Federal Telehealth Policy

David LeeNational Rural Health Association

What is “Telehealth” or “Telemedicine”

• The Federal Government defines telemedicine and telehealth generally as “interactive communication systems for real-time examinations, diagnosis and treatment .”

• Key Terms:– Originating Site: Where the patient is located– Distant Site: Where the medical specialist or practitioner is

located.

NRHA and Telemedicine Policy

• CMS should modify the clinical and payment regulation of Telehealth and Telemedicine delivery methods.

• Congress should liberalize rules governing originating sites and distant sites to extend benefits to a wider range of interactions and populations.

• Licensure and Credentialing requirements should be modified to allow for interstate care.

Health Care Shortages

• One of the primary challenges for rural populations is an inability to recruit physicians and other health providers. Specialty care is specifically challenging for rural communities.

• The Health Resources and Services Administration has established qualifications for designation as a Health Professional Shortage Area (HPSA). Usually, “HPSAs are designated using…population-to-clinician ratios. This ratio is…3,500 to 1 for primary care HPSAs.”

Rural America

• 62 million Americans live in rural areas following the most commonly used Federal definition.

• These 62 million people are scattered over 90% of the landmass.

• Extreme distances, challenging geography and weather complicate health care delivery.

• 77% of rural counties are HPSAs and 8% of counties have no physician at all.

Physician Shortages Getting Worse

• Through the Affordable Care Act (ACA), approximately 30 Million more people will gain health insurance or coverage by the end of 2014.

• While the ACA included a number of health care training provisions, many have not been funded.

Telehealth Offers a Solution

• The Federal Government, State governments, and private payers have funded numerous pilot projects that have evidenced the benefits of telehealth.

• These projects range from public health activities such as obesity counseling programs to significant medical procedures such as tele-stroke consultation.

• The VA and TriCARE have made great strides in national Telehealth networks.

Telehealth in Action

• In February, 2013 Clarence Renno, 66, experienced a massive stroke at his home in The City of the Dales in rural Oregon. The City of the Dales is the county seat of Wasco County in North-Central Oregon, and has approximately 25,000 people in the entire county

• Clarence was taken to Mid-Columbia Regional Hospital. This rural hospital, a CAH, participates in telehealth activities, specifically stroke care, with the Oregon Health and Science University Hospital in Portland, Oregon. Within minutes, neurologists in Portland, were analyzing CT Scans taken at Mid-Columbia and examining Clarence through a robot-controlled telehealth device, called a “Remote Presence System”.

• Through the examination the treatment team at the University decided to aggressively treat the stroke with TPA drugs, which research has found to be effective for patients primarily during the first three-four hours of stroke. Because of the availability of a health-care-delivering-robot, Clarence was given time-sensitive care by some of the foremost specialists in his state, notwithstanding his geographic isolation.

• Though Clarence was enrolled in Medicare, this Telehealth interaction was not reimbursed to either hospital participating in his care. This is because Tele-stroke care has not been approved for reimbursement by CMS

Licensure and Credentialing

• Because there is no national license for the practice of medicine, the promise of telemedicine has been confined, specifically in specialties

• Due to tedious regulations on credentialing, many providers are unwilling to participate in telemedicine

Licensure solutions

• NRHA’s Policy Congress has adopted a new official policy paper that would advocate for a volunteer national license that would allow for telehealth consultations and treatments without modifying any state licensure or scope-of-practice laws

• Recommendation was based on ICLAST Act, proposed legislation from the 111th Congress

Credentialing

• NRHA also support credentialing by proxy for the purpose of telehealth consultations. This would allow the credentialing board of one facility to carry out the same process for another facility by proxy, through agreements.

Medicare Barriers to Telehealth

• In spite of the benefits that have been shown by numerous programs, Medicare still fails to pay for a number of procedures and interactions. Additionally, payment for these services is significantly limited by geography and local HPSA status.

• This refusal to pay discourages originating sites from acquiring telehealth technology and distant sites from offering consulting services.

Medicare Obstacles

• What Telecommunications System can be used? The system must:– Be interactive audio and video– Use real-time communication– Not be “Store and Forward”

Provider Limitations• Physician– Medical Doctor– Doctor of Osteopathy

• Practitioner– Physician Assistant– Nurse Practitioner– Certified Nurse Specialist– Certified Registered Nurse Anesthetist– Clinical Social Worker– Clinical Psychologist– Registered Dietician

Medicare Telehealth Benefit

Located in a Rural Health Professional Shortage AreaLocated in a county that is not designated as part of a Metropolitan Statistical Area

•Physician office•Critical Access Hospital•Rural Health Clinic•Federally Qualified Health Center•Hospital•Hospital Based ESRD clinic•Skilled Nursing Facility•Community Mental Health Center

• Originating Site Geography • Originating Site Description

What does Medicare pay for?

• Required by Statute (42 USC 1935m(m))– Some Office or other Outpatient Consultations – Some Office or other Outpatient Visits– Individual Psychotherapy– Pharmacologic Management

• Secretary may add additional services at her discretion.

The process for “exercising discretion”

• CMS reviews telehealth approved services during their annual rulemaking process, in the Physician Fee Schedule annual update.

• The current review process was established following the passage of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA).

How does the Secretary exercise her discretion?

• Category I: • The new service must be “similar to existing services.” CMS’s review

of requests for coverage includes an assessment of whether the roles and interaction among the patient at the originating site and physician or practitioner at the distant site are similar to existing telehealth services.

• Category 2:• Roles of and interaction among doctor and patient in the proposed

service are not similar to existing telehealth services. Review of these requests includes an assessment of whether the service is accurately described by the corresponding code when delivered via telehealth and whether the use of a telecommunications system to deliver the service produces demonstrated clinical benefit to the patient.

What has been added?

• A limited number of services have been added over several years, including:– Smoking cessation counseling;– Nutritional counseling;– Individual health and behavior assessment and

intervention; and– End Stage Renal Disease services.

What’s wrong with this process?

• The process is tedious and time-consuming for providers with limited administrative resources.

• There has been little movement. According the American Hospital Association, CMS has never approved a new service under category two.

• Most importantly, Medicare beneficiaries are being denied services.

Counties to Lose Telehealth Status

• Medicare beneficiaries in 104 counties—across 36 states and territories—are slated to lose telehealth benefits because of updated federal delineations of Standards Metropolitan Statistical Areas (SMSAs).

• The new federal urban/rural categorization effectively revokes the option for Medicare recipients to receive healthcare services via videoconferencing—one of the most common and cost-effective forms of telehealth. Hundreds of thousands of beneficiaries are negatively impacted by this statistical realignment.

Box Elder County, UT

• 6,729 square miles of desert, mountains, and lakes.

• The county is larger than the state of Connecticut but home to only about 50,000 residents.

• Even though this averages out to about 8.7 persons per square mile, OMB no longer classifies the county as “rural” because of the proximity of the County Seat to metropolitan areas and the passing of 50,000 residents.

• Legislation likely needed to address issue. • Working with American Telemedicine

Association.• Goal: grandfather in recently-expired

classifications.• Note: IPPS regulation included some

modification to how CMS defines rural HPSA for purposes of Telehealth reimbursement. Will help some, not all counties.

Solutions

• CMS needs to adopt a policy to allow telemedicine providers to receive deemed status and to allow for health care facilities receiving telehealth services to perform credentialing by proxy (delegated credentialing). If a provider is already credentialed at a Medicare-participating facility (usually his or her home site), that credential would be sufficient for providing telemedicine services at another facility. The privileging process would still be conducted by the originating health care facility.

Solutions• Recommendation: Telehealth eliminates barriers to accessing

quality care by using audio-video technology to connect• patient with providers hundreds of miles away.• 1) Lift the geographical patient requirements of receiving care in

Health Professional Shortage Areas (HPSAs) and• non-Metropolitan Statistical Areas (MSAs).• 2) Eliminate separate billing procedures for telemedicine.• 3) Reimburse care provided by physical therapists, respiratory

therapists, occupational therapists, speech therapists, licensed professional counselors and therapists, and social workers.

• 4) Increase reimbursement for the originating telemedicine sites.• 5) Provide reimbursement for store-and-forward applications.

Solutions

• Facilitate a provider’s ability to appropriately practice across state lines through passage of the Increasing Credentialing and Licensing Access to Streamline Telehealth Act .

• Support existing state scope of practice and licensure laws while encouraging portability and practice across state lines.

Resources:

• http://www.ruralhealthweb.org/go/left/policy-and-advocacy/policy-documents-and-statements/official-nrha-policy-positions

• http://www.americantelemed.org• http://www.raconline.org

Thank you

David Leedlee@nrharural.org

(202) 639-0550