What the End of the COVID-19 Public Health Emergency Will Mean for Employers
April 11th, 2022
The current COVID-19 public health emergency declaration has now been in place for more than two years – since January 2020. While a new wave could cause its extension, it will most likely end this summer.
Several policies that grant health care providers and payers extended authorities and flexibilities have been tied to the public health emergency, meaning these policies will go away when the public health emergency ends. But the health system has grown used to these extended authorities, and large employers need to be prepared for the potential impact of these policy shifts.
Several policies that will have a direct impact on large employers and other purchasers when the public health emergency ends are described below.
Discretion on HIPAA enforcement: To increase access to telehealth and ease the burden on providers, telehealth can be delivered on non-HIPAA compliant platforms. This discretion on HIPAA enforcement will end with the public health emergency. Most employers have moved to HIPAA-compliant platforms as the pandemic has stretched on, but those who have not will need to ensure all telehealth vendors are HIPAA-compliant when the public health emergency ends.
Waiver of Medicare site-of-service and benefits rules: The waiver of Medicare site-of-service and benefits rules is also tied to the public health emergency. While this does not have a direct impact on employers, some follow Medicare rules on site-of-service and benefits. It is important for employers who do to be aware that the waiver will end with the public health emergency.
State licensure flexibilities: One of the challenges with telehealth is that physicians will have to be licensed in the same state as the patient receiving care. Some states have created significant new licensure flexibilities to improve access to telehealth providers, though not all states have tied those flexibilities to the public health emergency. To the extent employers are using telehealth providers who are in a different state from employees, they should investigate if their state licensure flexibilities will end with the public health emergency and adjust policies accordingly.
Pre-deductible coverage: The CARES Act of 2020 allowed for coverage of telehealth services pre-deductible in high-deductible health plans. Many employers have chosen to take advantage of this option because it provides better access to care for their employees. This provision, which does not fall under the public health emergency, expired in December 2021 but was just renewed effective April 1 and will end on December 31, 2022. While some policymakers have signaled their intent to make the provision permanent, the on-again, off-again nature of the expiration and renewal has created a sense of “whiplash” for employees and employers. Employers must decide whether they will re-enact this policy with its currently limited duration.
Enhanced federal match and continuous coverage: To reduce the rates of uninsured people during the pandemic, two Medicaid changes were put into effect – an enhanced federal match rate and a continuous coverage requirement. Both will go away when the public health emergency ends, and it is expected that more than 10 million people will lose Medicaid coverage. As people lose coverage, employers should be prepared for a possible increase in the number of people seeking employer-sponsored insurance.
Enhanced subsidies: Although not tied directly to the public health emergency, in response to COVID-19, enhanced subsidies were implemented in the individual market to help uninsured people get and stay covered during the COVID-19 pandemic. These subsidies expire on December 31, 2022. If the public health emergency and Medicaid provisions end in July, enhanced subsidies may enable people losing Medicaid coverage to purchase inexpensive coverage on Affordable Care Act health insurance exchanges. When the enhanced subsidies in the individual market expire, it is expected that there will be an increase in people joining employer-sponsored insurance coverage, in particular partners of employees already enrolled.
Patient Experience and Telehealth During COVID-19: Investigating Key Success Factors and Obstacles
February 26th, 2021
The global COVID-19 pandemic has led to a rapid increase in virtual care delivery that will likely be long-lasting. During the height of the pandemic, fear of infection and stay-at-home orders meant that many practices stopped seeing most patients in person for routine care. Relaxing of government regulations allowed for widespread national adoption of telehealth.
Telehealth holds great promise for improving primary care through increasing access, improving patient experience and enabling team-based care models. Importantly, while telehealth expands access to all patients, it may improve health equity for lower socio-economic patients who may lack transportation or sick leave.
To gather the patient perspective on telehealth, The Purchaser Business Group on Health developed and fielded a telehealth patient experience survey as part of the Patient Assessment Survey (PAS) program. Approximately 12,000 surveys were distributed by email to patients with commercial and Medicare coverage who had a virtual visit (phone or video) with a primary care provider in California; 1,500 email responses are reflected in the research findings.
- Equal satisfaction between virtual and in-person care: No significant differences were found in ratings of patient visits between telehealth and the regular PAS survey responses (which measure in-person care).
- Telehealth was popular: A total of 87% of survey respondents recommend telehealth; of survey respondents, 73% want to continue using telehealth in the future.
- Video visits were favored over audio-only: Ratings of visits and communications were nearly identical in video and telephonic visits, but patients who reported that they would likely recommend telehealth and engage in repeat telehealth visits significantly favored video appointments.
- Provider communication was good: Most patients said the provider with whom they met via telehealth methods explained information in a way that was easy to understand (92%), listened carefully (92%), spent enough time with them (91%) and had relevant patient medical history on hand during the visit (88%).
- Most patients received medical tests: Half of survey respondents had tests ordered by their provider. Most followed up to have the tests conducted (84%), and most patients were able to access their test results (88%). Patients were most likely to get the tests ordered on their behalf while being seen for COVID-19 concerns, whereas patients being seen for chronic health care or other health issues were least likely to have tests ordered for them. Patients who did not receive ordered tests (16%) scored their health care provider lower on communication scores.
Despite these promising findings, PBGH research has been, to date, limited to commercial populations in the state of California. Further research on patient experience and clinical outcomes should be conducted nationwide with more diverse populations, including Medicaid beneficiaries, racial and ethnic minorities and those with limited English proficiency. PBGH will have preliminary results from a survey with a sample of patients with Medi-Cal coverage in Spring 2021 and seeks to expand this measurement nationwide.
The findings of the PBGH Telehealth Survey are instructive for provider organizations, solution providers and health plans. The survey findings suggest the following four steps can make a meaningful difference in ensuring that patients have a positive experience with telehealth:
- Continue to offer telehealth. Patients enjoy telehealth and want to continue using virtual care in the future.
- Offer video visits. Satisfaction with telephonic and video care was high, but users of video visits were more likely to recommend telehealth and want to continue using telehealth.
- Provide instructions for video visits. Patient satisfaction is highest when clear instructions are provided to the patient in advance of a video visit.
- Offer both virtual and in-person care options. Patients indicated the need for in-person options to evaluate certain physical concerns, such as broken bones or rashes. Patients feel they can determine if an in-person appointment versus virtual care is appropriate for their unique health issues.
Read the full report.
Designing and Offering Responsive Telehealth Support
September 10th, 2020
Since the beginning of the COVID-19 public health emergency in mid March 2020, primary care practices across the nation have adopted telehealth at astronomical rates. Working closely with California provider organizations, the Pacific Business Group on Health’s California Quality Collaborative (CQC) designed technical assistance webinars supporting primary care practices rapidly implementing and optimizing telehealth to care for patients unable to be seen in-person during the pandemic. CQC’s work highlighted significant challenges providers are experiencing, as well as lessons on how to maintain telehealth gains in the future.
What Provider Organizations Need Today
To better understand operational needs and challenges after several months of telehealth use, CQC conducted a survey and interviews with five primary care provider organizations representing 700 providers. Three takeaways emerged:
- Providers reported their top concern for the future is addressing patients’ care deferred during shelter-in-place orders
- 100% of the five provider organizations representing over 700 primary care clinicians surveyed think primary care telehealth visits will increase in next 6 months
- Practices are likely not able to take on “optional” operational improvements this fall as they recover and also prepare for later COVID-19 waves
Lessons from Designing Responsive Telehealth Support
Throughout the early months of the pandemic, CQC hosted regular expert webinars and curated a COVID-19 resource page for primary care provider organizations. Our team observed five key learnings that quality improvement organizations should consider when designing telehealth support, which we shared with national peers on a recent webinar for the Network for Regional Healthcare Improvement:
- Telehealth implementation can happen very quickly.
Most provider organizations who reported launching telehealth capabilities during the months of March and early April had, prior to the pandemic, been delivering very little care virtually.
- Most providers and patients like telehealth.
The rapid adoption of telehealth proved popular with both providers and patients. In a CQC webinar poll, 73% of providers were satisfied or very satisfied with telehealth, and most reported that they and their patients wanted to continue using telehealth into the future.
- Most care can be delivered virtually.
Even before the pandemic, some primary care practices are successfully offering 95% of their care virtually, including for high-risk patients. For recent adopters of telehealth, provider organizations have found that they are able to conduct many types of visits, especially chronic condition management, virtually.
- Billing and reimbursement are challenges.
Providers are worried about keeping up with changing guidelines and getting paid, especially when in-person revenue is down. While there have been promising signals from the federal government, the precise future of telehealth reimbursement remains unclear.
- Providers must ensure patients are equitably able to use virtual care tools.
Providers are concerned about equal access for their patients for technology and broadband. In the course of the pandemic, we’ve seen some viable solutions that clinicians can practice, which include: asking patients their preferences between audio or video visits, using patient advisory bodies to incorporate feedback, and simplify workflows whenever possible.
The Opportunity: Join CalHIVE
Using this feedback, this fall CQC is launching a technical assistance program, CalHIVE, which will support provider organizations as they re-design primary care delivery for people with chronic conditions by fully leveraging the capabilities of virtual care. California-based provider organizations are invited to participate in CalHIVE and can learn more on CQC’s CalHIVE website. Interested organizations can reach out to Michael Au at email@example.com to learn how CalHIVE can help their organizations improve virtual care to help their patients.
5 Pandemic Takeaways: Large Employers See COVID-19 as Catalyst for Systemic Health Care Change
July 8th, 2020
COVID-19’s long-term impact on U.S. health care remains unclear, but amid the ongoing turmoil and uncertainty, large employers see opportunities for much-needed reforms.
Elizabeth Mitchell, president and CEO of Pacific Business Group on Health (PBGH) and Lisa Woods, PBGH chair and senior director, U.S. Healthcare for Walmart, recently outlined five key takeaways from the pandemic during an online summit on the future of health care in a post-COVID world.
PBGH works with some of the nation’s largest employers in addressing health care purchasing challenges. Member organizations include 40 public and private entities that collectively spend $100 billion annually purchasing health care services on behalf of more than 15 million Americans.
Among the repercussions of COVID-19 from an employer perspective, according to PBGH’s Mitchell and Woods:
1. Telehealth is the future. Telehealth will continue to gain traction as a means of delivering appropriate care from a distance. Close to half of physicians are using telehealth in the wake of the pandemic, up from less than 20% two years ago. Analysts expect virtual physician visits will rise by 64% in 2020.
“We’re looking at ways to ensure that our associates can get the care they need in their home communities if they don’t feel comfortable traveling,” Woods said.
“We have been very focused on telehealth [at Walmart] and feel like it is the future,” Woods said.
2. Primary care needs more investment. With many primary care physician groups struggling due to fewer office visits triggered by concerns about COVID-19 exposure, fears are rising that provider consolidation will continue to accelerate, leading to ever-higher health care costs.
PBGH recently joined 35 other employer-focused organizations in urging Congress to impose a 12-month ban on mergers and acquisitions for health care organizations that received federal bailout relief. PBGH also is calling for immediate federal assistance for vulnerable primary care practices and the elimination of all or part of cost-sharing requirements for primary care visits.
Employers additionally want to see a greater emphasis placed on mental health and public health within the context of primary care and are looking for ways to positively impact social determinants of health (education, finances, food and housing insecurity, transportation).
“We haven’t been paying for the right things,” Mitchell said. “We’ve been focused on expensive tertiary care and elective procedures, and we need to focus on primary care. That’s how we keep people healthy and out of hospitals.”
3. Employers are hyper-focused on quality. “We know there are huge opportunities to identify how to get better outcomes, and we think purchasers are going to lead that charge,” Mitchell said.
Woods pointed to PBGH’s Employers Centers for Excellence as an example of the kinds of solutions employers will increasingly turn to in the pandemic’s wake. Through a rigorous evaluation and qualification process, PBGH has identified regional care centers that deliver high-quality elective surgical care for PBGH member-employees.
The centers were pioneered by Walmart and have been instrumental in helping PBGH members improve quality and reduce costs.
4. Employers want more control over contracting. Employers continue to be deeply concerned about health care costs that have been rising irrationally for years and worry the pandemic will fuel even higher prices.
Mitchell said financial pressure from COVID-19 has only exacerbated those concerns and will likely accelerate employer efforts to gain greater control of the health care purchasing process through direct contracting and other quality improvement and cost reduction efforts.
Direct contracting between employers and providers represents a promising solution, she said, because it creates an opportunity to “cut out the noise in the middle” to produce better and more cost-effective outcomes through collaboration between employers and providers.
5. The pandemic is forcing innovation. “[Employers] are going to be forced to innovate much more rapidly than they might have anticipated, because you can’t sustain a bloated, inefficient [health care] system in this environment,” Mitchell said. “The health care system didn’t fix itself, so employers are going to step in and fill that gap.”
In addition to boosting quality, Woods said eliminating unnecessary care—estimated to account for about one-third of all care provided—represents a key objective for employers. She noted that as providers ramp up from the pandemic-driven shutdown of recent months, it will be important to find ways to prevent unnecessary care from creeping back into the system.
The June 22-25 virtual summit during which Mitchell and Woods spoke was produced by Global Health Care, LLC, and included a wide range of presenters, from health plan and hospital executives to clinicians, educators and former policymakers. Their discussion can be viewed online here.
Primary Care Practices Can Engage Patients in Virtual Care
June 6th, 2020
During the most challenging phases of the COVID-19 pandemic, one opportunity for the health care delivery system has been the rapid adoption of telehealth and virtual care by both primary care practices and patients. The Pacific Business Group on Health’s California Quality Collaborative (CQC) has hosted webinars to support and spread successful practices in virtual care for independent primary care practices and IPAs as they rapidly implemented telehealth technology and workflows.
Nationally, the trends reflect widespread virtual care adoption. By one May 2020 analysis, telehealth visits in the US increased 300-fold in March and April 2020 compared to the same time period in 2019 (Epic Health Research Network). Providers have been pleased with their telehealth experience, and patients have too: 88% of patients new to telehealth said they would like to use it again (PwC Health Research Institute). The health system is eager to build on the implementation gains around virtual care made during the public health emergency, especially its ability to improve access to care and reduce costs.
Patient engagement in virtual care
Yet today, more than ever, it’s essential for health care clinicians and care teams to ensure that virtual care being provided is as patient-centered as possible. This topic was the focus of a May 6 webinar hosted by CQC, which highlighted presentations from a number of experts including Dr. Courtney Lyles, Associate Professor, Center for Vulnerable Populations at UCSF; Libby Hoy, Founder & CEO, PFCC partners; and Dr. Fiona Wilson, former Teladoc provider and current Supervising Clinician Specialist, Workers Compensation Division, Department of Human Resources, City & County of San Francisco.
Dr. Lyles shared examples from decades-long research done around patient portals, telephone visits and tactics that help bridge the “digital divide,” even in regions of strong technology adoption, such as the Bay Area. Her advice was not to make any assumptions about what patients do or do not have access to, and establish ongoing trainings, where patients can be assured to get continuous support for the virtual care they are seeking.
Libby Hoy of PFCC partners shared lessons from her organization’s history building patient advisory capacity. She cautioned that the work, especially at this time, is messy, but reminded care teams and providers that involving patients in the design process of the workflows results in more effective care.
Dr. Wilson shared her experience as a telehealth provider during COVID-19 for Teladoc, an organization that provides virtual care for patients all over the United States. Her advice for clinicians was to be an empathetic and engaged listener to patients when they are sharing their health issues, and make sure to ask about non-medical needs that may be even more present today, such as social isolation and economic hardship.
What providers can do now
Today, primary care practices are regrouping after shelter-in-place restrictions lift, adapting to a hybrid of virtual and in-person care, and working to address any care needs of their patients that were deferred during the height of epidemic. Yet even in this time of transition, CQC’s expert panelists shared the following steps practices can take to focus on patient needs:
- Always ask patients their preferences. Ask what technology they have access to, and what makes them comfortable. Make sure your visit builds on your relationship, addresses what device they are using and that you ask how you can be of help during this process.
- Look to your patients and families as resources to designing your telehealth programs. Outside even the visit, consider implementing patient open-ended surveys, focus groups, telephone calls or advisory programs. Tap into the people with the least experience to help you improve your work.
- Make workflows as simple as you can. Technology can be part of the barrier, but at the same time, almost everyone has a phone. Start with the tools that you and patients have. You don’t need a smart phone to conduct these visits.
Access CQC’s May 29 webinar recording and summary here.
Doctors Expect to Use Telehealth More Extensively Post COVID-19
April 27th, 2020
Physicians Embracing Telehealth During Pandemic
Telehealth is quickly emerging as an important clinical tool for physicians scrambling to adapt to the COVID-19 pandemic. Both patients and physicians report being happy with treatment delivered via telehealth, but doctors say barriers to adoption still exist.
Two April surveys conducted by the Pacific Business Group on Health’s California Quality Collaborative, during a webinar with independent physician associations (IPAs), community health clinics and managed services organizations, found that more than 80% of polled physician practices in California are presently using telehealth to deliver care.
Most practices report having launched telehealth services in earnest only in the three-to-four weeks after the pandemic’s shelter-in-place orders rolled out. Providers are using a combination of both telephone and video technologies not only for COVID-19 patient screening, but also urgent care, wellness visits and other clinical services.
Nearly three-quarters of poll respondents said clinicians were satisfied or very satisfied with providing care via telehealth.
Nonetheless, uncertainties remain about payment, policy and patient uptake of this technology. About one-third of respondents said policies on payment for telehealth were confusing or very confusing, and 64% said they need more guidance from health plans on billing.
Notably, about 40% of IPA representatives said they were extremely or very worried about their organizations’ financial health, while another 47% said they were somewhat worried.
During CQC’s webinars, IPAs and small physician practices identified a range of additional barriers to launching or expanding telehealth, including:
- Helping patients adopt telehealth, notably older patients without smartphones or with low digital literacy
- Reaching hard-to-find patients, like homeless patients without phones
- Improving patient acceptance and technical training (providers did note that when patients tried telehealth, they generally liked it)
- Providing staff training
- Documenting and coding for telehealth visits
Despite the challenges, there’s broad agreement that the COVID-19 epidemic has helped to push past resistance to the more widespread use of telehealth; 94% of IPA respondents tell PBGH that they expect to use telehealth differently or more extensively once the pandemic begins to abate.
Telehealth Providing Critical Pregnancy Support During Pandemic
April 20th, 2020
Telehealth has emerged as a vital tool for helping expecting mothers and clinicians manage pregnancy in the time of COVID-19.
That was the overarching take away from a recent webinar on maternity issues and the COVID-19 pandemic held by Pacific Business Group on Health and co-hosted by the Washington Health Care Authority and Washington Health Alliance. Participants included employers who help cover the costs of about 70% of all births in Washington state.
Telehealth’s ability to regularly connect pregnant women and their doctors has become essential in the face of the need to practice social distancing, which keeps expectant moms at home, employers said. An audio-visual link becomes particularly useful as mothers approach their due date or face the questions and concerns that inevitably follow birth.
According to employers, a growing number of health plans are making changes in telehealth coverage due to the pandemic, including waiving costs for patients who access care this way.
Ensuring that both payers and providers continue to support and expand telehealth services after the pandemic eases will be important, they added. On April 14, the Federal Communications Commission (FCC) announced a $200 million program to help non-profit providers establish telehealth services to better connect with patients.
Adjusting to the New Normal
Beyond increased use of telehealth, employers said the epidemic has resulted in a small percentage of pregnant women (5-10%) requesting transfers to birthing centers to avoid the risks of COVID-19 infection by delivering at a hospital. While most women will still deliver in a hospital setting, the current crisis has underscored the need to leverage all available maternity assets in our communities.
Developing a better understanding of how health benefit designs can create incentives for giving birth in settings outside the hospital, when appropriate, will be important for the future, employers said. Some webinar participants suggested that designating specific medical centers or alternative care sites as maternity centers could reduce risk of infection.
Employers also indicated that innovative solutions are needed to provide socially isolated expectant moms and new parents with venues for learning and reestablishing a sense of community. Possible options could include weekly education and Q&A sessions via Facebook Live or regular forums for discussing pregnancy-related issues that could be established through an employer’s human resources department. Group prenatal classes not only engage patients in their care and improve quality, these types of resources provide expectant mothers with necessary support from both peers and providers during this vulnerable time.
Looking Ahead: New Payment Models
Virtually all webinar participants agreed that the current fee-for-service payment structure constrains the way providers can deliver care, and that alternate ways of paying clinicians who provide maternity care are long overdue. New models are needed to support high-quality care that puts the patient’s needs first. Instead of having to ask themselves “can I bill for this,” providers could focus on simply delivering care in the most effective and patient-centered way possible.
Webinar participants echo what PBGH has been consistently hearing from patients and employers: the COVID-19 epidemic is creating an important catalyst for changes across health care and barriers to adopting telehealth more broadly may finally be coming down.