the last 12 months for reasons associated with one of the conditions. Missouri has similar RPM criteria associated with hospitalizations, but allows for a greater number of conditions including pregnancy, stroke, and cancer.
Most states have yet to pay for store-and-forward services, technologies that enable the electronic transfer of photos, prerecorded videos, or documents. Only about 14 states reimburse for such technology, and many policies include limitations. California, for example, only reimburses for store-and-forward services in teledermatology, teledentistry, and teleophthalmology. Connecticut allows for store-and-forward payment between physicians through email. Missouri allows for store-and-forward services in orthopedics, dermatology, optometry, ophthalmology, and in cases of retinopathy, burn and wound care, dental services, and maternal-fetal ultrasounds.
Reimbursement for telehealth is still a challenge for many physicians, Dr. Sumner said. Part of the problem is the wide discrepancy in how telehealth is defined among states, she said. Some states only consider live or interactive two-way technology as telehealth, excluding services such as store-and-forward and RPM. Other states reimburse for certain technology-based services, but they do not consider them telehealth. Maryland’s Medicaid program for example, does not reimburse for store and forward under its telehealth policy. However, store and forward used in dermatology, radiology, and ophthalmology is reimbursed by Maryland under an alternate billing code, though not considered telehealth.
Establishing best practices in telehealth through careful evaluation and research would improve reimbursement, said S. David McSwain, MD, interim chief medical information officer at the Medical University of South Carolina, Charleston, and medical director for telehealth optimization.
“We can use that evidence to reduce the variation in telehealth payment policies across the states,” Dr. McSwain said in an interview. “By leveraging reimbursement models to promote best practices, we can encourage the spread of telehealth services that have the greatest impacts on patients, their families, and the health care system.”
Disruptive physicians: Is this an HR or MEC issue?
it can greatly lower staff morale and compromise patient care. Addressing this behavior head-on is imperative, experts said, but knowing which route to take is not always clear.
Physician leaders may wonder: When is this a human resources (HR) issue and when should the medical executive committee (MEC) step in?
The answer depends on the circumstances and the employment status of the physician in question, said Mark Peters, a labor and employment attorney based in Nashville, Tenn.
“There are a couple of different considerations when deciding how, or more accurately who, should address disruptive physician behavior in the workplace,” Mr. Peters said in an interview. “The first consideration is whether the physician is employed by the health care entity or is a contractor. Typically, absent an employment relationship with the physician, human resources is not involved directly with the physician and the issue is handled through the MEC.”
However, in some cases both HR and the MEC may become involved. For instance, if the complaint is made by an employee, HR would likely get involved – regardless of whether the disruptive physician is a contractor – because employers have a legal duty to ensure a “hostile-free environment,” Mr. Peters said.
The hospital may also ask that the MEC intervene to ensure the medical staff understands all of the facts and can weigh in on whether the doctor is being treated fairly by the hospital, he said.
There are a range of advantages and disadvantages to each resolution path, said Jeffrey Moseley, a health law attorney based in Franklin, Tenn. The HR route usually means dealing with a single point person and typically the issue is resolved more swiftly. Going through the MEC, on the other hand, often takes months. The MEC path also means more people will be involved, and it’s possible the case may become more political, depending on the culture of the MEC.
“If you have to end up taking an action, the employment setting may be a quicker way to address the issue than going through the medical staff side,” Mr. Moseley said in an interview. “Most medical staffs, if they were to try to restrict or revoke privileges, they are going to have to go through a fair hearing and appeals, [which] can take 6 months easily. The downside to the employment side is you don’t get all the immunities that you get on the medical staff side.”
A disruptive physician issue handled by the MEC as a peer review matter or professional review action is protected under the Healthcare Quality Improvement Act, which shields the medical staff and/or hospital from civil damages in the event that they are sued. Additionally, information disclosed during the MEC process that is part of the peer review privilege is confidential and not necessarily discoverable by plaintiff’s attorneys in a subsequent court case.
The way the MEC handles the issue often hinges on the makeup of the committee, Mr. Moseley noted. In his experience, older medical staffs tend to be more sensitive to the accused physician and question whether the behavior is egregious. Older physicians are generally used to a more “captain of the ship” leadership style, with the doctor as the authority figure. Younger staffs are generally more sensitive to concerns about a hostile work environment and lean toward a team approach to health care.
“If your leadership on the medical staff is a [group of older doctors] versus a mix or younger docs, they might be more or less receptive to discipline [for] a behavioral issue, based on their worldview,” he said.
Disruptive behavior is best avoided by implementing sensitivity training and employing a zero tolerance policy for unprofessional behavior that applies to all staff members from the highest revenue generators to the lowest, no exceptions, Mr. Peters advised. “A top down culture that expects and requires professionalism amongst all medical staff [is key].”
it can greatly lower staff morale and compromise patient care. Addressing this behavior head-on is imperative, experts said, but knowing which route to take is not always clear.
Physician leaders may wonder: When is this a human resources (HR) issue and when should the medical executive committee (MEC) step in?
The answer depends on the circumstances and the employment status of the physician in question, said Mark Peters, a labor and employment attorney based in Nashville, Tenn.
“There are a couple of different considerations when deciding how, or more accurately who, should address disruptive physician behavior in the workplace,” Mr. Peters said in an interview. “The first consideration is whether the physician is employed by the health care entity or is a contractor. Typically, absent an employment relationship with the physician, human resources is not involved directly with the physician and the issue is handled through the MEC.”
However, in some cases both HR and the MEC may become involved. For instance, if the complaint is made by an employee, HR would likely get involved – regardless of whether the disruptive physician is a contractor – because employers have a legal duty to ensure a “hostile-free environment,” Mr. Peters said.
The hospital may also ask that the MEC intervene to ensure the medical staff understands all of the facts and can weigh in on whether the doctor is being treated fairly by the hospital, he said.
There are a range of advantages and disadvantages to each resolution path, said Jeffrey Moseley, a health law attorney based in Franklin, Tenn. The HR route usually means dealing with a single point person and typically the issue is resolved more swiftly. Going through the MEC, on the other hand, often takes months. The MEC path also means more people will be involved, and it’s possible the case may become more political, depending on the culture of the MEC.
“If you have to end up taking an action, the employment setting may be a quicker way to address the issue than going through the medical staff side,” Mr. Moseley said in an interview. “Most medical staffs, if they were to try to restrict or revoke privileges, they are going to have to go through a fair hearing and appeals, [which] can take 6 months easily. The downside to the employment side is you don’t get all the immunities that you get on the medical staff side.”
A disruptive physician issue handled by the MEC as a peer review matter or professional review action is protected under the Healthcare Quality Improvement Act, which shields the medical staff and/or hospital from civil damages in the event that they are sued. Additionally, information disclosed during the MEC process that is part of the peer review privilege is confidential and not necessarily discoverable by plaintiff’s attorneys in a subsequent court case.
The way the MEC handles the issue often hinges on the makeup of the committee, Mr. Moseley noted. In his experience, older medical staffs tend to be more sensitive to the accused physician and question whether the behavior is egregious. Older physicians are generally used to a more “captain of the ship” leadership style, with the doctor as the authority figure. Younger staffs are generally more sensitive to concerns about a hostile work environment and lean toward a team approach to health care.
“If your leadership on the medical staff is a [group of older doctors] versus a mix or younger docs, they might be more or less receptive to discipline [for] a behavioral issue, based on their worldview,” he said.
Disruptive behavior is best avoided by implementing sensitivity training and employing a zero tolerance policy for unprofessional behavior that applies to all staff members from the highest revenue generators to the lowest, no exceptions, Mr. Peters advised. “A top down culture that expects and requires professionalism amongst all medical staff [is key].”
it can greatly lower staff morale and compromise patient care. Addressing this behavior head-on is imperative, experts said, but knowing which route to take is not always clear.
Physician leaders may wonder: When is this a human resources (HR) issue and when should the medical executive committee (MEC) step in?
The answer depends on the circumstances and the employment status of the physician in question, said Mark Peters, a labor and employment attorney based in Nashville, Tenn.
“There are a couple of different considerations when deciding how, or more accurately who, should address disruptive physician behavior in the workplace,” Mr. Peters said in an interview. “The first consideration is whether the physician is employed by the health care entity or is a contractor. Typically, absent an employment relationship with the physician, human resources is not involved directly with the physician and the issue is handled through the MEC.”
However, in some cases both HR and the MEC may become involved. For instance, if the complaint is made by an employee, HR would likely get involved – regardless of whether the disruptive physician is a contractor – because employers have a legal duty to ensure a “hostile-free environment,” Mr. Peters said.
The hospital may also ask that the MEC intervene to ensure the medical staff understands all of the facts and can weigh in on whether the doctor is being treated fairly by the hospital, he said.
There are a range of advantages and disadvantages to each resolution path, said Jeffrey Moseley, a health law attorney based in Franklin, Tenn. The HR route usually means dealing with a single point person and typically the issue is resolved more swiftly. Going through the MEC, on the other hand, often takes months. The MEC path also means more people will be involved, and it’s possible the case may become more political, depending on the culture of the MEC.
“If you have to end up taking an action, the employment setting may be a quicker way to address the issue than going through the medical staff side,” Mr. Moseley said in an interview. “Most medical staffs, if they were to try to restrict or revoke privileges, they are going to have to go through a fair hearing and appeals, [which] can take 6 months easily. The downside to the employment side is you don’t get all the immunities that you get on the medical staff side.”
A disruptive physician issue handled by the MEC as a peer review matter or professional review action is protected under the Healthcare Quality Improvement Act, which shields the medical staff and/or hospital from civil damages in the event that they are sued. Additionally, information disclosed during the MEC process that is part of the peer review privilege is confidential and not necessarily discoverable by plaintiff’s attorneys in a subsequent court case.
The way the MEC handles the issue often hinges on the makeup of the committee, Mr. Moseley noted. In his experience, older medical staffs tend to be more sensitive to the accused physician and question whether the behavior is egregious. Older physicians are generally used to a more “captain of the ship” leadership style, with the doctor as the authority figure. Younger staffs are generally more sensitive to concerns about a hostile work environment and lean toward a team approach to health care.
“If your leadership on the medical staff is a [group of older doctors] versus a mix or younger docs, they might be more or less receptive to discipline [for] a behavioral issue, based on their worldview,” he said.
Disruptive behavior is best avoided by implementing sensitivity training and employing a zero tolerance policy for unprofessional behavior that applies to all staff members from the highest revenue generators to the lowest, no exceptions, Mr. Peters advised. “A top down culture that expects and requires professionalism amongst all medical staff [is key].”