PLTC Talks: COVID-19 and Telepsychology

Image source: Norwood (Charity). Open license (CC 2.0).

So, a viral pandemic has happened – the United States, along with the rest of the world, has had to take extreme measures to prevent the spread of a potentially deadly pathogen within our population. As it happens, this virus, also known as COVID-19, is particularly deadly to older adults and those with chronic medical conditions:

In response to this elevated threat to the older adult population, it’s now become the accepted advice that older adults should practice the most extreme forms of social distancing possible – with the US Federal Government’s Centers for Disease Control advising early on that older adults should “stay home as much as possible” and across the pond, in the UK, over-70s (all over-70s) will be subject to a mandatory quarantine for at least 4 months.

Image source: Pixabay (free to use, no license required).

For us at Psychologists in Long-Term Care, this has highlighted something we have all known for quite some time – that older adults have, up until now only limited options for seeking mental health care when they are homebound and isolated. You would think that telehealth and telemedicine would have long been able to successfully fill the gap here – but not so fast. While older adults are quickly becoming tech-savvy and comfortable with technology, regulatory and bureaucratic limitations have held things back.

In my own personal blog and in a previous PLTC article by our esteemed former PLTC Treasurer, Alan Duretz in our Winter/Spring 2017 Newsletter (“CMS and Telehealth Reimbursement”), it’s been noted that while Medicare has in theory reimbursed psychological service providers for their services (psychotherapy, primarily) that are delivered via remote technology (so-called “e-therapy,”) in practice the regulations and limitations placed on these services have been so exacting that few, if any, providers have ever taken advantage of them. The main barriers have been the following:

  1. Requirement that e-therapy providers need use HIPAA compliant technology with “asynchronous store and forward” capabilities.
  2. Requirement that e-therapy is conducted in an audiovisual modality – e.g., telephone-only services don’t count.
  3. Requires that e-therapy consumers need to be located in an HPSA, or federally-designated Health Professional Shortage area
  4. Requires that e-therapy consumers receive services at an “eligible originating site” (e.g., typically a clinic or similar healthcare facility
  5. Requires that e-therapy services be provided to patients with whom you have a preexisting doctor-patient relationship (e.g., can only be provided to patients whom you have filed Medicare claims for over the last three years).

Something extremely noteworthy and groundbreaking is happening in the geropsychology and long-term care space in the midst of the COVID-19 crisis. Recently, at a press conference in Washington DC, Medicare administrator Seema Varna, flanked by President Donald Trump, Vice President Pence, and several other high-ranking officials, announced that they are relaxing #1, #3 #4, and #5 above (we’ll come back to #2 in a second).

In other words, this means that now, as long as psychologists make a “good faith” attempt to safeguard the privacy of their patients, they can now use platforms like Skype or Facetime to see older adult patients, and not be concerned about violating the HIPAA Privacy lsw. . There is a useful FAQ that was just released by CMS (Centers for Medicare Services) that you can read here. Moreover, these can be for newly-referred patients and residents in need, and therapy can be delivered in residents homes (whether the home is a facility or otherwise).

There’s a couple of catches, though. The waiver, known as “1135,” does not waive the requirement that providers use audiovisual modality with their patients. So, for the time being, telephone therapy is still not covered (except possibly in Texas or other states, see here). Which is unfortunate, because there are still any number of older adults out there who remain uncomfortable with videoconferencing and/or have visual limitations. Another is that the new waiver doesn’t spell out where providers can practice, so it’s not completely clear whether it’s acceptable for providers to deliver services from home, their office, or what have you (apparently APA has reached out to CMS to clarify this, and is awaiting a response).

So far, though, this is good – and really needed as the country tries to work through the COVID-19 crisis. But to me and others in PLTC – if rules and restrictions like these are to be relaxed during a crisis, it’s reasonable to ask whether these rules were necessary in the first place. COVID-19 will pass, but the problem of older adults being isolated and functionally impaired and unable to easily attend in-person medical or mental health appointments will remain, and technology is available to address these problems. Think about that.

Also, if you have anything to share about COVID-19 or how practice with older adults is changing in the face of this pandemic, please comment on this article below.

Finally, if you are a psychologist who practices in long-term care, or work with older adults in your practice and would like to learn more, we have an active Listserv, Newsletter, and other resources. Please consider joining PLTC:

http://www.pltcweb.org/membership.php#benefits

References / Links

APA PracticeUpdate on Telehealth

https://www.apaservices.org/practice/legal/technology/covid-19-telehealth-waiver

CMS FAQ on Waiver 1135

https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf

Press Release from CMS

https://www.cms.gov/newsroom/press-releases/telehealth-benefits-medicare-are-lifeline-patients-during-coronavirus-outbreak

Summary of law specifying waiver (bottom section):

https://www.congress.gov/bill/116th-congress/house-bill/6074

PLTC Invitation for Student Research Award 2019

Dear Members,

PLTC is again enthusiastically inviting applications for the Annual Student Research Award 2019. We have appreciated the quality of submissions in past years. Please note below the expanded scope of work that can be considered for the award. We have previously provided information on past winners and will be updating our new website with the names of past winners and their research.

Applications for the award this year should be submitted by June 1, 2019 and to allow time for review and announcements

The Student Research Award is being administered through the Research Committee of PLTC, with additional reviewing support from members as may be required and offered. In support of research/projects relevant to long-term care, we invite applications at this time and which should be submitted to Craig Schweon, Ph.D., Chair of the Research Committee at chsphd@gmail.com, and with your attachments.

We are requesting that those intending to apply submit an email letter of intent by May 1, 2019 to Craig Schweon, Ph.D, Chair of the Research Committee at chsphd@gmail.com, and so that we can best prepare for reviews.

Be sure to include a cover letter and contact information, your affiliation, research/faculty mentors you have worked with as relevant to this application, with their contact information,  as well as any other appropriate information in your application email. A resume is not required but may be submitted as well. Please note that we are requiring that you include an abstract of your study/manuscript before the text.

Consistent with what has traditionally been described on the PLTC website and which we will update on our current new website, graduate and post-doctoral students may submit a completed project relevant to long-term care( including geropsychology but relevant to long-term care ) for the PLTC Student Research Award. Submissions will be accepted from student members of PLTC, please note we do require student membership at the time of submission( student membership the first year is free at PLTC ). We certainly encourage faculty mentors to be professional members if at all possible.

Manuscripts should generally be 8-12 pages, exclusive of tables and figures. Manuscripts that are being presented as posters or in symposia at the annual GSA meeting( or at APA ) will be accepted and encouraged though this is not required. Please note in your letter if the manuscript you submit is being presented( or has been submitted, was recently presented). Manuscripts presented to others organizations’ award programs will not be considered for the award.

Please note that, again this year, though there would be one award, we are expanding the nature of projects that can be submitted, in an effort to recognize different contributions and broaden submissions. In addition to formal research, we will consider projects with a scholarly basis such as formal literature reviews, program evaluation studies, intervention studies, formal needs assessments. Qualitative and quantitative efforts will continue to be encouraged, different sample sizes depending on the nature of the study. A manuscript is required. Please feel free to consult if you have questions about the applicability of the project.

Here is a checksheet for you to use in your preparation.

Further details about the process may be sent at a later date. The award amount has been increased this year to 375 dollars in support of applications and the winner will receive this with a commemorative piece. The award will be announced and then presented at the PLTC meeting at the time of the Annual APA Convention in Chicago this year, during the period from August 8-11, 2019. We will also provide recognition for the University and the research/faculty mentor. While encouraged, you do not need to be present to accept the award and other arrangements can be made.

We look forward to receiving and reviewing applications.

Craig Schweon, Ph.D. Chair, Research Committee, PLTC

APA Practice Information Alert

November 26, 2018


Medicare 2019 Fee Schedule Final Rule (Part 3)

This is the third and last Information Alert on the 2019 Medicare fee schedule. This latest Alert focuses on what psychologists need to know about the Merit-based Incentive Payment System (MIPS).

Changes to Medicare’s Quality Payment Program in 2019 were included in the final rule on the Medicare fee schedule. As expected, CMS adopted its proposal to add practicing psychologists to MIPS in 2019 with payment adjustments taking effect in 2021. Effective January 1st, psychologists will join physicians and other healthcare providers defined as eligible clinicians (ECs) in the MIPS reporting program.

The APA Practice Organization anticipates that many psychologists in Medicare will be exempt from MIPS reporting under the low volume threshold (LVT). Only those who exceed all three criteria under the LVT are required to report under MIPS. For 2019 psychologists will be exempt if in 2018 they:

  • Treated 200 or fewer Medicare beneficiaries;
  • Billed Medicare for $90,000 or less in allowed charges; or
  • Provided 200 or fewer covered professional services.

In addition, any EC who first enrolled in Medicare in 2018 is automatically exempt from MIPS reporting in 2019. ECs who participate in Advanced Alternative Payment Models may also be exempt.

CMS is also implementing its proposal to allow MIPS ECs who meet some but not all the criteria under the LVT to “opt-in” to MIPS reporting. Psychologists who elect to exercise this option should understand that once the decision to opt-in is made it is irrevocable for the reporting year.

ECs in MIPS who are part of group practices (i.e., two or more providers billing under the same tax identification number) can choose whether to participate in MIPS as individual providers or as part of the group. Many may find that they would be required to report under MIPS if treated as a group but exempt under the LVT on an individual basis. Psychologists in this situation will need to decide if the practice wishes to report under MIPS as a group and possibly earn bonuses in 2021 or have each psychologist identify as an individual EC and possibly be exempt MIPS reporting.

For psychologists who surpass the LVT and must report under MIPS, the potential payment adjustments in 2021 will range from a bonus of 7% to a penalty of -7%. MIPS is designed so that most ECs will be considered average and thus have a payment adjustment of 0%. Psychologists reporting as individuals may report quality measures through claims along with other methods such as a MIPS registry, a qualified clinical data registry (like the APA’s Mental and Behavioral Health Registry), through electronic health records and the CMS web interface. Group reporting cannot be done through claims.

MIPS has four categories: quality, promoting interoperability, advancing care initiatives, and cost. For 2019 psychologists and the other non-physicians newly added to MIPS will only be responsible for reporting quality measures and advancing care initiatives. Cost data is taken from claims by CMS and does not require reporting. Because psychologists and certain other non-physicians were not included in the meaningful use incentives designed to promote the adoption of electronic health records, they will not be required to report under the promoting operability category in 2019. For purposes of the overall MIPS score CMS will weigh the promoting operability category to zero.

For 2019 the MIPS categories will be added together to give each EC a final score as follows:

Quality

Promoting Interoperability 


Cost

Improvement Activities

45% of MIPS final score

 25% (0% for psychologists and certain others in 2019)

15%

15%

The 2019 performance year will run from January 1, 2019 to December 31, 2019. All data must be submitted to CMS by March 31, 2020. CMS will provide reporting ECs with feedback in July 2020 and will apply payment adjustments based on MIPS reporting to each claim starting on January 1, 2021.

The Mental and Behavioral Health Registry (MBHR) was created by APA to help psychologists and other professionals collect data on patient outcomes and participate in quality reporting programs. The MBHR has been approved by CMS for MIPS reporting and is currently the only qualified clinical data registry that includes measures on anxiety. More information about the MBHR is available at: https://www.apapracticecentral.org/reimbursement/health-registry/index.

Psychologists with questions about the 2019 Medicare fee schedule changes are welcome to contact the Government Relations Office by telephone (202-336-5889) or by email (pracgovt@apa.org).