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Compassus CMO Merkelz: Better Payment System Needed for Hospice Telehealth

In this interview with Hospice News, Compassus Senior Vice President and Chief Medical Officer Dr. Kurt Merkelz describes how telehealth services increase efficiency and expand access to hospice care. “We value the high touch in-person relationship that hospice is there to provide, but we gained a deeper understanding of how we can optimize patient care through the use of telehealth. We are finding opportunities to leverage innovation and services that previously were unavailable to patients or had not been properly utilized,” he said. Read on to learn how telehealth and innovation can drive improvements in patient care and satisfaction and the barriers hospice providers face to maximize these opportunities.

This article was originally published by Hospice News.

Kurt Merkelz, MD

Kurt Merkelz, M.D., Senior Vice President and Chief Medical Officer

Telehealth boomed during the COVID-19 pandemic as hospice providers scrambled to stay connected to patients while limiting in-person contact to prevent the spread of the virus. Most stakeholders in the space agree that telehealth will be here to stay following the pandemic. While clear benefits exist for this trend, some are concerned that a lack of a reimbursement structure or quality metrics for telehealth could have adverse effects.

Hospice News spoke with Kurt Merkelz, M.D., chief medical officer for Compassus about how a lack of billing codes or quality reporting for telehealth could impact providers in the long term. Compassus, one of the nation’s largest hospice providers, is a portfolio company of the private equity firm Towerbrook Capital Partners and the health system Ascension Health.

What are your thoughts on the transformations you saw in telehealth during the pandemic?

Hospices have used telehealth before. We are trying to look at how we could potentially leverage the opportunity and leverage the communications support, but the pandemic accelerated the necessity. It became an opportunity to really provide choice to the patients and families to enjoy the more of a sense of feeling secure about their safety and not having a disturbance in their home. There was a tremendous amount of fear that existed in patients, families, and health care workers. Early in the pandemic, we had no idea what the mortality impact [of COVID] was going to be.

We can layer on top of that the whole crisis that we had around [personal protective equipment (PPE)]. Being able to reach out and access patients became so critically important during this time period. There’s the whole other issue that arose in which nursing homes were being devastated, so they locked their doors, essentially. We were not allowed access to patients we were jointly caring for. There was no other way to make contact short than telecommunications. of having telecommunications available to provide the needed care.

Then there was the grief that was taking place and the emotional toll this took. We had to reconsider how we support grieving families. We were able to reach out through virtual bereavement platforms to provide that grief support to family members who had lost loved ones.

There was also the emotional toll it took on the staff themselves. The staff were losing family and patients that they had cared for. There were colleagues who are becoming sick, which affected the workload. Individuals were working long hours seven-days-a-week. They were exhausted. We started offering the same type of virtual grief support services to clinicians and other caregivers.

Do you think of that overall, the boom in telehealth was a positive development?

Absolutely, we’re moving towards telehealth. We value the high touch in-person relationship that hospice is there to provide, but we gained a deeper understanding of how we can optimize patient care through the use of telehealth. We were using it [prior to the pandemic], but we weren’t really understanding its full potential. With the pandemic, we were forced into the process. We started realizing that this is something we should be doing for patients.

At Compassus, Innovation is part of who we are, a part of our culture. We are committed to improving the end-of-life and serious illness care experience. We consider important, often unasked questions. What are the outcomes that are important for patients to succeed? Who’s having to deal with serious illness and chronic disease management?

We know that one of the things they need, for instance, is good medication reconciliation. You don’t have to be in person to review a medication list. This is a real value- added service that can be more effectively implemented through a telehealth encounter. We are finding opportunities to leverage innovation and services that previously were unavailable to patients or had not been properly utilized.

Telehealth increased efficiency. We can reach out to more patients through telehealth and we save so much on the drive time to patient homes. Especially if the patient just has some questions about the utilization, further understanding of a medication and so forth. Through the ability to discuss this via telehealth, we save two hours of drive time for a clinician. And when that patient really needs that in-person visit, we’re there.

Are hospices reimbursed for the telehealth services through their usual per diem? Or is there a separate process for those claims?

Wouldn’t that be perfect if there was a separate process? Everything is covered under the same hospice per diem. No [billing] codes were added [by the U.S. Centers for Medicare & Medicaid Services (CMS)] into the proposed Fiscal Year 2022 hospice payment rule.

In addition, the proposed rule called for new quality metrics that actually work against the system. If we tried to do telehealth, they put in such metrics as the number of minutes of nursing time with the patient. In my 30 years as a health care provider, I’ve never once known that a certain number of minutes equals an improved outcome. I’m not sure how this is a quality metric. When you think about the number of minutes that are provided via telehealth, if it’s not getting captured it works against us, because now only in-person minutes are being recorded.

We’re not getting any credit for the truly valuable care that’s being provided through telehealth.

There’s another [proposed] called quality metric, noting time greater than seven days between patient visits. If the patient didn’t need or didn’t want a service sooner or didn’t want a service sooner or received care through a telehealth encounter, it’s not at all captured. This can adversely affect our quality metrics.

There’s a lot of barriers to there not being a payment mechanism for telehealth and not recognizing the value.

What do you think should happen in regards to telehealth reimbursement for hospice?

First, its value has to be appreciated, and it has to be understood. There’s little incentive right now for hospices to invest in telehealth because there’s no payment for it. It’s expensive. We need good quality, interoperable systems. Hospices have to do it at our own cost whereas hospitals have received millions to integrate effective [electronic medical records] systems. We receive no federal money for these systems, even though hospice is recognized as a value and benefit to patients.

The other thing is, maybe it was too much too soon with telecommunications. Everybody started doing it, and they didn’t have the training. They didn’t have the understanding. We probably need to slow down a little bit and we need to look at the training for clinicians and the patients and families as well.

How do we change our interaction? There’s a lot of nonverbal communication that takes place during in-person visits. We have to understand how to best design a patient-clinician interaction through a virtual encounter. We have to provide training on how to address hearing impairments and cognitive impairment so that information is appropriately being communicated. These types of barriers need to be addressed.

Ultimately, we need CMS to recognize that this [telehealth] valued and provide some means of capturing that experience through quality reporting and actually pay for the service that’s being provided.

Does the increase in telehealth affect the cost reports that hospices submit to CMS? And if so, how could that ultimately affect reimbursement in coming years in terms of the per diem?

Innovation is going to come at our expense. Telehealth visits are not captured at all in the hospice claims or [quality] metrics. The end result is our program’s quality scores will drop and potentially a decline in reimbursement rates because we’re capturing fewer visits.

Even though we may be providing more care; we may be providing more interactions; we may be providing more time with the patient, but it’s not going to get currently captured in the existing metrics. That could result in a reduction in payment for services in the coming fiscal years. That’s a real problem.

Innovation is going to drive improvements in patient care. It’s going to drive improvements in patient satisfaction. It’s going to improve program efficiency. We know these things, but if we do it, we can get penalized. We have to invest [in telehealth], potentially without getting a full return on our investment. There’s environmental barriers. These have to be overcome. If they’re not, we’re going to lose an opportunity that can really drive improvements for patients and the system as a whole.