A Step Where a Leap is Needed

By Matt Fisher, Healthcare Attorney
LinkedIn: Matthew Fisher
X: @matt_r_fisher
Host of Healthcare de Jure#HCdeJure

As part of its annual summer tradition, the Centers for Medicare and Medicaid Services published the proposed 2024 Medicare Physician Fee Schedule with some seeming shakeups to reimbursements. A relatively small part of the proposed rule could be a pebble being taken out of a dam that enables more change to flow.

What is that pebble? It is the introduction of Medicare payment for caregiver training services (CTS). Reimbursing CTS is a subtle, but important shift because it expands the focus of Medicare beyond just the patient to individuals who support the patient.

Why is CMS adding CTS Now?

Before getting to why CTS is being added to Medicare, it is necessary to give a quick overview of CTS. CTS is a clinician instructing an individual (or maybe a group) about how to support a patient to manage a chronic condition or other significant health issue. The training is from the clinician’s perspective of what is necessary. The training occurs without the patient present. Historically, CMS determined that it could reimburse CTS under the language of the Medicare enabling statute.

Why the reluctance to cover? The statute sets guardrails for the types of services that can be reimbursed by Medicare. Those guardrails require items and services to be reasonable and necessary for the diagnosis and treatment of a patient’s illness or injury or to help improve a patient’s bodily functioning.

What did CMS’s position amount to? The position meant that CMS would not allow Medicare to pay for services delivered to someone other than the patient. A caregiver is not the patient, so focusing on a caregiver was not in the cards. Even though CMS kept asserting that limitation, it did ask for comments about the importance and impact of caregiver involvement.

Public comments can be powerful (especially when high-profile individuals or groups participate), but unfortunately, CTS has not fit into that mold. A higher-level administrative directive made the difference this time, specifically the president. CMS reconsidered its position on CTS following the issuance of an executive order focused on supporting caregivers.

The executive order inspired creativity as CMS to recognize that caregivers are a key component of patient-centered care. Support from a caregiver is now seen as part of the reasonable and necessary services for a patient because of the valuable role played by caregivers in their connection with patients. That is a bit of an obvious conclusion for anyone with personal experience or who focuses on patient support, but CMS had to come around before it could even consider Medicare coverage.

CMS Definition of CTS

Caregiver training services, as laid out in billing codes, is the training that a clinician provides to a caregiver either individually or in a group training setting. The training must be administered by a physician or other qualified healthcare provider (technical Medicare language to mean a billing clinician). Not only does the clinician need to conduct the training, but the treating clinician also needs to identify the need for the training in the care plan. Patient consent is another requirement before training can be provided and paid for. The codes CMS proposes to adopt also require a minimum 60 minute time commitment (if less than 60 minutes is required, then no reimbursement will be made). There is no discussion of whether that much time is necessary. All of that sounds good, but the reimbursement under the proposal only goes to the clinician. Caregivers don’t receive anything.

The proposed rule goes on to address which patients, in CMS’s view, will benefit from the involvement of caregivers in their health journey. The determination is not up to the patient. The treating clinician makes the decision. The clinician has to make the determination when preparing the, “patient-centered treatment plan.” If the clinician feels that a caregiver is necessary to promote a successful outcome, then CTS can be added as a component of the treatment plan. A potential list of conditions when caregiver involvement could be helpful focuses on the patient having cognitive deficiencies or a cognitive injury. The implication is that CMS will limit CTS only to patients who ostensibly cannot take care of themselves.

Missing Real Patient Centricity

CMS goes out of its way to talk about patient-centric care and the value of a patient-centric approach. Improving care delivery and outcomes by focusing on patients as individuals is certainly a positive break from the past. Achieving actual progress requires more than just lip service though.

From that perspective, is CMS truly proposing a patient-centered approach? From a very simplistic and favorable point of view, yes. The overly favorable view finds a patient-centered approach because the CTS proposal asks the clinician to consider what will work best for a particular patient. The suggested approach could entail developing a tailored treatment plan that doesn’t just blindly follow a preset template. However, as set out in the proposed rule, all of the decision-making authority stays with the clinician. Input from the patient is not clear and not required beyond consenting to the CTS.

As explained, the clinician prepares the treatment plan. The clinician determines whether caregiver involvement will help the patient. The clinician initiates the patient’s consent process. Finally, the clinician gets paid for the CTS. Neither the patient nor the caregiver get a formal say in the development of the treatment plan or benefit financially. Admittedly, the deficiencies are driven to a large degree by limitations inherent in the Medicare governing statutes, but then a little less back-patting about the scope of patient-centricity would be advisable.

Considerations for More Comprehensive Health Equity

What would an approach that really embraces health equity look like? It’s an approach yet to be seen in meaningful depth, but the CTS proposal zeroes in on an area of particular pain. Caregivers shoulder a significant, largely unrecognized burden in healthcare. Caregivers support their loved ones, whether a family member or friend, non-stop and typically with a large amount of personal sacrifice. The sacrifice can take time, energy, money, and a lot more. All of those sacrifices strain caregivers when all of their focus should be on the individual that they are there to support.

The proposed CTS coverage does not sufficiently get to the stressors experienced by the caregivers themselves. CTS helps caregivers by providing information useful in supporting their loved one, but it does not introduce new resources to alleviate any of the practical day to day burdens. Instead, CTS, as laid out in the proposed rule, is geared more toward the treating clinicians.

Who will provide direct relief for caregivers? Who will help caregivers make up missed time at work? Who will help caregivers cover expenses when time is devoted to helping their loved one?

Tackling health equity means acknowledging the often silent burdens for caregivers, then pursuing meaningful ways to help. The healthcare industry has not traditionally recognized or properly accounted for the caregiver role. It is just assumed that help will be there and freely given. Despite mounting evidence around the scale of the economic impact essentially donated by caregivers, that free work has been accepted willingly and without consideration for how to help out. Caregivers take on a tough, thankless job. Recognition is overdue. Ongoing failure to do so drives burnout among caregivers, which is a real and also overlooked phenomenon.

What could a more equitable approach for caregivers entail? It is a good question. No single answer exists either. One way to start making an impact is to provide more external support and resources. Caregivers should not have to continue aiding their loved ones in isolation. Whether the support is monetary, care navigation insights, physical relief, or another form, it can be hard to come by, especially if the caregiver operates in the dark without exposure to professional members of the care team. CTS could be a step in the direction of opening those doors. However, the caregiver won’t have input into the scope of the training. Absent that input, CTS may not cover the actual needs of the caregiver or go far enough.

Regardless of the support offered, the first step is simply acknowledging the caregiver’s role in a patient’s journey. A caregiver is not just a person hopping in and out, but is usually involved in lockstep with the patient throughout the entire care journey. It may feel like attention is being diverted from the patient, but a caregiver also needs some focus and cannot just be taken for granted.

What Can We All Do?

All of this talk brings us back to CMS’s CTS proposal. While it is facially nice, it is only a very small incremental step that misses the bigger picture. Paying a clinician to train a caregiver does not get to many of the stressors that caregivers face. CTS only focuses on a part of the equation that is already paid (this is not a time to debate how well that is done or the stresses for clinicians). It does nothing to focus on the caregiver as an individual. Really getting to health equity and patient-centered care requires a bolder approach. Who will lend their voice to help make that a reality?

This article was originally published on The Pulse blog and is republished here with permission.