Advocacy & Policy Updates

Administration Disbursements from the Provider Relief Fund (PRF)

July 24, 2020

Additional distributions from the PRF have been announced in July, but no targeted distribution has been announced for primary care practices. Undisbursed funds remain available (as of July 24, estimated to be $58 billion) from the total $175 billion Congress appropriated under the CARES Act.  
Recent disbursements include:

  • $5 billion in much-needed funding has been announced for nursing homes to hire more staff, improve infection control, increase testing, and provide support for residents to communicate with family and friends.
  • $10 billion has been announced for a second round of funding for hospitals in “hotspots” in addition to a $12 billion allocation previously made.
  • HHS has also notified providers of reporting requirements it intends to issue in August.  

Summer update on PCC's policy and advocacy work

July 1, 2020

The PCC has been dedicated to documenting the plight of primary care practices and patients during the historic COVID-19 pandemic as well as leading multi-stakeholder strategies and advocacy to save and strengthen primary care right now.

  • We have amplified and lifted up key messages of the #SavePrimaryCare campaign, including disseminating our letter to Department of Health and Human Services Secretary Alex Azar widely and leveraging our social media presence. Feel free to use our letter to write your own letter to urge Azar to make a targeted allocation from the CARES Act provider relief fund for primary care practices.
  • We redoubled our outreach to congressional offices and HHS officials to highlight the staggering $15 billion figure - the recent estimate from researchers at Harvard Medical School’s Center for Primary Care of revenue losses that primary care practices will collectively sustain in 2020.  The PCC is grateful for the work of Sanjay Basu, MD, PhD, and colleagues and the willingness of Health Affairs to fast-track release of this careful, conservative estimate of financial losses by primary care practices sustained collectively and at the practice level. Most alarming, the study estimates losses could grow to $19 billion if the predicted second-infection wave comes in the fall, and losses could reach $39 billion if HHS retreats from the temporary emergency-based telehealth payment policies.  

Together with our leadership, the PCC is beginning to compile and prioritize which of the many regulatory waivers we would like to see become permanent to accelerate primary care transformation and payment-reform efforts. We signed on to a letter led by HIMSS to signal our interest in making some of the Medicare telehealth waivers permanent.

Temporary Federal Waivers of Payment, Other Rules

While the federal response to COVID-19 has been mixed at best, HHS leadership has taken extraordinary steps to waive regulations in order to give flexibility to the healthcare delivery system to more readily serve patients safely with virtual visits. With authorization from Congress, restrictive Medicare telehealth rules have been lifted, payment parity established, and telephonic visits made eligible for reimbursement. For more information about these changes and their contingency on different federal emergency declarations, see McDermott Consulting’s helpful summary.

Waivers Support Team-Based Care, Virtual Care

The broad sweep of regulatory waivers by federal and state authorities during the pandemic cannot be understated. The Alliance for Connect Care has been tracking them. The regulatory waivers encompass supervision requirements, whether a relationship has been “established” before treating a patient via telehealth, which clinicians are eligible to provide treatment and bill for telehealth services, how methadone is dispensed to patients in treatment for opioid addiction, and whether a licensed physician can treat a patient residing or staying across state lines. These are just a few of the regulations that have been waived by federal and state officials. Many of these regulations inhibit the development of team-based care and the ability of practices to innovate and optimize the team’s effectiveness and efficiency. Some are not patient-centered and rather paternalistic.

The PCC looks forward to hearing from our membership about how to leverage the possibilities created by these waivers if they were to be made permanent, while also including guardrails that ensure accountability for quality,  appropriateness of care and patient privacy.

(republished from PCC's summer 2020 newsletter)

Highlights from the States: Efforts to Increase Primary Care Investment Continue

July 1, 2020

Below are brief summaries of the efforts of five states to support primary care, including efforts that COVID-19 has prompted given the financial challenges that the pandemic has wrought.

North Carolina
As this newsletter is disseminated, PPC applauds Blue Cross and Blue Shield of North Carolina’s recent announcement to support independent primary care practices financially as they weather the COVID-19 storm. Financial support will be in the form of per BCBSNC beneficiary payments estimated to make the 2020 practice revenue equivalent to 2019 revenue. To be eligible, practices must commit to remaining independent and joining one of BCBSNC’s value-base primary care or ACO payment models by 2021, which means joining its Blue Premier network payment model. For more information, see Chief Medical Officer Rahul Rajkumar’s post.

In late 2019, Massachusetts Gov. Charlie Baker released comprehensive legislation that would incentivize health plans and providers to devote more resources to primary care and behavioral health services. It builds on Massachusetts’ comprehensive approach to managing growth in the total cost of care and its cost benchmarking process (see below). While the bill has not advanced in 2020, it remains a post-COVID-19 priority for the governor. See the summary.

In June 2020, Delaware issued a “preliminary look” at aggregate state healthcare spending under its state healthcare spending benchmark, which was established by executive order of Governor John Carney in 2018. The report, which uses data submitted by insurers, includes an attempt to measure primary care spending and will provide an opportunity for primary care advocates to dig deeper into the numbers and continue to educate stakeholders.

There were a number of recent efforts to support and further primary care, including those driven by employers, a health plan and nurse practitioners.    

The Pacific Business Group on Health teamed up with the California Medical Association on a proposal called the Care for Californians Initiative that would require health plans to use unspent premiums already collected from employers and consumers to pay primary care providers emergency prospective payments in 2020 and 2021.

Blue Shield of California announced an ambitious Health Reimagined initiative that will use value-based payment models and take a “holistic” approach to care while leveraging digital tools and efforts to reduce administrative burdens on physicians.

Legislation was introduced early in 2019 to give nurse practitioners expanded scope to practice independently. It passed out of the state assembly before stalling in the state senate but remains a priority for advocates of care for underserved communities, such as the California Health Care Foundation.  

The Milbank Memorial Fund sponsored an issue brief from the team leading Maryland’s Primary Care Program (MDPCP). A multi-payer model that is integrated with Maryland’s broader all-payer “total cost of care model,” the MDPCP is a comprehensive approach that builds on learnings from the CMMI Comprehensive Primary Care (CPC) and CPC+ models. Maryland’s investments in health information exchange and data collection will also support MDPCP.

If we missed your state and an item you want to share, please reach out to Alyssa Neumann at [email protected]

(republished from PCC's summer 2020 newsletter)

PCC Among 340 Organizations Sending Letter to Congress Urging Action on Telehealth

June 29, 2020

PCC is among the 340 organizations that sent a letter today urging congressional leaders to make telehealth flexibilities created during the COVID-19 pandemic permanent. Organizations signing this multi-stakeholder letter include national and regional organizations representing a full range of healthcare stakeholders and all 50 states, the District of Columbia, and Puerto Rico.

Congress quickly waived statutory barriers to allow for expanded access to telehealth at the beginning of the COVID-19 pandemic, providing federal agencies with the flexibility to allow healthcare providers to deliver care virtually. If Congress does not act before the COVID-19 public health emergency expires, current flexibilities will immediately disappear.

Therefore, 340 stakeholders have sent a powerful message to Congress outlining the immediate actions necessary to ensure CMS has the authority to continue to make telehealth services available once the national health emergency is rescinded:

  • Remove obsolete restrictions on the location of the patient to ensure that all patients can access care at home and other appropriate locations;
  • Maintain and enhance HHS authority to determine appropriate providers and services for telehealth;
  • Ensure Federally Qualified Health Centers and Rural Health Clinics can furnish telehealth services after the public health emergency; and
  • Make permanent Health and Human Services (HHS) temporary waiver authority for future emergencies.

While federal agencies can address some of these policies going forward, the Centers for Medicare and Medicaid (CMS) does not have the authority to make changes to Medicare reimbursement policy for telehealth under the outdated Section 1834(m) of the Social Security Act. Following these priorities will allow CMS to build on the experience gained during the pandemic and expand access to telehealth in a thoughtful, data-driven way.

Read the letter to Congress, including the list of 340 stakeholders

Former CMS Leaders Write to Congressional Leaders About Role of Payment and Regulatory Flexibility in COVID-19

June 12, 2020

Six former leaders of the Centers for Medicare and Medicaid Services sent a joint letter June 10 to congressional leaders about the role of payment and regulatory flexibility in responding to the COVID-19 pandemic and addressing serious challenges in access to care and disparities in health outcomes in the pandemic and beyond.

In the letter, the leaders, who have served in the roles of CMS Administrator, Acting CMS Administrator, and HCFA Administrator, proposed three steps to support clinicians and other health care providers in the COVID-19 response and to build on reforms for the future. The letter was addressed to Speaker of the House Nancy Pelosi; House Minority Leader Kevin McCarthy; Senate Majority Leader Mitch McConnell; and Senate Minority Leader Chuck Schumer.

Read the full letter.

PCC joins #saveprimarycare campaign to call for dedicated funding to primary care

June 1, 2020

Today (June 1) begins a week of national advocacy for primary care. The PCC and many other organizations are part of this campaign, called #saveprimarycare. We are reaching out to Congress and the administration to call for dedicated funding to primary care to help practices continue to serve patients during the public health and economic crisis posed by the coronavirus.

As part of the campaign, PCC, representing over 60 organizations, today sent a letter to Department of Health and Human Services Secretary Alex Azar urging him “and the Department of Health and Human Services (HHS) to make an immediate, targeted allocation from the Provider Relief Fund (PRF) to primary care clinicians and/or practices in order to offset reduced revenue and increased costs associated with COVID-19. The targeted allocation that HHS has already made to rural hospitals from the PRF should serve as a model for primary care.”

PCC will also be sharing campaign messages on its Facebook and Twitter pages this week. You are encouraged to join the campaign by reposting our social media messages or your own messages. Be sure your posts (especially on Twitter) include the campaign’s hashtag—#SavePrimaryCare—and tag Secretary Azar (@SecAzar) and his agency HHS (@HHSgov).

PCC’s COVID-19 Policy Priorities

May 5, 2020

Policies to Support Patients and Primary Care During the Coronavirus Pandemic

PCC is working with its members on a unified legislative ask that would to provide direct financial relief to primary care clinicians. In addition to the overall campaign to advocate with the administration and Congress for targeted funding for primary care from the Provider Relief Fund, the PCC is also advocating for these more specific COVID-19-related policy proposals. Read more.

The Stakes for Primary Care - Opening Presentation of a Capitol Hill Briefing

May 1, 2020

Two PCC Executive Members, the Pacific Business Group on Health and American Academy of Family Physicians, along with the Partnership to Empower Physician Led Care, hosted an online Capitol Hill briefing on April 30 titled The Stakes for Primary Care: Impact of COVID-19 on Primary Care Access and the Urgent Need for Action.

Among those who presented at the briefing was Rebecca S. Etz, PhD, Co-Director of The Larry A. Green Center and Associate Professor of Family Medicine and Population Health at Virginia Commonwealth University. Dr. Etz is leading the Green Center's work on a weekly survey of primary care clinicians that PCC is involved with. 

Dr. Etz's presentation was the first at the briefing, and it set the scene for the state of primary care during the pandemic and for other experts to provide their perspectives. Among her evidence on the precarious state of primary care amid COVID-19 were the results of the latest Green Center-PCC survey.

Following is the verbal part of her presentation. The emphases (capital and bold letters) in the following text are hers.

My name is Rebecca Etz. I’m an associate professor of family medicine and population health at Virginia Commonwealth University and Co-Director of the Larry Green Center.

Now I know this CONVERSATION is just another in a long line of meetings FOR YOU, BUT WE NEED TO TALK.

I’m asking you to hit the pause button,
put aside your other work
and focus.

We need your full attention
because primary care is dying.

The US has systematically starved it more than 30 years. The American public deserves better.

The data informing this presentation were collected 2 days ago. It’s a stark view of what primary care looks like on the ground – and one that you STILL have a chance to fix.

I only have time for highlights but would be happy to follow up on questions later. My comments are my own. I represent no particular specialty or organization. These data were collected across all primary care specialties and clinician types.

For most people, primary care is the first point of contact with the health care system. The literal front line. It is a relationship with a person and team who take into consideration your full social and medical history when participating in your care.

Primary care is over half of ALL medical visits ACROSS the US. That’s over 500 million PATIENT visits. It does this with one-third of the healthcare workforce and less than 7% of the national health budget. That bar for funding support is not a typo. Primary care receives zero-point two percent of NIH funding. This is an epic fail.

On March 13, the Green Center, in conjunction with the Primary Care Collaborative, launched a weekly survey of primary care clinicians. It is the first and only survey of its kind. We are seven weeks in with close to ten thousand responses collected.

The survey is distributed with the help of over 50 organizational partners across all primary care groups. This is no time to fight among the professional guilds – this isn’t a disciplinary crisis, it’s a humanitarian one. All of these first responders are battling the front line of a health crisis like none we have ever seen.

Primary care has a new normal: it is corrosive, debilitating, and constant.

Three quarters of clinicians work under continuous and severe stress. Regardless of governance or structure, primary care is STILL the FIRST on the scene and the LAST to receive support.

They have limited testing capacity and not nearly enough personal protective equipment but show up every day to help their patients fight a virus with no vaccine and no treatment.

When the pandemic hit, primary care moved swiftly and with clarity of purpose.

OVERNIGHT, they adopted virtual care systems to prevent unnecessary coronavirus exposures and to expand avenues of access that served the public. Despite the anticipated financial hit, clinicians adjusted to caring for patients at a distance. Despite significant decreases in patient volume, clinicians continue to work harder and longer, at great personal risk.

And yet seven weeks in, over two-thirds report the majority of their work is not covered by payment of any type. And almost 50% have had to furlough or lay off staff.

11% of primary care clinicians say they will close in the next 4 weeks while two thirds are uncertain about their
sustainability 4 weeks out.
One third are applying for loans.

Think about that.

11% of an industry will be shuttered and over 60% of that industry struggles to picture their future one month ahead.

There will be no easy fix when this happens. Fewer than 20% of medical graduates are entering primary care. Our failure to figure out how to hold up this critical resource means that the largest public health crisis of our lifetimes could be an extinction-level event for primary care.

What about virtual care? Care delivered through video, secure messaging, and phone has exponentially expanded in the past 7 weeks.
It is necessary and it is good, but it is not sufficient.

Payment for virtual health is not yet at parity. Among those payers who have expanded payment, the new coding requirements are dizzying and cumbersome. Virtual health offered is not the same as virtual health received. Broadband access is currently not sufficient to support the country’s needs. Many patients struggle with technical literacy and internet access. Over two-thirds of clinicians report patient obstacles to virtual

And this modality of care cannot replace the need for tests, vaccines, procedures, or touch.

In the immediate and necessary response to COVID, many usual activities have been pushed aside. 80% of clinicians report limited well and chronic care visits. Delayed usual care and avoidance of medical settings is starting to cause greater harm among segments of the population. Clinicians express grave concerns about chronic conditions that continue unchecked and cancer screenings or vaccinations that pass unaddressed.

We are bearing witness to a now tenuous and fragile contract.

The contract goes something like this – as your primary care clinician, I will be there for you when and where you need me.

I will be worthy of your trust.
I will treat you with fullness of dignity and personhood.
And I will put your interests above my own.

In exchange, we as a society agree to invest in this highly effective public good.

COVID-19 has caused a final blow to this social contract that has been eroding through decades of neglect. Quality measures are misaligned. Documentation is burdensome. And for too long, we have enacted piecemeal payment and delivery solutions.

I find it fascinating that many of these challenges have been completely set aside during the pandemic. To get done what needed to get done, primary care blew by these obstacles to accelerate the pace of change.

The next action lies with you.
The opportunity to restore this social contract is now.
The window is immediate.

Relaxed Telehealth Restrictions from CMS

March 31, 2020On March 17, CMS issued new guidance on telehealth services for Medicare beneficiaries to help providers more flexibly diagnose and manage patients during the novel coronavirus pandemic. Telehealth visits under Medicare are now reimbursed at the same rate as in-person visits, and practices have the flexibility to reduce or waive cost sharing for patients. This applies to physicians, nurse practitioners, clinical psychologists, and LCSWs. The updated policy also temporarily waives geographic and originating site restrictions for telehealth that previously limited eligibility to patients in rural areas who travel to a medical facility to access the services. During the emergency period, providers may now use a range of virtual platforms—including Skype, Facetime, and Google Hangouts—as long as they are “good faith use of telehealth.” The eased restrictions were based on authority granted in the “Phase 1” stimulus package as well as the president’s national emergency declaration.

Growing Number of Emergency Medicaid Waivers

March 31, 2020

The president’s national emergency declaration on March 13 authorized states to apply for 1135 waivers granting time-limited flexibilities to respond to the crisis. As of Friday, 34 states had been granted Medicaid waivers that offer a range of flexibilities such as the abilities to enroll out-of-state or new providers more quickly and to temporarily suspend prior authorization requirements. See the latest list of state waivers on Medicaid’s website.

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