HMA

Telehealth: Pearls and Pitfalls Jean Glossa, MD, MBA, FACP; Health Management Associates

Miro Barac, SHIP

August 17, 2016

PCMH Transformation Team Webinar #4: Telehealth: Pearls and Pitfalls

HMA

Learning Objectives

• Review definitions of common telehealth terms and distinguish between (compare) different models of technology facilitated care

• Determine which technology models could have the most impact in your medical community

• Identify the drivers for Telemedicine adoption

• Describe specific use cases and evidence to support the use of Telemedicine

• Recognize the importance of developing clearly defined use cases and a step by step business model for your Telemedicine program

• Review the national landscape on Telemedicine

• Discuss the implications of payment reform on Telemedicine

2

HMA

Models

Telemedicine virtual visit

EConsult

Direct to Consumer

Remote Patient

Monitoring

mHealth

Project Echo

3

HMA

Definitions

• Telemedicine - the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status (phone and fax?)

• Telehealth

• mHealth - text messaging using cell phones and wireless technology

• Originating site

• Remote/distant site

• Facility Fee

• Store and Forward

• Telepresenter

4

HMA

Array of Telehealth Applications

• Virtual visits - patient to provider – Clinic to clinic – Tertiary care to remote primary care clinic – Mobile van

• Hospital - acute care, stroke • Remote patient monitoring

– Cardiac care, glucometer, medication, movement • Store and Forward - teledermatology • Direct to consumer - a doctor in your home • Retail medicine/kiosk

– Walgreens, CVS • Project ECHO

5

HMA

Drivers for Telehealth Adoption

• Implementation of Affordable Care Act (ACA) that rewards efficiency in healthcare delivery

• Introduction of new payment models that reward outcomes

• Patient as a consumer

• Parity legislation for private payers

• Rapidly expanding broadband wireless telecommunications networks

• Mandates to provide care such as correctional medicine

• Physician shortage combined with more patients with coverage = access problems

HMA

7

Source: Association of American Medical Colleges: The 2016 Update: Complexities of Physician Supply and Demand: Projections from 2014 to 2025

HMA

Primary Care Physicians Per Capita

8

http://ahrf.hrsa.gov/arfdashboard/ArfGeo.aspx

HMA

Psychiatrists Per 100,000 US Residents in Hospital Referral Regions (2013)

9

Substantial variation with large concentrations of psychiatrists in New England, mid-Atlantic and Pacific regions. From 2003-2013, the median number of psychiatrists per 100k residents decreased by 10.2%

©2016 by Project HOPE - The People-to-People Health Foundation, Inc Tara F. Bishop et al. Health Aff 2016;35:1271-1277

HMA 10

Mobile Application (App)

HMA

Example of Telemedicine

11

HMA

How Telemedicine Is Transforming Health Care

12

The revolution is finally here – raising a host of questions for regulators, providers, insurers, and patients

Source: Melinda Beck June 26, 2016

HMA

Retail Medicine

13

HMA

Partnerships for Healthcare Delivery

14

HMA

Employers Offer Telemedicine Services

15

HMA

Connectivity

• 91% of Americans have a cell phone

• 68% of Americans have a smart phone

• 10% of Americans rely on the smart phone for their internet connectivity

• 86% of Americans with annual income below $30,000 owned a cell phone

• 83% of adults with less than a high school education owned a cell phone as of May 2013. (Pew 2013)

16

HMA

Adult Cell Phone Ownership and Use (May 2013)

17

91%

81%

60%

52%

Own a Cell Phone Send of Receive TextMessages

Access the Internet Send or Receive Email

Percent of adult cell phone users who use their cell phones to:

http://kff.org/medicaid/issue-brief/profiles-of-medicaid-outreach-and-enrollment-strategies-using-text-messaging-to-reach-and-enroll-uninsured-individuals-into-medicaid-and-chip/

HMA

Adult Cell Phone Use by Annual Income (May 2013)

18

78%

45%

83% 80%

39%

86% 88%

30%

94% 88%

27%

95%

Send or Receive Text MessagesUsing Cell Phone

Use Internet or Email Mostly onCell Phone

Use Internet or Email at Home

<$30,000 $30,000-$49,999 $50,000-$74,999 >$75,000

http://kff.org/medicaid/issue-brief/profiles-of-medicaid-outreach-and-enrollment-strategies-using-text-messaging-to-reach-and-enroll-uninsured-individuals-into-medicaid-and-chip/

HMA

Clinical Evidence for Telemedicine

Expands access: found to provide care to patients who have not had a previous connection to a physician

• Telestroke

• Congestive Heart Failure (CHF) - no difference in all cause mortality

• Diabetes Mellitus (DM) - reducing blood glucose levels (HgA1c)

• Post discharge CHF- avoiding readmissions

• Antibiotics for Upper Respiratory Infection

• Telederm

19

HMA

Veterans Administration (VA) Telehealth System

20

• 45 percent of visits are to rural areas

• 32 apps to monitor health and to connect patients and their care team.

– Telemental health

– Telerehab

– TeleOT (occupational therapy)

– Telepulmonology - CPAP (continuous positive airway pressure)

– Teleaudiology - hearing aid checks

– Home based telehealth

– Store and forward

HMA

Who pays for Telemedicine (TM)?

• Medicare - Yes, but…..limits of location and facility, provider discipline, etc.

• Medicaid - Yes, but……state by state definitions • Private insurance - parity laws • Employers • Patients (Consumers) - Direct to Consumer • School supported, grant funded • Correctional facilities • Nursing homes (ex. wound care)

Moving from Fee for Service (FFS) to Value Based

Purchasing (VBP) opens the door to more applications for TM

21

HMA

Managed Care Organizations (MCO) and Direct to Consumer (DTC) Health

Since at least 2007, MCOs have teamed up with TM vendors to provide on demand, direct to consumer care for their members in certain markets:

22

Telemedicine: The doctor will see you now

HMA

Telehealth Coverage & Reimbursement

23

HMA

State Telehealth Laws and Medicaid Policies

HMA

Telehealth Coverage & Reimbursement

25

HMA

Proposed Clinical Practice Improvement Activities Inventory

26

Subcategory Activity Weighting Expanded Practice Access

Use of telehealth services and analysis of data for quality improvement, such as participation in remote specialty

Medium

care consults, or teleaudiology pilots that assess ability to still deliver quality care to patients.

42 CFR 414 and 295. p. 946. Table H: Proposed Clinical Practice Improvement Activities Inventory. https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-10032.pdf

HMA

MACRA

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires the Government Accountability Office (GAO) to draft 2 reports:

– Medicare telehealth program

• Evaluate circumstances that help or inhibit the use of telehealth under Medicare and the possible effect of an expansion of telehealth on payment and delivery systems under Medicare (MCR) and Medicaid (MCD)

– Remote Patient Monitoring:

• Examine incentives for adopting patient monitoring technology and services by private health insurance

• Barriers for adopting this technology by Medicare

27

HMA

Legislation

• More than 200 telehealth related bills were introduced in 42 states in 2015

• Parity laws - only 21 states plus District of Columbia (DC)

• Physician should be paid the same

• Legislation regarding - requiring in-person visit prior to or following a TM visit

• Federation of State Medical Boards (FSMB) compact license

28

HMA

Telehealth Coverage & Reimbursement

29

HMA

Standards

• American Telemedicine Association (ATA) Accreditation

• Utilization Review Accreditation Commission (URAC)

• Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)

• National Committee for Quality Assurance (NCQA) credentialing

• Telemedicine training programs

30

HMA

Licensure

• Doctor of Medicine (MD) must be licensed in the state where the patient is located;

some states stipulate the MD must be located in the state where the patient is

located

• 9 states have special telemedicine licenses

• Federation of State Medical Boards (FSMB) - compact license - 14 states to date

have joined the proposal

31

HMA

Controversies in TM

• Establishing a doctor patient relationship

• Pre and post visits

• How much can you do by video or phone?

• Increase utilization?

• Access to medical records?

• Commercial health plan that may offer “free” TM service but a $35 copay for an in- person visit

• Unintended consequences of overuse and misdiagnosis; package visits with meds

• One visit = one issue

32

HMA

Considerations

• Licensure

• Credentialing

• Privacy and security

• Prescribing laws - state and Drug Enforcement Agency (DEA)

• Practice standards

• Establishing a relationship

• Health Insurance Portability and Accountability Act (HIPAA ) and Health Information Technology for Economic and Clinical Health (HITECH) Act issues

• Federal Trade Commission (FTC) regulatory compliance

• Anti-Kickback Statute and Stark Law - corporate practice of medicine, fee splitting

33

HMA

Building the Use Case

• Define the problem - what are you trying to solve? Emergency Department (ED) Diversion; access to specialist care?

• Who are the patients? The providers?

• Leverage internal resources - or vendor out?

• Who are all the stakeholders - is this a threat to another group/line of business?

• Information Technology (IT) system - actually the easy part

• How is this funded?

• How will you measure the outcome? Measure success?

• Is it scalable?

34

HMA

School-based Telehealth

• Problem: Low income student population with high absentee rate and lack of access to care

• Solution: Emergency Room (ER) physicians provide medical consultations to school nurse to handle low acuity medical concerns

35

HMA

School-based Telehealth Services

36

HMA

Telemental Health in Primary Care

• Clinic to clinic

• Warm hand off

• Telepresenter with patient

• Medication management

• Shared Electronic Medical Record (EMR) for care team communication

• Low no-show rate

• High patient satisfaction

37

HMA

Telehealth Summary

• New payment models will drive adoption

• Lower income populations are connected and will benefit

• Licensure and regulatory issues are significant

• Due diligence of all key factors is critical in developing a business plan

38

HMA

Telehealth Overview

Jean Glossa, MD, MBA, FACP jglossa@healthmanagement.com

https://www.healthmanagement.com/our-team/staff-directory/name/jean-glossa/

39

Telehealth Within SHIP Miro Barac, SHIP Project Manager

HMA

Plan for Successful Healthcare System Transformation

Seven SHIP Goals to Achieve the Triple Aim

Goal 1: Transform primary care practices across the State into patient-centered medical homes (PCMHs).

Goal 2: Improve care coordination through the use of electronic health records (EHRs) and health data connections among PCMHs and across the medical-health neighborhoods.

Goal 3: Establish seven Regional Health Collaboratives to support the integration of each PCMH with the broader medical-health neighborhood.

GOAL 4: IMPROVE RURAL PATIENT ACCESS TO PCMHs BY DEVELOPING VIRTUAL PCMHS. Goal 5: Build a statewide data analytics system that tracks progress on selected quality measures at the individual patient level, regional level and statewide.

Goal 6: Align payment mechanisms across payers to transform payment methodology from volume to value.

Goal 7: Reduce overall healthcare costs.

HMA

SHIP Model Design Elements

• Patient Centered Medical Home

• Virtual Patient Centered Medical Home

• Regional Collaboratives

• Quality Improvement

• Data Sharing/Interconnectivity/Analytics and Reporting

• Multi-payer Payment Model

• Idaho Healthcare Coalition

HMA

Model Design: Virtual PCMH

• Designed to improve access to primary care in rural and frontier communities

• Focus on extending the PCMH model through:

– telehealth expansion, equipment, and training.

– training for Community Health Workers (CHWs) and Community Health EMS workers (CHEMS) to extend PCMH team services to rural communities.

HMA

PCMH Incentives: Participating Clinics

Participation Incentives: • Participation Incentive Payment: $10,000 upon enrollment into

SHIP program with a signed Memorandum of Understanding (MOU)

• PCMH Recognition/Accreditation: $5,000 upon recognition or accreditation through NCQA, AAAHC, The Joint Commission, Oregon PCPCH, or other identified program/organization

• Virtual PCMH (optional): $2500 upon demonstration of utilization of Telehealth, Community Health Workers (CHWs), and/or Community Health Emergency Medical Services (CHEMS)

• Assistance in bi-directional connectivity with the Idaho Health Data Exchange (IHDE) – no cost to the clinic.

• Participation in unique payer models (still under development)

HMA

Background

• Idaho Telehealth Council • Telehealth Council – Goal 2 Subcommittee

“Develop a roadmap to operationalize and expand telehealth services in SHIP PCMHs and CHEMS programs.”

– Develop expansion plan

– Training, technical assistance, and mentoring

– Equipment

• SHIP Telehealth Technical Assistance and Telehealth Training Curriculum Contract – Consultative and Subject Matter Expertise

– Telehealth Webinars, Toolkit, and Training Services

HMA

SHIP Telehealth Goals

1. Establish rural telehealth capacity in 18 PCMHs across a range of specialty services.

2. Establish rural telehealth capacity in 18 PCMHs to provide behavioral health services.

3. Establish telehealth services in 6 CHEMS programs.

HMA

? Questions and Answers

Do you have a question or comment that you would like to share?

If you wish to ask your question or voice your comment, please be certain you have entered your Audio PIN so we can unmute your line.

You may click the ‘raise your hand’ icon or simply enter your question in the Questions pane and we will unmute your line.

HMA

Resources and Links

• Idaho Telehealth Council http://telehealthcouncil.idaho.gov/

• Telehealth Council – Goal 2 Subcommittee http://ship.idaho.gov/WorkGroups/

• Idaho Telehealth Access Act (H0098)

• Reimbursement Matrix

• Telehealth Expansion Plan