Telehealth

Chronic pain presents a variety of challenges to the healthcare system, including a high number of individuals suffering with chronic pain (ie, 40% of US adults), escalating costs (ie, $635 billion annually in the USA), and complex medical management.28 Furthermore, these challenges must be met by a limited workforce.28 The Association of American Medical Colleges 2017 specialty data report documented 5,435 total active pain physicians, with 93% of these physicians active in patient care.29 Therefore, physician specialist access and travel distance often complicate the ability for patients to receive high-quality pain care. Telemedicine is a viable digital therapy that may help overcome these obstacles.

Prior to the COVID-19 pandemic, the utilization and effectiveness of telemedicine in treating chronic pain had been investigated. Research demonstrated that telemedicine for treating chronic pain improved care access, reduced wait times, decreased costs, and maintained patient satisfaction.30–33 These findings have also been replicated in other fields, including emergency medical care, neurology, primary care, headache medicine, and surgery.34–41 Telehealth is also beneficial in assisting with biopsychosocial care for patients suffering with pain.42

While telehealth has increased in interest and viability as technology has continued to improve, prior to the COVID-19 pandemic its utilization has been deterred by challenges in reimbursement and coverage. However, the COVID-19 pandemic has catapulted the importance of telehealth and rapidly advanced its utilization. As stated, most pain management care falls under the Tier 1 or Tier 2 service classification and thus in-person care has been limited. Telehealth is well versed to meet non-urgent care needs during pandemics and global emergencies.43–45 In addition, it can help triage patients that need to be seen in care facilities for urgent needs.

Under the Coronavirus Preparedness and Response Supplemental Appropriations Act signed into law on March 6, 2020 and the 1135 waiver authority, CMS significantly improved patient access to virtual care services during the COVID-19 pandemic (table 1).46 The new legislation gave the US Department of Health and Human Services (HHS) Secretary the authority to waive numerous telehealth requirements for the duration of the COVID-19 Public Health Emergency (PHE), including the originating site, rural area designation, place of service, Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant telecommunication platform, and established patient requirements. Based on reducing the place of service requirement, Medicare beneficiaries can now receive these services in their home. In addition, on March 30, 2020, CMS issued additional emergency declaration blanket waivers for healthcare providers. One of these waivers allows physicians and other practitioners to render telehealth services from their home and bill from their currently enrolled location.47 Due to the US HHS waiving potential penalties for healthcare provider HIPAA violations that involve telehealth medical services for patients, everyday communication technologies can be used, including FaceTime, Skype, Facebook messenger video chat, Google Hangouts video, and Zoom.48 Strategies that still need to be avoided include public-facing platforms, including Facebook live, Twitch, and TikTok.48

CMS also removed some of the telehealth financial barriers and declared that telehealth visits will be paid at the same rate as in-person visits when virtual services are provided with interactive audio and video, real-time communication. On March 17, 2020, the US HHS Office of the Inspector General announced that they waived enforcement of federal penalties for providers who waive beneficiary cost-sharing requirements for federally paid telehealth services during the COVID-19 health emergency. Furthermore, under the interim final rule, CMS finalized separate payments for telephone-only evaluation and management (E/M) services (table 1).49 However, reimbursement remained a barrier for telephone E/M services and the reimbursement levels did not cover associated overhead costs. The American Society of Regional Anesthesia and Pain Medicine submitted comments to CMS urging the agency to use the authority to waive the video requirement for furnishing E/M services via telehealth across all settings and places of services or to increase reimbursement to telephone E/M services to bring them in line with office/outpatient in E/M services.50 On April 30, 2020, CMS issued additional changes to healthcare, including further expanding telehealth which included increasing payments for audio-only telehealth services to match payments for similar office and outpatient visits.51 Table 1 demonstrates the considerable difference in the office/outpatient E/M services versus the audio-only E/M service codes prior to the April 30 CMS telehealth expansion.

Remote prescribing

Due to change in the Drug Enforcement Agency (DEA) policies, the ability to provide patients with controlled substances following a telehealth visit became a possibility.52 The DEA lifted prescribing restrictions on treating new and established patients with chronic pain through telehealth during the COVID-19 PHE. On March 20, the DEA announced that telehealth may be used for prescribing controlled substances as long as the following conditions are met by the prescriber: (1) acting within their usual standard of care and the prescription is for a legitimate medical purpose; (2) acting within applicable federal and state laws; and (3) telehealth communication is conducted using real-time, two-way, audio-visual interactive communication system. On March 25, the DEA granted an exception to the requirement that a DEA registrant must be registered in each state in which the practitioner dispenses controlled substances. On March 27, 2020, the DEA broadened the requirements of paper delivery of a prescription of an oral emergency prescription to include photographed and scanned prescriptions. The DEA also expanded practitioners’ ability to treat opioid use disorders (OUDs) via telehealth by allowing for the prescription of buprenorphine to new and existing patients with OUD for maintenance and detoxification treatment.52 Although many DEA restrictions have been lifted during the COVID-19 PHE, physicians should still follow safe opioid prescribing procedures, including the assessment for an appropriate indication, adequate pain control, adverse events, aberrant behavior, and activities improvement.53 The opioid risks and benefits also need to be provided to patients and naloxone should be prescribed when appropriate.

Implementation

Once the COVID-19 pandemic imposed treatment restrictions, most practices, including the authors, had to move efficiently to implement an effective telehealth service that is financially viable. Steps required included (1) reviewing the telehealth expansion 1135 waiver; (2) analyzing local and national coverage determinations for telehealth; (3) implementing communication strategies, preferably an HIPAA-compliant telehealth service; (4) educating team members on the telehealth process; (5) detailing processes for billing, coding, and collections; and (6) defining processes to assist patients in their understanding of the technology. Although currently non-HIPAA-compliant services can be used, in a survey identifying patient perceptions of telehealth, privacy was identified as a primary concern.35 Furthermore, it is critical that staff members educate patients on the practices’ telehealth platform. Confidence in telehealth has been shown to positively correlate with a patient’s desire to use the relevant technology.54 It is also important to remember that many of the waivers and regulations that occurred during the COVID-19 pandemic will likely be reversed or modified. Private insurers may not necessarily follow the CMS policies. Practitioners must continuously monitor legislation and coverage determination policies to remain in compliance. Additionally, the limitations of telehealth must be recognized, and in-person visits need to be considered when telehealth services are inadequate.

The reduction in regulations related to telehealth during the COVID-19 has assisted in meeting the needs of patients with chronic pain in the Tier 1 and Tier 2 classifications. Clearly, the COVID-19 pandemic has accelerated the acceptance of digital medicine. Prior to the pandemic, it was estimated that the value of the telehealth market would be approximately $36 billion in 2022.44

Medical office staffing and management

With the loss of anticipated recurring revenue, maintaining the financial viability of the medical practice requires a complete analysis of variable and fixed costs. Practices need to maintain financial solvency in order to meet its core mission of providing and maintaining medical care. Unfortunately, in order to maintain this financial solvency, challenging and uncomfortable decisions are often needed. Although a majority of office care would be deemed a Tier 1 or Tier 2 service, high acuity treatment (Tier 3) strategies still need to be in place. Under the CMS framework, a Tier 3 service is defined as when the lack of in-person treatment or service would result in patient harm. In these cases, in-person medical office treatment is an essential service and needs to be available. Medical office patient care is an essential service required for the treatment of emergent and necessary follow-up care.

Since staffing is a variable cost, practices will need to employ new staffing models to decrease overhead. First, to provide care a practice must maintain a leadership staff to monitor and redirect resources and limited clinical and clerical staff to help with clinical daily duties. Staffing not needed based on clinical demands and financial indicators may need to have their schedule hours reduced or furloughed. Since there is the expectation to rehire staff once the situation improves, it is recommended to maintain employee benefits, including health insurance and other benefits. During this downtime, the billing department or service should be redeployed to focus on the collection of accounts receivable, especially older accounts (ie, accounts receivable greater than 30 days). Physician salaries will also need to be adjusted to maintain adequate cash flows and reserves.

Surgery center staffing and management

Ambulatory surgery centers are authorized by the State Department of Health (DOH) and licensed and regulated by the state. During the COVID-19 pandemic, ASCs are restricted by their respective states’ DOH to perform procedures only for life-sustaining measures. Cases that would fit under the guidelines would include (1) acute infection, (2) acute trauma that would significantly worsen without surgery, (3) potential malignancy, (4) uncontrollable pain that would otherwise require hospital admission, and (5) a condition or prognosis that would significantly worsen with a delay in treatment. The initial decision on whether to keep the ASC open depends on the needs and case mix of the medical staff. Although the caseload in our surgical center (GAB and DAP) has significantly decreased as we follow the DOH guidelines, we have elected to keep the center open. One reason was that the transition to an increased workload following the removal of ASC restrictions will progress more efficiently than reinitiating operations from a closed ASC. Critical staff including administrative leadership (Director of Operations and Administrative Director) is required. Cross-training of the remaining staff is a necessity. A small amount of staffing will be necessary for building maintenance, inventory management, and medical records. As with the office, the billing department continues to function and focuses on accounts receivable. Staffing is, again, decreased through furloughing and reducing staff hours. Benefits including health insurance are maintained. The Director of Operations provides daily feedback to the DOH and regional health alliances. Information in the reports includes performed cases and supplying capacity (eg, ventilators) availability to assist with overflow needs.

Medicare provider distributions

A CARES Act funding of $50 billion was dedicated to the Provider Relief Fund and was allocated for general distribution to Medicare facilities and providers based on eligible providers’ 2018 net patient revenue.55 The initial $30 billion was distributed between April 10 and April 17, and the remaining $20 billion began to be distributed on Friday, April 24. The following list summarizes the CARES Act Provider Relief Fund:

• To expedite providers getting money as quickly as possible, $30 billion was distributed immediately, proportionate to 6.2% of providers’ Medicare fee-for-service reimbursements in 2019. This simple formula used the data on hand to distribute money to providers as quickly as possible.

• The US HHS began distribution of the remaining $20 billion of the general distribution to these providers on April 24, allocating money proportional to providers’ share of 2018 net patient revenue.

• These funds are not loans and will not have to be repaid. However, providers receiving funds will need to sign an attestation confirming receipt of funds and agree to the terms and conditions of payment and confirm the CMS cost report.

• The terms and conditions of payments require the provider to submit documents enough to ensure that CARES Act funds were used for healthcare-related expenses or lost revenue attributable to coronavirus.

• The portal to sign the online attestation and accept the terms and conditions is now available: https://covid19.linkhealth.com/#/step/1.

PPP loans

Established by section 1102 of the CARES Act, the Small Business Association (SBA), in consultation with the Department of the Treasury, developed the PPP.56 In summary, the PPP is a loan designed to provide a direct incentive for small business, including pain medicine practices, to keep their workers on the payroll. The following list summarizes the PPP loans:

• Although funding through the PPP is a loan, the SBA will forgive loans if employees are kept on the payroll for 8 weeks following the loan origination and the money is used for payroll, rent, mortgage interest, or utilities.

• Any small business, non-profit organization, sole proprietor, or independent contractor may apply if they employ fewer than 500 per location.

• The non-fee loan will be fully forgiven if the funds are used for payroll costs, interest on mortgages, rent, and utilities, provided that 75% of the loan amount is used for payroll.

• Loan forgiveness is requested through the lender. The lender must decide on forgiveness within 60 days.

• Loan forgiveness will be reduced if full-time head count declines or if salaries and wages decrease.

• The PPP loan has a maturity of 2 years and an interest fixed rate of 1%. The interest will continue to accrue during the deferment period. The borrow application may be accessed online and processed from the local bank or eligible lender: https://www.sba.gov/document/sba-form--paycheck-protection-program-borrower-application-form.

In our practices, including the ASC, the PPP will assist in the re-employment of staff.

Accelerated and Advance Payment Program

CMS had expanded an existing Accelerated and Advance Payment Program to a broader group of Medicare providers during the COVID-19 PHE.57 This program was previously established to provide expedited payments due to national emergencies or natural disasters to accelerate cash flow to impacted healthcare providers. The following list summarizes the Accelerated Advance Payment Program:

• To qualify, medical practices or providers must have billed Medicare within 180 days prior the request application, not be in bankruptcy, not be under active medical review or investigation, and not have any delinquent Medicare overpayments.

• Providers may request up to 100% of the Medicare payment amount for a 3-month period.

• Repayment begins 120 days after the date of issuance.

• Accelerated and Advance Payment Program request forms are found on the individual provider’s geographic area Medicare Administrative Contractor website.

• On April 26, CMS announced that it is re-evaluating the amounts that will be paid under its Accelerated Payment Program and that it is suspending the Advance Payment Program to part B suppliers including physicians.58

While the above government support programs provide much needed funding to see medical practice and providers through the immediate crisis and rehire and retain staff, these programs are not the answer to long-term medical practice survival. A recent survey by the Primary Care Collaborative found an alarming 47% of practices report being unsure of whether they will be able to remain open due to lack of cash flow.59 Additionally, the Medical Group Management Association has surveyed medical practices of all sizes and specialties and found an alarming direct and indirect financial impact of the COVID-19 pandemic, with on average 55% decrease in revenue since the beginning of the pandemic crisis and a 60% decrease in volume.60 This paints a dire picture not only for independent medical providers, but for the millions of patients who rely on them for their care.

Business interruption insurance

Business interruption insurance is normally incorporated in most casualty and loss policies carried by medical practices and ASCs. The purpose of the insurance is to compensate an insured for losses due to a slowdown or suspension of its operations. The policy may include coverage for lost revenue and certain expenditures such as rent or lease payments, wages, and loan payments. Traditionally, the insurance generally required physical damage to the property restricting the ability to perform business. Recent legislation is being considered in several states to require business interruption insurance to provide coverage for lost revenue during the COVID-19 pandemic. A recent Pennsylvania Supreme Court ruling strengthens the argument for COVID-19 loss coverage. In ‘Friends of DeVito vs Wolfe’ the court supports the concept that business losses during the pandemic are indistinguishable from those caused by earthquakes, fires and other casualty events for which property-based insurance coverage was intended.61 It is important to contact your insurance carrier and gather loss information related to COVID-19. Most likely legislative intervention will be required for successful enforcement of these policies.