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CMS Update – Lana Dennis

CHART Model

CMS is providing funding for rural communities to build systems of care through a Community Transformation Track and is enabling providers to participate in value-based payment models where they are paid for quality and outcomes, instead of volume, through an Accountable Care Organizations (ACO) Transformation Track.

State Offices of Rural Health are eligible to be Lead Organizations for the Community Transformation Track. A Lead Organization is a single entity that represents a rural Community, comprised of either (a) a single county or census tract or (b) a set of contiguous or non-contiguous counties or census tracts. Each county or census tract must be classified as rural, as defined by the Federal Office of Rural Health Policy’s list of eligible counties and census tracts used for its grant programs.

Everyone is invited to learn more in our upcoming webinar on 8/18/20 and registration is open at: https://cmslearningeventscqpub.cosocloud.com/content/connect/c1/7/en/events/event/shared/default_template_simple/event_landing.html?sco-id=21747024

Changes in Atlanta

  • CMS recently reorganized and the Rural Health Coordinators are now housed in the Local Engagement and Administration area of the CMS Regional Offices. Lana Dennis is still the Regional Rural Health Coordinator for SORH Region B.  She sends the weekly CMS regional rural health update to anyone who requests to be on the distribution list. Thank you to those who receive the updates and help us disseminate important information and please let Lana know if you aren’t on the listserv and would like to join. It is a great way to stay in the CMS loop. 
  • In June, Sherard McKie was named the Regional Administrator for CMS Atlanta. Prior to joining CMS Atlanta, Sherard served as Project Officer in the Patient Care Models Group at CMS’ Center for Medicare & Medicaid Innovation.  He also served on a detail with the Centers for Disease Control and Prevention’s Office of the Associate Director for Policy.  Sherard holds a bachelor’s degree in psychology from Morehouse College, a master’s in Social Work from the University of South Carolina, and a Juris Doctor from the Charleston School of Law.  He is a native of Aiken, South Carolina.
  • On May 27, 2020, April Weaver was announced as the HHS Region IV Regional Director. She served ten years as a state legislator in the Alabama House of Representatives, including five years as the chair of the House Health Committee. She is also a registered nurse who holds bachelor’s and master’s degrees in business administration. She worked for over 23 years as a hospital leader in various management roles in urban, suburban and rural hospitals.

CMS Rural Health Activities this Year

  • In February, we held our CMS Quality conference and had rural and tribal themed sessions.
  • Participation in the National Advisory Committee on Rural Health and Human Services March 2020 meeting in Atlanta and the virtual meeting in July.
  • The CMS Rural Health Coordinators still have their monthly calls (our last one was July 28).
  • This year we have focused on rural maternal and infant health care and we published a request for information (RFI). The comment period closed on 5/31/20. I hope everyone had the chance to review it, comment, and/or share it with others. Specifically, we sought feedback about opportunities to improve access, quality, and outcomes before, during, and after pregnancy, and to develop and refine programs and policies. That feedback will be used to inform future discussions among stakeholders and future work by CMS toward the development and refinement of programs and policies that ensure rural women have access to high quality maternal health care that results in optimal health outcomes.  Thank you to everyone who commented.
  • Cara James and the Administrator both presented key notes at the NRHA Policy Institute. That is where the Administrator announced the rural maternal health Request For Information. Cara James presented on health equity.
  • To explore the issue of rural hospital bypass, the CMS Office of Minority Health is holding listening sessions in 4 states – Michigan, Georgia, Montana, and Kansas.  The goal of the listening sessions is to flesh out the “why” of hospital bypass to complement the quantitative work that has already been completed.  Lana Dennis, the rural health coordinator participated in the Georgia session held last month.
  • The Rural Health Coordinators were all asked to take a look at the Rural Health Open Door Forum web page and comments to improve and update it.  Lana sent comments on 7/31/20.
  • The CMS Rural Health Council will meet again in September.
  • We also expect the Rural Health Open Door Forums to resume in September.

CMS Proposed Changes

  • In May CMS published the Fiscal year 2021 Inpatient Hospital (IPPS) proposed rule and the comment period has ended. With it, we proposed an EHR (Electronic Health Record) reporting period of a minimum of any continuous 90-day period in Calendar Year 2022 for new and returning eligible hospitals and CAHs in the Medicare Promoting Interoperability Program.  We also proposed to implement the revised OMB (Office of Management and Budget) statistical area delineations beginning in Fiscal Year 2021 which can affect the wage index for rural and urban prospective payment hospitals and Critical Access Hospital designations. When calculating the area wage index, the wage data for hospitals located in these counties would be included in their new respective urban CBSAs (Core Based Statistical Areas). Typically, hospitals located in an urban area would receive a wage index value higher than or equal to hospitals located in their State’s rural area. Section III.A.2.c. of the preamble of the proposed rule has a discussion of our proposed wage index transition policy to apply a 5 percent cap in Fiscal year 2021 for hospitals that may experience any decrease in their final wage index from the prior fiscal year. We also note that due to the proposed adoption of the revised OMB delineations, some CAHs that were previously located in rural areas may be located in urban areas. The regulations provide affected CAHs with a two-year transition period that begins from the date the “redesignation” becomes effective. The affected CAHs must reclassify as rural during this transition period in order to retain their CAH status after the two-year transition period ends.
  • The Physician Fee Schedule rule was announced on 8/4/20 and CMS is proposing changes to expand telehealth permanently. In response to the COVID-19 pandemic, CMS moved swiftly to significantly expand payment for telehealth services and implement other flexibilities so that Medicare beneficiaries living in all areas of the country can get convenient and high-quality care from the comfort of their home while avoiding unnecessary exposure to the virus. Most of us know the Medicare telehealth benefit required a Medicare beneficiary to be presented from an originating site located in either a county outside a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) in a rural census tract.

During the Public Health Emergency (PHE), CMS added 135 services such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services that could be paid when delivered by telehealth. CMS is proposing to permanently allow some of those services to be done by telehealth, like home visits for the evaluation and management of a patient (in the case where the law allows telehealth services in the patient’s home) and certain types of visits for patients with cognitive impairments. We’d like input on other services to permanently add to the telehealth list beyond the PHE in order to give clinicians and patients time as they get ready to provide in-person care again. CMS is also proposing to temporarily extend payment for other telehealth services, such as emergency department visits for a specific time period, through the calendar year in which the PHE ends. This will also give the community time to consider whether these services should be delivered permanently through telehealth outside of the PHE.  

We also propose to allow nurse practitioners, clinical nurse specialists, physician assistants, and certified nurse-midwives (instead of only physicians) to supervise others performing diagnostic tests consistent with state law and licensure, providing that they maintain the required relationships with supervising/collaborating physicians as required by state law; clarifying that pharmacists can provide services as part of the professional services of a practitioner who bills Medicare; allowing physical and occupational therapy assistants (instead of only physical and occupational therapists) to provide maintenance therapy in outpatient settings; and allowing physical or occupational therapists, speech-language pathologists and other clinicians who directly bill Medicare to review and verify (sign and date), rather than re-document, information already entered by other members of the clinical team into a patient’s medical record. The rule also seeks to update opioid use disorder/substance use disorder provisions and the Quality Payment Program/MIPS Value Pathways so please take a look at it. Public comments are due by October 5, 2020.

  • The Outpatient Prospective Payment System (OPPS) & Ambulatory Surgical Center (ASC) proposed rule was also just announced. It’s comment period also ends on October 5, 2020. Proposals include expanding the number of procedures that Medicare would pay for in the hospital outpatient setting by eliminating the “Inpatient Only list.” This change would give beneficiaries the choice to receive these services in a lower cost setting and convenience to go home as early as the same day after a procedure. This would be phased in over three years and would gradually allow over 1,700 additional services to be paid when furnished in the hospital outpatient setting.

We propose to further reduce the payment rate for drugs purchased through the 340B Program based on hospital survey data on drug acquisition costs. We propose to pay for 340B acquired drugs at average sales price minus 28.7 percent. This could allow Medicare beneficiaries would save an additional $85 million on out-of-pocket payments for these drugs and that OPPS payments for 340B drugs would be reduced by approximately $427 million. The savings would be reallocated on an equal percentage basis to all hospitals paid under the OPPS. We propose that rural sole community hospitals would continue be excepted from these drug payment reductions. In the alternative, and in light of the court’s recent decision, we propose to continue our current policy of paying ASP minus 22.5% for 340B drugs.

We also propose to continue to adopt the IPPS post-reclassified wage index, including the wage index increase for certain low wage index hospitals. The increase addresses a concern that the current wage index system contributes to disparities between high and low wage index hospitals. We estimate that payment for outpatient services in rural hospitals across the country would increase by 3 percent, which is 0.5 percent higher than the national average increase of 2.5 percent. Please read and comment.

Upcoming Opportunities for Engagement-Please Join Us

Dr. Todd Graham Pain Management Study Listening Session

Thursday, August 27, 2020, from 1:30 to 3 pm ET

The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) outlines national strategies to help address the nation’s opioid crisis. Clinicians and health care systems need information about multimodal pain care options in outpatient and inpatient settings to effectively treat Medicare patients with acute or chronic pain, including complementary care, analgesic medications, and medical devices. TheDr. Todd Graham Pain Management Studywill give CMS important information about treatment and outcomes and help us understand the roles of behavioral health, specialty care integration, care planning, health disparities in pain, opioid use, and opioid use disorders treatment.  The target audience: Clinicians and state and national associations that represent health care providers.  CMS is requesting feedback on:

  • What evidence-based treatments, technologies, and models should Medicare cover that it currently does not?
  • What barriers impede Medicare clinicians and beneficiaries from utilizing non-opioid treatments and technologies to help treat acute and chronic pain?
  • How can Medicare improve care for beneficiaries with pain who have a current or past history of mental or substance use disorder(s) or are at higher risk for these conditions, including people at increased suicide risk?
  • How has the COVID-19 public health emergency, including federal waivers and other flexibilities, impacted your ability to treat pain in Medicare beneficiaries and their access to pain treatment?

Physician Fee Schedule Proposed Rule Listening Session

August 13, 2020
1:30 PM Eastern Time

Medicare Part B fee-for-service clinicians; office managers and administrators; state and national associations that represent health care providers; and other stakeholders are invited to learn more about proposals in the Calendar Year 2021 Physician Fee Schedule proposed rule. Feedback received during the listening session is not considered formal comment on the rule. See the proposed rule for information on submitting these comments by October 5. Please register to join this listening session.

In closing

CMS has three main objectives, to:

Improve the quality and affordability of healthcare for all Americans

Drive American healthcare towards payment for value, not volume; and

Lower the rate of growth in America’s healthcare spending.

Within our focus is also the Rural Health Strategy and through our continued work to implement it, CMS and its partners will help make health care in rural America accessible, accountable, and affordable – resulting in the highest quality of care. Please continue to stay engaged with us. Tell us what we can do better to serve you. Please help us share helpful news to those within your states you work with to improve/shape rural health. And most importantly thank you for all you do.