Month: September 2024

On September 18, 2024, NYHealth Senior Program Officer Derek Coy submitted the following testimony to the New York City Council Committee on Veterans oversight hearing on increasing veterans’ civic engagement in New York City:

Thank you for the opportunity to testify on behalf of the New York Health Foundation (NYHealth) and address this important issue of increasing veterans’ civic engagement in New York City. NYHealth is a private, independent, statewide foundation dedicated to improving the health of all New Yorkers—including the more than 133,000 or so veterans who call New York City their home. And I myself am a proud veteran, having served as a Sergeant in the United States Marine Corps.

Veterans play a crucial role in our communities, and while most return from service to their lives and communities without issue, some veterans don’t feel ready for civilian life.^[1] They may face barriers including limited access to mental health services, health care, and peer support. Ensuring that veterans are civically engaged reduces social isolation, contributes to their overall wellbeing, and strengthens the fabric of New York City’s communities through their active participation.

The Connection Between Civic Engagement and Health
Veterans who feel healthy and connected to their communities are more likely to engage civically, and vice versa. Research indicates that civically active people tend to have better physical and mental health, and healthier people tend to be more civically engaged.^[2] For example, veterans with quality health care are likelier to vote, volunteer, and be involved in their communities. At the same time, veterans are at greater risk than their civilian counterparts for social isolation and mental health challenges such as PTSD, depression, and substance use, all of which can limit their participation in civic activities.

Fostering Veteran Civic Engagement to Promote Health in New York
It’s perhaps not surprising that veterans have higher levels of civic engagement than their civilian counterparts; separating from the military doesn’t dim veterans’ interest in service. Multiple organizations are operating programs in New York City to capitalize on veterans’ ongoing commitment to service and civic engagement as a means to improve mental health and strengthen their community connections, including programs launched with support from the New York City Department of Veterans’ Services (NYC DVS).

NYHealth has supported several of these efforts in partnership with NYC DVS. For example, the award-winning Mission: VetCheck program trained veteran volunteers to provide buddy checks, peer-to-peer support, and referrals to nearly 30,000 veterans across New York City during the COVID-19 pandemic. More recently, the program has pivoted to focus on educating veterans about expanded health and mental health benefits available to them through the recently enacted Honoring Our Promise to Address Comprehensive Toxics (PACT) Act.

In partnership with NYC DVS, we also supported Black Veterans for Social Justice to mobilize veteran and civilian volunteers to connect food-insecure veterans with healthy, nutritious meals during the pandemic. The program conducted extensive outreach to veterans in the Bronx and other parts of New York City, with a focus on areas hardest hit by the pandemic.

Team Rubicon, a veteran-led humanitarian organization, used an NYHealth grant to mobilize veteran volunteers to provide critical services to New Yorkers in need during the pandemic. They helped coordinate emergency food distribution, medical shelter support, and sanitation efforts; the project offered the added benefit of combating social isolation and promoting cohesion and connection among veterans.

And The Mission Continues, which empowers veterans through community service, organizes “service platoons” that offer veterans a new mission in communities that need their help, from planting community gardens to doing Earth Day clean-ups to laying wreaths on Veterans Day. Veterans who participated in the organization’s fellowship program reported decreased social isolation and an increased sense of social support.^[3]

Additionally, peer mentor programs support veterans to draw on their unique experiences to offer practical skills, support, community connection, and hope to fellow veterans. Programs like the statewide and City-run Joseph P. Dwyer Veterans’ Support Program are effective in helping veterans navigate mental health challenges and access services, while also encouraging them to engage in civic activities. And Veterans Treatment Courts (VTCs)—a type of problem-solving court that provide an alternative to incarceration for justice-involved veterans—include peer mentorship as a core component. These court programs highlight how peer support and engagement can improve mental health and reduce recidivism. A recent NYHealth data brief, developed with the Office of Court Administration, noted high success rates for veterans who participate in VTC, showing the power of community-based interventions and peer support.^[4]

Recommendations for Action
New York City has laid a strong foundation for increasing civic engagement among veterans. I urge the Committee to consider the following steps to continue to improve and leverage existing infrastructure and programs:

Ensure Veterans are Connected to Health Benefits: Veterans who have more access to quality health and mental health services are more likely to have the time and energy to be civically engaged. New York City should continue to take advantage of the recent unprecedented expansions of federal health benefits through the PACT Act. In fact, New York City is responsible for informing veterans and the organizations serving them about these expanded benefits, and has been using one of its core engagement programs to do so. To aid this work, the Foundation is supporting the extension of the Mission: VetCheck program, in partnership with NYC DVS, to ensure all veterans in the five boroughs know about and can access and use their benefits. The City Council also has the opportunity to support these outreach and education efforts and further ensure that all New York City veterans have access to the resources they have earned.

Leverage Civic Engagement as a Pathway to Health Access: Programs such as those led by The Mission Continues and Team Rubicon provide veterans with a sense of purpose and community connection. Expanding and funding initiatives like these can further foster civic involvement as a means to improve health access and outcomes, including responding to medical emergencies and addressing food insecurity. Programs that integrate peer mentors to offer comprehensive support are particularly effective at helping veterans overcome barriers and participate more fully in civic life in New York City. The City Council can help drive additional resources toward peer support programs, including organizations that will be funded through NYC DVS’s open Request for Proposals for Joseph P. Dwyer Veterans’ Support Program initiatives.

Conclusion
Civic engagement is not only a measure of veterans’ involvement in society but also a key indicator and driver of their overall health and wellbeing. By fostering civic participation and expanding access to health services, we can ensure that veterans remain active, valued members of their communities. This approach will benefit our veterans and strengthen the fabric of New York City. I hope you will look to the New York Health Foundation as a resource for your important work. You can learn about our veterans’ health work and more by visiting our website, www.nyhealthfoundation.org.

Thank you.

 

 

^[1] Pew Research Center, “The American Veteran Experience and the Post-9/11 Generation,” www.pewresearch.org/social-trends/2019/09/10/readjusting-to-civilian-life/#:~:text=While%20most%20veterans%20say%20the,it%20prepared%20them%20somewhat%20well, accessed September 2024.

^[2] Healthy Democracy Healthy People, “Health & Democracy Index,” https://democracyindex.hdhp.us/, accessed September 2024.

^[3] The Mission Continues. 2020. “The Empowered Veteran Index.” The Mission Continues. Available at: images.missioncontinues.org/wp-content/uploads/The-Empowered-Veteran-Index.pdf.

^[4] Coy, D. Cobbs, E. Ford, MM. Havusha, A. Sandman, D. 2024. “Veterans Treatment Courts in New York State: Past and Future.” New York Health Foundation. New York, NY. Available at: https://nyhealthfoundation.org/resource/veterans-treatment-courts-in-new-york-state-past-and-future.

September 9, 2024

The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Attention: CMS-1807-P
P.O. Box 8016
Baltimore, MD 21244-1850

RE: File Code CMS-1807-P; Medicare Program; CY 2025 Payment Policies under the Physician Fee Schedule and other Changes to Part B Payment and Coverage Policies

Dear Administrator Brooks-LaSure:

The New York Health Foundation (NYHealth) appreciates the opportunity to provide comments to the Centers for Medicare & Medicaid Services (CMS) on the Notice of Proposed Rulemaking regarding the Medicare Physician Fee Schedule for Calendar Year 2025. Nearly 3.8 million New York State residents^[1]—almost 20% of the population—are enrolled in Medicare. CMS’s policies have a significant bearing on the health of New Yorkers.

NYHealth is a private, independent, statewide foundation dedicated to improving the health of all New Yorkers, especially people of color and others who have been historically marginalized. Our Primary Care program works to advance policies and programs that enhance primary care services and health equity in New York State; this work has provided us with in-depth knowledge of how high-quality primary care systems and programs can maximize health care access and delivery.

The experience of NYHealth, our grantees, and our partners is particularly relevant to three areas in the proposed regulations: the new Advanced Primary Care Management codes, telehealth regulatory flexibility extensions, and the Community Health Integration codes. We offer comments on each of these topics below.

1. Establish Coding and Payment for Advanced Primary Care Management Services
We applaud CMS for introducing coding and payments for Advanced Primary Care Management (APCM) services. Many of the chronic disease management and care coordination services that define primary care occur outside the traditional clinical encounter. As a result, they have been historically undervalued in the fee-for-service reimbursement model. These new APCM services—that pay clinicians per person per month for a range of services—would better compensate many of these activities (e.g., ongoing communication, care transitions) and encourage team-based care. By combining services such as care management and remote communication into a single set of codes, removing references to clinician time, reducing documentation requirements, and allowing multiple types of primary care practitioners to bill for these services, the proposed codes offer primary care providers greater flexibility and resources for care management. Moreover, these codes align with CMS’s broader, multi-year effort to move toward hybrid payments and accountable care.^[2] Successful adoption of APCM service codes in the Medicare market could also influence the commercial and Medicaid markets, thereby strengthening primary care services nationwide. Together, these codes reflect a needed improvement in the current fee-for-service environment.

Over the longer term, we urge CMS to move primary care providers further away from fee-for-service reimbursements and consider ways to induce more holistic, transformative changes for primary care payment, including implementing a hybrid capitated payment model for primary care, aligned with the National Academies of Sciences, Engineering, and Medicine’s recommendations.^[3]

2. Preserve Equitable Patient Access to Telehealth
The temporary policies and regulatory flexibilities that CMS and state governments used during the Public Health Emergency facilitated increases in telehealth during the pandemic. CMS’s removal of delivery restrictions and broadening of Medicare reimbursement policies allowed providers to offer patients a wide range of virtual health care services in a variety of settings. These flexibilities were critical to expand access for patients facing barriers to in-person care, extend providers’ reach in the face of shortages and strain, and meet unmet need for primary care and behavioral health services.

CMS’s proposed extensions and expansions of regulatory flexibility continue to facilitate telehealth use. They align with recommendations for New York State policymakers to expand equitable access to telehealth, as outlined in a recent NYHealth-supported report from Manatt Health.^[4] These recommendations include extending telehealth coverage and reimbursement, covering audio-only services on par with audio-visual services, and supporting telehealth policies that benefit federally qualified health centers (FQHCs). Among others, we commend CMS’s proposed provisions to:

• Create an expansive definition for “interactive telecommunications system” that includes audio-only technologies when patients cannot or do not wish to use video. Our grantees have demonstrated that marginalized patient populations often rely on audio-only technologies. For instance, New York City Health + Hospitals, the country’s largest safety net hospital, found that patients who were above 65 years of age, Black, and Hispanic were more likely to use audio-only visits than video visits.^[5] This regulatory flexibility will help ensure marginalized patients have the option to seek care remotely—thereby narrowing, rather than exacerbating, disparities in access. It also signals to providers and policymakers that audio-only is a common and acceptable form of telehealth delivery.
• Continue to allow FQHCs to initiate and deliver mental health services without first providing in-person care. FQHCs are critical safety net providers for marginalized patient populations, and telehealth has been instrumental in enhancing access to care for FQHC patients. A recent NYHealth-commissioned analysis shows that behavioral health is the most common use of telehealth, now accounting for two-thirds of all virtual care encounters.^[6] Telehealth also expands the reach of safety net clinicians amid behavioral health workforce shortages.
• Continue to allow providers to work from home to deliver telehealth services and permit clinicians to bill using their enrolled practice site rather than their home address. This flexibility reduces administrative burdens and, as CMS acknowledges, protects provider safety and privacy in the event of a future public health emergency. These continued flexibilities are also an important tool for clinician retention. In New York, where health care facilities like hospitals and FQHCs are now required to have either the provider or the patient on-site at the facility to receive full Medicaid reimbursement for telehealth, we have observed the opposite effect. In response, numerous FQHCs in New York have reported resignations from behavioral health clinicians, who seek flexible virtual work options in settings like behavioral health and substance use disorder clinics that do not face similar restrictions.^[7]

 3. Continue—and Adapt—Implementation of the Community Health Integration Billing Code for Community Health Workers (CHWs)
Last year, we commended CMS for establishing a Medicare benefit that allows providers to bill for Community Health Integration (CHI) services provided by CHWs—a first for Medicare beneficiaries. CMS leveraged its role as the largest health care payer in the country to expand access to services provided by CHWs and drove innovation by other payers like Medicaid.

We appreciate CMS’s invitation to provide feedback on barriers to providing and billing for these CHI services. Despite the promise of this new code, largely, our grantees and partners who serve Medicare beneficiaries have reported that it has been used to a limited extent or not at all. Many hospital systems, FQHCs, and community-based organizations (CBOs) have deemed it too burdensome to adopt new workflows and IT infrastructure needed to bill for CHI, given the small proportion of Medicare beneficiaries in their patient panels. Even among health systems serving a substantial number of Medicare beneficiaries, they have cited these operational issues, as well as a scarcity of CHWs, as reasons for limited uptake. For instance, an Accountable Care Organization in rural upstate New York that serves 10,000 Medicare (non-Medicare Advantage) beneficiaries has made no CHI claims in 2024.

In light of these barriers and in order for CMS to realize the promise of the CHI code, CMS should consider partnering with State Medicaid agencies to design complementary CHW benefits. For example, CHI only reimburses for CHWs’ labor to make connections to services, while State Medicaid programs are starting to reimburse for the delivery of health-related social needs services (e.g., medically tailored meals). There may be more opportunities to coordinate with State Medicaid agencies on reimbursement. Medicare and Medicaid benefits should cover similar services, be set at competitive rates, and have similar and streamlined documentation requirements; this would create incentives for and reduce barriers to greater uptake. In New York, as in numerous other states, CMS can align the CHI benefit with Medicaid benefits and 1115 demonstration waivers. CMS should also marshal its resources to help providers and CBOs gain awareness about the new CHI services and build the IT capacity needed to adopt and bill using these codes. Funding for IT infrastructure-building would be particularly useful in enabling referrals and data-sharing between providers and their CBO contractors.

In addition to addressing these broad challenges, we encourage CMS to consider and address specific issues raised by our partners about the documentation burdens of the current CHI code. For instance, our partners have reported challenges with the current requirement that only the clinician initiating the visit can bill for CHI services. In team-based care settings, where CHWs are delivering CHI services and other clinicians like social workers are supervising them, this requirement results in administrative burdens and confusion. Another issue is that, in the initiating visit, clinicians are required to document a specific chronic condition that CHI services can help manage, but often these services help manage overall health and not a specific chronic condition. One NYHealth grantee, a major health care system with an institutional commitment to integrating CHWs, has largely not billed CHI services because of these burdens; these documentation issues likely cause an even greater barrier to small health care providers and CBOs. We encourage CMS to explore other, more flexible documentation methods for initiating CHI services, such as using existing health-related social need screenings.

While our New York partners have shared their documentation issues, many providers and CBOs across the country have also reported challenges with the CHI benefit itself. For instance, national colleagues like the Partnership to Align Social Care have recommended changes with respect to the 60-minute minimum threshold, initiating visit requirements, FQHC billing limitations, and other elements. We encourage CMS to consider these suggestions.

While CMS may consider adjusting elements of and requirements for the CHI code to support implementation and enhance service uptake, it should maintain the focus on CHWs. We, like CMS, recognize that there are other “auxiliary personnel” that can provide CHI services to better manage patients’ health. However, CHWs are uniquely positioned to build trusting relationships with patients, and this code was pioneering because it supported CHWs through Medicare reimbursement. In New York State, the health care and CBO communities view the CHI code as one of several new sources of CHW reimbursement that can be leveraged to support integrating CHWs in health care. We urge CMS to avoid redirecting resources that are crucial for sustaining the CHW workforce and to maintain the flexible training and/or certification requirements that are appropriate for, and desired by, the community-based professionals in each state.

Thank you for the opportunity to provide comments on these proposed enhancements to the CMS 2025 Physician Fee Schedule. If you have any additional questions regarding the APCM codes, please reach out to Nicky Tettamanti, Program Officer. For additional questions related to telehealth or Community Health Integration, please contact Ali Foti, Program Officer.

Sincerely,

David Sandman, Ph.D.
President & CEO
New York Health Foundation

 

^[1] Centers for Medicare & Medicaid Services. (2024, April). Medicare monthly enrollment. https://data.cms.gov/summary-statistics-on-beneficiary-enrollment/medicare-and-medicaid-reports/medicare-monthly-enrollment.

^[2] U.S. Department of Health and Human Services. (2023, November). HHS is taking action to strengthen primary care. https://www.hhs.gov/sites/default/files/primary-care-issue-brief.pdf.

^[3] National Academies of Sciences, Engineering, and Medicine. (2021). Implementing high-quality primary care: Rebuilding the foundation of health care. The National Academies Press. https://nap.nationalacademies.org/catalog/25983/implementing-high-quality-primary-care-rebuilding-the-foundation-of-health.

^[4] Smith, J., Savuto, M., & Augenstein, J. (2024, July). Advancing telehealth access and utilization in New York State. Manatt Health. https://nyhealthfoundation.org/resource/ensuring-long-term-equitable-access-to-telehealth-in-new-york-state-opportunities-and-challenges/.

^[5] Chen, K., Zhang, C., Gurley, A., Akkem, S., & Jackson, H. (2023). Patient characteristics associated with telehealth scheduling and completion in primary care at a large, urban public healthcare system. Journal of Urban Health, 100(3), 468–477. https://doi.org/10.1007/s11524-023-00744-9.

^[6] Smith, J., Savuto, M., & Augenstein, J. (2024, July). Advancing telehealth access and utilization in New York State. Manatt Health. https://nyhealthfoundation.org/wp-content/uploads/2024/07/NYHealth_Manatt_Telehealth_Access.pdf.

^[7] Ibid.