There has been a flurry of activity with states filing Appendix K and 1135 waivers in an effort to ensure service continuity despite challenges associated with the COVID-19 pandemic. These waivers are all designed to create flexibilities for providers and state agencies. Examples include expanded use of remote technologies, allowing use of alternative settings, suspension of some screening (PASRR) and prior approval processes, streamlined certification for new providers and to allow existing providers to add alternative services, and waiving face to face assessments for initial or annual eligibility, and many others.
All of these changes are rooted in reducing or eliminating regulatory requirements that are perceived to be obstacles or barriers to service access and/or provision. Many of these emergency flexibilities are things that providers and/or other stakeholders have been complaining about for some time. In some ways, the long term care system has been facing a slow motion crisis for some time now. The pandemic is bringing demographic changes and workforce capacity issues to light in an urgent and dramatic fashion.
The American LTSS service delivery system is not prepared to meet the challenges associated with the rapidly growing numbers of people who will need some degree of long term services or supports, and the strains that will place on Medicaid as the largest payer source for LTSS. While states and their federal partners have been working to make changes that will aid in meeting those needs, those efforts have been incremental, nibbling around the edges of needed change and possibly constrained by cultures organized around compliance and risk mitigation. They are not keeping pace with the demographic changes and the workforce challenges that abound impacting LTSS system capacity and quality.
Regulatory structures are major drivers of LTSS service delivery systems all over the country. Disrupting these structures could be a way to introduce needed change to LTSS and what could be more disruptive than a global pandemic? Disruption is often a necessary element in transformative change. This disruption, while unplanned and definitely not welcome, may provide an opportunity that should not be wasted. While we would never want a pandemic in order to spark transformative change in LTSS service delivery and regulatory structure, there is an opportunity here for state and federal regulators and payers to give careful consideration to what they need and why they need it before just reinstating all of the previous requirements when things return to “normal”.
While the pandemic is certainly not over (sadly), the flurry of emergency activity may be slowing down. In a perfect world, close consideration would have been given to the longer term consequences of the emergency measures (see our last blog entry), but the last few weeks has seen rapidly changing guidance that have varied widely across the country, so situations have been fluid and suggest that long term implications have been a secondary consideration. Now may be the time to look forward to what will happen on the other side of the pandemic.
Telehealth has been a topic of strong interest for years now in terms of building system capacity and improving quality of care, but payment systems have been slow in places to take that up. Workforce challenges should drive us all to consider the role that informal caregivers play in supporting people and how systems can support and maximize their ability to do this. People are better off in systems of consistent care and support so why shouldn’t providers like adult day centers have the flexibility to provide blended support models? Improving the speed and ease of access to home and community based services in order to prevent costly or unnecessary nursing facility admissions has been a challenge for states attempting to “rebalance” their Medicaid spending.
I don’t know anyone who thinks that the world is ever going to be “normal” again – there will be a new normal as we adjust to the long term presence of the COVID-19 virus and its impacts on our health and livelihoods. The pandemic has been and will continue to be a significant disruption in every area of life including LTSS. It would be a shame to simply go back to “normal” without making the most of this disruption. State and federal agencies, providers and advocates can all consider what changes are actually beneficial to systems and working to make adjustments to capture that benefit for the long haul. If there are regulations that are truly barriers to access, or prevent the use and support of informal caregivers, or make it difficult to use telehealth and other remote monitoring tools, then isn’t it time to look at them even once we are past this pandemic? Let’s not waste this crisis. There are lessons to be learned and disruption enough to fuel real change.