New CMS Rule: Through the Prism of Chronic Disease Management and Telemedicine

On April 25, 2016 The CMS blog has announced the major improvements made in Medicaid managed care regulations. New rules were anticipated, as CMS hasn't provided any changes to the program since 2002.

Chronic conditions pull on large expenses, thus at ScienceSoft we were mostly interested in regulation of such subjects as chronic care management services and telemedicine. Telemedicine is the only way to offer effective and affordable distant care to patients.

The LTSS (long-term services and supports) definition includes services and supports provided to patients with functional limitations and/or chronic diseases that have the key goal to support the patient's ability to live or work where they desire (including home, a worksite, a residential setting, a nursing facility, etc.).

To allow a consistent LTSS, the states with managed care organizations, prepaid ambulatory health plan (PAHP) and prepaid inpatient health plan (PIHP) have to develop and enforce the following standards:

• time and distance for each type of LTSS providers whom patients must travel to in order to receive services
• other network adequacy standards for each type of LTSS providers who come to patients to deliver care

When speaking about developing network adequacy standards, the rule binds the states to consider, at least, the list of 9 elements, and among them “the availability of triage lines or screening systems, as well as the use of telemedicine, e-visits, and/or other evolving and innovative technological solutions.”

The thing is, it's the only entry about telemedicine in this rule. This element was added only because of comments to the proposed rule, it wasn't initially there. Among the commenters were State Medicaid agencies, healthcare providers and associations, health insurers, advocacy groups, health care associations and society.

It seems like CMS underestimates the value that technology can bring. Moreover, there is not a single word about mHealth in the rule. Although it belongs to telemedicine, mHealth is its most evolved part, designed to bring in great care delivery improvements. It is especially important to regulate (at least to mention) mobile health solutions in respect to the benefits expected from this new rule, such as:

• improved health outcomes
• reduced unnecessary services
• improved beneficiary experience
• improved access
• improved program transparency which facilitates better decision making

One of the commenters has also suggested to include the following definition of 'telemedicine' into the new rule: “Telemedicine or Telehealth means covered health care services provided to a covered person from a health care professional who is at a site other than where the covered person is located using telecommunications technology.”

This comment was rejected, as, in the lawmaker's opinion, “the term has a generally accepted definition that is sufficient for purposes of that regulation.”

In the context of the current telehealth definition in 42 CFR 410.78, ScienceSoft believes this comment could bring a certain value. It is comprehensive and embraces the entire scope of accepted telemedicine technologies. Such a definition can encourage providers to adopt telehealth in a wide range of forms convenient both for a practice and a patient.

Apparently, there are no chronic disease management and telemedicine game-changers in the newest edition of Medicaid managed care regulations. Health organizations do think about the importance of telemedicine and mHealth and their benefits for patients, especially those who qualify for LTSS due to disability and/or chronic disease management needs. However, caregivers tend to hesitate to widely adopt the newest technologies, largely owing to CMS's conservatism in these areas.

Being the largest payer, CMS is also able to incentivize the use of healthcare IT to reduce costs and improve outcomes at the same time. Still, they play safe. At the same time, chronic disease rates are growing, and they are growing even faster among Medicaid patients.

In the rule, CMS 'encourages' providers, payers and vendors to use the provided roadmap for effective HIE and acknowledges the importance of healthcare IT for improved care delivery. As there is no any strict requirements or incentives, there can be only guesses about the lawmaker's next steps towards incentivizing the use of telehealth for LTSS.

Founded in 1989, ScienceSoft is a US-headquartered provider of custom software development and IT consulting services with 450+ IT professionals located internationally.

For over 27 years we've been bringing custom and platform-based solutions to midsized and large companies in Healthcare, Telecom, Retail, Financial Services and other industries. The likes of Walmart, Nestle, eBay, T-Mobile, Baxter and IBM rely on our solutions in their daily operations.