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Time to bring back post-acute waivers

The average American’s response to the COVID-19 public health emergency (PHE) in the spring of 2020 was swift and rapid, with personal mobility quickly reduced by over 50 percent and millions of people newly working from home. The actions of America’s hospitals were similarly rapid, with elective surgeries being cancelled, reconfiguration of floors to increase the number of ICU beds, and the procurement of massive quantities of personal protective equipment (PPE).

What may not be as well known is that the actions of health insurers were just as rapid and far-reaching. The Board of America’s Health Insurance Plans (AHIP) committed on March 23 to matching the post-acute authorization waivers issued by Medicare to facilitate discharge and enhance much-needed hospital capacity. That same week, Cigna and UnitedHealthcare announced waivers on prior authorization for post-acute care destinations – skilled nursing facilities (SNFs), acute inpatient rehab (AIR) facilities, and long-term acute-care hospitals (LTACHs). Practically every major insurer quickly announced similar policies, waiving prior authorization for post-acute destinations for COVID-19 and non-COVID-19 patients alike.

The nation’s COVID-19 healthcare policies over the ensuing seven months have been a picture of dizzying change. The Centers for Medicare & Medicaid Services (CMS) has issued four interim final rules addressing the pandemic. The Coronavirus Aid, Relief, and Economic Security (CARES) Act simplified acute rehab qualification requirements and expanded access to LTACHs. CMS’s PHE regulations expanded Medicare Advantage post-acute networks to include out-of-network facilities.

We experienced coverage policies providing greater access to COVID-19 testing and telehealth services, and broader shielding of patients from COVID-19-related cost-sharing requirements. We also noticed a much-needed policy focus on protection of our long-term care residents, the facilities they reside in, and the staff who care for them. Hospitals and long-term care facilities alike have grappled with visitation policies, balancing the needs of limiting the pandemic with the ability to meet with our most vulnerable loved ones. The vast majority of these policies remain in effect to this day, except for one – the waiving of post-acute prior authorization by health insurance plans.

A gap has arisen between the waivers that traditional Medicare has in place for post-acute destinations and those granted by health insurance plans. By the summer, all major insurers had resumed prior authorization activities for post-acute destinations, except in states where mandates existed (almost all have since expired). Currently, UnitedHealthcare, Aetna, and Anthem have no post-acute authorization waivers in place for any patients, including COVID-19 patients. Humana had maintained post-acute waivers for COVID-19 patients while resuming normal prior authorizations for non-COVID-19-related services, but those too ended on Oct. 24. To our knowledge, Cigna is currently the only national insurer to have a COVID-related post-acute waiver policy in place, having been very recently extended to Dec. 31.

The United States is now facing a fall and winter COVID-19 surge (sometimes called the “third wave”) that is already ravaging several western and midwestern states, and it is expected to worsen everywhere. As of Oct. 25, the Johns Hopkins Coronavirus Resource Center showed that 49 states were experiencing an increase in the seven-day moving average of new COVID cases. According to the University of Washington Institute for Health Metrics and Evaluation (IHME) tracker, by December, the number of hospitalized COVID-19 patients nationally will exceed both the spring and summer peaks, and by January, it will double either peak. In Wisconsin, the non-surge ICU capacity of the state has already been exceeded, and it is projected to get a lot worse, increasing multifold. In Utah, patients are having to be transferred out of state.

Post-acute waivers are urgently needed to free up hospital beds and ICU capacity needed to care for COVID-19 and non-COVID-19 patients. We, as physicians at the bedside, treating patients suffering from COVID-19, have seen the significant negative impact on patient care that occurs when hospital capacity is reached and exceeded. One of us, a medical officer in the U.S. Army Reserves, was called to service as a treating physician to the Federal Emergency Management Agency (FEMA) temporary field hospital at the Javits Center when the capacity of New York City’s hospitals was being stretched past the breaking point by COVID-19.

At the time of this writing, the U.S. is experiencing record numbers of daily positive COVID-19 tests, with a corresponding increase in hospitalizations sure to follow. The country once again needs our health insurance partners to reinstitute post-acute authorization waivers nationally. The waivers, both governmental and commercial, were certainly effective in freeing up hospital capacity earlier this year. Now that the commercial post-acute waivers have largely expired, hospitals must once again go through the authorization process for post-acute stays. The life cycle of a post-acute authorization is that insurers typically have two weeks to render a standard pre-service decision, and 72 hours if an expedited pre-service decision is requested. If not approved, a peer-to-peer discussion may ensue, and an expedited appeal that takes another 72 hours then occurs. The effect is that patients who can be cared for in other facilities remain in an inpatient hospital bed much longer than is actually necessary.

Delays of 3-7 days waiting for post-acute authorization have become commonplace, putting unnecessary pressure on hospital capacity and dis-servicing new patients who need those beds.

Post-acute facilities themselves have been challenged with accepting patients, due to their own staffing, PPE, COVID-19 testing, regulatory reporting, and COVID-19 outbreak issues. As a result, transitioning inpatients to post-acute destinations has become increasingly difficult, independent of the issue of prior authorization. Insurers have also experienced strain on the adequacy of post-acute networks in certain areas. These complicating factors cannot be solved by a waiver policy, which makes it even more imperative that insurers reissue post-acute authorization waivers to help patients and providers through the coming winter surge.

We can neither assume nor rely on the interventions that most of the nation used to avoid surge catastrophe earlier this year, such as cancelling surgeries and avoidance of EDs. Evidence is emerging that patient harm related to non-COVID-19 illness is occurring by avoiding or delaying necessary medical care. The Centers for Disease Control and Prevention (CDC) highlighted this issue in September, concluding that caregivers, patients with medical conditions or disabilities, and minorities have been disproportionately affected by medical care avoidance and delay. Health Affairs noted that non-COVID-19-related admissions for pneumonia, COPD, sepsis, STEMI, and stroke remain significantly below pre-pandemic levels, almost certainly associated with patient harm. Elective surgeries turn into urgent surgeries when breast biopsies, colonic polyp removals, and other “elective” surgeries are delayed too long. We have learned that greater adherence to public health measures can curtail spikes, as we saw in Florida and Arizona this summer, and no doubt, that will be needed again. However, those spikes were largely the result of a lack of adherence to public health recommendations. What we are seeing today across the country is different, as it is being driven by cold-weather behavior, rather than more easily modifiable summer behavior.

America’s Health Insurance Plans has not changed its official Board policy committing to post-acute waivers to match Medicare’s PHE exemptions. While almost all of its member plans have continued other COVID-19 allowances in the telehealth and cost-sharing space, what the country needs now is a reinstitution of post-acute prior authorization waivers. As communities continue to scramble to meet the demands of the COVID-19 pandemic, which include extraordinary efforts such as building field hospitals, we call on our commercial insurance partners to once again rise to meet the demands on hospital capacity through a reissuance of post-acute authorization waivers.
Now is the time.

Programming Note: Listen to Dr. Edward Hu report this story live during Monitor Mondays, Nov. 9, 10 a.m. EST.


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