By Emily Maxson, Chief Medical Officer

Today’s update has three sections: AWV Late Breaking News, Reopening Guidance, and Limitations of Antibody Testing - Education.

AWV Late Breaking News

We finally have clear guidance from CMS on the ability to provide Annual Wellness Visits via telehealth. Excerpted from an email dated May 15, 2020: 

“If the patient can self-report elements of the AWV (i.e., height. weight, blood pressure, other measurements deemed appropriate based on medical and family history), those measurements may be included and recorded in the medical record as reported by the patient. Guidance for when the patient cannot self-report is currently under review, and CMS plans to issue guidance soon.” 

Our interpretation of this guidance is that we should encourage an AWV via telehealth for all patients who are able to measure their blood pressure and weight at home, and we will await clarity from CMS on how to handle patients who cannot provide their vital signs. Some of our practices have received guidance directly from their Medicare Administrative Contractor (MAC) and can rely on that guidance as well. You can always reach out to your MAC to determine if they have more specific local guidance than CMS is currently providing. 

Though CMS has allowed for AWVs to be billed even with telephone alone (in the event that video is unavailable), risk codes are not currently accepted with telephone only visits. As such, every effort should be made to provide the visit with video enablement. HHS continues to permit the use of commercial (non-HIPAA compliant) video communication technologies provided they can be used privately. 

Our suggested workflow for telehealth AWVs can be found here for users with App access and here for users without App access.

Reopening Guidance

My news feed is crowded by States’ plans to reopen, alongside reports of inclining cases and portents of an inevitable second peak. The contents of my email inbox are far more personal, with updates from stricken colleagues, reports of hospitalized providers and staff within Aledade nation, and questions from concerned individuals across our network. For me, the balance is a heightened sense of worry for primary care professionals and their staff. Even as I remain aware of the community's need to welcome patients back for procedures and visits, I fear for our practices’ health and how they will be able to protect themselves and their staff from becoming ill if an asymptomatic or presymptomatic carrier presents for care. I’m grateful that we were able to provide an initial “bolus” of PPE and connections for reordering PPE, but I worry that it won’t be enough and that too many practices will find themselves compromising their own health to serve others. This is the plight of our frontline heroes who put themselves in harm's way, every day, to keep others safe.  

We have received numerous requests for Reopening Guidance. I’m quite conflicted on this topic - my personal and professional opinion is that many States are rushing to reopen regardless of the science and local epidemiology. I recognize that those practices that must reopen to serve the community still need an objective source of information on how to reopen once the decision has been made. State and local public health agencies are the best sources of information on allowable services, while federal sources (like these from CMS) list guidance and recommendations.  

Humbly and with acknowledgment that I do not have all the answers, here are a few best practices for reopening collated from the literature and Aledade practices:

Guiding Principle: Virtual Whenever Possible 

Because telehealth is always safe and pays just the same, practices should continue to utilize telehealth for office visits whenever possible. The CMS changes to allow for E&M televisit Parity WITHOUT video should radically change the dialogue for elderly patients hesitant to use technology.  

Farzad’s recent email on financial health is a handy reference to the high-value services you can provide to your patients telephonically or via video chat. For easy reference, see here for users with App access and here for users without App access. We also recently hosted a webinar on telehealth that you can find here.

When is the optimal time to reopen, in order to mitigate the risk of infection for staff and patients? 

This is especially challenging because some key data points to guide responsible reopening are not publicly available. Ideally, a practice’s area should have declining cases over 14 days with sufficient testing, declining emergency room and outpatient visits with influenza-like illness, and hospital surge capacity if the outbreak flares up (see Resolve’s draft here).  We are advocating actively for a national entity to take up the responsibility of tracking and publishing this vital information. Though this resource (www.covidactnow.org) doesn’t include information about trends in influenza-like illness, I have found the data herein illuminating.

Protect yourselves and your patients with safe reopening actions.

Consider Paul Farmer’s 4S’s for global health, which are as relevant for the United States’ COVID-19 response as they were for the international Ebola response.

STAFF

• Monitor all staff daily for symptoms. The CDC has comprehensive return-to-work protocols for symptomatic staff regardless of testing availability as well as staff who have tested positive but remain asymptomatic. Note that antibody testing does not play a role in CDC’s recommendations to return-to-work.
• Train all staff in proper PPE procedures, including donning and doffing and universal precautions.

STUFF

• Ensure adequate PPE - practice universal precautions for all healthcare providers and staff (a mask all day, fresh gloves for every patient) whether patients have symptoms or not.  
• All patients should wear at least a cloth mask.
• Disinfect all contacted surfaces and rooms thoroughly after exposure to symptomatic patients

SPACE: Optimize your space for social distancing, however feasible

• Place waiting room chairs 6 feet apart
• Use a separate entrance and separate exam rooms for well patients, if possible
• Open windows periodically for air circulation

SYSTEMS

• Decrease surprise walk-ins with “call us first” policies and signage (available through the Aledade App and on our website)
• Start with lower in-person patient volumes
• Encourage patients to wait in their cars until it is their turn to be seen 
• Minimize visitors and companions by encouraging non-essential companions to wait in the car, and screening all visitors and companions for symptoms.  

New Education Available

Limitations of Antibody Testing

Recently, national labs have amplified direct-to-consumer advertising for antibody tests, encouraging prescriptions from doctors. We have had many questions on this and have developed educational materials for providers to facilitate healthy dialogue on the limitations of these tests. 

The take-home points are that the positive predictive value of any test depends on these testing characteristics AND the prevalence of the condition in the population. Even though COVID-19 is widespread, the actual prevalence is low enough to create a huge problem with false positives. Even a test with high sensitivity and a 94% specificity can generate a tremendous amount of false reassurance in the community if the prevalence is low.  

Consider the difference between an area of relatively high and relatively low prevalence: 80% of positive antibody test results in an area with 20% prevalence (NYC) will actually be true positives; but in an area with 2% prevalence (average prevalence outside NYC), only 24% of positive results will actually be true positives. This means that 76% of all people in the latter community will have false reassurance from their test results (and may feel encouraged to diminish responsible social distancing behaviors).  

Our advice to practices is this: Encourage patients who are seeking testing to have a telehealth visit with you to discuss the limitations of antibody testing prior to executing or recommending the test. Dr. Sarah Mullins at Stoney Batter Family Practice in Delaware is doing this with great success - patients need to understand their risks of false positives. Attached and linked here is our education on the limitations of antibody testing. 

Get the Latest COVID-19 Information in the Aledade App

The resources mentioned above and much more are available to Aledade ACO practices in the Aledade App, and more broadly to any primary care practice through the Aledade website. Patient, Practice & Staff, Telehealth, and COVID-19 resources are continuously refreshed and always ready when Aledade ACO practices need them.

To all of the people serving in primary care practices across the country, please stay well. All of Aledade nation stands ready to support you