In March and April 2019, the Centers for Medicare and Medicaid Services (CMS) issued several proposed and final rules that affect patient coverage for cancer-related benefits, payment models, and the paperwork nurses often complete to ensure those benefits are billed correctly.
Medicare Advantage Final Rule Expands Telehealth Benefits
To improve access to care in rural and underserved areas and to reduce patients’ need to travel to and from providers, CMS issued a final rule on April 16, 2019, that expanded coverage for telehealth services in Medicare Advantage plans. The financing change enables health plans to better fund the cost of telehealth services through government-paid capitation instead of rebate dollars or premium increases, which have been a disincentive for using telehealth more broadly.
The final rule implements telehealth services as an expanded Medicare Advantage basic benefit effective January 1, 2020. If the plans choose to offer expanded telehealth benefits, nurses may have more opportunity to provide remote patient monitoring services and use technologies such as e-mail, video, and two-way nurse telephone call-in. ONS is supportive of expanded telehealth coverage and reimbursement for nurses and nurse practitioners to perform those services.
Primary Care First Payment Models Incent Palliative Care and Hospice Services
CMS’s two new alternative payment models incorporate recommendations that ONS (2018) and other patient advocacy organizations submitted to the Department of Health and Human Services to improve access to palliative care services for those with serious illness such as cancer.
To reduce cost and improve outcomes, the Primary Care First initiative, which CMS released April 22, will allow nurse practitioners (NPs) to participate in a five-year alternative payment model. Eligible NPs and other health providers must be certified in internal medicine, general medicine, geriatric medicine, family medicine, and/or hospice and palliative medicine; work in primary care settings in select regions; and meet certain other specified criteria. CMS will provide participants with a monthly, population-based payment, plus a flat fee for each primary care visit, and offer performance-based incentives for reducing costs, including lowering hospital visits.
A second Primary Care First model will offer higher payments for primary care providers serving high-need populations—Medicare beneficiaries with complex, chronic, or serious illnesses who lack primary care and/or care coordination. Medicare providers of hospice and palliative care services are also included. The CMS Innovation Center will launch both models in 2020 in 26 regions.
Interoperability Changes Could Help Relieve Nurses’ Paperwork Burdens
CMS introduced the Interoperability and Patient Access proposed rule on March 4, 2019, to make “patient health data more useful and transferable through open, secure, standardized and machine-readable formats while reducing restrictive burdens on providers”. Nurses and other healthcare providers would benefit from the proposed improvements that would streamline the prior authorization process and eliminate the need to write duplicative letters of medical necessity or repeat utilization reviews, risk screenings, and assessments for patients.
If the rule is approved, it would help overcome current barriers to electronic health record adoption, such as lack of a unique patient identifier, lack of standardized interface technologies, information blocking by providers, and data privacy concerns. Specific areas it addresses:
- APIs: A key provision is requiring certain insurers to adopt standard and transparent open application interfaces (APIs) that connect software among vendors’ systems so that patients can access their data. Vendors would be required to develop standardized health data that all EHR systems could capture.
- Trust networks: Certain federal health plans would be required to participate in trust networks to improve interoperability.
- Dual-eligible beneficiaries: The proposed rule would require daily versus monthly data exchange between state Medicaid and federal Medicare programs to ensure interoperability for dual-eligible beneficiaries.
ONS submitted comments to share nurses’ support for efforts to improve interoperability and care coordination among providers, particularly those caring for patients with complex advanced illness such as cancer.