This is an unedited transcript.
Hello, everyone. Thank you for joining today’s Alliance for Health Policy Briefing on Understanding the Future of COVID-related Medicare and Medicaid flexibilities. I’m Sarah Dash, president and CEO at the Alliance for Health Policy. For those who are not familiar with the Alliance, welcome, We are a non partisan resource for the health policy community, dedicated to advancing knowledge and understanding of health policy issues.
Today, we will be discussing Medicare and Medicaid flexibilities that were put into place in concert with the public health emergency. There were hundreds of such changes that were truly unprecedented, covering public health delivery system reform coverage and much, much more. Today, we’re going to focus specifically on Medicare and Medicaid flexibilities that dealt with primarily delivery system reform as they apply to the future of person centered care for people with complex care needs, older adults, and people with disabilities. So, there will be a narrower scope to the to the conversation today. But before we get started, I want to I want to briefly lay out the current lay of the land on the PHE Declaration and the timing of it, so that everyone has a little bit of context.
We will not be debating in this conversation when the PHE declaration should end, but simply, having a conversation about preparing for that potential eventual future, it is an active debate right now. And in policy circles. So just, just very briefly, that the Federal Public Health Emergency Declaration for coven 19 was originally issued in January, 2020. It’s been extended eight times since then. Each PHE declaration lasts for 90 days, unless the administration chooses to ended early, the current public health emergency declaration is slated to end on April 16th, 2022.
But most predictions expect that this will be extended for another 90 days into mid July, the administration has committed to providing 60 days prior notice prior to ending the PHE So if so, the next state to watch if the PH is extended beyond April would be amid May announcement. So again, that is at the federal level. And then at the state level, state Emergency declarations allowed governors to issue masked mandate state homeworkers vaccination requirements among other things. And as of March 2020 to 20 states have covered, 19 related emergency declarations in place, most will expire within the next 1 to 2 months unless GOV’s choose to extend them, and it’s beginning of the pandemic all 50 states had emergency powers in place. So again, there are active conversations about the public health emergency declaration extension occurring at the federal and state levels with important implications.
And the purpose of today’s briefing is going to be to focus on the eventuality of when when that does, when that does, and what happens with the multitude of Medicare and Medicaid flexibility. So, with that, our panel is going to be a forward look. And our expert panelists are going to help us explore what we know, what we don’t know, and provide some considerations for how to assess these flexibilities moving forward.
So, with that, this event was organized by the Alliance for Health Policy. We were pleased to partner with Health Management Associates, eminent health strategies, with generous support from the scan Foundation. Let me share a few quick housekeeping notes. You can join the conversation on Twitter using hashtag … live. Join our Community at all Health Policy, as well as on Facebook and LinkedIn. Today’s panel will have a Q&A section. We have 90 minutes today for our panel. Please do participate in the Q&A. Actively, share your questions at any time during the broadcast, and you can chat with us if you have any technical issues. And now, I am excited to introduce doctor Sarita Mohanty, who is President and Chief Executive Officer of the Scan Foundation. Doctor Mohanty? Hello, it’s so good to see you. Doctor Mohanty is a practicing internal medicine physician with Kaiser Permanente.
She previously served as vice president of care co-ordination for Medicaid and vulnerable populations at Kaiser Permanente as an Assistant Professor of Medicine at University of Southern California Chief Medical Officer of Health Solutions’ Health Care Management Consulting Company, and Senior Medical Director at LA. Care. the large, largest US. Public health plan. So, thanks for joining us, doctor Mohanty, and I’ll turn it over to you.
Thank you so much, Sarah. And I really want to thank the Alliance, H M a, and Banat teens, especially you Sarah, Dash, Jennifer … and Stephanie Anthony. And I really appreciate this opportunity to briefly reflect on this important topic.
And because today’s discussion, as Sarah mentioned, is focused on the temporary flexibilities of Medicare and Medicaid that were approved during the …
19 pandemic to really ensure people could maintain access to the care and services they needed.
These flexibilities that have really allowed states and local providers, substantial benefits and how medical and long term care can be organized, delivered and paid for through Medicare and Medicaid.
And these flexibilities have elevated new ways to deliver person centered care to Aging Americans, those living with complex care needs and family caregivers beyond what was previously imagined.
Know, we recognize that policymakers, know, has to wait many considerations, as well as navigate some unknowns which will take time to assess whether and how to make these flexibilities permanent.
So, we see tremendous value in using a person centered equity oriented framework as a real focal point for considering the future of these flexibilities.
There are changes in how Medicare and Medicaid pay for care that could better support older adults with complex care needs and their family caregivers can expand self directed care models, leverage remote technologies, and provide care at home, know, the scan Foundation. So, appreciate our partnership with the Alliance, …, and Banat teams, And I am also thrilled to announce that our board just approved a major next phase of this important work.
So, over the next 15 months, these organizations will work with a diverse group of experts to prioritize the most relevant Medicare and Medicaid flexibilities for permanent, focusing on those flexibilities where policy makers can architect a more person centered and equitable future for Medicare, Medicaid, and dual eligible beneficiaries.
Thank you for allowing me to make these … remarks and for joining today’s discussion.
With that, I will now turn it back to Sarah.
Thank you so much, doctor Mohanty, really appreciate it. Appreciate our partnership. And as doctor Monte mentioned, we’re so pleased to be continuing this partnership and convening real solution focused dialogs and educational events on this topic into the next year. And now, I’d like to introduce today’s panelists, who will be giving opening remarks to frame today’s conversation. First, Stephanie.
Anthony is a Senior advisor at May not help. She provides research analysis, and advisory services on health policy and health law to public and private sector clients. Stephanie provides counsel on healthcare Reform, Medicaid, and Children’s Health insurance program financing, program design and waivers, post acute care, and long-term services and supports. She also advise us on best practices and care management, integrated care models, and coverage options for the uninsured. Jennifer Podulka is a principal at Health Management Associates with extensive data analysis and project management expertise. Much of her work has focused on physician payment policy, Traditional Medicare, Medicare Advantage, Part D, CMS Innovation Center models, the federal budget, and the broader health care system context for Medicare policy. Lisa Hayes is the executive director for Rolling Start, a center for independent living, serving people with disabilities and San Bernardino.
Mono and in your counties in California. She also serves on the National Council for Independent Living, Long Term Services Subcommittee. And as an appointed Commissioner of the California State Independent Living Council, Lisa brings over 20 years of experience in health care operations and contracting. She previously worked with Molina Healthcare where she focused on shaping its health care delivery system to meet the needs of older adults And people with disabilities. Hemi Tewarson will be next. And she is the Executive Director of the National Academy of State Health Policy and non partisan Forum of Policymakers throughout the state government, learning, leading, and implementing innovative solutions to health policy challenges. Ms. Tewarson
joins NASHP from the Duke Margolis Center for Health Policy, where she had led the Center’s Emerging State Policy portfolio, including …, vaccine distribution, coverage and health System Reform, Medicaid system improvements, and addressing equity within and beyond the curve at 19 pandemic. Finally, we’ll be joined on the panel by Jonathan Gonzales Smith’s, a Research Associate at the Duke Margolis Center for Health Policy where he’s responsible for helping lead the Center’s work on international models of accountable care, health financing, global health innovation, payment, and delivery system reform. His research evaluates how to support health system transformation at the organizational, regional, national, and international level to achieve better population health while promoting efficiency, equity, and high quality care. And lastly, I’d like to acknowledge that doctor Robert Saunders will be present during the Q&A session. Doctor saunders’s Research Director for Payment and Delivery Reform, also at Duke Margolis where he directs a portfolio of payment delivery reform initiatives and we look forward to having him at the Q and A So, we have a really great panel. We have a lot to cover. Don’t forget to put your questions in the Q and A so that we can get to them throughout the broadcast. And let me, without further ado, turn it over to Stephanie. Anthony.
Thank you, Sarah.
So first in our part of the presentation, Jennifer and I, before we start, we’d like to thank the Scan Foundation for their generous and ongoing support of …
and our efforts to track and assess how the Medicare and Medicaid programs have responded to the pandemic, to support older adults and people with chronic conditions or disabilities.
We’d also like to thank Sarah, you, and your team at the Alliance for Health Policy for your partnership and advancing the discussion on these really important topics and ways to strengthen our system for systems of care for these populations.
You can go to the next slide.
So, Jennifer and I, in the next, many minutes, are going to together, go through what’s on this agenda.
I’m going to talk about, provide some background on how our work that the Scan Foundation funded fits into the broader context of the covert 19 related regulatory flexibilities, and convey what we learned from our research about. Some of the impacts of these flexibilities are having on consumers, providers, and the broader system. And then Jennifer is going to pick up.
And she’s going to describe a person centered assessment and decision making framework for federal and state policy makers to use as they consider the future of the temporary reforms implemented during the pandemic. And then also elevate some high value flexibilities for consideration for permanent.
Go to the next slide.
Before we jump in to the lessons learned, I just want to provide some quick background and context on our work.
So, we do hear a lot about telehealth and the expansion of telehealth, which no doubt was a huge flexibility that was enhanced on both the Medicare and Medicaid side during the pandemic, but we want to just highlight that the federal government and the states really implemented hundreds and hundreds and hundreds of policy and regulatory changes.
Really, almost on a dime back in 20 20, to prevent disruptions in care for Medicare and Medicaid beneficiaries that were caused by the pandemic and the shutdowns of isolation and quarantines. These flexibilities provide a broad relief for beneficiaries and providers to minimize administrative, clinical, and financial barriers to accessing and providing care while ensuring protections for beneficiaries.
These changes expanded program eligibility, benefits, and workforce capacity, authorize the use of alternative care sites and expanded the use of telehealth, among many, many other things.
Over the past two years, manatt, on the medicaid side, and …, on the Medicare side, catalog, these flexibilities, and various publications that are linked here on the right side. And in the we also have some content that I think is posted on the website that goes into a lot more details and specific examples on the flexibilities across each of these categories of activities.
You can go to the next slide.
So two years into the pandemic. You know, the first few years really just implementing and monitoring and sustaining these flexibilities.
We’re starting to see some flexibilities expire such as the initial pause and the Medicare 2% payment reduction and some made permanent, such as telehealth policies in Massachusetts and Pennsylvania. In addition to other states and pharmacy scope of practice changes in Arkansas, that’s just one example of a state that has made permanent some pharmacy scope of practice changes.
So, the past few years has provided an opportunity for us to test policies and practices that enhanced access to care for close to 140 million Americans enrolled in Medicare and Medicaid, including 12 million people who are enrolled in both programs, the so-called dual eligible population.
And now, at the end of the public health emergency, hopefully, insight, there’s an opportunity to assess the impacts these flexibilities have had on consumers, providers in the healthcare system, and consider which temporary flexibility should expire, possibly to be re-instated in future emergencies. In which flexibilities enhance access to care and promote better quality and outcomes and should be extended, evaluated further or made permanent. And this is, you know, as I just mentioned already happening in real time.
You can go to the next slide.
So, as we all know, for a multitude of reasons, the covert 19 pandemic has had a disproportionate impact on older adults, people with disabilities, populations and communities of color and other marginalized populations.
The pandemic reinforce that our health care system does not fully meet the needs of all people.
As these populations faced, higher rates of disease, and mortality, disparities, and vaccine access, and barriers to accessing essential services and providers, simply put, the system is not delivering person centered care or community centered care in a way that advances health equity across diverse populations. These facts guided and underpinned the work. Jennifer and I are going to talk about, and I will just say, we do. We did use specific definitions of person centered and community centered in health equity, that are contained in some of our deliverables.
We recognize there’s a lot of different definitions, but are the ones we used, are contained in our final deliverables.
You can go to the next slide.
So, using a mixed method approach and guided by the Communications Network, Diversity, Equity, and inclusion, research framework, …, and banat, looked across all of those flexibilities that we have reviewed and identified those that best advance, person centered and community centered care, and better align Medicare and Medicaid for individuals and providers participating in both programs.
We created an organizing framework for policymakers to use to assess the impacts of the flexibilities and make informed decisions about their future, and elevated, select Medicare and Medicaid flexibilities for priority consideration by policymakers, because they do advanced person centered care and health equity. The culmination of our work is contained in an issue brief and a shorter policymaker playbook.
I can go to the next slide OK, some lessons learned from the pandemic from our Research. Our first lesson learning Yeah, thank you. Our first lesson learned is that quantitative data on the impact of the Flexibilities on Consumer Access Service utilization and outcomes and on providers in the workforce is growing but incomplete. What does exist is skewed toward Medicare data and then across both programs is centered around telehealth utilization data, this data does resoundingly show that telehealth utilization for both Medicare and Medicaid beneficiaries enhanced access to care in people’s homes and communities.
Particularly for primary care, behavioral health, and some long-term services, and supports it really across all populations, although, at varying rates, across those populations.
But from all accounts, more data is needed on the quality of care and outcomes from telehealth utilization, and how different populations and communities have been impacted by the expansion of Telehealth. You know, get it, enhance access to care, or did it worsen existing disparities and access to, you know, from access to broadband and other resources. And more data is needed on the many other categories. And types of flexibilities that we have cataloged.
In the absence of quantitative impact data stakeholders that we talked to, urge policymakers not to ignore qualitative data, and stakeholder experiences, which are critical inputs to decision making.
They also caution policymakers not to rush into any flexibility or making it permanent, but, instead to consider extending flexibilities, as Congress recently did in the Consolidated Appropriations Act of 2022, for a broad array of Medicare Telehealth Flexibilities. And, you know, extensions like this could allow time for further testing, further gathering additional quantitative or qualitative data, and can signal to the market wants to come, giving providers and health plans, and others time to prepare and respond.
Go to the next slide.
Medicare and Medicaid, telehealth utilization exploded at the beginning of the pandemic when in person visits were just not possible or advisable.
While telehealth utilization has since declined slightly, it is higher than pre coven utilization rate. And the lesson learned really is that it’s here to stay across both programs.
These flexibilities expanded the types of providers who could use Telehealth, the services that can be delivered via Telehealth modalities of remote care delivery, including audio only and text based communications, and the author. And they also authorized no different different originating sites for Telehealth.
There’s clear data that Medicare Telehealth visits substituted for what would have been no visits at all, meaning that Telehealth visits offset what would have been larger declines in person clinical visits due to the pandemic.
And, on the Medicaid side, Telehealth visits also expanded dramatically, particularly for tele behavioral health visits, which became a Lifeline for many people as their behavioral health conditions worsen because of the pandemic.
All States expanded their use of telehealth and telehealth modalities, including telephone only, and text based communications.
From all accounts, the expansion of telehealth is here to stay. So, a focus going forward should be on solving issues related to beneficiaries, supports, and training.
Provider practice redesign and supports reimbursement and parody issues and eliminating disparities and access to telehealth, while also ensuring access to in person visits are not curtailed at when necessary. And, at one second, I’m gonna go through one more slide. And then, before Jennifer starts, I was going to have a weigh in with some additional Medicare Telehealth inputs, because there’s a lot of data there. And I want her to weigh in on that. But I’m going to quickly go to the next and final lesson learned before turning to Jennifer.
And say. So, at this point in time, it really provides an opportunity for policymakers to better align the Medicare and Medicaid programs for the over 12 million individuals and multitude of providers across the country that participate in both programs.
Most of the regulatory flexibilities were implemented quickly across Medicare and Medicaid at the beginning of the pandemic to prevent immediate disruptions and access to care. In many cases, the regulatory changes aligned Medicare and Medicaid policies that were previously misaligned.
For example, in Rwanda this graphic, which captures policies and a sampling of five states compared to Medicare, you can see that Medicare temporary allowed, temporarily allowed people to use telehealth in their homes, which has been allowed by many states outside of the pandemic, you know, prior to coven.
So while the Consolidated Appropriations Act has temporarily extended this Medicare flexibility a reversion to pre pandemic policies without deliberate review and thought or specific action could perpetuate ongoing misalignments between the two programs and unnecessarily, you know, put and keep in place administrative and regulatory complexities for the providers who deliver care to the 12 million dual eligibles.
So, with that, I’m going to turn to Jennifer see if she wants to weigh in on any of the Medicare Telehealth flexibilities, and then continue on.
Thanks, Stephanie. Um, I would add on the telehealth side for Medicare, in addition to the data that Stephanie referred to.
There are data that characterize the experience of people who are both in traditional fee for service Medicare, as well as Medicare Advantage.
And those indicate that while that share and total number of telehealth visits increased, the share was actually only about 5% of visits, which means that while those telehealth visit substituted for what would have been no pair, as Stephanie indicated, they were greatly substituting for existing in person care. So when a Medicare beneficiary sees their position every month or two throughout the year, maybe they’re swapping in 1 or 2 visits during that time period.
The data also indicate that the relatively small share of visits happening by telehealth is fairly evenly distributed across different groups of people by age reasons and ethnicity and other characteristics.
The one characteristic that consistently called for more telehealth use was dual eligible and that means that people who are dually enrolled in both the Medicare and Medicaid plans tended to use telehealth more frequently than patients who are enrolled in Medicare alone.
So, back to Stephanie.
Great, Thanks. Thank you to both of you for that. Stephanie, did you have any any other comments? Or if I had a, I did have a follow-up question. And while I have both the view, I think I’d love to ask this question before we move on to Lisa’s presentation.
Stephanie, You mentioned, you know, the importance of, you know, what stakeholders, particularly with an equity focus, really talked about that. You know, we need to look at the quantitative data, but we also need to think about qualitative data.
And I’m wondering, how do you think, how can policymakers get access to that kind of quiet, qualitative data, Like where should they be looking, what should they be looking for?
And, and just more broadly than that, like, how do you see the trajectory of just the timing of, you know, like, when will it be enough to sort of make a decision? You know, how, how long is it going to take to really collect, analyze, and assess some of the key questions here?
So, I’ll start.
Jennifer can jump in, but I think that, so, whether it’s federal or state policymakers, you cannot do this in isolation.
There are consumer groups, provider, consumers, consumer advocacy groups, providers, plans who have been literally living and breathing this for the past two years who have real life on the ground experiences of how these flexibilities have been working. So, the most important thing I think to do is to bring everyone to the table to, to have discussions about some of the impacts.
You know, some organizations are collecting data that, you know, policymakers may not know about what, you know, quantitative data, but also, again, qualitative experiences on the ground experiences, operational experiences from providers and plans that are just, you know, you can’t capture necessarily in a long term quantitative study, but a real information that can be used to informed policy. Making a decision making.
Thank you for that. And I’m going to ask one clarifying question from the audience, which is time timely. And so what you just shared, and then the question was whether you looked at all at rare diseases, and the questionnaire notes that people with rare diseases needed care across state lines before, co fit, will need it afterwards, and that telehealth made that possible during ….
So, any any specifics there, as far as as rare disease or, you know, people, people with other kinds of special special conditions.
I’ll quickly say something, and, Jennifer, I’m sure you have thoughts. And there’s just from even somebody I talked to today, Massachusetts, on these topics, this exact topic about the critical role that out of state providers and the ability, You know, kind of the network expansion throughout a state providers or the use of out of state providers through telehealth was absolutely critical to certain people with disabilities and other chronic conditions. Where in because they couldn’t they couldn’t access providers in Massachusetts to cut it. And the only way to do it was through telehealth. And just having that ability to have an expanded network of providers at a time when there’s such a workforce capacity issue across the services that are delivered and received by these populations. was just critical.
So, I mean, I think it’s, it’s going to be, I, that’s one where you obviously want to be balancing and weighing beneficiary protections, making sure that people are qualified, providers to qualify, making sure that there’s beneficiary protections in place where there might be a little bit of test further testing that may want to be done.
But I think it’s absolutely one that should be considered, or longer term reform.
Jennifer, I don’t know if you want to weigh in?
First, I really want to thank the person who submitted that question. I think it’s such a great issue for both Medicare and Medicaid programs to pay attention to.
As you noted, rare diseases affect a significant number of Medicare and Medicaid beneficiaries like they do for the rest of the population, and the needs there are kind of different.
Then, for everyone else, although I want to note, there’s also some similarities, Medicare beneficiaries tend to see their physicians and other sort of chronic care providers, mostly throughout the year. It’s pretty rare for a Medicare beneficiary to not have some contact with a clinician, but big events like surgeries and other major procedures don’t happen on a regular basis for Medicare beneficiaries.
And I think some of those characteristics are similar for, for patients with rare conditions.
If you want to get us serious, procedure done, your probably going to travel to a major hospital or a teaching hospital, that might be your preference, and probably your local provider is going to hurt, or something like that.
In those situations, there’s a great deal of follow on here, and I’ve talked to so many people who said, No, that’s a great situation for potential flexibility around telehealth, so that you’re traveling over a distance to get a major procedure, And then that sort of regular following here, that proceeds every time. Some of that is by Telehealth, some of that’s in person, Some of it’s maybe your local physician talking to the physician or surgeon or someone else at the site where you originally had the procedure done.
So I think there are situations where we can basically apply telehealth, as an extender for Centers of Excellence, and linking local Provider communities to Centers of Excellence.
Thank you so much, OK? That was a great interlude and we got deep into telehealth, and then Jennifer, I just realized you haven’t done your slides yet. Moderator apology. We need to get your do your slides. And then we’re gonna hear from Lisa Hayes who works directly with people every single day day in and day out. And I’m sure snaps of stuff to say about this, so I’m Jennifer, off to you.
Thanks so much, Sarah. And I will try to do this quickly, though, if we jump to the next slide.
Um, we began this project recognizing, As Stephanie said, there had been hundreds of temporary flexibilities, and these presented a unique opportunity to learn about whether these benefited Medicare and Medicaid beneficiaries or if they didn’t.
We also recognize that the temporary flexibilities were implemented quickly under emergency authority and regular actions, rulemaking legislating. Take a lot more time.
So if we’re going to focus on continuing, either in a permanent or continue testing situation, we needed to focus on goals and a tool that would help policymakers determine how to proceed.
So the tool we developed is the person centered assessment framework, which is a, we hope, user friendly tool for policymakers to use of the assess individuals’ flexibilities.
And we focused specifically on three goals so that we could sort of prioritize down to some of the flexibilities that show the most promise first, for advancing person and community centered care by meeting the needs of people and communities based on who they are, and mitigating program obstacles to care created, or that predated Coburn 19.
Our second goal was the ability to facilitate care in the least intensive or least restrictive setting.
But always based on a person’s needs, goals and preferences, and third, the policy’s ability to better align the Medicare and Medicaid program rules. To enable people to seamlessly access care, regardless of their insurance status, and enable providers participating in both programs to deliver care quickly, nimbly, and uniformly.
We’ve included some specific instructions for you, so if we jump to the next slide, I can talk about how that works.
So, the framework that we’ve developed in concert with stakeholders, consists of three questions, or questions arranged into three sections.
It begins first with questions focused on benefits and risks for key stakeholders, such as consumers, communities, federal and state programs, providers, and health plans.
And, this provides some great examples of how we really refined this framework based on input from stakeholders.
They stress the importance of asking questions about the impact of flexibilities on social determinants of health as standalone questions to focus interest there and, and research, and, it was also our expert stakeholders who first elevated the importance of community centered as an essential concept for assessing the effect of flexibilities.
Section two of the framework includes a series of questions that help inform decision making based on what has been learned about the impact and potential impact of the flexibilities.
Then, three, we wrap with questions about which and entities have the authority to potentially make temporary flexibilities permanent and the best pathway for pursuing that.
So, next slide, please.
And let’s go ahead and jump to the next one.
Don’t talk about which of the flexibilities we focused on and, as I mentioned, we started off with three goals.
And we applied these goals to filter down from our hundreds of flexibility to ones that we wanted to draw your most attention to.
And these flexibilities fall into three categories with an other category.
The first is expanding the telehealth benefits from what was allowed before coded to some version, perhaps a modified version of what was implemented in response to that.
Second, modify modifying scope of practice and workforce requirements in the programs.
Third, modifying Medicare Advantage requirements.
And then our fourth category includes a Medicare policy related to the three day sniff rule as well as to Medicaid flexibilities one on self directed home and community based services, and the other on long term substances and supports.
If we could jump to the next slide, please.
And Stephanie, I wanted to, very quickly at a high level walk through what this might look like, applying the framework to a specific flexibility.
So, just as an example, I grabbed the one that says, allowing physicians and non physician practitioners to provide services in states in which they are not licensed, and walking through.
The different benefits, one, it, this benefit, could include improved access and care within states where there are currently limited participating providers and Medicare program.
Secondly, it could serve to advance person centered care by allowing beneficiaries greater choice in their providers.
And, third, it advances equity by enabling beneficiaries with fewer financial and other resources to access care. It is two thirds.
These benefits are, of course, weighed against risk.
So, our first risk is an over potential risk of, over reliance on out of state providers, may end up perpetuating small provider networks in rural and under other under resourced areas.
Second, greater disparities for rural and other under resourced areas with less access to broadband technology.
Third, the risk for fraud and abuse.
And finally, there’s a great number of other considerations, but we wanted to highlight, perhaps, the most significant one for this policy would be significant political challenge from provider groups and others.
Then we discuss the potential authority path for having this policy extended.
Let me jump and have Stephanie weigh in, because our next slide deals with Medicaid.
Sure, and I will be quick. I know we have other speakers to get to. We did highlight a Medicaid one that we thought were really is kind of represents the essence of person centeredness, which is the expansion of self directed home and community based service opportunities, which is allowed. currently under many existing Medicaid authorities. Whether it be 915 C waiver or some of the newer home and community based service state plan options, 11 15 waiver. So this can already be done expansion of self directed, HTTPS, home community based services, as well as who individuals can hire to provide those services. So, you know, we really thought this flexibility particularly, really, again, is kind of the essence of person centeredness because it also helps fill in workforce capacity gaps, helps with addressing health disparities to the extent the individual hires.
People who might be in their communities look like them to have the same cultural and linguistic preferences as they do. So, really, is, it can be used for advancing health equity? The only thing I would say is that there are so many others. I’m sure. Will, you know that? We just pulled out two examples, so we hopefully can talk about more in the next when we get to the Q&A. And I think, just on the last slide, we just wanted to say, more data collection. And analysis may be needed for some of these. Remember, there’s a third option. Which we instead of, you know, just unwind or make permanent, but explore a little bit further test a little further. And, there’s a lot of other researchers in the field funded. And, we’re going to hear from some today funded by the scan, foundations, and others that are contributing to ideas for flexibilities, for permanent.
Great, Thank you so much, Jennifer, Stephanie, for that, joint presentation, super helpful. And now, without further ado, I’m so pleased to introduce Lisa Hayes, the Executive Director for only Start Inc, and, which is a Center for Independent Living, Lisa, welcome.
And kinky just so much, sorry, I hope you can hear me OK.
Awesome, My name is Lisa Hayes.
I am representing the National Council on Independent Living Today and I’m also the executive director of Rolling Start which is a Center for Independent living in California’s serving the San Bernardino And you and Mono Counties. So I’m so excited first.
I wanna just thank the Alliance Scan Foundation Minot for allowing us to present this side of what it really looks like, some of these flexibilities, what they looked like on the ground, on the street, and how our consumers were affected and in managing the pandemic. So we’ll go on to the next slide.
So, Nicole, as we are typically called, where the National Council on Independent Living were the longest running national, cross disability, grassroots organization run by, and for people with disabilities, we feel that’s a unique perspective.
Are, typically, our boards of directors are predominantly people with disabilities.
The people that run the Centers for Independent Living are people with disabilities.
And, you know, our governing bodies. So it’s, it’s, we have a unique perspective of peer model that we has worked for many years and, you know, this is a proven model that really serves well.
Nicole represents thousands of organizations and individuals throughout the United States, individuals with disabilities, centers for independent living, the state, independent living councils, and any other organization that advocates for the human and civil rights of people with disabilities.
So, the sils, the Independent Living Network, we are consumer controlled, community based, cross disability, non residential, non-profit agencies, designed and operated by people with disabilities. I know that’s a mouthful.
We are funded to provide five core services: information and referral, peer support, advocacy, independent living skills, and transitions transitions just for clarification or transitions from nursing facilities to community. We also do assist from hospitals to community, but the goal, of course, is to get people independent in their own communities, in the setting that they prefer.
We serve all ages, so, you know, is from birth to death. I mean, I think you’re rolling start. The oldest consumer we’ve served is about 105 years old, getting services, and, and it’s, very, and the youngest is, probably, I think, in our center, is probably about three.
Most of our consumers are low income people living below the poverty level, undocumented folks.
People managing chronic conditions. And, of course, utilizes of Medicaid, Medicare, and dual. We don’t typically focus on knowing if they have Medicaid Medicare, or if there are duals. But often it helps us co-ordinate services, especially with the health plans that they’re assigned to. And I just want to also real quick, and make sure we identify the folks that we serve as consumers or clients, largely, because I know a lot of the medical community community identifies our folks as patients.
We tried to stay away from the medical model, being more person centered and looking at people outside of the clinical encounter, which is why we’re all the similar I just wanted to make sure you understood that. We’re talking about the same folks, the consumers that we serve.
So traditionally our before pandemic services were in person.
Many folks come in with, you know, some issues, we’ll do an intensive intake process. help them identify their what they tell us, what their goals are. We devise person centered independent living plans. We do one-on-one support.
We’re really known a lot for our group support social supports. And we do a lot of follow ups, 3690 follow ups for all of our consumers.
Go to the next slide.
So addressing social determinants of health and a pandemic.
So, you know, some of the flexibilities that were extended to the cells were Wilkins from our federal and state partners, where we’ll continue to find you if you can figure out how to serve and provide these services to folks in in in a quarantined environment, which was extraordinarily challenging for a lot of us. I don’t think, you know, as a community based organization we had probably very similar challenges as a lot of books did.
We had an unprecedented amount of collaborations with health plans and all the other community based organizations.
We had to address the digital divide, and, you know, that you’re gonna probably hear a lot about that today. The digital divide, you know, people who could access technology, it worked really well.
But we were dealing with consumers who did not have access to broadband, they didn’t have, they couldn’t, they’re low-income and couldn’t afford internet access.
I add, you know, we worked with a lot of seniors that thought they would get through life without using a computer and realized that they’ve got to figure this out, and we provided we were able to do. With some generous funding to get computers out to folks? To Provide that training with a lot of folks And it is it had been for those who were able to access was a game changer. I’ve got a, you know, an 86 year old consumer who says, you know, she loves being able to e-mail.
She loves being able to see the world through YouTube, and, you know, some of the things that she never thought possible, Just having access to the internet and access.
You know, having a computer and learning how to do it was, you know, changed her whole perspective on life.
And but then there are others who live in some of our high desert areas where there is no internet access.
So we really do need to kinda figure out how we can broaden that digital divide.
It a manage fear, like a lot of folks, a lot of folks living in social isolation, a lot of people really afraid to have people come into their homes.
I can share a story of someone who I zoomed with. About a month before she passed away, She was deathly afraid to have her caregiver come into her home because she wouldn’t wear a mask.
She had advanced age amass she ended up, you know, in the hospital and didn’t make it and it was a really sad situation but there was, you know, it early on in the pandemic we couldn’t get, you know, people didn’t have access to PPE, gloves masks, hand sanitizers care. We had to you know address that. Unfortunately we were able to do that.
People afraid of health care rationing.
I know that in particular, we had a consumer who had an intellectual and developmental disability, he was a senior, he called us.
He was in the hospital, and he had …, and he was.
He told us about, you know, the doctor told them, he was going to get these five rounds of I think it was remedies of error or something like that, and they were after two, they were he. He was crying because he, they were going to send him home and he goes, They’re not going to give me the rest of it.
It. And they’re sending me home and they expect my caregiver to to pick up, but my caregiver doesn’t want to get covance. So, I don’t know how I’m going to get home.
So, it was, you know, a real big challenge.
I really had to engage our health, His health plan, to, you know, get some serious advocacy. We ended up getting him home safely and getting the remainder of care that he needed in his house. So, but, you know, just, this was a very common story that we heard that people weren’t going to value people with disabilities because of their disability.
A lot of, as I mentioned, the fear of getting it, getting PPE needs to consumers, to caregivers, to family members. These were, you know, a lot of things that we were trying to manage.
Some of the gaps. Of course, identified is the consistent caregiving.
We had a real problem with backup provider shortages, if your caregiver got sick.
We didn’t have enough backup providers to get up to serve the needs. I can tell you a story of a consumer who spent nearly five months without her needs, getting matts, because she could not get a backup caregiver.
And her regular one, decided they weren’t They weren’t going to go and seek consumers anymore because they had their own families to be concerned with.
And, you know, these are real stories of people on the ground.
You know, going without, you know, the care that they needed, this person ended up with pressure sores and is having surgery.
Because of that, you know, access to food. We never thought there’s a Center for Independent Living.
We’d be in the business of food, and getting food out to our consumers, so it really required us to be flexible in terms of, you know, finding where we can, you know, access food at a lower cost.
You know, collaborations with our health plans, to help us with, with this, you know, meeting special diet needs of consumers, people, couldn’t get transportation E paratransit, was, was challenge. They, you know, you had to schedule something two weeks in advance in order to get you needed to get anywhere.
And even that was, you know, people are afraid to do that, so, getting access to food and getting it into their homes was a big challenge of access to assistive technology, to avoid, you know, any nursing facility placement placements. We know what was going on in nursing homes.
Nobody wanted to go or end up in a nursing facility when you heard the massive amounts of people that were getting infected.
So, assistive technology could be anything from, no, getting them.
Walker, you know, a bedside commode you know, Keynes, you know, ads, you know, some kind of threshold ramps or whatever. Whatever they needed to get, you know, be able to stay as independent as possible. We would get that to our consumers.
You know, a lot of people, you know, people with disabilities and older adults are people.
First, family members were moving in together, rent was not, you know, you know, people were having challenges in meeting their basic needs because a lot of things going on with people with disabilities that lost their jobs, because of covert and, and we need to provide rental assistance, utility assistance vaccine prioritization. That was a big one. When the vaccine became available, when people with disabilities were not given priority status, that was really, really hard.
It was a lot of folks, you know, there was a lot of advocacy around that, and we really need to, and I understand on a level of why that there was a data issue. They didn’t have the data to do, to know that this was important, but we heard this all over people wanting to get vaccinated and couldn’t, couldn’t get vaccinated. Home health and, in home vaccinations was, you know, big, advocacy push, Which happened eventually. Getting care in the home was critical. And, you know, you know, these kinds of things really need to continue. These flexibilities need to continue.
We can go on to the next slide.
So, some of our recommendations, kind of going forward at home and community based services, as you heard earlier, is extremely critical.
We, you know, as far from our Center’s perspective, we, you know, the digital divide was obviously, was, was big. And trying to bridge that and, you know, it allowed us to see consumers that. We were typically may not have been able to get to our offices and, you know, to provide services to them either through video or telephonically.
We need to get sustainable wages for caregivers.
We need to figure this out in terms of, you know, I think it was just probably one of the biggest you know challenges that We had is getting consistent caregiving, getting people that wanted to get out and to help the consumers. The alternative is nursing home placement and nobody wants that.
So you know, figuring out this backup registry’s, getting backup providers we need to this needs to be something that that’s a priority.
Housing is really huge.
I you know I want to tell you just you know even maybe not a result of the pandemic. I’m not really even sure but lately more seniors and people with disabilities are homeless.
And the reason for that there you know that part of it is due to the housing market. You know, rent.
owners that have rentals want to get more money further, further properties where they want to sell it and take advantage of where the market is. But it’s pushing a lot of seniors out and not because they’re on limited incomes.
Know, they’re people living in their cars, people living, you know, getting mobile homes, or in a trailer so that they can live in because they don’t have any alternatives.
We need permanent authorization of money follows the person.
You know we found and now even more than pre pandemic, more people wanting to get out of nursing homes. You know and we I feel like we’re chasing money follows the person on a, you know.
It gets a 30 day authorization and 90 day authorization, we need permanent authorization of this because there are a lot of folks that, you know, can we can help transition out that will have the opportunity to live that the Olmstead dream and to live in the environment of their choosing utilization of community health workers to support health education, to support getting stuff to consumers. I think would be a huge help to a lot of the consumers that we serve.
Long-term supports and services, You’re gonna hear a lot about that today, but we need to look at it from a broader lens. Yes.
Long-term supports and services is the waivers and getting, you know, all the specialized community waivers that are out there but, you know, the home care providers. But we need to look at it in terms of emergency preparedness. How do we prepare our communities for the next pandemic, for the next major earthquake, for the next, whatever. How do we addressing the digital divide? You know, we’ve got to make sure people have access to technology. We’ve got to make sure that, you know, there’s recognition to of, of day habilitation programs, like what the centers provide, that really provide this.
the, the, you know, around, you know, services that outside of the medical, you know, clinical encounter. Everything that makes a person, human, everything that, you know, allows that person to have a normal life recognition of the community based organizations, like the cells that are providing this.
And that’s about all I had to offer if you have any questions. There’s some folks to contact from nickel.
Thank you so much, Lisa.
That was really, really stark and D overview of what life is really like out there and how policy can affect it. So, thanks again. And I apologize. everyone. We’re running a little bit behind, but there’s so much great content. So, I am now going to turn it over to Amy Tursun to talk about what’s going on in the state. Tammy, thanks for joining.
Hi, Sarah. And thanks so much to the Alliance and scan Foundation for having me here, I’m happy to arson and I’m the Executive Director here at the National Academy for State Health Policy. And so next slide, please. Just wanted to bring a slightly different perspective to the conversation today, which, I think is a very important conversation about where we go next with all these flexibilities after the end of the public health emergency at the federal level.
Just for those of you that aren’t familiar with Nash B, The way what I’m going to talk about is what I really hear from the members of our academy. So we are of buy in for the states. And really, I think, what’s unique about Nash B is we work with all levels of state government. So we work with legislators. We work with governors offices. We work with Medicaid directors, We work with public health officials, were social services agencies. And so, we really do have a broad perspective on, frankly, Coburn 19, the recover from Coburn 19 and all of these pieces that are really involved in really recovering.
Some of the next slide, please, What I wanted to do is just paint a broad brush of, you know, talking to our members of our academy, in which we have over 60 state leaders, and we have various workgroups and all these different areas that were mentioned earlier today, including focusing on aging and disabled communities. And, really, talking to them, we asked them, you know, What are really your top priorities?
And I thought it might help just to set that frame of what those priorities are, And then how they flow into the thinking around what states may do after the Federal public health emergency, and what they’re already doing it, what they may do. So at the top of the list, as healthcare workforce, and really, you know, I’ve done state health policy for a longtime healthcare workforce was always an issue, But it has come to the forefront in a way that I haven’t seen before, in many, many years. And really, it’s it’s really different types of workforce. There’s concern around, you know, nurses and in hospital staff, given kind of what we experience through coven and the departures we’re seeing in that profession. But there’s also a real need for workforce in the long term care arena, which I think is very integral to this discussion, of, you know, how do we really think about or rethink, how folks are doing in nursing homes. They’re, they’re interested in staying at home. What kind of workforce will be able to support that? What are the improvements to the system to be able to sustain that?
And I think thinking about these flexibilities play into that piece, but it’s a sort of a bigger I think quandary that states are trying to solve.
Behavioral health, behavioral health has really risen. It always has been a challenge, both on the mental health side and substance use disorder side. But, the pandemic has really, I think, driven some of these levels to crisis levels. And, and, I do think thinking about the flexibilities, especially in the telehealth and scope of practice realm, of how do we really get more behavioral health providers and more services to people is a really part of the big part of the conversation. Cost of health care.
So state leaders are always wanting to make sure they have sustainable budgets. Unlike the federal government, they actually have to balance their budgets and have to make sure they’re accountable for all the dollars, generally on a year to year basis. And so one of the things that has come up historically is, you know, how are we doing with our spend on health care? Medicaid Has become a bigger and bigger piece of the state budget, but they’re also has been, I think, some concern on how are consumers affording their health care. And so thinking about how those two relate. With respect to thinking about what comes next in this pandemic and with the flexibilities that we’re talking about today, I think is also important to consider public health you know? Where are we going next to really modernize our public health system, connect public health to the other parts of our health care system, thinking about how we can do better.
How we can be prepared both in serving our populations you know, if there’s another pandemic, another disaster and I really I think a focus on sort of the aging and disabled populations in particular is part of that combo or station.
And again, I think somebody’s flexibility is plain to that.
Then social determines of health and equity has certainly come up as a priority area. Both in how do we invest in those different pieces that we know all amount to better health? And then how do we really have better connections to communities? And I was really happy to hear those last remarks of how what does a community experiences pandemic And it’s been hard. It’s been a hard two years. I think we’ve learned a lot, And I think we, at the state leaders, are really trying to understand what our lessons learned, what are the things we double down on and that we continue to do, and what are the things we need to improve upon? So, I wanted to just provide the perspective.
I also wanted to note, just on the fiscal fiscal piece, you know, some of these flexibilities, if they are made permanent, they do have fiscal impact. And so I just wanted to mention, on the state budget side, most enacted state fiscal 2022 budgets include an increase in both state spending and revenues. So, that’s good news for states they have, they have money to spend. They have more flexibility to think about the programming. I think there was a fear that, you know, state revenues would be cut dramatically, and that states would have to scramble in order to make up those deficits. But I think because of the federal stimulus dollars and put money to the economy, personal income tax wasn’t impact is heavily due to higher income individuals being insulated.
So, and texts from goods are mostly unaffected, so good news for states in the short-term.
I think the other piece is states are continue to get an infusion of federal funds through things like the American Rescue Plan Act and they’re really thinking about how to continue to spend those. Some have decided already, some are the midst of deciding.
And I think that also plays into how we think about some of these flexibilities in the, in the law OK, next slide, please.
I did want to also just mention, you know, here at …, we track governors and legislators and Medicaid visuals and all those folks doing all the different programming. On the gubernatorial level, we do have 36 states electing governors in 20 22 and 8 of those elections are guaranteed to result in a new governor. And I just mentioned that because it could be a year of significant transition if some of these governors don’t get re-elected. And that always has an impact on programming and policy.
And so, you know, how we think about what’s being done now and sort of building the, the bench and the knowledge base, at those who are not sort of the political level, to understand the need for different types of flexibility. To be extended and what the program implications are, I think, are really important to carry into potentially new administrations that may come into Office in 2023.
OK, next slide please.
OK, so, I won’t go through this whole slide because I think Stephanie, Jennifer, did a wonderful job talking about some of the flexibilities that states have been taking advantage of as a result of the pandemic but I did just want to mention a couple of things. So, you know, we’re very focused on Medicaid and chip declarations, the flexibilities as we work with the state policymakers. And a couple of things, just to note, you know, states really implemented wide reaching changes to their Medicaid programs. And response took over 19. And, you know, the type of authorities that they use, their just listed at the top, you know, 135 waivers, Disaster Response, 1015 K, Appendix K, …, Appendix, K, etcetera. And all of those different flexibilities have different timelines. So some, depending on what authority they use, some will end along with the end of the federal PG. Others will, and six months after the PG ends.
Still others go out farther. It could be the first calendar quarter, at the at least one year, for the PG. And, so, there’s a lot of different timing components, and states are having to track all of that, because there are all these different authorities.
I think, of the categories states can make, and some of them have already made many of the changes, permanent, through things like a State plan amendment or Medicaid waiver demonstration, if they choose to do so. And, states are making these determinations on a State by state and program by program basis. And just at a high level, you know, what are the type of flexibility states implemented eligibility. And enrollment. And I know we’re not going to talk about continuous Medicaid eligibility. That will end once. We hit the end of the federal public health emergency. And I just wanted to note that is a huge looming challenge for states and probably there are number one issue as they think about end of the public health emergency. So, I just wanted to highlight that. I know, we’re not going to talk about that today, but it really is, I think, a big task for states. And, probably, you know, the biggest enrollment event they’re going to have in, in the short term, long term future.
But, the other things that they did was supporting the workforce. And reducing barriers to enter the Medicaid program. As a provider. adding or adjusting benefits, and service provision roles and reducing administrative burden, barriers, access to care, and timeframes for administrative processes. And a lot of different flexibilities related to long term services and supports in home and community based services, which I think were driven by the need of people not being able to reach services, not being able to leave their homes. Having all those limitations that, we just heard about that at the, at the individual level. So, one of the things I wanted to talk about maybe next slide please. This is drill down into a few of these buckets.
So we can go to the next slide.
So I wanted to just talk a little bit about Telehealth.
So, I think um, we all acknowledge and have been talking about how the pandemic has really changed how we’re experiencing health care and Telehealth is a big part of that And Telehealth is here to stay. It’s, it’s been built into the service provision. Consumers like it. and are using it. And so I think states are thinking about, how do we consider making these changes permanent? Do we make them permanent? What are the considerations?
So, what I thought I would do for this slide is just talk a little bit about what states have done and what they’re considering about doing to make some of these more permanent.
So, they, um, they had a number of different flexibilities, and those were tied to the federal public health emergency. one bucket was many states relaxed, or wave requirements for in-state licensure for providers are granted temporary licenses for the state providers. They had to. They did not have the workforce. They had to have new ideas and new ways to provide services. And a number of states are making those changes more permanent. They’re creating new pathways for licensure. For telehealth, they’re participating inter-state inter-state compacts that will make that a more permanent option. While at the same time, others are retracting their licensure waivers and flexibilities, because they do want to do more thinking about what makes sense in terms of who can operate in my state.
I think a number of states implemented temporary payment parity for telehealth and in person services and just reflecting where we are now. There are 19 states that are implementing payment parity on a permanent basis, and for additional states are doing so, with some caveats, it’s only for specific services, and that was specific specific sunset.
So, I definitely think, you know, my view is know all the work we’ve done in telehealth before the pandemic. We’ve made so much progress over the past two years, he probably you know, 10 years worth of work that we’d done beforehand. And we’re now at a different place.
Um, I think during the pandemic, many states have expanded coverage for telehealth modalities to include telephone only, text based communication, and remote patient monitoring, as well as authorizing patients’ homes as an originating site.
And, I think you’re starting to see a number of states are, you know, on the cusp of really making some of those authorities permanent, such as, allowing telehealth for our patients home under Medicaid. And a couple of states have made permanent the ability to use audio only telehealth under Medicaid. And then, the last bucket I wanted to just mention is back back back a slide is most states expanded the type of services eligible to be delivered through telehealth for the Medicaid program. In many states have made that permanent for Medicaid providers to bill for services. A couple of things, just to talk about, OK, but not all the states have done it, and where are they going and why? So, we had roundtable discussions with state leaders around what are you going to do with telehealth? You know, what’s, what’s your next steps?
And a couple of things I just wanted to share with you, all of a pro, obviously is we need more access for individuals. We have a limited access to providers, especially specialty providers in their geographic areas, behavioral health, specialty disease experts. Those with disabilities or other conditions, benefit from technology enabled visits. We heard that from Stephanie and Jennifer. And then there are many with transportation access limitations. So, those are all the reasons why that, why move forward.
But there’s also concerns on the flip side of are we really going to hurt our networks. Are we going to limit the ability of in person care, will the Insurer’s manipulate network adequacy rules and limit access to in person options?
Is there going to be a shift of low hanging fruit, patients to remote care, leaving the more expensive, and demanding patients in person providers?
And does that further stress the system, and how do we think about access to adequate providers, including licensing standards? And how do we have appropriate oversight over those providers in the long term? I think the other thing is they are thinking about how to incorporate a mix of telehealth, an in person delivery options. So like, they brought up questions about, for required well child exams. What elements of the exam makes sense to be delivered remotely? But what should still be in person? How do we, you know, as an oversight agency running this program? How do we make sure we’re doing the right thing? And there’s two concerns also about equity. We don’t want to exacerbate equity concerns. So how can we optimize how Telehealth can be used to improve access, but where might it not improve access? And, you know, if you read the State of the States, some governors are really investing in broadband and working with their legislators to think about, where’s broadband not reaching certain populations in our state, and how do we do that as a first step.
And the last thing I’ll say is, on the behavioral health side, I think the data has shown that telehealth has exponentially, it’s exponentially increased behavioral health services, and right now, we are in a crisis and we really need that.
And so, I think, statesville, like, OK, we do want to continue tell us, I think the question is, how do we do then, how do we make sure we have an adequate network.
OK, next slide, please.
I want to talk also, just briefly about workforce, so, as I said, at the top of my remarks, healthcare workforce has become the pressing issue. And so, during the public health emergency, states, took advantage of the flexibilities that the Federal government offered, and they, they did a number of things. They increased reimbursement and allowed interim or retainer payments to providers through Medicaid. They relaxed provider provider licensure requirements and licensure for … providers, and provider screening requirements. Not just for telehealth, but also more broadly to allow folks to enter the Medicaid program.
They allowed services provided by graduate, graduate clinicians. They reduce the need for direction by physician or a dentist when practicing within scope of practice. And so I think the question is, what are what our state’s going to do? And I think they’re they’re really balancing the immediate access with quality, local, and right care considerations. They’re also thinking about the cost of payment increases cannot be sustainable over the long term. And I think there’s also some political implications, for example, on scope of practice that has been a longstanding sort of political battle about, you know, who should be able to practice without supervision. And those, those concerns continue to be raised and legislatures across the country as this, as this conversation is going on. I think the other thing I wanted to just mention, too, is states are also pursuing expanded workforce initiatives. And they’re thinking about how that fits in to telehealth scope of practice, and all these other reforms, and looking at it holistically about how do we really create a package of reforms? We’re really going to short the workforce in our state.
And just to mention a couple of things, you know, there’s, there’s things like scholarships and loan forgiveness that states are thinking about, recognizing out of state licenses, expanding training programs, increasing compensation for certain parts of the healthcare field. On the home and community based services side, which I’m gonna talk about in a minute, There has been a lot of consideration of increasing rates and how we do more with that workforce.
I think there’s also some considerations at the gubernatorial level of how do we attract different education programs and train more and make sure we’re having the right like a pipeline to reach the workforce that we need. So, if you’re interested in any of this, we actually went through each day to the state governors. And they’ve mentioned a lot of different pieces in, in different ways of how to address workforce. And that could be something, If you’re interested. We can follow up on OK. And then the last I just wanted to mention was just talking a little bit more about home and community based services, I think, for this conversation so relevant. And so, you know, I won’t go through all the, all the flexibility. We’ve talked about that. Really. I think, have been just really shown how people, who are aging, or disabled, who require services in the home. What we’ve been able to do with the additional flexibilities has really made a difference.
I think one of the things states are doing, they’re thinking about, OK, do we extend these flexibilities permanently?
And some of the considerations are, we need more data. What were the impacts on utilization cost and quality? So I was so happy to hear earlier in the conversation about researchers really digging into this, to understand what the impact has been. What was the feedback from enrollees and families, what worked, what didn’t, what tweaks need to be made? How did these changes impact waiver capacity? Where we actually able to serve, Maureen, is that sort of a way to think about how we reduce our waiting list for some of our home and community based services waivers in the future? And then how does this overlay with all of the different reforms that states are thinking about with the enhanced dollars that they’re getting for the home and community based services? And as part of the, the bump, which is, you know, the increased F map by 10% points that’s in place, from 20, 21 through 20 20 tube, and they’ll have until 20 24 to spend the funds. Since you’re planning a lot of different things, they’re thinking about increase wages and benefits for the HCBS workforce. They’re investing in training.
They’re incentivizing recruitment and retention payments, their service expansions, home modifications, assistive technology, meals and nutrition, transportation, caregiver support, self directed services, et cetera, technology for providers and state agencies, adding waiver slots, making assessment changes, and eligibility changes.
And I think all of that is also related to what do we think about with respect to extending the flexibilities that we have be possible through the temporary waivers that we have through the federal Federal Public Health emergency? So, I guess I’ll just sum it up, and I’ll turn it back to Sarah, that. I think, for states, there’s a lot of different considerations of how all these pieces fit together. They are looking at things from server totality of circumstances of, you know, federal funding coming in. We have a big enrollment challenge looming. We’re trying to sort of address all of these immediate needs across workforce, across modernizing public health. Across, you know, equity and how that all fits with these authorities, I think, is, is the challenge. And I’m really happy to see this in-depth work, so states will have more to think about in that respect. So that I’ll turn it back to you, Sarah. Thank you. Thank you. Thank you so much, Amy. And I’m going to turn it right over to Jonathan now for his presentation. Hopefully, we can fit in a few minutes of questions, Jonathan?
Great. So, thank you, everyone. I’m going to try and run through these remarks very quickly on Jonathan’s Al Smith. I’m with the Margolis Center for Health Policy at Duke University. I’m going to be speaking on the flexibilities particularly within the context of home based care. I’ll try and provide some top of the remarks on the landscape home based care examples of how these were impacted by the pandemic related flexibilities. And then some of the broader implications moving forward. Also, note that Robert … is joining me in the Q and A.
And that my remarks today are part of a larger project funded by the Commonwealth Fund Scan Foundation, the John A Hartford Foundation, to identify short-term practical policy recommendations for expanding home based care, and we’re very appreciative of their support.
So to begin this conversation like to take a step back and describe why I’m talking about home based care, but it is and why it’s relevant to today’s conversation. As we’ve heard from others, there were a number of flexibilities introduced during the pandemic that expanded where people were able to get care. We’ve heard a lot of about telehealth, but there are also a number of other flexibilities that allow care to be provided directly in a patient’s home. one of the more notable examples is hospital at home, which I’ll discuss in a little bit, but before I do that, I’m going to describe a bit more about home based care more generally.
So, um, and again, apologies if I’m rushing through this, I just want to leave some time for Q&A.
So, home based care is a broad term, and encompasses a variety of ways of providing caring home setting, which can include managing patients medicine, providing physical therapy, or social services, like transportation or food.
Over the last two decades, there has been a substantial shift to providing more home based and community based services driven by patient preferences, advances in technologies, as well as changes in how some of these services are regulated and paid for. But despite this growing trend, there remains significant gap between the demand and supply of home based care with an estimated seven million Americans.
I’m able to access home based care services due to a number of reasons. First, it’s expensive, it requires a lot of time and resources to go to patients’ homes.
Second and related, the way that we often pay for health services can be an impediment.
Many people have noted already the fee for service payment model, wherein you get reimbursed more services you provide.
But in the context of home based care, this can leave providers with less revenue since they’re spending more time traveling and enforcing less patients. And then third, there are a number of regulations that can limit who can provide care in the home setting and what types of services can be delivered outside of the clinic.
For instance, prior to the pandemic, Medicare didn’t have a reimbursement mechanism to pay hospitals for providing hospital related care in the home setting.
Then the response to the pandemic many of these regulatory peanut barriers were changed to allow services to be delivered outside of a clinical setting. As an example, CMS created to waiver that will speak on the Hospital Without Laws Waiver, which allowed Medicare to pay health systems to deliver hospital level care in the home setting for certain services. Prior to this, many of these services weren’t reimburse. And, as a result, we saw dramatic expansion of around 12 programs existing prior to the waiver, to more than 140 programs, after the waivers were introduced.
This rapid change created momentum for home based care services more broadly, and it also is tied into a larger strategy across Medicare, Medicaid, and other stakeholders to expand not just hospital level services, but a number of other home based care services as well.
For instance, the Center for Medicare and Medicaid Innovation has been strategically evaluated a portfolio of models.
And as part of this, they’ve been very explicit on the need to expand access to home based care services with an model design.
So, there’s a unique policy window, which has been some of the impetus for our work, and there’s also a significant appetite for this type of home based care.
But moving forward, there are a number of things that we should consider as we think about making these flexibilities more permanent.
I’ll name a few, but note that there are many more considerations.
First, we need to be mindful of how these flexibilities fit into the broader healthcare delivery system.
one of the challenges that we’ve remarked in some of our policy briefs is that there are a lot of diversity in home based care models, but there isn’t a lot of co-ordination across these models.
For instance, when a patient is discharged from the hospital program, there isn’t necessarily a seamless transition or fall back to the home based primary care setting. This can lead to gaps in care which might detrimentally impact patient outcomes.
And so we need to think about ways of programs like hospital at home and some of the flexibilities around expanding access to the home based care setting should be could be expanded without leading to more fragmentation. Second, we need to be mindful of equity considerations when expanding these flexibilities.
We and others have mentioned the digital divide, so I won’t go into this in detail, but echoing what many of the other panelists have said, and noting that many individuals don’t have access to the resources needed to benefit from Telehealth or may not have family or caregiver support.
Third, we need to consider the financial implications and how we will pay for some of these services.
For instance, in the hospital and home program, Medicare, paid hospitals. the same rate for providing care in the home setting, as in the hospital setting. And, this was appropriate to sort of scale up really quickly.
But, in the long term, we need to think about whether this is financially sustainable, whether encourages more co-ordinated or fragmented care, Whether it encourages the type of care that leads to better patient outcomes.
And so, sort of putting this all together, one of the things that our team at Duke has been thinking about, is whether there are alternative ways of paying for these types of services that might be more appropriate.
For instance, value based payment models are one approach that has been increasingly seen as a better way to support home based care services. Under value based payment models, providers are paid for the quality of the quantity of care delivered.
And there are a number of different ways of doing this, which I won’t go into. But, one of the benefits, at least in the context of home based care, is that they offer providers’ flexibility to deliver care tailored to patient needs, while ensuring accountability for patient outcomes across the different variety of care settings.
And I think this is a really critical element that often gets overlooked. Because the conversations around sort of the future flexibility seems to be more finer.
Either these flexibilities will be renewed, or they won’t, but there are a number of value based payment models that have actually enabled these types of services to be provided already.
And we’ve seen this with some organizations participating in total cost of care models providing home based care services prior to the pandemic.
So in wrapping up, one of the things that my colleagues and I proposed in our recommendations is that as we move out of the pandemic, we need to consider ways that existing payment models can support the range of services that an individual might need as their health and social status changes. Sort of three top level recommendations.
First, these models must support accountability and co-ordination, which I’ve already discussed.
But it’s particularly important as we think about ways to integrate the pandemic related flexibilities into the broader fabric of the healthcare ecosystem. Second, we don’t need to re-invent the wheel. There are a number of existing models at the state and federal level that can be leveraged to support home based services. Medicare Advantage, Medicaid, 115 waivers, or the recently announced ACL Reach model. And third, we must ensure that these models are accessible to small, independent care providers with limited resources. So I’m going to come or short, and provide some time for Q&A.
I’d like to thank everyone for the opportunity to speak, and I encourage everyone to go to our website, to see our recommendations. And we’ve also published an article, Unhealth Forefront that summarizes some of our recommendations. Thanks.
Thank you so much, Jonathan. And sorry for you to have to cut your remarks short. And let me invite everybody, now, up for about 10 minutes of Q&A.
And I want to pick up on something you said, Jonathan and Amy also alluded to, write like this idea of it.
No, there’s no, there isn’t like this dual aspect of permanent, versus going away, there’s could be a lot of middle ground, and then something you talked about, you know, with regard to the state elections. I wonder, my question for the panel is kind of a process question, because what strikes me in everything that you all have talked about, is the hundreds and hundreds of decision points, you know, data points that need to be addressed and thought through across multiple layers, local, state, federal jurisdictional. So this is a huge like information transfer decision, support, and continuity question.
And so, so, what I’m wondering, you, know, if you could comment on, like, what do you think is the best way to support policymakers, as they think through these mulches, multitudes of questions?
And, Jonathan, I’ll let you go ahead and start since you’re blessed.
Actually, my turn to Rob to help answer this question first, that’s OK.
Happy to bring up a good point, that there’s a lot of planning that goes into all of these jobs, I mean, even as we talk about policy where there’s a whole new work force or army of folks who will need to actually respond to set policies and being able to move and practice. And so, there’s some timing challenges here as we do it. I think one point that I want to double back to is that there’s no, no. There doesn’t necessarily have to be an all or nothing. Consideration here. There’s a lot of middle ground options that can continue these flexibilities in some form can can provide the flexibility is where there’s a corporate need for them while recognizing that they may look differently non public health emergency timeframe as a public health emergency. So, I think that’s a topline point here.
But, Jonathan, are there parts that you would add to that, that consideration already? That’s great.
Anyone else like to comment on that?
Think the only thing I would say, from a state perspective is the timeline. So as I said, you know, some of these expire six months after the public health emergencies. Some expire when it ends. So there really is a different timeframe. And just for planning for state legislative sessions, I just wanted to add that into the conversation. So all the work is done in a very short timeframe. I mean, some state legislative sessions or January to March, and you’re done, right. Summer, longer. So I’m going through May, and really the work for, I think, you know, policy influence is really before that. Because they have their slate of legislation ready to go, and then they, they have a short timeframe in, which to work. So, I really do think, from the academic side, the more data we can provide state policymakers on, like, what has been the impact in telehealth on your populations, what has been the sort of the the benefits and any challenges with adequate providers. I think that’s key to provide them now. And going into the fall, if you really want to sort of get it, but you need a legislative solution at the state level going into next year.
And, can I add a couple of points. one, is this concept about the middle ground, and there may be opportunities for, I call it toggle on, toggle off, and, you know, when we were looking through the different regulatory flexibility across the states. There were states like Florida North Carolina who’ve used these PHDs before related to floods and hurricanes. But did, you know? It’s never been used in an infectious disease way. And definitely not in a nationwide, what states, These states that have done this before and use these emergency authorities on the flex.
On the Medicaid side, You know, talked about having like a plan, B, you know, the Managed Care plan contract addendum that’s kinda ready to go in the case of another infectious disease pandemic from, based on lessons learned. So, there definitely is a middle ground. It’s not necessarily all, know, expire. All, you know, adopt, there could be further testing, and then there could be toggle on top of law. And the other point is, you know, the assessment framework and decision making framework that we developed each may mean that, you know, hopefully, could be a tool to think through some of these. Because these are really complicated questions, Really complicated flexibilities while impact data is critical.
I just, you know, there’s also some that maybe you don’t ignore. The obvious is, you know, there were some that, you know, I mentioned, like, I don’t know if every state to this, but a lot of states did have, you know, pharmacy scope of practice.
Flexibilities that allowed pharmacy technicians and pharmacist to administer jacoba tests and vaccines and states have started to adopt these, because they just makes sense, the community centered, there, They drive and advance health equity, So, just don’t ignore the obvious and learn from other states, know, there seem to be best practices across, you know, 48 states, maybe it’s a best practice, and the other stuff, you know, so just not to ignore the obvious.
Thanks, and let me turn to Lisa, to ask a slightly different angle on the question.
You run an organization, you run a small organization that directly serve consumers, from your perspective, from an operational standpoint, like what, what keeps you up at night with regard to decisions about, you know, these these flexibilities.
Whether they’ll be permanent, whether they’ll be unwound, whether there will be some kind of testing period in the middle, I think obviously, we hope that they continue.
There, I think what keeps me up at night is, is really just the ever changing needs of the consumers that we’re serving, and it seems to never, be a dull moment.
I mean, I think, um, You know, the there’s a lot of focus, you know, in health plan contracts, to work with community based organizations, and a recognition.
I think that, you know, of the work that we are doing, to provide those wraparound services that, uh, that, maybe, the health plans don’t provide.
So, you know, really trying to make sure that we can work with them and and look at, LTSS as much broader than it is than what what maybe, traditionally, health plans think of, or health care things.
So you know and how you know you know one of the issues we have in California obviously you’ve all heard of our fires right and so we we’ve got tons of fires but what happens too?
The person who has has an oxygen concentrator where power was shut off to avoid try to avoid a fire. How do they sustain themselves if they don’t have electricity and they can’t get oxygen? So, you know, when I, when I talk about emergency preparedness, I’m talking about really, you know, how do we help people sustain and thrive in an another emergency when we have to relocate and we’ve had to relocate consumers because there, they were in fire areas that were being evacuated. So, you know, we’ve gotta get them transportation and that could mean that, have to be, it, might be gurney transportation. That might be power chair transportation, that they can take their oxygen concentrators that you know, what about you know, people that on medic, even medications that have to be refrigerated.
These kinds of things are becoming more and more real and more and more frequent, you know, for every fire season. So we know that those things keep me up at night.
How do I, how do I possibly? And there needs to be some recognition these things we have to deal with.
I am so glad Stephanie, you were talking about the states that, that, you know, you, the hurricanes.
And I was, I asked myself, how did they, however they surviving. How are the folks that are having these, you know, people with disabilities and older adults dealing with this?
You know, I’d love to hear what, how they’re doing.
And what, what are some lessons learned from them, because we’re, you know, where, I feel sometimes chasing our tails and trying to figure out, you know, how can I find a backup battery for this person you know, get them so that they can sustain themselves and thrive throughout the next emergency.
Thank you so much, Lisa. And I think there could be a lot more to talk about there.
But, I am going to leave this panel right there at that individual level, person centered perspective, because it might come down to a battery or an oxygen tank, or, know, the ability of a caregiver to come into the home or, you know, access broadband. So, so, thank you for for bringing us that perspective. Thanks to all of you on this really amazing panel for bringing all of your perspectives. I apologize that we didn’t have more time for Q and A But hopefully, you can have you all back. I want to thank, again, the scan Foundation for their support. Thanks to our audience for joining us today. Please do share your feedback through the evaluation.
We are a continuous quality improvement organization so we try to really take that into account. And again, I want to thank Jonathan Gonzalez Smith, Saunders, Amy Tursun, Lisa Hayes, Jennifer Pahlka, Stephanie Anthony, for your amazing work and thought leadership and research and analysis. And for bringing all of this work forward, you can check out a recording of anyone can check out a recording on our website, off policy dot org, following the webinar. And finally, stay tuned for an announcement about the Alliance’s, next three part series on the future of Medicare. Thank you all, so, so much. Have a great afternoon, everybody, and much appreciated.
Return to main event »