Letter to Hon. Alex M. Azar II, Secretary of the U.S. Department of Health and Human Services - New Mexico Delegation Leads Bipartisan, Bicameral Effort to Expand Telehealth Care in Underserved Communities through Medicare and Medicaid

Letter

The Department of Health and Human Services has identified value-based care as one of four core priorities to improve the health and well-being of the American people. In order to achieve that worthy objective, we must identify and support new and emerging health care delivery models in Medicare and Medicaid.

We believe that Project ECHO, and technology-enabled collaborative learning and capacity-building models more generally, help to move us closer to this goal. We are writing to specifically encourage the Department to explore ways to support and sustain the integration of this successful national initiative into the health care delivery system.

Project ECHO is a telehealth mentoring model that enhances workforce capacity in underserved areas by providing community-based primary care teams with the evidence-based knowledge to manage patients with complex conditions. As of September 25, 2019, it is now operating in 462 programs at 210 hubs across 48 states and addressing over 70 different complex conditions. Collectively, more than 50,000 primary care providers and health care professionals have participated in mentorship programs using the ECHOmodel.

By leveraging multi-disciplinary teams of experts at academic medical centers to permanently enhance primary care capacity in local communities, Project ECHO expands specialty care access in rural and urban underserved areas, increasing the likelihood that patients get the care they need, when they need it, without having to rely on referrals and travelling long distances. It can enable the more effective use of existing health care resources to achieve better outcomes, providing greater value to patients and taxpayers.

Despite growing interest and some financial support from the federal government and specific states, no ongoing funding streams exist to support Project ECHO, and technology-enabled collaborative learning and capacity building models more broadly. We respectfully request your consideration of the below actions--using existing authorities--that could accelerate ECHO's integration into the health care delivery system, and, in doing so, advance federal and state efforts to provide value-based care.

Issue CMS Guidance to States on Financing Strategies Available Through Existing Medicaid Authorities

Several states are currently exploring ways to finance new and existing ECHOprograms to advance their states' health and quality goals. While there are examples of Medicaid financing mechanisms for ECHO in practice, there are no clear federally-approved templates for states to reference. States may be unwilling to consider supporting ECHO programs if the path for federal approval is unclear or uncertain. Having CMS issue guidance on existing authorities that could be used under Medicaid would confirm that there are approvable models and clarify the steps for securing that approval, opening a pathway for states.

We encourage CMS to issue guidance specific to ECHO, or to technology-enabled collaborative learning and capacity building models more broadly, that would describe available authorities that states could use to leverage Medicaid financing and/or managed care contracting parameters for Project ECHO, and clarify the actions that states would need to undertake for securing CMS approval, thereby streamlining the implementation process and encouraging states to explore these strategies. CMS could issue an informational bulletin or State Medicaid Director's Letter that could include topics such as: capitation payments (required or voluntary); disease management programs; health homes; Delivery System Reform Incentive Payment (DSRIP) programs; care coordination payments; episodes of care; network adequacy; in lieu of and value-added services; and shared savings arrangements through accountable care organizations.

Explore Opportunities to Support ECHO, and ECHO-like models, Under Existing Medicare Authorities

We encourage CMS to explore opportunities under existing Medicare authorities to support ECHO--and technology-enabled collaborative learning and capacity building models more broadly--to advance CMS quality strategy goals. In particular, ECHO's activities are consistent with improvement activities under the Merit-Based Incentive Payment System (MIPS), and participation in such activities align with ECHO's and CMS' shared quality goals. CMS should explore whether participation in ECHO could count for meeting the thresholds under the "Improvement Activity" category. Activities in this category include: enhancing care coordination; patient and clinician shared decision-making; and expansion of practice access. Allowing physicians to count ECHO activities in this category could encourage new providers to participate in ECHO and would help CMS achieve its quality goals.

Ultimately, as states and the federal government pursue delivery system reforms to achieve better patient outcomes and value, we recognize the need to improve access to high-quality, cost-effective specialty care. Technology-enabled collaborative learning and capacity building models like Project ECHO move us closer to this shared objective, and they deserve our close attention and continued support.

We appreciate your consideration of this request, and we want to recognize the efforts to date by multiple agencies across the Department to explore the model. We believe the actions outlined above will continue to build on this growing momentum.

We look forward to your response.