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Improving Health Care Quality

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Which Medicare Changes Should Continue Beyond the COVID-19 Pandemic? Four Questions for Policymakers

A CVS pharmacist intern talks with a resident at Emerald Court senior living community in Anaheim, CA on Friday, January 8, 2021 after giving the Pfizer/BioNTech COVID-19 vaccine.

Abstract

  • Issue: The COVID-19 pandemic prompted Congress and the Trump administration to rapidly waive or change existing Medicare regulations, providing unprecedented flexibility for providers and health plans in how they serve beneficiaries. Policymakers can either allow these actions to expire as scheduled or consider potential modifications to these policies, including whether to make them permanent.
  • Goals: Track and categorize these regulatory changes, describe the benefits and risks of the changes, and establish a framework to support policymakers’ decisions on the future of these temporary policies.
  • Methods: Analysis of COVID-19-related legislative, regulatory, and subregulatory changes to existing Medicare regulations issued January 1, 2020, through January 8, 2021.
  • Key Findings and Conclusion: The Centers for Medicare and Medicaid Services (CMS) has the authority to modify many of the waived provisions after the end of the public health emergency and may choose to make some of the temporary policies permanent. Data will be available before the provisions expire that could provide answers to four key questions that comprise a framework designed to inform these decisions. Based on these results, policymakers could opt to make some temporary Medicare changes permanent after the public health emergency ends.

Background

Congress and the Trump Administration responded to the COVID-19 pandemic with a series of policy changes designed to provide temporary relief from certain Medicare rules. Most of these pandemic-related regulatory changes will expire at the end of the public health emergency, which began in January 2020 and is expected to run through the end of 2021. To date, the Centers for Medicare and Medicaid Services (CMS) has not issued a public plan or statement for how it plans to extend or phase out most of these policies.1

We cataloged the array of COVID-19-related regulatory changes during this period and categorized them according to their characteristics, such as theme, including modifications made to these changes after they were first implemented.

Of the 244 COVID-19-related regulatory changes that were implemented through January 8, 2021:

  • Twenty-seven, or 11 percent, have been expanded or made permanent.
  • Two have been terminated.
  • Twelve affect payment systems and quality programs.
  • Five relate to provider capacity and workforce.
  • Three concern telehealth.

Types of Temporary Regulatory Changes That Have Been Expanded or Made Permanent

Payment Systems and Quality Programs

Regulatory changes that the Centers for Medicare and Medicaid Services (CMS) has made permanent or expanded — for example, by making the regulatory change more permissive or more broadly applicable to providers and beneficiaries:

  • Made permanent: Added telehealth services to the list of codes used to assign beneficiaries to accountable care organizations (ACOs)
  • Expanded: Established payment codes and amounts for COVID-19 testing
  • Expanded: Created a performance measure to reward physicians for submitting COVID-19 patient data to clinical data registries to be used for research
  • Expanded: Waived claims data performance calculations and reporting requirements for hospitals under value-based payment (VBP) and for dialysis providers under the end-stage renal disease quality incentive program (ESRD QIP) for the first half of 2020
  • Expanded: Implemented extreme and uncontrollable circumstances policies to minimize impacts on payments for ACOs and for providers under the comprehensive care for joint replacement (CJR) model.

Provider Capacity, Workforce, and Telehealth

Regulatory changes that CMS has made permanent:

  • Modestly expanded the scope of practice for nonphysician practitioners to the extent permissible under state law and regulation
  • Allowed Medicare to pay for certain services provided by medical residents
  • Moved nine temporary telehealth services to the Medicare-approved list
  • Enabled the use of certain telehealth services for the treatment of substance use disorders
  • Permitted teaching physicians to provide services to residents by telehealth in certain situations.

Considering Future Policy Actions

With more than 200 COVID-19-related regulatory changes still in effect on a temporary basis, it is likely that the Biden administration and Congress will continue efforts to modify and extend at least some additional changes.

Because it normally takes at least six months to propose, finalize, and implement new Medicare rules, CMS and Congress may now begin to consider which additional provisions should be made permanent. They also may choose to modify these policy actions or add companion policies to mitigate unintended consequences for beneficiaries or Medicare program spending. Given that the effects of all COVID-19-related regulatory changes are not yet clear, CMS could explore these impacts and provide findings to policymakers and other stakeholders in a transparent manner.

With more than 200 COVID-19-related regulatory changes still in effect on a temporary basis, it is likely that the Biden administration and Congress will continue efforts to modify and extend at least some additional changes.

Research on Effects of Changes Needed

As previously mentioned, policymakers and health care stakeholders still know too little about the actual effects of these policy changes. Yet some of these changes are likely having a significant impact on how care is provided to Medicare beneficiaries.

Many of the changes, such as waiving the three-day hospital stay requirement for skilled nursing facility (SNF) services and expanding the use of telehealth, are already being studied on a smaller scale, through CMS Innovation Center demonstrations and Medicare Advantage (MA) plans’ use of certain Medicare requirement waivers and supplemental benefits.

The breadth and scale of these changes — which, because of their national scale, generally affect more providers and beneficiaries than Innovation Center and MA efforts — could provide unique insights into how Medicare’s regulatory structures could be modified to improve beneficiary care. If CMS releases its findings to the public (as it does with Innovation Center payment model demonstrations), the results could inform future legislation and enable stakeholders to make meaningful contributions through the rulemaking process.

CMS has a window of opportunity to treat the current situation as a large-scale demonstration of how policy changes could affect the cost and quality of care. Sufficient Medicare claims data are available to begin to assess effects on cost of care in aggregate and by characteristics such as type of service, geography, and groups of beneficiaries. CMS also could begin to examine some population health quality measures, such as changes in the rates of hospital readmissions and unexpected emergency room visits.

Additional data, such as which providers and beneficiaries made use of the flexibilities as well as trends in service use, also could contribute to policymakers’ decision-making. Ideally, these initial findings will help answer the following questions:

  • Why did Medicare providers and beneficiaries respond as they did?
  • How can CMS offer an array of access options so that Medicare benefits are flexible enough to account for the various needs and limitations of all beneficiaries? For example, if audio-only telehealth services increased during the emergency, was this because providers or beneficiaries lacked access to audio/video technology? Or for other reasons?
  • How did changes in the use of services that were permitted or expanded during the emergency affect quality of patient care? For example, if audio-only telehealth services increased during the emergency, did outcomes for patients who used these services differ from those for patients who used audio-video telehealth or in-person visits?
  • Did use of these newly permitted or expanded services increase throughout the country or did different regions or markets make different decisions? If the response differed by region or market, what drove those decisions and how was beneficiary care affected?
  • How did providers ensure all their patients had adequate access to care, whether by making use of newly permitted or expanded services or by relying on existing services — regardless of individual abilities and limitations? For example, were people who were unable to use telehealth services able to access in-person visits?

Framework Questions for Future Policy Actions

Recognizing that more research is needed to understand the effects of these policy actions, we offer a framework for policymakers to use in considering whether to modify, extend, or make permanent pandemic-related regulatory changes to Medicare. To start, CMS and lawmakers could consider four key questions for each of the temporary regulatory changes.

Podulka_Medicare_Changes_Exhibit

Examples of How the Four Key Questions Might Be Answered

We focused our analysis on temporary regulatory changes that fall under the themes of alternate sites of care, benefits and care management, and telehealth. Telehealth changes are relatively well known and have received attention from policymakers and stakeholders. The changes that affect alternate sites of care and benefits and care management are less discussed but also may have potentially significant impacts to the Medicare program and beneficiary care.

Does CMS have the authority to make the change permanent after the public health emergency ends?

CMS has the authority to make many temporary Medicare changes permanent (see Appendix). Only a fraction of the total number of temporary COVID-19-related Medicare regulatory changes would require legislation to be extended beyond the end of the public health emergency.

What key potential benefits and risks to beneficiary care and out-of-pocket spending do the changes pose?

To answer this (and the remaining questions), CMS or Congress could undertake a benefit–risk analysis to determine which beneficiary care experiences could be affected by the particular change, or, in some cases, group of changes. For example, CMS could assess whether the change will permanently alter beneficiary rights, such as their ability to receive medical records in a timely manner from hospitals. CMS also could review how changes might affect beneficiaries’ ability to understand their care plan.

CMS could also evaluate how each policy change might affect beneficiaries by making it more challenging for them to access their benefits or by increasing their out-of-pocket obligations. CMS could also determine whether permanent changes to move more care to alternate care settings could lead to poorer-quality outcomes. Detailed data analytics could provide insights into whether actual outcomes are more reflective of potential benefits or potential risks.

What key potential benefits and risks to Medicare spending do the changes pose?

For this question, CMS could evaluate whether or not the changes led to an inappropriate increase or decrease in spending, both at an individual service level and across the total cost of care. Many of the Medicare policy changes, such as increasing flexibility around telehealth and waiving some out-of-pocket costs, could lead to greater overutilization and unnecessary spending. These same changes also could result in less spending across a total episode of care if more services are provided in lower-intensity settings and if beneficiaries receive more timely access to care. Many of the changes also carry a greater risk for fraud and abuse.

What are key policies that CMS or Congress could implement to mitigate the potential risks?

From this benefit–risk analysis, CMS and Congress could identify specific mitigation policies to answer this final question. For example, to manage the risk of increased fraud and abuse, CMS could rely on established policies and procedures employed by its existing programs, including outlier analysis and other strategies to identify providers that have a higher than expected use of services for further review.

To mitigate concerns about patient access and quality, CMS could implement policies that, for example, allow for site visits and the fast-tracking of responses to concerns raised by beneficiaries who receive services at these sites.

To help beneficiaries understand how regulatory changes affect how they access Medicare services, CMS could develop educational materials. For example, it could create information that describes how cost sharing operates for alternate sites and broadly distribute the materials through CMS communication channels and through its partners, such as State Health Insurance Assistance Programs (SHIPs).

Conclusion

In response to the COVID-19 public health emergency, CMS and Congress made an unprecedented number of legislative, regulatory, and subregulatory changes to the Medicare program. More than 200 of these actions are currently in effect and are likely to remain part of the Medicare program through the end of 2021.

Some of these actions could prove to be beneficial after the end of the public health emergency and could become permanent Medicare policies. If CMS were to capitalize on this unique opportunity by undertaking rapid, large-scale evaluations of the effects of the changes, the results could inform policymakers’ decisions about future actions. Such a substantial research effort would provide CMS and the new Congress with data-supported insights into the relative benefits and risks of each COVID-19-related action as they consider which policies should continue in the future.

How We Conducted This Study

Health Management Associates reviewed the COVID-19-related legislative, regulatory, and subregulatory changes to the Medicare program that occurred between January 1, 2020, and January 8, 2021. We cataloged these changes and categorized them according to their characteristics, including types of providers and plans affected, effective date, and expected duration. This information is available in a companion policy tracker.

The mission of the Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff.

 

The SCAN Foundation

Supported in part by a grant from The SCAN Foundation — advancing a coordinated and easily navigated system of high-quality services for older adults that preserve dignity and independence. For more information, visit www.TheSCANFoundation.org.

NOTES

1. U.S. Department of Health and Human Services (HHS) Secretary Azar used his authority in the Public Health Service Act to declare a public health emergency in the entire United States on January 31, 2020, giving CMS the flexibility to make regulatory changes, effective January 27, 2020. The declaration lasts for the duration of the emergency or 90 days but may be extended by the secretary. The secretary has renewed the determination April 2, 2020; April 21, 2020; July 23, 2020; October 2, 2020, effective October 23, 2020; and January 7, 2021, effective January 21, 2021. On January 22, 2021, the HHS acting secretary sent a letter to governors announcing that, “the [public health emergency] will likely remain in place for the entirety of 2021, and when a decision is made to terminate the declaration or let it expire, HHS will provide states with 60 days’ notice prior to termination.”

Publication Details

Date

Contact

Jennifer Podulka, Senior Consultant, Health Management Associates

[email protected]

Citation

Jennifer Podulka and Jonathan Blum, Which Medicare Changes Should Continue Beyond the COVID-19 Pandemic? Four Questions for Policymakers (Commonwealth Fund, May 2021). https://doi.org/10.26099/ke1n-gz27