Neal Shore: Welcome everyone to this program by UroToday. I'm so pleased to be able to present this program for you and be a small part. Our title of our program is LUGPA Update on Cares Act and Assistance for Physician Practices During the COVID-19 Crisis. LUGPA is the Large Urology Group Practice Association in the United States. This organization began 12 years ago.

Let me go right to our introductions because we have an outstanding faculty and we have a group here tonight who have been working around the clock given the incredible, somewhat torturous changes that have happened because of this pandemic known as the COVID-19 crisis and things have just been happening at breakneck speed. And so we have with us for our program, Deepak Kapoor, who was a founding member of LUGPA and our current Chairman of Health Policy. We have Gary Kirsh, also a founding member of LUGPA and Chairman of our Political Advocacy Group. I should also mention that both Deepak and Gary are past presidents of LUGPA. We're also incredibly pleased to have John McManus who is our Republican Political Consultant for LUGPA Health Policy from McManus Group and Tracy Spicer who is our Democrat Political Consultant and both Tracy and John have been with us since really the inception of LUGPA. Tracy is with Avenue Solutions.

So much has happened. Our program tonight we're going to be introduced by Gary Kirsh's summary of the reasons for LUGPA policy and advocacy. We'll then talk about telemedicine and the essential role it's taking place now and helping our independent practices, specifically urology, deal with this healthcare crisis and offer care to our patients in an inappropriate and safe manner. And then most importantly, we'll transition to a review of the coronavirus age recovery emergency services stimulus package and John McManus will begin that review along with Tracy Spicer. They will review how to understand this really long piece of legislation, how to implement it and what's really salient for men and women who are trying to continue to salvage and bolster independent medicine. So with that, Gary, if you would please review for us. Thank you.

Gary Kirsh: Well, thank you, Neal. It's a great privilege to participate in this program. I wish we were doing it under better circumstances, obviously. Neal, in the last 10 days, all of our worlds have been turned upside down. It was only 10 days ago that we were operating essentially normally in most cities in America and then rapidly we had many, many government actions all, of course, appropriately aimed at stemming the pandemic.

These actions have resulted in stay at home orders in many states and also in many states prohibitions on the performance of elective surgery. Everyone understands when the restaurants are shut down, the restaurant owner is distressed. That person he or she may lay off their staff, try to hunker down and pay the rent, but I think less obvious is what happens to independent physician practices all across the United States. This is a unique crisis. Other recessions, for example, the 2008 financial crisis candidly really didn't hit healthcare like this crisis is hitting healthcare.

When independent practices are told, again, understandable not to treat patients because they should stay home and not to do any surgery, especially if they're a surgical subspecialty like urology. All of a sudden the revenue begins to tumble while the infrastructure of the practice is still there. This has resulted in a lot of practices furloughing employees and taking many other measures. In the last 10 days, this has happened very, very quickly. And in Washington DC we are well aware of the sensitivities that policymakers have, appropriately so, to the financial and operational condition of the hospital system at the time of this pandemic, but what we were finding was that really the policymakers were not aware of the financial stress and operational stress hitting independent practices as their revenue streams were essentially shut down and as they were increasingly unable to really meet the needs of the public with various medical conditions that weren't really COVID-19 related.

We became at LUGPA increasingly concerned about this last week and so we swung into action in order to protect independent urology and by extension independent medicine. And I believe we have had a significant impact. We've really done this, Neal, on a couple of levels. First on the policy level and Dr. Kapoor of course who will speak shortly, has been very involved at this level. We worked with Senator Barrasso and Bennett, bi-partisan members of the Senate finance committee, and much of the work, as you may know, has come out of the Senate on relief for COVID-19 as well as a couple of great allies on the House side. Congressman Ruiz from California and Dr. Phil Roe from Tennessee. And we provided language that impacted how final drafting would be done on some of the packages in order to protect independent physician practices and ASCs in addition to hospitals.

So that was on the policy side. And then on the advocacy side, we really had to raise awareness in Washington because they don't focus on the independent practice as much as they do the hospitals because the hospitals are on the front line and they're a much bigger employer and economic driver. But independent medicine is a key part of our landscape. It's a key part of our healthcare infrastructure and if we allow it to go under, then when this crisis is over, patients across the country will not be able to be cared for.

So what we've done on the advocacy side is we have mobilized our grassroots network across the entire country with LUGPA practices and equally, or perhaps more importantly because of the work we've done over the last dozen years building relationships in Washington, being a resource to policymakers in Washington, we were able to specifically interact with members of the Senate finance committee often on a personal level through various constituents and other leaders in LUGPA to impress upon policymakers the importance of providing relief to independent practices as part of this package.

Neal Shore: Gary, that was a wonderful review. You did it in a few minutes and it's been over a decade of work and now it's sort of culminating in this pandemic crisis. A lot of the education that we're seeing that's web-based, academic, nonacademic is really focusing on protecting patients, protecting the healthcare team. But really what we're focusing on here is protecting our economic viability and sustainability. And so maybe with that, I'd like to transition over to Deepak Kapoor. And Deepak, if you want to comment on some of Gary's intro, but also where we are right now in this rapidly changing world of telehealth and telemedicine.

Deepak Kapoor: Thank you, Neal. First I'd like to thank you for offering me the opportunity to participate in this forum with some folks that have really been on the front line and have worked very, very hard. I can't overemphasize the work that John and Tracy have been doing in Washington, the yeomanlike efforts that Gary has done over the last decade in political advocacy that really puts the policy apparatus and the physician to communicate with key individuals.

It really is a very, very longterm relationship. These two committees really work hand in glove, one, to obtain access to key legislative bodies as well as regulatory agencies to be able to portray our views to them. Because really the importance about access isn't that somebody necessarily does what you want, it's just that you have the opportunity to make a case for you and most importantly your patients because if we're not advocating for our patients, then genuinely nobody else is going to. These efforts have been going on for a decade, and what's happened, which I think the listeners really need to appreciate, is you go from being one of many, many stakeholders buying for attention and ultimately when you have access and LUGPA has always taken the position to speak in a very data-oriented fashion.

We have transitioned from being seen as a purely an advocacy organization to actually being a resource to individuals that are making rules. And so what happens now is that staffers in committee, when they're thinking about something thanks and they have a question, "Hey, how do you think this is going to impact not only hospitals but the independent practice of medicine?" We've gotten to the point after a decade that we're really one of the first people that they call. Now, we're not making policy. Obviously that's done on a much higher level and they have many factors to consider, but at least they're asking for our input to say, "Hey, we're thinking about doing this. Is there unintended consequence to our actions from these bills?" The graduation from simply lobbying and advocating to being viewed as a resource has been an extremely gratifying transition that only happened because of the longterm relationships that we've developed.

Before I pivot over to talk a little bit about telehealth, one thing that I will tell you is my practice is here in New York. For many places in the United States, COVID-19 is somewhat of a distant cry. But I will tell you that it has been in 30 plus years of clinical practice, I genuinely have never seen anything like this. How fast the resources of the systems here in New York and we have a lot of hospitals, a lot of amazing academic centers, a tremendous network of community hospitals, maybe one of the highest hospital density in the entire United States. And this system became overwhelmed in five days.

So for those people, I wish that nobody has to deal with this, but for those people that are listening to this, I would urge you to take this very, very seriously because, from an epidemiological standpoint, this is very, very real. The key for us is to be part of the surge component to manage overflow from the hospital in a crisis situation. So in order to be part of the surge, we have to stay open, but we can't stay open for everybody. Many of our patients are elderly, many of our staff are not young. We have to stay open to provide care for those patients that require therapy, that require treatment. So those that are furiously, chronically ill or people with acute non-life-threatening injuries so they don't have to go to the emergency room, because here in New York, the hospitals are just completely, completely overloaded.

The key to telemedicine is to be able to identify your outpatient clinic schedule, triage those people that do not absolutely need to come into the office and be able to develop a mechanism so that you can provide that type of subacute care to individuals without exposing them to the risk of travel and without exposing your staff to the risk of seeing patients whose status is unknown.

Historically, telemedicine was very, very restricted. So the ability to provide telehealth services was restricted to certain rural communities. You need to have consent. You needed a very robust mechanism for audio and video capability. As a consequence, and in addition to that, the reimbursement was so relatively low that it was really out of the reach for most providers. So the COVID Relief Act works in multiple stages. And in earlier portion of the act, there was a recognition that we needed to see people more remotely than in the offices and some provisions easing Medicare requirements were put into place. But unfortunately, that wasn't detailed enough to provide administrative guidance, the Medicare and implement it. So nobody really did.

About a little over a week ago, President Trump signed an executive order, which issued what's known as a section 1135 waiver. In the course of this waiver, the executive order really significantly eased the requirements for who could do telehealth, the requirements for telehealth, the HIPAA requirements for telehealth as well as the ability to be reimbursed for those services. That didn't really change that much in the Cares Act. But what the Cares Act did is it took the executive order. And of course, the problem with any executive orders, it can be overturned by a stroke of a pen by the next executive that may not like it. Only Congress can enact laws and what the Cares Act does is it codifies in the statute, the previous executive order, which is a very, very big deal.

So what this does is it includes E&M services, mental health counseling, preventive screening. It allows for equilibrating payments for telehealth services in the same level as we have for certain other E&M visits. It allows for all practitioners to do this, including APPs who's an important caveat because APPs cannot bill incident-to. So this is an area where people could get into some difficulty if they built incident-to billing for their APPs. The APPs must bill at the level of their license, which is 85% of the position reimbursement and it does allocate 27 billion to HHS 200 million to the FCC to expand services.

And in broad brush strokes, you can do three different things. The first is called a Medicare telehealth. Medicare telehealth visits are really the key. What this does is it's considered the same as an in-person face-to-face visit and it can be used for both new patients as well as a followup patient. You use the standard coding rubric that you use and you get paid for a standard E&M visit. Medicare coinsurance and deductibles generally apply to these visits, although there are certain waivers for patients that HHS is able to do. And importantly, certain audit requirements regarding the patient are waived during this emergency period.

The one thing though is you must have bi-directional audio-video capability. However, it does not have to be fully compliant, so you can FaceTime a patient or Google video a patient or do a Zoom meeting like we're doing right now. So in any way that you want to do it, as long as you have video capability, you will qualify to bill for a full E&M code for the service, which is very, very important.

The next step is a virtual check-in. A virtual check-in can only be done when you have an established relationship with the patient. So you cannot do a virtual check-in for a new patient visit. It used to be limited to rural settings. It has been expanded to all geographies right now. The patient needs to consent for the service, but you're allowed now to market the patient. So you could proactively reach out to the patient and send a mass email or something through your portal saying, "Hey, we've got virtual check-ins right now. You can do this." So you can actually proactively market the service to the patient as opposed to waiting for it to be on-demand. And you can use audio only so you can just use your phone as long as you're not looking at images.

There are two codes that you can use. It's a five to 10 minute discussion. One of the codes is if you don't review an image or test results, the other one is if you do. So the patient is allowed to message you or send you an email or send you a graphic, however, they want to show you a video image that's not live. And by reviewing that, you get to bill a higher level of service.

The third type of telehealth provision, it's called an e-visit. Again, is only allowed when you have an established relationship with the patient. Again, there are no more geographic or location restrictions for these patients and you're communicating with the patient through using some type of portal. Again, you can market this to the patient. This is something that you can do with over your computer, over your portal and do that and again there's actually a number of different codes that are related to the type of service that you provide and the length of time that you're spending doing it.

If everybody's looking now, this is a quick summary slide that describes the three levels of visits. It's described in summary, what is the level of service, the coding requirement as well as the patient relationship with a provider. Also embedded in there is the link to the CMS website to provide guidance. Importantly, virtually all private insurers are doing this, and some of the rules for that vary state by state. For example, here in New York, private commercial insurers are prohibited from collecting co-insurances or copayment for telehealth visits. So it is required that they reimburse the full amount of the allowed service for any one of these codes. But that's something that the listeners are going to have to review on a state-by-state basis.

Neal Shore: That was a wonderful review, Deepak. This is information that's just been coming out very rapidly. I know that both you and Gary, as being the leaders of a very successful large urology group practices are implementing this. We are as well. I'd like to ask both of you, maybe Deepak you take it first and then Gary. What has been the adoption within your practices? Specifically, what type of range of reactions have you received from your urology partners as well as from patients? And then also once we get through this crisis, your thoughts on where the use of telemedicine will be in and maybe this is one of these sort of silver lining moments in crisis. This may have a longstanding impact on the practice of medicine, so perhaps first Deepak and then Gary.

Deepak Kapoor: Thank you. Great question and really good points. I have been amazed at how fast the uptake has been. We rolled the service out over the weekend. We started based on the executive order, which of course is now codified. Our first day we saw over a hundred patients on full telemedicine. The second day, 206 and today we saw 440 patients. Our practice typically sees about 1500 patients in a day. We have cut back some services, but I would say between telemedicine and the urgent visits, we saw about 1200 patients.

Neal Shore: That's great. Deepak, thank you. Gary, a couple of comments and then we can talk about the nuts and bolts of the Cares Act and how the financial implementation can help our practices sustain viability.

Gary Kirsh: We've also started doing telehealth. I don't think we've been as successful as Dr. Kapoor's practice in ramping up, we hope to be. Just a word of caution about the sea change that this might or might not represent. Remember that this change is only good through this emergency period and then barring additional executive orders or legislation, we'll go back to the old rules where primarily we were only serving rural regions with telehealth. So I think it's a bit too soon to know if this is really going to be a sea change or just something during the emergency.