Letter to CMS Regarding Medicare Rules

The letter below is from the steering committee members of the NH CHW Coalition commenting on the billing codes that is enabling Medicare for services based on SDOH needs.

RE: File Code CMS-1784-P; Medicare Program; CY 2024 Payment Policies under the Physician Payment Schedule and Other Changes to Part B Payment and Coverage Policies; (August 7, 2023)

Dear Administrator Brooks-LaSure:

The New Hampshire Community Health Worker Coalition (NH CHW Coalition) writes to provide comment on the Centers for Medicare & Medicaid Services (CMS) Notice of Proposed Rule Making (NPRM) on the revisions to Medicare payment policies under the Medicare Physician Fee Schedule (PFS) for calendar year (CY) 2024, published in the August 7, 2023, Federal Register (Vol. 88, No. 150 FR, pages 52262-53197)

     The NH CHW Coalition is an organization that has promoted the CHW workforce for over 9 years. Our purpose is to bring together Community Health Workers, along with supportive health professionals, stakeholders and community leaders, to promote the role and value of CHWs in improving health outcomes A CHW is an important member of the healthcare, public health and human service workforce, and a trusted member of the community. This trusting relationship enables him/her to serve as a bridge between community members in need and the services that can help improve their health and quality of life. The NH CHW Coalition advocates to define a scope of practice and roles for delivering quality CHW services; to recognize and integrate CHWs in healthcare-related planning and policy; promote recognition of the CHW workforce as vital to advancing New Hampshire’s healthcare value; encourages utilization of CHWs in planning, policymaking and funding decisions and involvement in statewide CHW continuing education, advocacy and networking.

 Supported by Southern New Hampshire Area Health Education Center and North Country Health Consortium home of the Northern New Hampshire Area Health Education Center

Header 1:  Regarding Under GXXX1- Building patient self-advocacy skills, so that the patient can interact with members of the health care team and related community-based services addressing the SDOH need(s), in ways that are more likely to promote personalized and effective diagnosis or treatment. Response: We suggest adding language that includes “health literacy” such as “Building patient self-advocacy and health literacy skills”.

The majority of the clients that are seen in direct service do not understand healthcare language and process, it is important that education around health literacy is specified to enable the improvement of self-advocacy skills.

Header 2: Regarding: “To help inform whether our proposed descriptor times are appropriate and reflect typical service times, and whether a frequency limit is relevant for the add-on code, we are seeking comment on the typical amount of time practitioners spend per month furnishing CHI services to address SDOH needs that pose barriers to diagnosis and treatment of problem(s) addressed in an E/M visit. We are also seeking comments to better understand the typical duration of CHI services, in terms of the number of months for which practitioners furnish the services” Response: From the CHW perspective the ability to have the flexibility to meet the multiple and sometimes interconnected needs of the client/patient being served is critical. Often in the initial stages of care there is more time and visits needed to address these needs and educate the client/patient, efficiently and effectively. As priorities are completed the time needed with the patient/client naturally decreases but is still required to monitor progress. For this reason, we strongly suggest that there is flexibility provided for the frequency and number of visits. This could be monitored and approved by the provider overseeing services.

Header 3: Regarding “^–We are seeking public comment on whether it would be appropriate to specify the number of hours of required training, as well as the training content and who should provide the training.” Response:  As home to the Northern New Hampshire Area Health Education Center, we have been training CHWs for 8 years. Through this experience we have developed a curriculum based on the C3 Project and Core Competencies and strongly recommend that all CHW training be based on the nationally accepted CHW Core Competencies. We support providing a minimum number of hours required for training. Based on our experience, to adequately train potential CHWs in these competencies the training needs to be a minimum of 60 hours that includes face to face instruction and independent work. Regarding who should provide the training: each individual state has the expertise and knowledge to identify preferred training entities. For example, in New Hampshire, both the Southern and Northern AHECs are the only organizations that provide CHW training. It is critical that there are basic criteria defined for providing these trainings to maintain fidelity to the core competencies and is inclusive of CHWs as trained trainers. A possible solution is a list of competent and vetted training organizations by state.

Header 4: Regarding: “We are seeking public comment, in particular regarding whether we should require patient consent for CHI services. For care management services that could generally be performed without any direct patient contact, we require advance patient consent to receive the services as a prerequisite to furnishing and billing the services, to avoid patients receiving bills for cost sharing that they might not be expecting to receive” Response: We support requiring patient consent.

Header 5: Regarding: “We believe these services would largely involve direct patient contact between the billing practitioner or billing practitioner’s auxiliary personnel and the patient through in-person interactions, which could be conducted via telecommunications as appropriate. Therefore, we are proposing to add this code to the Medicare Telehealth Services List to accommodate a scenario in which the practitioner (or their auxiliary personnel incident to the practitioner’s services) completes the risk assessment in an interview format, if appropriate. We believe it is important that when furnishing this service, all communication with the patient be appropriate for the patient’s educational, developmental, and health literacy level, and be culturally and linguistically appropriate.”  We are seeking comment on where and how these services would be typically provided, along with other aspects of the proposed SDOH assessment service. Response: We believe that there should be flexibility in location of meetings. Many of the NH CHW services are provided in the community either at a client’s home or a mutually agreed upon location, but there are also programs that function through Telehealth or see clients in the Provider location. Having this flexibility is important to provide culturally competent services, that meets the client where they are at and most comfortable.

Header 6: Regarding: “We are proposing that a billing practitioner may arrange to have CHI services provided by auxiliary personnel who are external to, and under contract with, the practitioner or their practice, such as through a community-based organization (CBO) that employs CHWs, if all of the “incident to” and other requirements and conditions for payment of CHI services are met.” Response: We agree that it would be beneficial for practitioners to contract with community based, public health focused organizations that train and employee CHWs, with the stated criteria.

Conclusion

Thank you for the opportunity to comment. We believe that the proposed coding for CHI services is an important step in supporting individuals on Medicare to improve their “whole” health and maintaining a independent quality of life. Please reach out to Annette Carbonneau at Acarbonneau@nchcnh.org (Technical Assistance Advisor to the NH CHW Coalition) if you have any questions or if we can be of any further assistance.

Sincerely,

The New Hampshire Community Health Worker Coalition

Steering Committee members:

Amber Culver

Nancy Collins

Carolyn Schofield

Lindsey Boisvert

Rebecca Hill Larsen