May Newsletter

BREAKING: Nursing homes slated for 1.3% — or $444 million — Medicare pay hike for 2022
James M. Berklan

Nursing homes would receive a 1.3% net Medicare increase for fiscal year 2022 under a proposal announced by the Centers for Medicare & Medicaid Services late Thursday afternoon.

The update would result in a $444 million aggregate pay boost in Medicare Part A payments for skilled nursing facilities.

CMS also is proposing a new quality measure that would require skilled nursing facilities to report staff COVID-19 vaccination rates, starting Oct. 1, 2021. Reporting would take place through the Centers for Disease Control and Prevention National Healthcare Safety Network.

In addition, the proposed rule would expand the SNF Quality Reporting Program (QRP), including a reporting requirement and potential penalties for healthcare-acquired infections such as sepsis, urinary tract infection, and pneumonia. It also proposes changes to the SNF Value-Based Program (VBP) for FY 2022.

The Skilled Nursing Facility Prospective Payment System proposed rule would take effect Oct. 1, 2021, the start of the new fiscal year.

The 2022 proposed Medicare pay increase actually is $445 million, but that is affected by a $1.2 million decrease due to a proposed cut to account for the recent blood-clotting factors exclusion.

These impact figures also do not incorporate the SNF VBP reductions that CMS estimates to be $184.25 million for fiscal 2022, the agency added.

CMS noted that its analysis of the Patient Driven Payment System pay rates, which went into effect in October 2019, revealed an unintended average hike of about 5%, or $1.7 billion, in payments. But in deference to the ongoing public health emergency, it is only seeking comments at this time as to how the system can be brought back in line with its payment-neutral goal.

“CMS is soliciting broad public comments on a potential methodology for recalibrating the PDPM parity adjustment that would account for the potential effects of the COVID-19 PHE without compromising the accuracy of the adjustment,” the agency said. “CMS also seeks comment on whether any necessary adjustment should be delayed or phased in over time to provide payment stability.”

The new Medicare payment increase is the byproduct of a 2.3% market basket increase, minus a 0.8 percentage point forecast error adjustment and a 0.2 percentage point multifactor productivity (MFP) adjustment.

CMS also proposes to rebase and revise the SNF market basket index, including updating the base year from 2014 to 2018.

The proposed COVID-19 vaccination coverage measure would require skilled nursing facilities to report worker vaccination fates to gauge “whether SNFs are taking steps to limit the spread of COVID-19 among their HCP, reduce the risk of transmission within their facilities and help sustain the ability of SNFs to continue serving their communities throughout the COVID-19 PHE and beyond.”

Nothing dramatic had been expected by many industry insiders since a new CMS administrator has not been confirmed yet. President Joe Biden nominated Chiquita Brooks-LaSure in February but required Senate confirmation hearings have not taken place. Liz Richter is the acting CMS administrator.

Even the small boost should come as a relief to providers, many of whom report operating at a loss due to COVID-19.

“This ongoing work makes government support and robust reimbursement rates more important than ever,” Mark Parkinson, president and CEO of AHCA said in a statement Thursday. “With the skilled nursing profession grappling with an economic crisis and hundreds of facilities on the brink of closure due to the pandemic, it is critical that Medicare remain a reliable funding source and reflect the increasing costs providers are facing.”

Parkinson also acknowledged that new worker-vaccination reporting proposal, albeit without an outright endorsement.

“We also recognize the importance of quality measures associated with COVID-19 including a proposed measure of the COVID-19 Vaccination Coverage among health care personnel, he said. “We thank Acting Administrator Richter and the Administration for their support through the pandemic.”

Last year, for fiscal 2021, nursing homes wound up with a net 2.2% Medicare raise, which was 0.1% less than the 2.3% rate originally proposed in April 2020. The increase amounted to an additional $750 million injected into the skilled nursing funding stream.

Also last year, CMS also proposed revised geographic delineations used to identify a provider’s status as an urban or rural facility. They were to be used “to calculate the wage index and apply a 5% cap to wage index decreases.” Slight changes to ICD-10 code mapping under the Patient-Driven Payment Model also were proposed.

A CMS fact sheet on the proposed 2022 rule can be found here. CMS will be taking comments on the proposals until June 7. The agency will announce any adjustments to the rule after collecting and making decisions about comments gathered.

Telehealth: Driving more effective, qualitative and accessible care for U.S. seniors
Ed Mercadante, BSPharm, R.Ph., D.Sc.(Hon)

When the COVID-19 pandemic began within the United States in early 2020, residents of long-term care facilities — including assisted living communities, skilled nursing facilities, nursing homes and other facilities — were severely affected by widespread infections and deaths. Operators acted quickly to restrict visitor access and limit resident activities. As a result of social distancing measures and other safety precautions enacted to reduce the spread of the virus, many older adults faced detrimental interruptions to care that have severely decreased quality of life.


Telehealth quickly was leveraged to provide safe, virtual care to meet the ever-increasing needs of the senior population, who have faced additional loneliness, depression and isolation during these troubled times. Now more than a year since the COVID-19 pandemic began in the United States, telehealth has proven its value and is a necessary solution that is here to stay. Its ability to facilitate essential care for the senior community — particularly mental health care — is a testament to its potential longevity beyond the pandemic.


The mental health need for elderly through virtual care

A critical need for telehealth exists — more specifically, behavioral telehealth — within the nation’s senior community. The U.S. senior population is growing at a rapid rate and is expected to double over the next three decades from 48 million to 88 million. This significant increase necessitates scalable, more accessible healthcare solutions designed to provide care efficiently and effectively for an aging and mobile population.


Unfortunately, many older adults choose not to seek mental healthcare due to social stigma, which can leave serious conditions such as depression and cognitive decline untreated. The CDC estimates that more than 20% of the 55 and older community face some form of mental health concern, most commonly depression, anxiety and isolation. Some studies have indicated that these factors lead to an accelerated cognitive decline. The CDC also says that more than 40% of assisted living communities do not offer mental health services.


Mental health challenges are even more predominant for older adults within long-term care facilities, and circumstances undoubtedly only have worsened over the past year. Research shows that more than half of nursing home residents without cognitive impairment have reported feeling loneliness, isolation and depression. Additionally, behavioral conditions amongst the elderly often contribute to a significant decline of other comorbid ailments such as diabetes and cardiac issues.


A serious need exists for quality healthcare for the aging population, and with the physical and social limitations that older adults face when seeking in-person care, which in some cases only have been magnified by the COVID-19 pandemic, telehealth is a viable solution.


Telehealth drives improvement in care

Not only does telehealth safely provide more accessible patient/resident care desperately needed for the senior population, but it also improves care outcomes. According to our recent data study, telehealth can result in considerable reductions in the use of dangerous psychotropic drugs. Telehealth empowers mental health professionals and other practitioners to reach patients/residents who otherwise may not receive the specialized, one-on-one care they need.


There is a significant shortage of mental health providers, including psychiatrists, clinical psychologists and psychiatric providers such as nurse practitioners. In senior living, this shortage of trained professionals can lead to dire consequences for the elderly, a vulnerable population.


Virtual care is the great equalizer, disrupting the existing paradigm barriers of geography, travel, weather conditions and other impediments that contribute to accessibility difficulties and inefficiencies of care. Not only is virtual care lifting the burden off of patients/residents, but according to our estimates, we are able to see more than 25% more people in need of care.


Before the availability of behavioral telehealth services, mental health providers often were unable to accommodate patients requiring emergency or more acute needs. With tele-technologies, including mobile health app-based access, people can be cared for in place without interruption and providers can transition care to whatever location the individual requires, including a traditional home or congregate setting. Hopefully, the pandemic will accelerate federal and state legislation enabling permanent access to telehealth and digital technologies by removing regulatory hurdles that existed before COVID-19.


By improving access to quality care and the efficiency with which that care is delivered, telehealth has the potential to positively affect quality of life — and it hopefully will serve as a catalyst that drives more mental healthcare for the country’s older adult population moving forward. I strongly believe that we are at the beginning of a “change healthcare movement” through tele-technologies and that it will lead to improved care for millions of Americans.


Ed Mercadante, BSPharm, R.Ph., D.Sc.(Hon) is CEO of MediTelecare, a leading provider of telehealth behavioral services to SNFs and assisted living facilities.


Scaling Up Telepharmacy for the Future
April 5, 2021
Fred Gebhart

Telepharmacy turns 20 this year. Two decades after it emerged as a way of preserving and expanding pharmacy access across rural North Dakota, telepharmacy innovators are moving into sterile compounding, secure medication storage, primary care consults, and more.


 Telepharmacy has gone from a pilot project to accepted practice in 25 states, according to Jessica Adams, PharmD, director of regulatory affairs for Telepharm, an early telepharmacy provider acquired by Cardinal Health in 2016. Many states who do not have telepharmacy rules in place today, are in some stage of approving telepharmacy as pharmacists and patients continue to push the need for access to pharmacy care. As pharmacists, providers, patients, payers, and regulators recognize the benefits that telehealth can bring to pharmacy, technology-based services will continue to expand.


At its simplest, telepharmacy allows a pharmacist to supervise a remote dispensing site via HIPAA-compliant, 2-way audio-visual technology. The pharmacist remotely supervises the telepharmacy technicians, verifies prescriptions, and counsels patients from their host pharmacy location. Newer iterations are combining remote oversight with other familiar technologies to expand the reach of pharmacy care.


Remote Sterile Compounding


 One of the newest expansions is using remote verification for sterile IV compounding at the University of North Carolina (UNC). Pharmacists saw the potential to balance workload across multiple pharmacies that were using BD Pyxis IV Prep to prepare sterile IV solutions, explained Lindsey B. Amerine, PharmD, MS, BCPS, director of pharmacy and associate professor of clinical education at the UNC Eshelman School of Pharmacy in Chapel Hill, North Carolina. She proposed a double arm, prospective study of remote versus onsite verification at 4 UNC pharmacies.


 The Pyxis system uses gravimetric-based technology to weigh and verify compounded products, Amerine explained. The system images the compounding process, which is typically managed by a technician and reviewed by a local pharmacist. Because the onsite pharmacist was using images generated by the system, there was no obvious difference between reviewing images in the next room or 25 miles away.


 Results of the 90-day trial demonstrated no difference in accuracy or safety for remote versus local oversight, and resulted in an annualized cost savings of nearly $24,800, according to Amerine. “When we did the study, the state had no rules around this kind of telepharmacy,” Amerine said, “so we designed the trial with remote plus onsite review of all compounded sterile products.” When the COVID-19 pandemic started, “we received a waiver from the [State] Board of Pharmacy to be able to do this remote sterile product check as long as the health emergency lasts,” she said.


“Our next initiative is to be able to use telepharmacy routinely in the long term to do more workload sharing across sites. There is also the advantage of having a pharmacist able to check product from anywhere in the hospital. Not being tied to the pharmacy frees you up to spend more time with patients.”


Secure Medication Storage


 Roger Rose, RPh, director of pharmacy services for Wickenburg Community Hospital, opened the first telepharmacy in Arizona in 2019. Wickenburg has long had a satellite clinic in the town of Congress, which is about 16 miles away. With a population of 3500, Congress is too small to support an onsite pharmacist, Rose said. The drive to Wickenburg to fill prescriptions is not always practical for patients.


 “We were doing deliveries to the Congress clinic twice a day, but that didn’t always work, either,” Rose said. “Patients still had to go home after their clinic visit, then come back later, or maybe the next day. Too many prescriptions never got picked up.”


 When Arizona approved telepharmacy in 2018, Rose had a solution and 2 more problems. One was security. Most telepharmacy operations he visited had a single technician handling the entire operation.


 “You’ve got your front end, you’ve got prescriptions at the back, and just 1 person,” Rose said. “For any pharmacist who has been around for a while, that’s a stress.”


 The second problem was space. State telepharmacy regulations required at least 300 square feet. The only available space at the Congress clinic was 125 square feet.


 His solution was RxSafe, a secure medication storage unit that can hold about 1300 medication vials. The unit weighs every container coming out and going back into storage to verify the medication removed for each prescription.


 “Combining telepharmacy and RxSafe answered our questions,” Rose said. “We can stock just about everything our providers write in the limited space, and I know the location is safe for our tech. The technologies work well together.”


A Pharmacist in Every Room


Adam Chesler, PharmD, MBA, senior vice president for pharmacy integration at VillageMD, a network of primary care clinics, envisions a day when every patient in nearly 2000 primary care clinics can have a pharmacist consult. Some consults will likely come through an in-person Walgreens pharmacist. Walgreens is investing $1 billion to support up to 700 new Village Medical primary care clinics at its locations by 2025. Other consults will likely come via telepharmacy.


“Having a pharmacist directly involved in care improves patient outcomes,” said Chesler. “By integrating a pharmacist into primary care, we have shown significant, sustained increases in medication adherence to treat cholesterol, diabetes, and hypertension. We can utilize telepharmacy and telehealth technology by taking an iPad or tablet into any exam room and having a conversation between the pharmacist, physician, and patient anywhere, anytime.”


The telepharmacy technology already exists and VillageMD already has a focus on pharmacy integration. Patients with multiple chronic disease states or those who use multiple pharmacies have an elevated risk of therapy failure. These patients already receive in-person or telephonic pharmacy consults, as do discharged and homebound patients. Telepharmacy can further expand this reach. Pharmacists in these settings have full access to patient electronic medical records, a common communication platform with clinicians, and collaborative practice agreements with delegated prescribing authority.


“We are taking full financial risk for many Medicare patients,” Chesler explained. “The physicians here understand that the best way, the only way, to successfully improve outcomes and reduce costs is by having pharmacists directly integrated into the care team. Having a pharmacist on the care team is integral to our success and telepharmacy can help make that integration happen.”


Smoothing Regulatory Bumps


As telepharmacy evolves, regulators are playing catch-up. On a federal level, the COVID-19 pandemic called for loosened telehealth restrictions overall during the public health emergency. The Centers for Medicare and Medicaid Services (CMS) expanded the number of covered services that can be provided via telehealth. Many of these changes are noted as temporary during the COVID-19 emergency period. However, as telehealth benefits prove valuable, it is the hope that these changes will carry over post pandemic, enabling telepharmacy expansion.


Many states already had telepharmacy laws in place prior to the pandemic. California’s Legislature authorized telepharmacy in 2018. It took 2 years to work out the regulatory details and open the state’s first telepharmacy. Arizona’s first telepharmacy was 6 years in the making.


 “When we first asked, the state pharmacy board told us they had no regulations and nothing in the practice act that would let them authorize telepharmacy for the hospital’s remote clinic,” said Rose. “Five years later, they had changes to the practice act, called us back for a hearing in July, and we were licensed the next April.”


 Outreach to the state board, showing up at board meetings, and providing public comments make the difference, said Adams. “ Each state is unique and has its own challenges, but access is an issue everywhere. Telepharmacy has been proven to work for 20 years, and is now permitted in 25 states. If pharmacists attend board of pharmacy meetings and explain how telepharmacy can reduce gaps in pharmacy care that their patients are experiencing, it can make a positive difference in getting telepharmacy moving,” she explained.


 Changing pharmacy regulation and legislation is a team sport, Adams continued. Arizona was slow to adopt telepharmacy in part because chain pharmacists feared remote oversight could lead to job losses. The Arizona Pharmacy Association demanded language in the practice act to safeguard pharmacist employment.


 Rural health associations can be solid partners, particularly for pharmacists seeking to bring telepharmacy to underserved rural areas. Federally qualified health centers, health systems, and physician practices that recognize the advantages of bringing pharmacy to the care team can help build support.


 “The basic message is telepharmacy safely provides greater access to pharmacist care,” Adams said. “Why are we not using a proven technology to help ensure that our patients are getting the best pharmacy care possible? The more stakeholders you bring to support your message, the more likely you are to get a positive response.”

155 assisted living communities get bad rap after being put on governor’s ‘not vaccinating’ list
Amy Novotney

More than 150 assisted living communities are being called out — unfairly, they say — by Ohio Gov. Mike DeWine and the state’s Department of Aging, according to local media reports.


The department on Thursday released a list of facilities that they said either have not opted into the state’s vaccine program or have not confirmed how they are administering vaccines. But some operators said that the lists is inaccurate.


The Office of the Aging compiled the list of 155 assisted living communities and 52 nursing homes that the agency said have not signed up for what’s called the “Covid Maintenance Program,” designed to make sure new senior living and nursing home residents and new staff members have access to a vaccine. The agency reportedly sent the survey to operators in the state, and if a facility did not respond, then its name automatically was put on the list. Yet several facilities are claiming their inclusion is a mistake.


“Since we’ve completed the survey four times, no reason we should be on any list but a good list,” John Stone, administrator of Merit House in Toledo, OH, which was included on the list, told 24 News. Stone said that residents of his facility, which offers assisted living and skilled care, are fully vaccinated after he held three CVS Health vaccination clinics: one each in December, January and February.


“100% of our residents have been vaccinated, and probably upwards of 60% of staff. We took a pretty aggressive stance to get everyone vaccinated and get everyone on board,” he told the news agency.


Similarly, the Cottage at Wexner Heritage Village in Columbus, OH, told WBNS News that it vaccinated 90% of its residents on Jan. 7.


“It was of course offered to everyone,” said Chris Christian, the facility’s president and CEO. “For our organization to be on the list, we knew clearly there was an error and something they got mixed up somewhere or some wires were crossed.”


Many operators said they hadn’t received the survey, prompting LeadingAge Ohio President and CEO Kathryn Brod to condemn the governor for publishing the list.


“Nearly every LeadingAge Ohio member appearing on the list had a plan in place for offering the vaccine to new residents and staff,” Brod told McKnight’s Senior Living in a statement. “Many of the organizations on the list are leaders among their peers, with vaccination rates among residents and staff far above the state averages.”


Brod noted that many members confirmed that their issues stemmed from the process of reporting vaccine plans to the state, particularly life plan communities (also known as continuing care retirement communities) that offer both assisted living and skilled nursing at the same site.


“Gov. DeWine’s statement of frustration for providers working tirelessly to protect high-risk Ohioans was profoundly disheartening, particularly given the ease with which the reporting issue was rectified,” she said.

The COVID race: Vaccines 90% effective in frontline workers, but variant cases rising
Alicia Lasek

A vial of SARS-CoV2 COVID-19 vaccine in a medical research laboratory

A study of healthcare and other essential workers provides strong evidence that messenger, or mRNA, vaccines, are 90% effective against COVID-19, according to the Centers for Disease Control and Prevention. But case rates are increasing again, pitting the pace of vaccinations against the effects of spreading virus variants, observers say.


The agency’s latest investigation followed almost 4,000 participants in six states after they received either the Pfizer-BioNTech or Moderna mRNA vaccines. Risk of infection dropped by 90% two or more weeks after the second dose, the researchers found.


The findings demonstrate that U.S. vaccination efforts are having a substantial preventive effect among working-age adults, the agency said. They also bolster the CDC’s recommendation for getting the full two-dose immunization with mRNA vaccines, it added. A third federally approved vaccine, from Johnson & Johnson, uses a different technology and was not included in the study. It has been shown to be 67% effective overall in preventing moderate to severe/critical COVID-19, and 100% protective against ICU admission and death.


More vaccinations needed to combat variants


In the meantime, U.S. COVID-19 case rates have begun to increase again for the first time since January, the agency said. In a Monday press briefing, CDC Director Rochelle Walensky, M.D., pleaded with Americans not to let down their guard, according to the Associated Press.


Cases were up 10% last week from the previous week, and hospitalizations and deaths are rising as well, the news outlet reported.


Experts say the increase in cases may be related to new genetic variants of SARS-CoV-2, the virus that causes the COVID-19. What the CDC calls “variants of concern” have mutated to spread more easily and to possibly cause more severe disease, according to a report by NPR. Now they are making inroads nationwide and becoming the dominant strains of the virus in many places.


One expert has called the new circumstances a race between vaccinations and variants, tweeting that the variants have recently “pulled ahead” of the pace of U.S. vaccination. “Holding tight until more folks vaccinated [is the] key to winning this race,” tweeted Ashish Jha, M.D., MPH, a public health policy researcher from Brown University’s School of Public Health.


“We are not powerless; we can change this trajectory of the pandemic,” the CDC’s Walensky said, according to NPR. She and the White House’s chief medical adviser, Anthony Fauci, M.D., have asked Americans to continue maintaining social distancing measures and mask wearing.

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