Opinion | CMS in the Post-COVID World

In this exclusive video interview, Jeremy Faust, MD, editor-in-chief of MedPage Today, and Chiquita Brooks-LaSure, administrator of the Centers for Medicare & Medicaid Services (CMS), discuss the future of CMS policies and priorities after the COVID-19 pandemic. Watch part 1 of the interview here.

The following is a transcript of their remarks:

Faust: With the time we have left, I want to cover two topics, one is Medicare Advantage and then a little bit on hospital nursing home safety.

With Medicare Advantage, first of all, I’m curious to know just what your overall impression is on the growth of Medicare Advantage, giving some pros and cons of that. Also I’d like you to comment, if you would, on the fact that you and your agency took a tougher stand on some of the advertising that was suboptimal, shall we say, and I’m curious to see if we can also expect more of that.

Brooks-LaSure: Medicare Advantage is a crucial part of the Medicare program. People choose between original or traditional Medicare, which we think of as the fee-for-service program where every doctor that participates in Medicare, you have access to as a Medicare beneficiary, and then Medicare Advantage, which is growing.

I think that’s not surprising in some respects, especially as increasingly baby boomers are coming out of employer-sponsored insurance and they come to Medicare and enroll in a plan that looks very much like employer-sponsored insurance. It’s very similar in many respects. There also is the ability to offer additional benefits, which we know often attract seniors.

I think that’s why the marketing is so important, because it’s really important that people know what they’re getting into when they choose a Medicare Advantage plan. It can be very advantageous to them, but it can also come with some limitations, like, you have to see a doctor that’s in your network. The benefits that you’re being provided might be very limited.

Dental is a perfect example of how a lot of the coverage that’s offered by Medicare Advantage plans may be very limited, which is fine, but we just want to make sure that Medicare Advantage plans are giving accurate information. That’s why we’ve really focused on marketing.

I’ve been talking with seniors across this country, and increasingly with physicians, who’ve told me about their frustrations with MA. We really try to make sure that whether it’s us looking at the prior authorization rules for doctors being able to deliver care to patients, or whether it’s making sure that seniors really know what they’re getting into when they get calls when they’re being encouraged to enroll in MA.

Faust: Yeah. I worry, based on a lot of reporting that we and others have done, that a lot of times people don’t get what they think they’re getting or they’re not signing up for what they think they’re signing up for. And there’s a predatory component here. Is there some way to crack down on those kinds of rogue iterations of MA?

Brooks-LaSure: We are working as hard as we can. As we hear issues coming up, we continue to look and think about what other additional oversight we need to do.

This first step was really looking at the marketing materials, because we’ve seen a rise in those, but we continue to really make sure that we are staying at the forefront — whether it’s in terms of agent and broker behavior — to make sure that seniors are being given the information accurately and with an opportunity to ask the right questions.

Faust: I’d like to close with a topic that we could take about 6 weeks to discuss, so we’ll get it done in 2 or 3 minutes, which is nursing home and hospital safety. This is an area that CMS probably has more influence on than most people realize. CMS has great regulatory authority there.

In particular, there are two topics I think we could delve into just for a moment. First is infection control, both in nursing homes and in hospitals. And I think that if the COVID pandemic taught us anything, it’s that we can stop flu and RSV because everything we did eliminated pathogens like those. Testing and masking and other mitigation measures had a real benefit in hospital- and nursing home-acquired infections.

I feel like CMS has a lot going on when it comes to things like antibiotic stewardship and catheter-associated infections, but less focus on respiratory pathogens. Is that an area where we could really beef up our safety?

Brooks-LaSure: Well, I would say that CMS has become increasingly involved in making sure that we focus on quality and safety. You’re exactly right to say that we have, I think, an outsized role that’s really unknown in terms of insuring and working with facilities.

We still are right now very actively talking with nursing homes, in particular, as we head into flu season, RSV, and of course COVID-19. We continue to work to make sure that nursing homes and other facilities are prepared for the winter months, and that will remain a focus.

One of the pieces in that is regulation, but another of it is having support. We certainly hope that Congress will pass our budget so that we can make sure that we will be able to help survey a lot of the facilities to make sure they’re meeting the standards, because we do have a very important role in making sure that we have safe facilities across this country.

Faust: Just to be specific, are nursing homes and hospitals required to report the hospital- and nursing home-associated infection rates in their facilities?

Brooks-LaSure: I will have to check whether they need to report on the infection rates. We do have requirements about a whole host of things related to respiratory — particularly as I mentioned, the three related to flu, RSV, and COVID-19.

Faust: Okay. I think this is one area where, especially with nursing homes, we saw something happen positively for a little while, and I worry that the alignment of incentives needs to be reiterated or reinforced by CMS, and there’s a huge opportunity there. I think we’d love to see leadership there.

I also want to talk about a topic that’s, unfortunately, near and dear to my experience as an emergency physician, which is boarding. This is when patients who are in the hospital have been hospitalized, but they don’t have a place to go in the hospital. So they’re literally still in the ER for hours and days.

This is a very dangerous thing because it taxes all the healthcare workers, it leads to actual deterioration of the kind of care the patients need because we can’t possibly be managing patients who we admitted 6 hours ago and also the new trauma coming in or the new stroke or heart attack.

CMS in the past has had metrics on this, but they have not been continued and certainly aren’t part of its highest stratum of concerns if you read the tea leaves through the metric instrument. What can CMS do to address this issue, especially with the pressures in ERs and in hospitals in the post-COVID world that we are in?

Brooks-LaSure: CMS is definitely trying to work with all of our sister agencies when it comes to workforce, and certainly making sure that people can get the care that they need.

In moving from the emergency room to the hospital, one of the areas that I hear a lot about is people who are in hospitals and really need to be in other types of facilities. So I would say in terms of our quality, we’ve really been trying to think very hard.

A lot of our rules were suspended during the COVID-19 pandemic because facilities were so focused on really treating COVID-19. We really let a lot of facilities stop or pause their reporting because we knew that they had their hands full. As we start to bring back many of these metrics, we’ve been bringing them back over the last year, we’re really focused on trying to make sure we’re aligning across our programs and looking for ways to reflect a variety of priorities.

There are so many things that we need to continue to track, and that’s part of our strategy. So just because something is removed, doesn’t mean we don’t care. It may be that we’re focusing on additional priorities or looking for ways to streamline.

Faust: And along that line, in terms of decompression, will CMS continue to support telehealth — including for things like opioid replacement therapies, buprenorphine, via telehealth — as it has done since the beginning of the pandemic?

Brooks-LaSure: We are very supportive of telehealth. I hear about telehealth from so many stakeholders about what a difference it’s made. We are trying to extend that authority as far as we can. There are some limitations.

Congress has extended a lot of our telehealth authority through the end of next year, so through the end of 2024, and particularly for mental health services, that’s a key area where we’re able to extend telehealth.

Faust: Okay. The last question is going to be just another personal bugaboo for me. It’s an area of interest for me, which is sepsis, a devastating condition.

CMS has had a regulation on sepsis for quite some time, which unfortunately is not a very popular one and not one that’s very adhered to. The IDSA — the Infectious Diseases Society of America — has called for it to be retired and replaced with an outcomes metric as opposed to a process metric. We care about outcomes as opposed to process.

Will CMS heed the call of the nation’s leading infectious disease experts and retire SEP-1 and replace it with something better?

Brooks-LaSure: I can’t speak to our future actions, but I do know how much we take what the scientific community says and what the clinical community says seriously. We continue to review sepsis and other conditions.

Faust: Alright. Well, thank you for your work leading CMS, one of the most important agencies in the United States, whether it’s for health or just well-being for our fellow Americans. So thank you for the work you do and for sharing your views today.

Brooks-LaSure: Thank you for having me.

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