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Telehealth: programs, pitfalls and payment

Tom Brazelton, MD, MPH February 25, 2016

•  Nothing to declare

•  Thanks to Chris Green, Jeff Grossman, and to Ken Wood, for mentoring and leading the way

Conflict of Interest

1750s Tobacco Resuscitator Kit The Dutch Method of Resuscitation

The “Fumigator”!Maatschappy tot Redding van Drenklingen, 1767, (the Society for the Rescue

of Drowned Persons)!

The past has caught up

Ar#clefromFebruary1925CoverofScience&Inven*on

Not “the future” anymore

The Jetsons, ABC, 1962

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The expanding universe The expanding universe

Telemedicine & Telehealth

•  The convergence of (1) high tech, (2) medical care and (3) access for patients to the system

•  Disruptive •  Innovative •  Immediate •  “www.” = “Wild Wild West”

– Few laws, little regulation, lots of money & cowboys and a few land barons

•  On the horizon for ACOs – Expands revenue via increased # covered lives – Engages patients: convenience, satisfaction – Saves costs: avoidable penalties, overutilization

•  Revenue generation, extended reach – Off-hour urgent care services – Capacity management: lower wait times,

balance loads, improved triage – Billing synergy with community clinics

Telemedicine: ideal world

•  Engages patients – “Convenience care:” wait times, travel, lost

work, child care – Engaged patient = better outcomes – Technology supports adherence to rx – May help identify and fill gaps in care

•  Saves money---maybe – Avert some readmissions, better d/c care – Re-direct inappropriate acute care utilization

Telemedicine: ideal world The forces on us internally

Theglobalcrisisofharmandwastemustbeaddressed.Ourgoalmustbetomovefromharmtohealingandfromwastetovalueashospitalsmovefromaprovider-centered,volume-drivencaretoaperson-centered,value-drivencare.

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The forces on us externally The patient always comes first “Thebestinterestofthepa#entistheonlyinteresttobeconsidered,andinorderthatthesickmayhavethebenefitofadvancedknowledge,unionofforcesisnecessary…IthasbecomenecessarytodevelopMedicineasacoopera#vescience.”

WilliamJ.Mayo,MD,1910

“Itisnotatallcertainthatwhetherhospitalsastheyarenowmanagedexistforthepa#entsorthedoctors…Ithasbeenanaimofourhospitaltocutawayfromalloftheseprac#cesandtoputtheinterestofthepa#entfirst.”

HenryFord,MyLifeandWork,1922

Squeeze to Juice Ratio Continuum

High Low

SqueezeJuice

Telehealth Vision & Mission

Vision: The UW Health Telehealth program will be the comprehensive resource for all initiatives incorporating the use of telehealth to achieve UW Health’s strategic goals. Mission: Through collaborative program design, development, and implementation: •  Improve outcomes, access to care, and enhance the patient and family experience. •  Provide innovative tools and care delivery models to serve Wisconsin and beyond. •  Utilize scarce resources efficiently to provide the highest quality of care.

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•  Move rapidly down the pathway of robust Telehealth services deployment

•  Embrace crisply-defined approach to retail healthcare •  Define an Approach to “Retail” healthcare, including Best

Deployment of Telehealth –  Retail healthcare extends well beyond the concept of a “nurse in a

box” or “doc in a box” to a much broader view of how healthcare – preventative, primary, sub-specialty, chronic and acute – can be provided to meet the needs of those in our care in ways that are most attractive to them. This implies adding to our traditional methods of interaction the spectrum of modern communication modalities that we so depend upon in the rest of our lives.

Organizational Strategic Charge

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•  History: 2011-ish, started in an outreach arm of UWHealth

•  Mission: unify programs, create efficiencies, save $$$ on MD outreach, “look for small wins”

•  2014: 4 staff, medical director, no representation on the 8th floor (C suite), steering committee lacked both rudder and sail/engine

•  No mandate from IT to help, only “hope”

UW Health’s Telehealth Program

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•  Moved into hospital organization under Ambulatory Ops

•  New Ambulatory dyad leadership •  New CEO’s dream realized? •  Hired CMIO with extensive EHR/IT hx •  Renewed attention to IT infrastructure, gaps •  Timing (2015): AboutHealth member health

systems came together officially

UW Health’s Telehealth Program UW Telehealth External Services

•  Dept.ofCorrec.ons&MentalHealthIns.tute

•  Allergy,Cardiology,Endo,GI,ID,Nephrology,Pulm,Rehab,Rheum,Transplant,Urology

•  Ophthalmology

•  Gene.cs•  ICU•  Interpreters•  MyCharte-Visits•  NICUVirtualVisitors

•  NICU/PICUTransport•  Pathology•  Psychiatry•  Stroke•  Virtualrounds

UW Telehealth & ImageShare UW Telehealth Internal Services

•  VirtualConsults(Inpt.):•  Infec.ousDz•  Pulmonary•  DiabetesMgmt•  Wound&Skin•  Psychiatry•  Teamrounds•  ICU•  Stroke•  Nutri.on

•  VirtualConsults(ED):•  Psychiatry•  TraumaSurgery•  Stroke•  NICU/PICU

•  Interpreters•  Pathology•  Ebola/SpecialPathogensUnit

Strategies for Robust Telehealth Deployment

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•  Direct to consumer (Retail) •  Employer Groups •  Health Plans •  Ambulatory Clinic Visits

o  Specialty Clinics o  Primary Care o  Urgent Care

•  Transitional Care •  Chronic Care •  Complex Case Management •  Other Clinical Services

o  Nutrition o  Wound o  Etc.

•  Inpatient Video Consults •  Ambulatory Clinic Visits

o  Specialty Clinics o  Primary Care o  Urgent Care

•  eConsults •  eVisits

Strategies

Outside UW Health IS Network

Within UW Health IS Network

Digital Health Strategy Internal Strategy

Operationalizing Digital Health Partners Strategy

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Operational Strategy 1 Digital Health Partner

Ø  Select and begin partnership with a third party vendor

Ø  Telehealth and IS Stakeholders have narrowed the partner candidates to MDLive and American Well

Ø  Considerations of a Partnership Strategy: Ø  Capital investment Ø  Ongoing cost Ø  Internal resource demand (project

scope, build, implementation) Ø  Long term strategy

Outside UW Health IS Network

•  Direct to consumer (Retail) •  Employer Groups •  Health Plans •  Ambulatory Clinic Visits

o  Specialty Clinics o  Primary Care o  Urgent Care

•  Transitional Care •  Chronic Care •  Complex Case Management •  Other Clinical Services

o  Nutrition o  Wound o  Etc.

Digital Health Strategy

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Operationalizing Digital Health Partners Strategy

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Operational Strategy 2 MyChart/EPIC Functionality

Ø  Develop internal system for implementing

Digital Health Strategies Ø  Considerations of Internal System Strategy:

Ø  Capital investment Ø  Ongoing cost Ø  Internal resource capacity Ø  Technical Infrastructure Ø  Scalability Ø  Ongoing support

Outside UW Health IS Network

•  Direct to consumer (Retail) •  Employer Groups •  Health Plans •  Ambulatory Clinic Visits

o  Specialty Clinics o  Primary Care o  Urgent Care

•  Transitional Care •  Chronic Care •  Complex Case Management •  Other Clinical Services

o  Nutrition o  Wound o  Etc.

Internal Strategy

UW Health Telehealth Project Requests Real Time

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Real Time Video Visit Real Time Video Consult Real Time Video Case Management An outpatient video interaction between a patient and a remote- provider who is located at an office, clinic, or other qualifying location

A video interaction between a patient and remote-provider initiated at the request of another provider to recommend care for a specific condition or problem

A video collaboration process that facilitates recommended treatment plans to ensure that the appropriate medical care is provided to the patient

Schedule Schedule Schedule §  Geriatric video visits §  DOC video visit expansion. §  Additional services and TAC Departments §  Adult Congenital Heart Clinic Video Visits §  Telepsychology Regional Visits §  Telesportspychology §  Plastic Surgery Video Visits §  Pediatric Waisman Center Visits with patients at home §  Adult Nephrology Stone Clinic group sessions §  Pediatric Endocrinology Outreach §  Pediatric Speciality Care: surgical pre-ops and post-op checks §  Epilepsy Clinic visits to patients located at home §  Transplant Video Visits/Education Sessions §  Primary Care Video Visits §  Pediatric Care of the Complex Child §  Interstage single ventricle home weekly follow-up

§  Expand services using video consults at UW Rehab §  Expand services using video consults at TAC §  Develop solution for providers to conduct consults from home §  Interventional Radiology ED consults §  Video Rounding on Patients located at TAC §  Ebola Response and Telemedicine Workflow

§  Pediatric complex care §  Chartwell Midwest Infusion Patient

Education §  NICU Virtual Visitor Modifications §  Discharge planning with primary care §  Pediatric pulmonary evaluations of home

vented/complex care patients

Urgent/Emergent Urgent/Emergent Urgent/Emergent §  Develop retail direct to consumer on demand video visits §  Employee/Occupation Health

§  eCare Manager upgrade §  eCare (eICU) services ‒ mobile carts at referring hospitals §  eCare (eICU) services ‒ additional support for referring

hospitals §  Implement Telekids at all existing Telestroke sites §  Develop internal Epic documentation tool for Telestroke §  Re provision telestroke carts in region not using Vidyo §  Expand telestroke services to region rapidly §  Trauma Surgery Regional ED consults §  Implement Telestroke at referring hospitals

§  TLC virtual visitors

UW Health Telehealth Project Requests Non-Real Time

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Non-Real Time Visit (eVisit) Non-Real Time Consult Non-Real Time Case Management An online interaction between a patient and a health care provider using a system that supports the secure exchange of health care information (i.e., MyChart)

An online interaction between providers to recommend care for a specific condition or problem using a system that supports the secure exchange of health care information (i.e., Healthlink)

A HIPAA compliant online collaboration process that facilitates recommended treatment plans to ensure that the appropriate medical care is provided to the patient

§  Expand RA Rheumatology e-Visits to all Rheum providers §  TeleOphthalmology in UWH Primary Care Clinics §  SwedishAmerican pediatric Neurology/EEG reads §  SwedishAmerican NICU Genetic Support §  Diabetic retinopathy screening certification

§  Develop mHealth program

•  Siloes beget small start-ups without a unified vision

•  Three-headed monster in the AMC family: – Slow-moving – Competing priorities – Limited resources – Confusing decision-making process

•  The ACO: are we in or out? – 75M e-visits in 2014 nationally

Pitfalls

•  Information Technology – “The only group in the hospital that can say no

and get away with it” – Need for strong clinical IT leadership

•  CMIO, MD informaticists, Dept. of Nursing Informatics – Alignment of major IT infrastructure (EHR) with

telemedicine technologies •  Legal: 3 lawyers = 4 opinions •  Build it or buy it? A recurring dilemma . . .

Pitfalls Telehealth ReimbursementThe Macro Picture

•  Medicare–  NoreimbursementforMetropolitan

Sta.s.calAreacoun.es:anessen.alnuancetounderstand

–  Rural-AreaUrbanCommu.ngHealthProfessionalShortageAreaExcep.on

–  Censustractcommu.ngareas(circle)

–  ReimbursementonlyforselectgroupofCPTcodes(~30,s.llrestricted)

•  PrivateInsurance–  ParityLaws–  InsuranceCoverage

•  UnitedHealthcare•  BlueCross/BlueShield•  Coventry•  Unity(ourown)

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Telehealth Reimbursement: Evaluating Your Current State Reimbursement

1.  WillMedicarereimburseinyourservicearea(s)?2.  DoesyourstatehaveaTelehealthParityLaw?3.  DoesyourpayermixhavefavorableTelehealthreimbursementpolicies?4.  Whatisyourorganiza.on’sRiskprofile?

•  Evalua.ngRiskProfile:Capita.onàFFS•  Differentriskrequiredifferentapproachestofinancialmodeling

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Telehealth ReimbursementFinancial Models: Revenue

HighPayorRiskStrategies(FarLeX)

•  ClassicFeeforService-Revenue/CostModel•  Reimbursementfrompayersisusedtooffsetthecostoftheservice/program•  Someprogramsmaybelossleaders/downstreamgenerators(leadstoadmission/surgery)•  Non-reimbursement:onusonyoutofundlostreimbursement

•  Con:Makesitdifficulttojus.fyprogramanddifficulttounderstandfullvalue•  Pro:Iffor-profit,canwrite-offdenials

•  ContractedServices/AssignedBilling•  Marketvalue-basedfeesreplaceinsurancereimbursement(e.g.PSA)•  Mustdemonstratevaluetocontrac.ngfacility/provider(e.g.linktoAMCsystem)•  Assigningbillingshiesreimbursementrisktopa.entsitebuttelehealthsupportmightliewithyou

allowingstreamlining/standardiza.onofIT/equipment,whichmightlessenyourTHcosts•  Pa.entsitecanbillapplicablein-personservices(technicalcomponent)andcouldbillownprofessional

feeaswellifavailable

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•  Bill all inpatient and ED videoconsults – Anticipate 40% payment

•  Write off claims with denials of non-covered service – Anticipate 60% denials

•  Supplement departments at 100% of billing and give 1:1 RVU credit, same as a F2F visit

•  Requires supplemental funding for initial yrs •  Pay Dept semi-annually

Payment: how we are doing it UWMF Department Revenue Proposal •  Theamountpaidwillbe:TheaveragerevenuenormallycollectedbyUWMFfor

consultsmul9pliedbythepercentageoftotalconsultsthatarebothwri=enoff

andnon-capitated. 3rdPartyBilling DepartmentRevenueImpact WriteOff

(A)Capitated,ReimbursedConsults(CREIMB) ClaimAccepted CapRevenueAllocatedtoDepartment NO

(B)Capitated,Non-Reimbursed(CNON) ClaimDenied CapRevenueAllocatedtoDepartment YES

(C)Non-Capitated,ReimbursedConsults(NCREIMB) ClaimAccepted RevenueCollectedbyDepartment NO

(D)Non-Capitated,Non-ReimbursedConsults(NCNON) ClaimDenied NO3rdPartyRevenueCollected YES

AvgRevxNON-CAP,NON-REIMB(D)TotalConsults(A+B+C+D)

UWMF Department Revenue Proposal

•  Theamountpaidwillbe: TheaveragerevenuenormallycollectedbyUWMFfor

consultsmul9pliedbythepercentageoftotalconsultsthatarebothwri=enoff

andnon-capitated.

•  Example:

*Numbersshownarees.matesfordiscussionpurposesonly

PayorCodeBilled

CoveredService?

3rdPartyPayment*

AverageConsultReimbursment

%ofconsultsw/no3rdPartyReimb

UWHealthPayment

TotalDeptRevenue*

BlueCrossBlueShieldofWisconsin 99251-GT Yes 130$ 91.23$ 60% 54.74$ 184.74$Medicaid 99251-GT Yes 13$ 91.23$ 60% 54.74$ 67.74$Dean 99251-GT No -$ 91.23$ 60% 54.74$ 54.74$Medicare 99251-GT No -$ 91.23$ 60% 54.74$ 54.74$

Telehealth ReimbursementFinancial Models: Cost

HighProviderRiskStrategies(FarRight)ALLCAPITATEDBUSINESSAVOIDEDISCOSTAVOIDANCE

CostSavings/CostAvoidance•  Incrementalcostsavingstoevaluateprojects•  Totalcostsavingsforsystemandprogramplanning•  Costsavingsmodelsarespecificandcannotignorerevenuemodel

Costsaresaved/avoidedthrough:•  Appropriateuseofresources,especiallyscarceorspecialized•  Opera.onalefficiencies•  Preven.onofnega.vemarginFFSbusiness(e.g.low-levelurgentcareopera.onalcosts>

reimbursementfromvisits,RPMforchroniccomplexpa.ents)•  Backfillwithhigher-marginFFSservices(e.g.freesupsurgeontooperate)•  AvoidCMSpenal.es(e.g.readmissionsofthebig5dx’s)•  Societalcostsavings(e.g.workdayslost)

Opera#onalEfficiencies/QualityImprovements•  Non-billableservices(e.g.virtualvisitorsincludesfamily,speedsdecisionmaking)•  Indirectbenefits(e.g.improvedpa.entexperience,sa.sfac.on)

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Cost avoidance: how we’re doing it

•  eConsults: UCSF’s experience -> CMMI grant with AAMC

•  Use of a Digital Health Partner – Retail urgent care replacing ED visits---if we

could do most level 2s vs eVisits/DHP, then we could see more level 3s and faster---would result in more revenue from various payers (in our mix)

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Our Model : Cost Savings

•  Virtual Health/Digital Health – Offer Video visits to patients on their smart

phone/tablet/computer 24/7 – Save incremental cost for each capitated

patient visit avoided

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EDVisitLevelRevenue/EDVisit

TotalVariableCost/EDVisit Difference

EDLEVEL1VISIT $63.01 $70.68 $(7.67)

EDLEVEL2VISIT $70.05 $119.73 $(49.68)

EDLEVEL3VISIT $223.01 $205.86 $17.14

EDLEVEL4VISIT $377.34 $274.42 $102.91

EDLEVEL5VISIT $804.55 $396.86 $407.69

Our Model : Cost Savings

•  Virtual Health/Digital Health – Reduce unnecessary visits to ED for low

level acuity to reduce cost – Replace with higher acuity, higher margin

business

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Telehealth ReimbursementKeys to Success

•  Understandyourpayerenvironment

•  Understandyourfinancialrisk

•  Definefinancialsuccess

•  Communicatewithleadership

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Development

•  Patient portal & mHealth •  Retail “on demand” •  Regional specialty clinics •  Episodic consults •  Physician collaboration •  The Virtual Hospital

Questions

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•  http://www.americantelemed.org •  http://ctel.org/ •  http://cchpca.org/ •  http://www.telehealthresourcecenter.org/

References