Public Comments Regarding Proposed Telemedicine Regulations August 9, 2019 - September 27, 2019

DATE

RECEIVED FROM ORGANIZATION COMMENT

08/12/2019 Dr. Corinna Muller Aurora Maternal Fetal Medicine, LLC I was born and raised in Alaska (Eagle River) and am a graduate of the University of Alaska,

Fairbanks. I started my own private practice in Anchorage (Aurora Maternal-Fetal Medicine) in

July 2018, and have been serving Alaskans (and Medicaid beneficiaries) in my home state with

subspecialty care as one of the few Maternal-Fetal Medicine Specialists in the state.

I use personal business funds from my private practice to travel to see high risk patients (mostly

Medicaid beneficiaries) to areas such as Fairbanks, Kenai and Wasilla. My main practice office is

in Anchorage. In my previous positions working for a hospital in Pennsylvania, we used

telemedicine to perform outreach to outlying clinics within our large health system to perform

consultation and management of high risk conditions. I could see this framework working well in

Alaska where modern technology allows us to communicate in many different ways.

In Alaska, there are various aspects of patient care that I believe could be safely provided by a

physician via telemedicine. I believe the limiting factor is that these services are not reimbursed

if the patient is on their personal device rather than a remote office site with computer

capabilities. Telemedicine visits for review of blood sugars (gestational or pre-existing diabetes

in pregnancy) or buprenorphine management for opioid addicted pregnant patients are

examples of points of care that I think would benefit patients, decrease travel costs and allow

higher level of care without much extra cost to the Medicaid system. I would be happy to meet

with any of your representatives to discuss how this has worked in other systems that I have

worked in during my past employment.

Please consider full reimbursement for telemedicine equipment costs and upkeep on the side of

the physicians providing this care to Medicaid patients. It saves the program money by

decreasing travel costs to the patients. Also, I have hosted remote clinics using practice funds to

travel and bring portable ultrasound machines to evaluate patients. Incentives for physicians

traveling and saving Medicaid dollars by decreasing patient travel expenses should be

considered.

09/09/2019 Dr. Phil Hofstetter Petersburg Medical Center A couple of my concerns are whether the focus on payment only to the "distant" site provider

will create an obstacle to a facility like Petersburg in supporting delivery of services by

telemedicine. There is no provision for a presenting provider to be reimbursed for the cost of

facilitating the service.

There is also a new use for Health Professional Shortage Area (see below) that I think could

mean Petersburg Medical Center would not get paid to provide telemedicine services to people

in Petersburg since we are not a HPSA.

Telemedicine Regulations 2019

Public Comments Received

09/09/2019 Kelly Puff Hello. I am the parent and sole caregiver for an adult son with severe autism. The new

legislation against telehealth access through Medicaid if you live close enough to provider to see

in person is going to be extremely detrimental to our family. My son can be extremely

dangerous in the car transporting to an office. This is a danger to himself and me and other

drivers on the road. We absolutely rely on telehealth to provide him the care he requires to be

safe in the home and community. We have not had to rely on API services yet but have had

numerous police interactions. I promise you if we have no access to telehealth during critical

medication management issues that we will have to access other more expensive state and city

services. Please know every day we are doing our best to care for our son at home. Telehealth

has been a lifesaver to our son and our family. I cannot stress this enough. Please do not pass

this restriction against the most vulnerable in our community. I beg of you. Sincerely and

thankful for your attention

09/09/2019 Kelly Puff I have just learned that the Telehealth Visits for Medicaid patients living in the Anchorage area is

being considered for elimination.

My grandson, Gage Puff, who is now 20 years old, has Autism. His parents are his legal

guardians. His mother is not able to work because she has to stay home with him. His father is

the breadwinner and they live paycheck to paycheck. He is severely Autistic and can be very

dangerous. He needs medication to help control him. Because of the severity of his condition,

he cannot visit a doctor in the office. In the past when they have tried to take him to a doctor’s

office, he has actually attacked the doctor. The only way to be able to get the medical help he

so desperately needs is by the use of Telehealth. This is necessary for the protection of

everyone involved.

So I am asking you to please do everything you can to continue this program for the Anchorage

area people in need of this very valuable service.

09/09/2019 Ryan Thompson My name is Ryan Thompson and I am a lifelong Alaskan, raised in Anchorage along with most of

my immediate family.

My cousin relies heavily on the Telehealth program here in anchorage to attend visits with his

providers from the comfort of his home. He is unable to leave the house most days and travel by

car is dangerous for himself, my Aunt, and any other drivers on the road due to complicated

nature of his condition.

If he is unable to access healthcare via telehealth, our family is forced to use Emergency Room

Psychiatric care (an already overburdened system) and ultimately he is not receiving the care he

needs to maintain a reasonable quality of life.

This system invaluable him and our family and I know we are not alone. Please consider the

“little guys” like our family when deciding on Anchorage area telehealth access.

Telemedicine Regulations 2019

Public Comments Received

09/11/2019 Kellie Puff I am writing to provide you with brief comments on the proposed telemedicine changes. My

family relies heavily on the telehealth access to receive doctor care and prescription renewals

greatly needed for my low functioning autistic nephew. It is nearly impossible for him to leave

the home in a safe manner. He can be very unpredictable and dangerous especially when

confined in a vehicle, thus presenting a health and safety issue to himself, the driver and all

others on the road. Please reconsider supporting this change and continue to allow Anchorage

residents access to this incredibly helpful service that greatly reduces stress on my family and

my nephew. Thank you for your time and consideration!

09/20/2019 Jeannie Monk ASHNHA See Attached

09/26/2019 Kevin Munson Mat-Su Health Services See Attached

09/27/2019 Krissy Floyd Foundation Health Partners See Attached

09/27/2019 Autumn Vea Alaska Mental Health Trust Authority See Attached

09/27/2019 Alyson Currey Planned Parenthood Votes NW & Hawaii See Attached

09/27/2019 Jerry Moses ANTHC See Attached

09/27/2019 Carol "Bunny" Schaeffer Maniilaq Association See Attached

09/27/2019 Andrew Jimmie Alaska Native Health Board See Attached

10/02/2019 Rick Calcote DBH See Attached

September 27, 2019 Susan Dunkin Department of Health and Social Services 4501 Business Park Blvd., Building L Anchorage, AK 99503 Re: Notice of Proposed Changes Project #2019200392 –Medicaid Coverage & Payment, Telemedicine Services. Dear Ms. Dunkin: Thank you for the opportunity to provide comment on the proposed changes to Medicaid Coverage & Payment, Telemedicine Services. The Trust does not support the adoption of the proposed changes because we believe the regulations a proposed will limit access to health and behavioral health services across the state for all Alaskans but especially Trust beneficiaries. Below you will find some general comments as well as some specific comments and concerns that the Trust recommends addressing before the adoption of these regulations sections the Trust’s general comment and regulation recommendations are as follows:

General Comments 1. We recommend that the provisions, documentation, and guidelines and

additional requirements in the proposed regulations be reviewed and compared to SB74 (2016). We further recommend that after this review the regulation package in its entirety be revised to reflect the bill’s enacted requirements and intentions. The intent of SB74 was to manage costs by using more telemedicine application. The legislation further recognized the positive impact telemedicine services would have on expanding access to care.

2. We recommend further analysis be conducted to fully understand the fiscal impacts to the State, health care providers and other stakeholders because of the proposed regulations. And, to identify other potential barriers that the proposed regulations could have on access to care in our unique service system. We further recommend that the analysis be documented, used to modify the proposed regulations accordingly, and the public be provided an opportunity to provide public comment.

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Specific Comments and Concerns 1. 7 AAC 110.620(a)(1) HIPAA-compliant - We recommend removing the added

requirement that all telemedicine applications be “HIPAA-compliant.” The added requirement that all telemedicine applications need to be HIPAA- compliant may decrease access to providers who allow their patients to use their personal devices to initiate contact via telephone or real-time video applications such as Skype and/ or Apple, Inc. Facetime, and through text message.

2. 7 AAC 110.625(a) Telemedicine applications; limitations - We recommend that current sections (a)(2) store- and-forward; and (a)(3) self-monitoring or testing; be expanded to include a provider’s ability to utilize both store- and-forward and self-monitoring or testing. If adopted, the proposed changes potentially limit access to care for a Trust beneficiary seeking services in their home community.

3. 7 AAC 110.625(b)(2) Telemedicine applications - We recommend broadening the list of reimbursable behavioral health services to include:

a. the full-service array listed in 7 AAC 135 Medicaid Coverage; Behavioral Health Services;

b. psychiatric crisis assessment and evaluation services for a civil involuntary psychiatric commitment;

c. court ordered examinations and evaluations of a person’s legal competency to stand trial raised in the course of a criminal case proceedings; and,

d. all the identified services included in the 1115 Behavioral Health Waiver. 4. 7 AAC 110.630(d) Conditions for Payment - We recommend that this

regulation not be repealed. A presenting provider should receive Medicaid payment for a live or interactive telemedicine application as described in 7 AAC 110.625(a)(1).

5. 7 AAC 110.630(e) Conditions for Payment - We recommend removing this section, which is more restrictive and will reduce access to health and behavioral health care for Alaskans, particularly in rural areas.

6. 7 AAC 110.630(f) Conditions for Payment - We recommend removing this section requiring the provider of service and beneficiary live together in a federally designated Health Professional Shortage Area (HPSA) for the provider to be reimbursed for services. If this change is implemented it will decrease access to care for beneficiaries who seeking care from a local provider through a cost-effective means in rural and urban communities of Alaska. Simply, we believe the HPSA definition does not adequately account for how health and behavioral services are delivered in all communities across Alaska.

7. 7 AAC 110.630(g) Conditions for Payment - We recommend allowing providers to document that a service was provided via telemedicine using coding modifiers instead of the proposed subsection to reduce provider administrative burden as was intended in SB74.

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8. 7 AAC 110.635(b) Facilitation - We recommend allowing “facilitation” to be reimbursed to promote the use of telemedicine for greater access to health care in our state with limited inter-community transportation. This section if adopted will disincentive the use of telemedicine and will result in reduced access to health and behavioral health care services in Alaska; particularly, in rural areas. The Trust provided similar comment on July 29, 2019 to the Division of Behavioral Health.

The Trust recently collaborated with the Department to develop Strengthening the System: Alaska’s Comprehensive Mental Health Program Plan to ensure Alaskans receive comprehensive prevention, treatment, and support services at the appropriate level of care across their lifespan. Through this plan’s lens, the Trust is supportive of statutory and regulatory changes that expand access to the comprehensive behavioral health system and are aligned with the strategies detailed in Strengthening the System. Many of the proposed regulatory changes would limit access to care, and contradict the goals and objectives outlined in the Department’s plan.

Thank you for this opportunity to comment on the proposed regulations, and for your consideration. If you have any questions please contact Autumn Vea 269-3492 or Michael Baldwin 269-7969.

Sincerely,

Michael K. Abbott, CEO Cc

Director of the Division of Behavioral Health - Gennifer Moreau Advisory Board on Alcoholism and Drug Abuse/Alaska Mental Health Board Acting Executive Director - Bev Schoonover Alaska Commission on Aging – Lesley Thompson Governor’s Council on Disabilities and Special Education Executive Director - Kristin Vandagriff Alaska Behavioral Health Association CEO - Tom Chard Alaska Hospital and Nursing Home Association President/CEO - Becky Hultberg

Alaska Native Health Board THE VOICE OF ALASKA TRIBAL HEALTH SINCE 1968 907.562.6006 907.563.2001 � 4000 Ambassador Drive, Suite 101 � Anchorage, Alaska 99508 � www.anhb.org

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ALASKA NATIVE TRIBAL HEALTH CONSORTIUM

ALEUTIAN PRIBILOF ISLANDS ASSOCIATION

ARCTIC SLOPE NATIVE ASSOCIATION

BRISTOL BAY AREA HEALTH CORPORATION

CHICKALOON VILLAGE TRADITIONAL COUNCIL

CHUGACHMIUT

COPPER RIVER NATIVE ASSOCIATION

COUNCIL OF ATHABASCAN TRIBAL GOVERNMENTS

EASTERN ALEUTIAN TRIBES

KARLUK IRA TRIBAL COUNCIL

KENAITZE INDIAN TRIBE

KETCHIKAN INDIAN COMMUNITY

KODIAK AREA NATIVE ASSOCIATION

MANllLAQ ASSOCIATION

METLAKATLA INDIAN COMMUNITY

MT. SANFORD TRIBAL CONSORTIUM

NATIVE VILLAGE OF EKLUTNA

NATIVE VILLAGE OF EYAK

NATIVE VILLAGE OF TYONEK

NINILCHIK TRADITIONAL COUNCIL

NORTON SOUND HEALTH CORPORATION

SELDOVIA VILLAGE TRIBE

SOUTHCENTRAL FOUNDATION

SOUTHEAST ALASKA REGIONAL HEALTH CONSORTIUM

TANANA CHIEFS CONFERENCE

YAKUTAT TLINGIT TRIBE

YUKON-KUSKOKWIM HEALTH CORPORATION

VALDEZ NATIVE TRIBE

September 27, 2019 Susan Dunkin, Regulations and Publications Coordinator Division of Health Care Services, Alaska Department of Health & Social Services, 4501 Business Park Blvd., Building L, Anchorage, AK 99503 Re: Proposed Changes to Medicaid Coverage and Payment of Telemedicine Services Dear Ms. Dunkin, The Alaska Native Health Board (ANHB) is glad to have the opportunity to provide comment to the Department of Health & Social Services (the Department or DHSS) on the proposed regulatory changes to Title 7 of the Alaska Administrative Code regarding Medicaid telemedicine services.1 For the reasons explained below, we urge the Department to withdraw the proposal in its entirety. The proposed regulations would have a devastating impact on rural health care, including services to Alaska Natives and American Indians (AN/AI), by eliminating coverage for all services furnished via “store-and-forward” delivery methods, disqualifying for coverage all 1115 Behavioral health waiver services furnished even via live-and-interactive methods, and creating other unnecessary barriers to essential health care services. The Alaska Tribal Health System (ATHS) is the largest health care system in the state and has developed an extensive, sophisticated, and very successful telemedicine system to meet the challenges of serving isolated patient populations in a vast geographic area whose extreme climate conditions also engender chronic health workforce shortages. Based on our assessment, the Department’s proposed regulations would largely pull the rug out from under this extremely successful and essential healthcare delivery system, jeopardizing both the physical health of thousands of patients and the fiscal health of Alaska’s tribal health system. Our Concerns The proposed telemedicine regulations will severely restrict the delivery of telemedicine to many AN/AI beneficiaries; and eliminate many telemedicine services from being

1ANHB was established in 1968 with the purpose of promoting the spiritual, physical, mental, social, and cultural well-being and pride of Alaska Native people. ANHB is the statewide voice on Alaska Native health issues and is the advocacy organization for the ATHS, which is comprised of tribal health programs that serve all of the 229 tribes and over 175,000 Alaska Natives and American Indians (AN/AI) throughout the state. As the statewide tribal health advocacy organization, ANHB helps Alaska’s tribes and tribal programs achieve effective consultation and communication with state and federal agencies on matters of mutual concern.

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delivered by and being reimbursed to the ATHS. We are deeply concerned and alarmed that the proposed regulations would:

• Eliminate reimbursement for Store and Forward telemedicine services, despite the demonstrated strengths and efficiencies of that service delivery method;

• Limit payment to only the professional component of a telemedicine service; • Create ambiguity about telemedicine services related to CHAP supervision and

reimbursement; • Make all 1115 behavioral health waiver services ineligible for reimbursement if furnished

via telemedicine, and otherwise limit which behavioral and mental health services qualify for reimbursement;

• Introduce ambiguity in other areas of telemedicine services – (e.g. removing “consultation” but potentially allowing the patient’s home to be a billable location; adding geographic requirements for providers to be located in HPSA locations; adding a stipulation that a presenting provider can only bill for “separately identifiable services”);

• Impose additional documentation requirements on providers which do not add any beneficial information to the Department’s billing and claims adjudication process;

• Potentially impose health IT changes and costs to Electronic Medical Records (EHR) to comply with new requirements of the proposed regulation.

Of particular concern is the proposed change to the definition of telemedicine and its limitations, which the Department proposes to define as “the real-time use of interactive audio, interactive video, or interactive data communication to link patients face to face with health care professionals at distant locations” (proposed 7 AAC 110.639(4)). That proposed definition is much narrower than under current and past regulations, and it would prevent the ATHS from using its most reliable and cost-effective method to provide telemedicine, Store and Forward. Store and Forward (S&F) telehealth is an extremely efficient and robust form of telehealth, that works better than any other form of telehealth in rural Alaska. This system was originally implemented when broadband connectivity was unavailable at most village clinics, and the connectivity was intermittent. Consequently, AFHCAN, the telehealth arm of the Alaska Native Tribal Health Consortium (ANTHC), pioneered many concepts in multi-organizational “store-and-forward” telehealth and developed technologies that are now used on all continents except for Antarctica. Each year, almost 1,400 providers use the AFHCAN system to create 38,000 cases for 23,000 patients. This means that S&F telehealth impacts the care for approximately one in seven Alaska Natives on an annual basis. The continued development in these areas has allowed Alaska to become a world leader in this form of telemedicine, which has demonstrated dramatic advantages compared to live video-based telehealth. Many telehealth programs across the world have adopted S&F telehealth based on the evidence provided by Alaska. S&F telehealth offers a number of benefits that have made it the right tool for the ATHS’s multi-organizational, referral-based structure:

1) S&F telehealth works very effectively across organizational boundaries. Most of the specialty telehealth consults that occurs in Alaska span organizational boundaries; i.e. the patient and rural provider are at a clinic managed by one organization while the consulting provider is located at a facility managed by another organization. The ATHS,

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for example, is composed of 30 individual organizations managing more than 200 sites. This makes it extremely difficult to coordinate time for two providers and the patient to be available at the same time, as schedules (and even EHRs) are often not visible or shared across organizational boundaries. However – S&F telemedicine does not require simultaneous scheduling of individuals, and allows each organization to manage their workflow and schedules independently.

2) S&F achieves a much faster response rate than live video tele-conference (VtC), due to the fact that a specialist can review an S&F case during a free time in their day and respond quickly. The Alaska Native Medical Center (ANMC) has demonstrated an ability to respond to the majority of S&F cases within a work day, often within 60 minutes. By comparison, it can take days (and even weeks) to coordinate a visit for a patient over live VtC and multiple calls between case managers and clinic staff are needed to arrange the appointment, then technical issues can delay or prevent the consult from happening, or the specialist provider may be called away on emergency and the appointment is rescheduled.

3) S&F provides a significantly higher level of documentation for EHR and for coding

and billing purposes, as all the images and notes between the providers are documented and made available in the EHR. Moreover, time stamps and metadata on all components of the encounter provide excellent documentation for auditing and compliance checking.

4) S&F telehealth works when other forms of telehealth cannot. Rural Alaska locations

still suffer from outages or disruptions to connectivity – spanning minutes to days or weeks. This makes reliance upon live video completely impossible. It may be possible to push S&F cases through with poor connectivity as the technology is design to packetize and continuously attempt to transmit data. We have evidence of S&F telehealth being transmitted successfully over networks when phones, faxes, emails and VtC were impossible. Perhaps more importantly, images can still be captured at the appropriate moment and stored for transmission. If a patient needs to wait hours or days for a consult, then changes occur and the original view of the wound or lesion or EKG is lost, whereas S&F allows for accurate and timely data capture.

Tribes, funding agencies, and the Federal government invest more than $130 million every year for technology that supports S&F telehealth. There are more than 200 AFHCAN carts with devices throughout rural Alaska, and tribal organizations have invested millions of dollars in maintaining these carts and the medical devices that accompany them. For example, a diagnostic-quality otoscope costs $9,000. Otoscopes like this are critical to capturing images of ear disease, a disease in which Alaska, sadly, continues to lead the world. Tribal organizations and Federal subsidies continue to support the connectivity critical to S&F telehealth at an annual expenditure of more than $120 million. While that is also used for live videoconferencing, S&F telehealth is still the dominant form of telehealth in the ATHS. We have ample evidence that S&F telehealth improves the quality of care and access to care throughout rural Alaska. A study conducted in Nome found, for example, that prior to use of telemedicine by audiology and ear, nose & throat specialties (ENT), 47% of new patient referrals

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would wait 5 months or longer to obtain an in-person ENT appointment; this dropped to 8% of all patients in the first three-year period with telemedicine, and then dropped to less than 3% of all patients in second three-year span using telemedicine.2 This reduces patient wait times, reduces the backlog of patients scheduled for in-person specialty clinic visits, and opens up in-person appointment slots. Patients who need additional testing or in-person evaluation and care are seen in an expedited manner. In fact, most specialty consultations are now completed within 2 to 4 hours. This system is now used in support of new care delivery models – such as travelling providers3, pre-surgical planning4 and post-surgical follow-up5 that lead to efficiencies and more timely access to care. Removing S&F telehealth as a viable alternative for health care is akin to removing texting and email as a viable form for business communication. We would be lost if we lost the ability to text or email, and were forced to rely solely on live phone calls for communication. We have found in the 21st century that S&F communication is critical as it allows us to capture information when it’s available, for others to access that data at a time that is most convenient to them, and (most importantly) that we do not have to try and coordinate calendars and schedules to communicate with each other. The Impacts of The Proposed Changes The proposed regulations will actually result in higher expenses to Alaska’s Medicaid program and will not save money as telemedicine is intended to do. The elimination of S&F asynchronous telemedicine services coupled with the requirements that remain will result in many Medicaid patients not receiving timely access to care. When patients go without care for long periods, this results in patients developing more severe and chronic illnesses which cost more money to the Medicaid program. These changes will also result in higher transportation costs for airfare, lodging, and meals when local care is not available. Because the telemedicine system currently used in the ATHS is built on a well-established, broader definition of telemedicine, any changes to this definition and to the scope of billable telemedicine Medicaid services will likely require a return to significant reliance on travel to see patients from remote communities. Currently, more than 70% of all consultations prevent the patient from having to travel to see the specialist – resulting in statewide savings estimated at $8 million to $10 million annually in avoided patient travel costs. In 2019 alone, it is estimated that approximately 4,000 S&F services at ANMC will be provided, including the following services:

• Orthopedics (50% of total encounters are via S&F); 2Hofstetter PJ, Kokesh J, Ferguson AS, Hood LJ. “The Impact of Telehealth on Wait Time for ENT Specialty Care”. Telemedicine and e-Health, 16(5):551-556., 2010. 3 Kokesh J, Ferguson AS, Patricoski C, LeMaster B. “Traveling an Audiologist to Provide Otolaryngology Care Using Store-and-Forward Telemedicine”. Telemedicine and e-Health, 15(8):758-763, 2009. 4 Kokesh J, Ferguson AS, Patricoski C. “Preoperative planning for ear surgery using store-and-forward telemedicine”. Otolaryngology-Head and Neck Surgery, 143:253-257, 2010. 5 Kokesh J, Ferguson AS, Patricoski C, Koller K, Zwack G, Provost E, Holck P. “Digital images for postsurgical follow-up of tympanostomy tubes in remote Alaska”. Otolaryngology-Head and Neck Surgery, 139:87-93, 2008.

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• ENT (41% of total encounters are via S&F); • Dermatology (6% of total encounters are via S&F): • Neurosurgery (1% of total encounters are via S&F); and • Endocrinology, Gastroenterology, Rheumatology, Nephrology, Ophthalmology,

Palliative Care, Podiatry, Infectious Disease, Pain Center, Surgery (each < 1% of total encounters are via S&F).

Note that these numbers are only for services furnished at ANMC. While we do not know the exact figures, the total number of S&F services furnished across the entire ATHS is certainly significantly higher, and the likely impact of the proposed changes will be similar to those anticipated by ANMC. Further, as stated above, the telemedicine services provided in these areas save a conservatively estimated $8-10 million in transportation services each year. In addition to the impacts across the wider health system, behavioral health services will be dramatically and adversely impacted by these proposed regulations. For example, proposed 7 AAC 110.625(b)(2) would exclude all proposed 1115 waiver services from coverage if furnished via any telemedicine modality. This will severely limit, if not outright discriminate against, rural and remote Alaskan communities’ access to the new waiver services that are being developed and implemented by the State of Alaska. Further, by placing new personnel or documentation burdens on telemedicine services, the proposed regulations would increase administrative burdens on providers to track the information proposed by the regulation. The administrative burden to develop or alter systems to document new elements at every service delivered is unnecessary and duplicative, especially in telemedicine services which already produce documentation as part of the process. For example, the proposed changes at 7 AAC 110.630 adding a new subsection (g) may appear routine, but the request to have “(4) the method of telemedicine used;” and “(5) the names of all persons participating in the telemedicine service and their role in the encounter,” does not appear to add any beneficial information to the State for claims adjudication; and, noting the roles of all individuals involved does not provide any clinical relevance or claims data. These types of documentation are burdensome and time consuming in addition to the time related issues of managing a live, interactive audio-video feed. Recommendations and Closing Remarks The ATHS shares the Department’s goal to provide quality and cost-effective telemedicine services in the Medicaid program. However, limiting the services available through telemedicine, removing methods for delivery of telemedicine, and placing new personnel and documentation burdens onto the telemedicine process will only drive up costs to the Medicaid program, while seriously jeopardizing the health of rural Alaskans. Instead of adopting these dramatic and counter-productive proposed changes, we strongly urge the Department to withdraw them at this time. Instead, we recommend the Department appoint a telemedicine workgroup to produce a revised draft. We believe that by partnering together we can better identify the Department’s chief concerns and come up with targeted, conservative solutions to address them, without doing irreparable damage to our successful, efficient, cost-saving, state-of-the-art, celebrated telemedicine system.

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We look forward to working with the Department more on telemedicine services. If you have any comments or questions about our comments or recommendations, please contact ANHB at (907) 562-6006 or by email at anhb@anhb.org. Sincerely,

Andrew Jimmie Chairman, Elected Tribal Leader, Village of Minto

SENT VIA EMAIL: susan.dunkin@alaska.gov

September 27, 2019

September 19, 2019

Adam Crum, Commissioner

ATTN: Susan Dunkin

Alaska Department of Health & Social Services

601 C Street, Suite 902

Anchorage, Alaska 99503-5923

REF: Telemedicine Regulation changes to Titles 7 AAC 110; 7 AAC 135; and 7 AAC 145

Dear Commissioner Crum/Ms. Dunkin:

The Alaska Native Tribal Health Consortium (ANTHC) is a statewide tribal health organization that

serves all 229 tribes and more than 173,000 Alaska Native and American Indian (AN/AI) individuals in

Alaska. ANTHC and Southcentral Foundation co-manage the Alaska Native Medical Center, the tertiary

care hospital for all AN/AI people in Alaska. I am writing to you about the State’s proposed changes to

the telemedicine regulations.

We have serious concerns that the outcome of the proposed telemedicine regulations will have a

destabilizing effect on the investment and support of telemedicine infrastructure and personnel across the

Alaska. This will disrupt the delivery of telemedicine services to AN/AI beneficiaries and reimbursement

to Tribal health providers, which will ultimately result in increased travel costs to the Medicaid program.

We have the following concerns with the proposed regulations:

Will eliminate reimbursement for store and forward telemedicine services.

Limits payment to only the professional component of a telemedicine service and excludes

payment for operational/support/facility expenses that are typically covered in a face to face visit.

Creates ambiguity about telemedicine services related to CHAP supervision and reimbursement.

Introduces ambiguity in other areas of telemedicine services (e.g. removing “consultation” with

no language left for a specialist (e.g. an Orthopedist) to review a patient case/imaging and render

an opinion on care of another provider without seeing the patient in person or over video; adding

geographic requirements for providers to be located in HPSA locations; adding a stipulation that a

presenting provider can only bill for “separately identifiable services”).

Potentially imposes work flow and health IT costs for changes to Electronic Medical Records to

comply with new requirements of the proposed regulation.

The most alarming changes in the proposed regulation relate to Store and Forward (S&F) services. S&F

is an extremely robust form of telehealth that works more efficiently than any other form of telehealth in

rural Alaska. This system was originally implemented when broadband connectivity was unavailable at

most village clinics, and the connectivity was intermittent. Consequently, AFHCAN pioneered many

concepts in multi-organizational “store-and-forward” telehealth and developed technologies now used in

all of the continents except for Antarctica.

Each year, almost 1,400 providers use the AFHCAN system to create 38,000 cases for 23,000 patients, or

approximately one in seven Alaska Natives receive care via telehealth on an annual basis. The continued

development in these areas has allowed Alaska to become a world leader in this form of telemedicine, and

demonstrated dramatic advantages of this form of telehealth compared to live video-based telehealth.

Many telehealth programs across the world have adopted S&F telehealth based on the evidence provided

by Alaska.

ANTHC has conducted an internal analysis of over 187,000 primary care telemedicine cases, 98,000

specialty care telemedicine cases, and 19,000 orthopedic cases provided since FY 2012. The results from

this analysis are as follows:

Our analysis of primary care cases indicates that on average the use of telemedicine avoided

travel in 19.2% of the cases. Had travel been required on these cases it would resulted in

approximately $16.2 million in Medicaid spending;

The analysis of specialty care cases indicates that on average over 51% of the cases since 2012

eliminated the need for travel. Had travel been required on these cases, it would have resulted in

$40.8 million in Medicaid spending;

Our analysis of orthopedic cases found that on over 19,000 cases the use of telemedicine services

saved over $14 million in Medicaid spending;

We also analyzed approximately 9,500 VTC visits at ANMC and estimate these cases saved at

least $3.3 million in travel since FY 2012.

The proposed regulations will actually result in higher expenses to Alaska’s Medicaid program and not

save money as telemedicine is intended to do. The elimination of store & forward asynchronous

telemedicine service services and the requirements that remain will result in many Medicaid patients not

receiving timely access to care. This will result in patients going without care and result in more chronic

services that will cost more money for Medicaid. Most importantly, it will result in higher transportation

costs for airfare, lodging, and meals when local care is not available.

Recommendation:

In light of the additional costs that the regulation will have on Medicaid travel when telemedicine services

are not available, as well as the impact it will have to maintain telemedicine infrastructure and personnel

across the State, ANTHC respectfully request that the Department withdraw the proposed telemedicine

regulation.

ANTHC shares the Department’s goal to provide quality and cost effective telemedicine services in the

Medicaid program. If the state is set on revising the regulation, we further recommend it appoint a

telemedicine workgroup to work with the Department to redraft the regulation to help achieve its

objective, while also mitigating the impact that the proposed regulation will have on Medicaid patients

and providers in the state.

In response to the administrative procedures process, we provide our comment and recommendations on

the proposed regulation in the attached document. We do not are our comments and recommendations to

be misconstrued that we support amending the current draft regulation, as our primary recommendation is

that the regulation as drafted is unworkable and should be withdrawn.

Sincerely,

Jerry Moses, Vice-President

Intergovernmental Affairs

Attachment:

ATTACHMENT A

ANTHC Comments and Recommendations

7 AAC 110.625. Telemedicine applications; limitations

The proposed regulation repeals and readopts 7 AAC 110.625 with substantive changes to telemedicine

applications and sets forth limitations. The proposed changes to the regulation limit payment for

applications of telemedicine services to live or interactive methods. The proposed change is substantive

in that it eliminates payment for store and forward (S&F) services. This change would require that for

telemedicine services to be eligible for reimbursement, they must be provided through live or interactive

methods of service or telecommunication.

Recommendation: ANTHC recommends that store and forward services be made eligible for payment

under this paragraph. We further recommend that this paragraph should also allow a consulting provider

to obtain information, analyze it, and report back to the referring provider. The following provides

justification for our recommendation.

Justification:

S&F telehealth is an extremely efficient and robust form of telehealth that works better than any other

form of telehealth in rural Alaska. This system was originally implemented when broadband connectivity

was either unavailable or intermittent at most village clinics. Consequently, AFHCAN pioneered many

concepts in multi-organizational “store-and-forward” telehealth and developed technologies that are now

used in all of the continents except for Antarctica. Each year, almost 1,400 providers use the AFHCAN

system to create 38,000 cases for 23,000 patients. This means that S&F telehealth impacts the care for

approximately one in seven Alaska Natives on an annual basis.

The continued development in this areas has allowed Alaska to become a world leader in this form of

telemedicine, and demonstrated dramatic advantages of this form of telehealth compared to live video-

based telehealth. Many telehealth programs across the world have adopted S&F telehealth based on the

evidence provided by Alaska.

1. S&F telehealth works very effectively across organizational boundaries. Most of the specialty

telehealth consults that occurs in Alaska span organizational boundaries (i.e. the patient and rural

provider are at a clinic managed by one organization while the consulting provider is located at a

facility managed by another organization). The Alaska Tribal Health System, for example, is

composed of 30 individual organizations managing more than 200 sites.

This makes it extremely difficult to coordinate time for two providers and the patient to be

available at the same time, as schedules (and even EHRs) are often not visible or shared across

organizational boundaries. However, S&F telemedicine does not require simultaneous

scheduling of individuals, and allows each organization to manage their workflow and schedules

independently.

2. S&F achieves a much faster response rate than live video tele-conference (VtC), due to the fact

that a specialist can review an S&F case during an open time in their day and respond quickly.

ANMC has demonstrated an ability to respond to the majority of S&F cases within a work day,

often within 60 minutes.

By comparison, it can take days (and even weeks) to coordinate a visit for a patient over live VtC

and multiple calls between case managers and clinic staff to arrange the appointment, then

technical issues can delay or prevent the consult from happening, or the specialist provider is

called away on emergency and the appointment is rescheduled.

3. S&F telehealth works when other forms of telehealth cannot. Rural Alaska location still suffer

from outages or disruptions to connectivity, spanning minutes to days or weeks, making live

video unreliable. It may be possible to push S&F cases through with poor connectivity as the

technology is design to packetize and continuously attempt to transmit data.

4. S&F telehealth is more likely to be successfully transmitted over networks when phones, faxes,

emails and VtC are impossible. Perhaps more importantly, images can still be captured at the

appropriate moment and stored for transmission. If a patient needs to wait hours or days for a

consult, when changes inevitably occur, the original view of the wound or lesion or EKG is lost,

whereas S&F allows for accurate and timely data capture.

5. Removing S&F telemedicine as a viable alternative for health care is akin to removing texting

and email as a viable form for communication. We would be lost without the ability to text or

email, forced to rely solely on live phone calls for communication. We have found in the 21st

century that S&F communication is critical as it allows us to capture information when it is

available, for others to access that data at a time that is most convenient to them, and that we do

not have to try and coordinate calendars and schedules to communicate with each other.

6. Eliminating S&F reimbursement threatens the investment made in telemedicine infrastructure.

Tribal organizations and the federal government invest more than $120M every year for

technology that supports S&F telehealth. There are more than 200 AFHCAN carts with devices

throughout rural Alaska, and tribal organizations have invested millions of dollars in maintaining

these medical devices. A diagnostic-quality otoscope, for example, costs $9,000. These devices

are critical to capturing images of ear disease, which ANs continue to experience at some of the

highest rates in the world. Tribal organizations and federal investment continue to support the

connectivity critical to S&F telehealth infrastructure. While also used for live videoconferencing,

S&F telehealth is still the dominant form of telehealth over these network lines.

7. There is ample evidence that S&F improves quality care of care and access to care throughout

Alaska. There is ample evidence that S&F telehealth improve the quality of care and access to

care throughout rural Alaska. A study conducted in Nome found, for example, that prior to use of

telemedicine by audiology and ENT, 47% of new patient referrals would wait five months or

longer to obtain an in-person ENT appointment. This dropped to 8% of all patients in the first

three years with telemedicine, then less than 3% of all patients in next three years using

telemedicine. This reduces patient wait times, reduces the backlog of patients scheduled for in-

person specialty clinic, and opens up in-person appointment slots.

Patients who need additional testing or in-person evaluation and care are seen in an expedited

manner. In fact, most specialty consultations are now completed within two to four hours. More

than 70% of all consultations prevent the patient from having to travel to see the specialist. This

system is now used in support of new care delivery models – such as travelling providers, pre-

surgical planning and post-surgical follow-up that lead to efficiencies and more timely access to

care.

Eliminating S&F will increase Medicaid travel

ANTHC has conducted an internal analysis of over 187,000 primary care telemedicine cases, 98,000

specialty care telemedicine cases, and 19,000 orthopedic cases provided since FY 2012. The volume of

services that include S&F provided at ANMC services could potentially include:

Orthopedics (50% of total encounters);

Ears, Nose, and Throat (41% of total encounters);

Dermatology (6% of total encounters):

Neurosurgery (1% of total encounters); and

Endocrinology, Gastroenterology, Rheumatology, Nephrology, Ophthalmology, Palliative

Care, Podiatry, Infectious Disease, Pain Center, Surgery (each < 1% of total encounters).

A significant impact on travel and access to care will likely result if S&F services are eliminated. Our

internal analysis of telemedicine cases in which S&F services have been utilized conservatively estimates

the following cost savings for Medicaid-related travel:

Primary care cases indicates that on average the use of telemedicine avoided travel in 19.2% of

the cases. Had travel been required on these cases it would have resulted in approximately $16.2

million of Medicaid spending;

Specialty care cases indicates that on average over 51% of the cases since 2012 eliminated the

need for travel. Had travel been required on these cases it would have resulted in over $40.8

million of Medicaid spending;

Orthopedic cases found that on average over 19,000 cases the use of telemedicine services saved

over $14 million in related Medicaid travel spending;

We also analyzed approximately 9,500 VtC visits at ANMC and estimate these cases saved at

least $3.3 million in travel since FY 2012.

The proposed regulations will result in higher expenses to Alaska’s Medicaid program. The elimination of

S&F asynchronous telemedicine services will result in many Medicaid patients not receiving timely

access to care. This will result in patients going without care and more costly chronic conditions along

with higher transportation costs for airfare, lodging, and meals when local care is not available.

7 AAC 110.630. Conditions for payment

The proposed changes to 7 AAC 110.630 replace the previous terms for “treating, consulting, presenting

or referring provider” with a new term “distant site” provider. The proposed regulations also remove

language that “A presenting provider is only eligible to receive Medicaid payment for a live or interactive

telemedicine application as described in 7 AAC 110.625(a)(1).” The revised regulation will also disallow

payment for a presenting provider on the same date of service “unless the presenting provider is billing

for a separately identifiable billable service. Health records must document that all the components of the

billed service were provided.” The revisions to the regulation also add new documentation requirements

for electronic medical records. Lastly, the proposed changes will also restrict payment for services

rendered to a patient located in the same community as the provider to only federally-designated Health

Professional Shortage Areas (HPSA).

Recommendation:

ANTHC recommend that treating, consulting, presenting, or referring providers be eligible for

reimbursement under this section. ANTHC recommends adding the term “location or facilities” to the

requirement that restricts payment for services to a patient located in the same community as the provider

in a HPSA.

Justification:

The proposed regulation makes it unclear whether payment for a telemedicine presenter at the originating

site is allowed. There is no clear language left in the regulation stating that a presenter’s services are

payable. The proposed regulation adds a stipulation that the presenting provider can only bill for a

“separately identifiable billable service.” We recognize this revision may be intended to clarify that a

provider can be reimbursed for same day services for a different purpose (unrelated to the patient

presentation). If a presentation code is no longer allowable, then this dis-incentivizes telemedicine

partners to provide live video telemedicine since they would not be reimbursed for their time.

HPSA designations indicate health care provider shortages in primary care, dental health, or mental

health. The HPSA designations may be geographic, population, or facility-based. IHS and tribally-

operated health facilities are automatically deemed in regulation to be a HPSA. Adding the term

“facility” will clarify that the HPSA requirement applies to both HPSA geographic and facility

requirement.

7 AAC 110.635. Exclusions.

The proposed regulations disallow payment of telemedicine services for the “supervision under the

presenting provider’s license or certification.” The changes to this section also stipulate that the

“professional services” component of telemedicine services are only reimbursable. It is not clear what

this change is intended to accomplish. We are concerned how this provision relates to CHAP providers

consulting with their supervising primary care provider. ANTHC recommends that the new section (11)

supervision under the presenting provider’s licensure or certification be stricken from the proposed

change to this section.

7 AAC 110.639. Definitions.

As previously discussed, the proposed changes to 7 AAC 110.639 will eliminate S&F telemedicine

services and also include the removal of “consulting provider” and add the terms “presenting provider”

and “referring provider.” These changes are substantive and eliminate asynchronous/S&F reimbursement

by Medicaid such that only live video telemedicine is covered (see impact described in AAC 110.625

above). It is not clear why the Department is proposing that the specific services are covered, but other

services that rely on digital images, sounds or video recordings are not. Examples of those services

include EEGs, ECG tracings, ear or skin images, etc. ATNTC recommends that the definition section of

the regulation not be changed at all, or to add back the definition requirements of the current regulation.

###

September 20, 2019

Submitted by email to: susan.dunkin@alaska.gov Dear Ms. Dunkin, The Alaska State Hospital and Nursing Home Association (ASHNHA) is submitting comments on the Department of Health and Social Services regulations on proposed changes on Medicaid telemedicine services coverage & payment. ASHNHA is opposed to a number of the proposed changes to the regulations and believe these changes will limit access to telemedicine services for Medicaid recipients and create significant challenges for rural and critical access hospitals to serve rural residents. ASHNHA is concerned that the direction of the regulations is not in alignment with telehealth provisions included in SB74 Medicaid reform legislation passed in 2016. We support the expansion of behavioral health services that can be provided through telemedicine. Access to behavioral health is a significant challenge and allowing additional services to be paid for could make a big difference in access to care. However, some of the other provisions decrease the likelihood that access will be realized as outlined below. Summary of concerns:

• Proposed changes could reduce access to care for Medicaid recipients and hamper new models designed to improve care and reduce cost. Proposed regulations may not support Medicaid Reform legislation (SB74) requirements and new definition/scope of telemedicine may conflict with Sec. 47.05.270.

• Removing store and forward and self-monitoring services will reduce access to important services and potentially increase costs to the Medicaid program by requiring direct contact with a provider even when not necessary.

• Removing presenting provider will limit local provision of telemedicine services especially for rural hospitals and clinics. The removal of 7 AAC 135.290 facilitation of a telemedicine session will make it more difficult for a provider or clinic to facilitate behavioral health services.

• Adding a requirement related to Health Professional Shortage Area will limit non-tribal critical access hospitals and larger urban facilities from providing telemedicine services to their community while allowing anyone from outside the community or state to provide services. This will hamper care coordination, continuity of care and increase the financial vulnerability of rural hospitals by not allowing them to serve their own community.

• The regulation introduces potentially onerous documentation requirements that will add to the burden without clear benefit.

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• Regulation changes could allow expanded delivery of telemedicine services by out of state providers directly to Medicaid recipients in their home with no coordination of care by local providers. This could both increase costs to the Medicaid program and reduce quality and continuity of care.

Overall, we are concerned that there has not been adequate analysis of data to understand cost and utilization of telemedicine services for Medicaid recipients prior to changing how Medicaid covers telehealth services. Will these changes save the program money or add to the cost of the program? Will access services in rural areas be expanded or restricted. Without analysis we have no idea and must express our concern. Our concerns are outlined in detail below.

1. SB 74 Medicaid Reform legislation (2016) included specific requirements for DHSS related to telehealth. The legislation included the following;

• Requires the Medicaid program to expand the use of telehealth for primary care, behavioral health, and urgent care. (Section 43)

• Identify areas of the state where improvements in access to telehealth would be most effective in reducing Medicaid costs and improving access to care for Medicaid recipients;

• Improve access to telehealth for recipients in those locations; and, • enter into agreements with Indian Health Service providers, if necessary, to improve

access by medical assistance recipients to telehealth facilities and equipment. (Sec. 43) • Requires DHSS to include in an annual report on Medicaid reform to the legislature

information on the legal and technological barriers to expanded use of telehealth, improvements in the use of telehealth in the state, and recommendations for changes or investments that would allow cost-effective expansion of telehealth. (Section 43)

• Allows DHSS to increase the capability for and reimbursement of telehealth for Medicaid recipients. (Section 45)

• Requires the Department of Health & Social Services to identify legal or cost barriers preventing the expanded use of telehealth and recommend remedies for identified barriers. (Section 46)

In reviewing the draft regulations, there is no evidence that the DHSS is focusing on regulation changes that will support these requirements. Based on our review of the proposed regulations we have concerns that the changes could limit access to care and are not focused on “cost-effective expansion of telehealth”. The Medicaid Redesign Telehealth Stakeholder Workgroup met many times and a report with recommendations was created. The proposed regulations do not appear to incorporate or show consideration of these recommendations. The document is found here: http://dhss.alaska.gov/HealthyAlaska/Documents/redesign/MCDRE_Telehealth_Workgroup_Report.pdf

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2. Amend the modes of delivery and the type of services for which the department will

pay. We are concerned about removing store and forward and self-monitoring services. Some medical services (example dermatology or EEG) can be provided in a cost-effective way using a store and forward delivery. No rationale is provided for why audiologic and radiologic interpretation of digital images, sounds or video recordings are covered, but other clinical services that rely on EEGs, ECG tracings, ear or skin images, etc, are not covered.

Requiring direct real-time contact with a provider for services that could be provided through store and forward asynchronous telemedicine could increase cost and restrict access to care. Remote patient monitoring (self-monitoring) is an emerging way to care for people with chronic health conditions and to reduce readmissions. Eliminating this option could increase costs by removing a lower cost way to monitor a patient at home. Many managed care programs are beginning to rely on these methods of providing care to reduce costs and meet patient needs.

We are concerned about the removal of “a consultation made to confirm a diagnosis” from the type of services covered. Paying for a consultation to confirm diagnosis or get a second opinion by telemedicine prior to treatment seems like a cost-effective service and a way to improve quality of care.

3. 7 AAC 110.630. Conditions for payment - Removing presenting provider and limiting

payment to the distant provider Removing presenting provider will limit local provision of telemedicine services especially for rural hospitals and clinics. Currently a minimal “presentation fee” for a live video encounter provides a small amount of reimbursement to support the presenting site in covering costs associated with providing access to telemedicine. Without this reimbursement, presenting providers will be less able to support telemedicine services.

4. Include a requirement related to a Health Professional Shortage Area.

We are very concerned about the provision that “services can only be provided through telemedicine by “a provider located in the same community as the patient is located only if the location is a federally designated Health Professional Shortage Area (HPSA).” This is will limit the services facilities can provide in their local communities and is especially bad for non-tribal rural facilities. The existing HPSA designation criteria has many problems for rural critical access hospitals that are not operated by a tribal organization. The result of this requirement will be that facilities cannot provide services to patients in their own community while allowing providers from outside the community or the state to directly serve the Medicaid recipients. This does not support good care coordination or continuity.

5. New documentation requirements. The regulation introduces potentially onerous

documentation requirements such that providers must include within the EHR: a statement

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that the service was provided using telemedicine; the address location of the patient; the address location of the provider; the method of telemedicine used; and the names of all persons participating in the telemedicine service and their role in the encounter. There is a lack of clarity on what documentation can be auto-populated on billing forms versus what the provider needs to document themselves in their note.

6. Removal of 7 AAC 135.290 Facilitation of a telemedicine session. This will make it more

difficult for a provider or clinic to facilitate behavioral health services. There will be no reimbursement for supporting the telemedicine encounter and make it far less likely that Medicaid recipients will receive behavioral health services by telemedicine.

7. Lack of data to identify high need and/or shortage areas

The Telehealth Stakeholder Workgroup report referenced above includes a recommendation related to the lack of data related to telemedicine. Specifically, the report includes the following. Recommendation 9: Identify baseline data for cost and utilization of telemedicine services for Alaska Medicaid. Develop and routinely prepare data reports on telehealth utilization among Alaska Medicaid enrollees to analyze telehealth utilization by location, provider type, diagnosis code, and service category. Use reports to determine priorities for targeted telehealth expansion. This is an excellent recommendation to complete prior to dramatically changing how Medicaid covers telehealth services. Thank you for the opportunity to provide comments on the proposed regulations. Sincerely,

Jeannie Monk Senior Vice President

From: Calcote, Rick M (HSS)To: Dunkin, Susan M (HSS)Cc: Brown, Farina E (HSS); Calcote, Rick M (HSS); Roth, Terry A (HSS); Moreau-Johnson, Gennifer L (HSS)Subject: Comment / Recommendation Telemedicine RegulationsDate: Wednesday, October 02, 2019 12:55:52 PMImportance: High

Susan,Thank-you for the earlier phone conversation and for letting us provide comment after the close ofthe Public Comment period. I understand that you intend to continue to work with providers aboutthe proposed regulations prior to final adoption. Hopefully, our recommendations below will assist. Explanation: A significant number of individuals across the state each year are assessed for civilinvoluntary commitment, and to a lesser degree evaluated for competency to stand trial in criminalproceedings. By Statute these services must be provided by a mental health professional employedby, or that receives money from, the department, or a psychiatrist or forensic psychologist. Theavailability of these professionals is quite limited. Providing these services in a timely fashionremains a challenge and often is a critical factor in successfully processing an individual through thelegal system as well as assuring the person receives needed treatment. Allowing these services to beprovided via tele-medicine will greatly improve system capability and efficiency. Recommendation: 7 AAC 110.625(b)(1) is amended to read:

(1)    the service is limited to. . .(D) a psychiatric, substance abuse assessment, or psychotherapy; [OR]

(E) a screening investigation under AS 47.30.700; or (F) a psychiatric examination under AS 12.47.070; Explanation: 7 AAC 110.625(b)(2) lists the behavioral health services that are limited totelemedicine. Since that regulation was drafted we have expanded the behavioral health State Planservices that can be provided via tele-med. All of the BH services that we have approved to beprovided via tele-med still meet the criteria under 7 AAC 110.625(b)(1). Because we decided we donot want our Community Behavioral Health and Mental Health Physician Clinic Medicaid CoveredServices chart to be adopted by reference in regulation we will need to list the additional approvedservices in Section 625. Recommendation: 7 AAC 110.625(b)(2) is amended to read: (2) the behavioral health services is limited to (A) professional behavioral health assessments under 7 AAC 135.110; (B) pharmacologic management services under 7 AAC 135.140; (C) psychotherapy under 7 AAC 135.150; (D) short-term crisis intervention services under 7 AAC 135.160; (E) short-term crisis stabilization services under 7 AAC 135.170; [AND] (F) comprehensive community support services for adults under 7 AAC 135.200;

(G) psychological testing services under 7 AAC 110.550;(H) neuropsychological testing under 7 AAC 110.550;(I) case management under 7 AAC 135.180;

(J) behavioral health screening under 7 AAC 135.100; and (K) screening and brief interventions services under 7 AAC 135.240. Explanation: The department was recently successful in obtaining approval from CMS to operate an1115 Behavioral Health Services Demonstration Waiver. The department was directed to explorethe potential for this program under SB 74. The 1115 waiver includes both substance use disordertreatment services, and behavioral health services. The waiver is designed to fill the gaps in thecontinuum of care and to increase access to services. Many of the waiver services have beendetermined to be eligible for delivery via telemedicine. Including these services in the proposedtelemedicine regulations is instrumental to achieving waiver objectives. Because these services arepaid under a separate authority from behavioral health State Plan services, we suggest that they belisted separately. Recommendation: 7 AAC 110.625(b) is amended by adding a new subsection to read: (3) the section 1115 demonstration waiver services is limited to (A) treatment plan development and review under 7 AAC 138.100; (B) intensive outpatient substance use disorder services under 7 AAC 138.250; (C) community recovery support services under 7 AAC 138.400; (D) substance use disorder care coordination services under 7 AAC 138.400; and (E) intensive case management services under 7 AAC 138.400; Again, thank you for everything, and do let us know if we can assist in any other way. Cheers,rick Rick M. Calcote, M.S.Policy, Regulations, and PlansState Behavioral Health3601 C. St., Suite 878Anchorage, AK. 99503907-269-3617907-269-3623 FAX

September 27, 2019 Susan Dunkin Division of Health Care Services Department of Health & Social Services 4501 Business Park Blvd, Building L Anchorage AK 99503

Submitted by email to: susan.dunkin@alaska.gov

Dear Ms. Dunkin:

Thank you for the opportunity to comment on the proposed changes to the state’s Medicaid

telemedicine services coverage and payment regulations.

Foundation Health Partners (FHP) is a community owned and operated health system and is committed

to caring for all members of our community regardless of ability to pay or type of insurance. FHP is

consequently the primary provider of services to Medicaid patients in the Interior Alaska region.

Although the Department of Health & Social Services (DHSS) has not posted an explanation of the intent

behind the proposed revisions to the telemedicine regulations, the revisions do not appear to be in

alignment with the provisions of SB 74 signed in 2016 or with the Medicaid Redesign Telehealth

Workgroup report of 2017. FHP understands DHSS is seeking ways to reduce the cost of its Medicaid

program. We at FHP also seek to be more cost efficient while maintaining, or even improving, patient

access and service quality. We are therefore dismayed by the draft revised telemedicine regulations

posted for public review as we believe that, if implemented, more patients will have to travel for care or

more patients might choose to forego care resulting in worsening health outcomes, either of which might

drive additional costs.

As you no doubt are aware, the American Medical Association (AMA) has recognized that telemedicine

is a new modality for the delivery of care. The AMA guidelines underscore the need for a valid physician-

patient relationship before a telemedicine modality is deployed, either through a face-to-face

examination or through consultation with another provider who already has an ongoing relationship with

the patient. Although practice safeguards are recommended, the AMA telemedicine guidelines explicitly

provide for physician discretion in using this care modality. Furthermore, in 2018, recognizing potential

cost efficiencies, CMS made provision for reimbursement of both store-and-forward consultations and

remote patient monitoring services.

FHP currently makes only limited use of telemedicine (including store-and-forward consultations and remote patient monitoring); we currently contract with Providence’s Telestroke program, and use store-

September 27, 2019 Page 2 ________________ and-forward for after-hours radiology reads. That said, we are interested in expanding the use of store- and-forward into additional specialty areas underrepresented in our region (such as EEG and pulmonary function tests), exploring the use of remote patient health monitoring services for our primary care patients living with chronic health conditions, and are particularly interested in exploring the use of telemedicine for our primary care patients or recently discharged inpatient patients who are managing behavioral health conditions. We appreciate that the proposed regulation revisions would enable expanded use of

telemedicine to support patients using behavioral health care services. We do think this will be

good practice, limiting unnecessary travel for vulnerable patients.

We are concerned that the proposed regulations would prevent us from providing services via

telemedicine in our region to our own patients. Although we absolutely believe face-to-face care

is important for the ability of a provider to form an initial assessment and to develop a strong

provider-patient relationship, we do not necessarily believe it is critical for all care appointments

to be delivered in-person. Interior Alaska is a very large geographic area, and traveling to a clinic

site might mean, even within just the Fairbanks North Star Borough (FNSB), many miles on

wintery roads or, outside of FNSB, even a bush plane ride. We strongly believe that it should be

left to the physician to determine whether an in-person visit is best.

We do not understand the repeal of the store-and-forward and patient self-monitoring

provisions as this runs counter to national best practice. It is not clear if DHSS plans to continue

to fund these types of activities, but just not call them “telemedicine.” If so, it is possible DHSS

has not fully considered the scope of provider costs incurred in facilitating such services. We are

concerned that the proposed regulations would limit reimbursement to presenting providers. As

noted above in the discussion of the AMA guidelines, it is recommended that the consulting

physician rely upon the physician-patient relationship of the presenting provider. The presenting

provider has the duty to facilitate the connection, sometimes provide the site and technology,

perhaps support the patient and family during the consultation, and certainly support the patient

and family in considering options. It would be of particular concern if a non-local provider

attempted to provide services to a patient without any involvement of the patient’s other

previous providers. If the patient’s primary care provider cannot be reimbursed for facilitating

consultations with specialty providers, the presenting provider will naturally scale back

involvement in the interaction to the possible detriment of both the patient and the consulting

provider. Given Interior Alaska lacks providers in several specialty areas, FHP does quite a bit of

September 27, 2019 Page 3 ________________

work in supporting our patients to get these services elsewhere. We strongly believe we should

be compensated for these patient support activities which support positive outcomes.

It is unclear to us what the intent is of the proposed revisions, but as written we believe

telemedicine use would be constrained. FHP believes this would be very unfortunate as we

believe telemedicine options have untapped potential in Interior Alaska for improving patient

access and care outcomes and for reducing Medicaid program costs. As the state’s largest

partner in serving Medicaid patients in this region, we would be happy to work with you more

closely to consider alternate options for achieving your Medicaid program goals.

Sincerely,

Shelley Ebenal, Chief Executive Officer

Received from Kevin Munson, via email, on 09/26/2019

Please see the below included Mat-Su Health Services comments regarding the proposed changes to Medicaid Coverage & Payment, Telemedicine Services including 7 AAC 110., 7 AAC 135., and 7 AAC 145. In the proposed change to 7 AAC 110.630 that adds subsection (f) where it now limits payment if the patient and the provider are in the same community unless the location in in a HPSA. First, what is the definition of community? This critical term is not defined. Second, who must be located in the HIPSA? Is it both? Is it only the patient? Thirdly, is it any HIPSA? Is there a threshold HIPSA score? If, so is it for that service type (primary care, behavioral health, dental)? Finally, telemedicine is about expanding and enabling access, so why limit it? If a patient who might otherwise encounter transportation and logistical challenges to get to the appointment can instead receive the care from their home or other location, should they be penalized because their provider happens to work in their community rather than in the lower 48? Would it not bring the cost of care down if the patient does not have to use a travel voucher to get a cab to travel across town to get care? If there is some legitimate reason the provider cannot get into the office does the facility cancel all the appointments or can the provider deliver the care via telemedicine and preserve the continuity and access to care for the patients? This section should be removed. In the proposed change to 7 AAC 110.630 that adds subsection (g) item number (2) requires “the address location of the patient;”. Medicare currently requires patient and provider locations to be provided in each note; this is operationally understood to be the city and state. There seems to be no public purpose served to require more than Medicare; it simply adds to the administrative burden on providers. Additionally, this requirement has some additional complexity for patients. How do we record homeless patients where their location may be the woods or down by the river? What do we do with service delivery to those who may be housed but lack a physical address? We have many of those in the Valley. It would be far simpler and easier to have the regulations conform to the Medicare standards and require city and state rather than more precise locations. In the proposed change to 7 AAC 110.630 that adds subsection (g) item number (3) requires “the address location of the provider;”. Medicare currently requires patient and provider locations to be provided in each note; this is operationally understood to be the city and state. A plain reading of the language used in this proposed new section would require the actual physical, street address of the provider. Many of our telemedicine providers conduct their activities from their home. Medicare does not require this granularity of detail why should the State? We see no public interest served in adding the actual, physical address of the provider to the record, and in fact see a potential harm created violating a provider’s privacy and their safety by disclosing the home address of providers to some patients. A patient, and anyone receiving and/or reviewing the record, would have ready access to the provider’s home address simply

by asking for a copy of their personal patient record. As an employer, we have an obligation to keep employee addresses confidential; this requirement would abridge that responsibility. In the proposed change to 7 AAC 110.630 that adds subsection (g) item number (5) requires “the names of all persons participating in the telemedicine service and their role in the encounter.” 7 AAC 110.625(b)(2)(c) allows various forms of psychotherapy described in 7 AAC 135.150, which includes group psychotherapy. This proposed amendment would require a provider to enter into each of the participating patient’s treatment record the full name of every other patient participating in the encounter. This is a requirement that exceeds the current documentary standards for group therapy delivered where everyone is physically present in the room. This new requirement would compromise the confidentiality of each patient and result in HIPAA violations whenever a record would be disclosed. Either that, or it would create an enormous administrative burden on the provider to redact that information each time. It would inevitably result in inadvertent violations of HIPAA on the part of the provider. Currently, in a normal medical encounter, the names of the scribe, medical assistant, x-ray tech and lab tech are not required though they are often in the room at various points of the encounter. This becomes an even greater issue when we consider the delivery of substance use disorder (SUD) groups that additionally fall under 42 CFR Part 2. This particular requirement would most likely make SUD groups impossible to deliver in a telemedicine format because the State regulation would violate a federal regulation and the provider could be prosecuted under both or either. We would propose that this requirement be eliminated. In general, the proposed addition of subsection (g) to 7 AAC 110.630 adds unnecessary administrative burden without a reasonable public interest being served. In the proposed changes it is proposed to eliminate “7 AAC 135.290. Facilitation of a telemedicine session.” We would oppose that change. There is a very real and unique cost to support telehealth service delivery. A cost not compensated within the professional reimbursement fees. In our particular case, the patient comes to our facility and the provider is in another city, often out of state. These, for us, are typically behavioral health assessment and psychiatric services for which we need staff assistance beyond the telemedicine provider him(her)self. Our non-provider staff must assure the equipment is functioning, orient the patient and family and/or participating supports to the use of the equipment, address safety and infection control for the equipment, and remain available to step in if there is connectivity or other interruptions to the telemedicine visit. Additionally, the telemedicine facilitator must assist in any type of crisis or concern the telemedicine provider feels needs addressing by face to face staff. Up to the adoption of this section, the costs for telehealth facilitation have been recoverable for our behavioral health program. It should be noted that there are clear standards and requirements for the provision of telemedicine facilitation as a requirement of at least CARF accreditation standards; other national accrediting bodies are likely to have standards as well. Meeting these standards (which the State requires

we meet) are a cost add to the provision of telemedicine services and become an unfunded mandate if facilitation is no longer reimbursable. As a Federally Qualified Community Health Center (FQHC) these proposed regulation changes spawn a series of questions and concerns. Will DHSS amend the cost report instructions to provide for inclusion of telehealth technology costs, and agree to adjust the PPS rates to reflect these costs so that the elimination of the separate payments will not pose significant hardship on FQHCs? It is currently unclear from the state regulations whether costs relating to telehealth activities are allowable on the cost report. Contradictory language raises concerns as to whether telehealth encounters are billable Medicaid “visits” under PPS. Under the FQHC PPS as described in the Alaska Administrative Code, an FQHC visit is defined as “the aggregate of face-to-face encounters, occurring on the same calendar day and at a single location.” 7 AAC 145.739 (emphasis added). In addition, the rules on allowable costs under the Alaska Medicaid FQHC PPS (see 7 AAC 145.700) incorporate by reference the allowable cost principles for FQHCs under Medicare. It would be extremely helpful if the State could harmonize all the regulations that impact telemedicine and resolve this apparent conflict in the definition of what qualifies. It is clear that the public policy intent is to facilitate telehealth delivery—this confusion constrains it. These regulations do not resolve the ambiguity that exists in current regulation impacting telemedicine with dual eligible patients. With respect to dual eligible issues, the two main questions are, does Medicaid pay up to the Medicaid PPS rate (where higher than Medicare) for a service that qualifies as both a Medicare and Medicaid visit; and, what measures are needed to ensure Medicaid will pay fully for a service furnished to a dual eligible that is not covered by Medicare (without requiring the provider to bill Medicare and receive a denial notice before billing Medicaid)?

3231 Glacier Hwy, Juneau, AK 99801 | Alyson.Currey@ppvnh.org | 907-957-8708

Ms. Susan Dunkin Department of Health and Social Services Division of Health Care Services 4501 Business Park Blvd., Building L Anchorage, AK 99503 Re: Comments on proposed changes to regulations on Medicaid coverage and payment for telemedicine services (7 AAC 110, 7 AAC 135, and 7 AAC 145)

September 27th, 2019

Dear Ms. Dunkin,

On behalf of Planned Parenthood Votes Northwest and Hawaii (PPVNH), I write today to comment on the Alaska Department of Health and Social Services’ proposed regulation to make changes to Medicaid coverage and payment for telemedicine services.

As a leading provider of sexual and reproductive health care services in Alaska, Planned Parenthood advocates for policies and programs that positively impact all aspects of peoples’ health and wellness. As part of our mission of ensuring that all people in Alaska can access affordable, high-quality health care services, we are proud to be a leader in using technology to deliver health care to people across the state.

We strongly support the use of telemedicine to expand access to high quality health care. Telemedicine can improve health equity and ensure that more people get the care they need in a timely manner by reducing barriers that make it harder for people to access care, such as transportation, childcare, and time off work.1 In Alaska, where many people lack access to care due to geographic and other barriers, telemedicine is a particularly important tool to improve health care accessibility and affordability.

While the Department has demonstrated a commitment to expanding access to telemedicine in the past, we are concerned that some of the requirements in this proposed regulation will create additional unnecessary barriers for patients who may benefit from access to telemedicine. We encourage the Department to prioritize improving Alaskans’ ability to access and benefit from telemedicine and offer the following suggestions to achieve this goal.

I. Remove restrictions on reimbursable methods of providing telemedicine.

This draft narrows the methods providers can use to provide telemedicine by removing previous language that allowed for the use of store-and-forward and self-monitoring and testing methods. There are a variety of methods for safely and securely providing telemedicine services, and different methods may be appropriate in different circumstances. Limiting reimbursement for certain methods of telemedicine restricts providers’ ability to determine the best means of treating their patients, which may or may not require live or interactive communications. For example, non-acute care may not require immediate live interactions, and store-and-forward technology may be more appropriate.

1 The Mayo Clinic, Telehealth: Technology Meets Healthcare, https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/telehealth/art-20044878

3231 Glacier Hwy, Juneau, AK 99801 | Alyson.Currey@ppvnh.org | 907-957-8708

Requiring live or interactive interactions may also restrict patients’ ability to access services. For patients who do not have the technology needed for these live video, audio, or data communications, or for patients who live in areas without reliable phone and internet service, this requirement could prevent them from using telemedicine services. This is of particular relevance in Alaska, where many residents live in rural areas or areas that do not have reliable phone and internet service.2

Alaska has historically been a leader in expanding access to telemedicine, but this regulation would move Alaska in the opposite direction of the federal government and other states, which are increasingly recognizing the value of expanding access to a broader range of telemedicine services. Until recently, Medicare limited the use of store-and-forward technology to Alaska and Hawaii, two states where geographic and transportation barriers create unique barriers to health care access. However, in 2019 Medicare expanded providers’ ability to seek reimbursement for services provided via store-and-forward technology, recognizing that this technology can be safely and effectively used to provide care in certain situations.3 As CMS has recognized with this policy change, changes in technology have the potential to improve patient access to care. Alaska should not impose reimbursement restrictions that discourage providers from quickly implementing new, more effective telemedicine technologies.

To increase access to care, improve providers’ ability to care for their patients, and align with federal reimbursement policies, we ask that the Department return to previous language in 7 AAC 110.625 that allowed reimbursement for a range of telemedicine technologies.

II. Do not restrict use of telemedicine to regions that have received a Health Provider Shortage Area (HPSA) designation.

Telemedicine has the potential to expand health care access for Alaskans who currently struggle to access care. Alaskans who do not live in regions that are designated as HPSAs often still experience very real barriers to health care that could be remedied via access to telemedicine services that allow them to conveniently and affordably access health care services. These may include a lack of reliable transportation; difficulty obtaining childcare; an inability to take time off work to go to an appointment; severe weather or existing health conditions that prevent patients from physically traveling to a provider’s office; and more.4

Telemedicine helps individuals in urban areas that may not be designated as HPSAs access specialty care. Alaska has one of the lowest concentrations of specialty providers in the country, and without access to telemedicine services many Alaskans may be forced to travel outside of their community to access needed specialty care.5 And because specialty care is generally not considered in determining HPSA designations, these designations typically do not recognize this shortage.

2 TechTarget Network, Telehealth Program Key to Quality Healthcare in Alaska, https://searchhealthit.techtarget.com/feature/Telehealth-program-key-to-quality-healthcare-in-Alaska 3 mHealth Intelligence, CMS Code Gives Docs a Change to Use Store-and-Forward Telehealth, https://mhealthintelligence.com/news/cms-code-gives-docs-a-chance-to-use-store-and-forward-telehealth 4 The Mayo Clinic, Telehealth: Technology Meets Healthcare, https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/telehealth/art-20044878 55 Agency for Healthcare Research and Quality, Telehealth Improves Access and Quality of Care for Alaska Natives, https://innovations.ahrq.gov/perspectives/telehealth-improves-access-and-quality-care-alaska-natives

3231 Glacier Hwy, Juneau, AK 99801 | Alyson.Currey@ppvnh.org | 907-957-8708

Telemedicine also allows individuals to quickly access urgent care services, without unnecessary delay. Many common ailments can be quickly and effectively evaluated via telemedicine. And the nature of urgent care visits, which typically arise from unexpected symptoms or conditions, make them particularly hard to plan for, exacerbating existing challenges such as transportation, scheduling, and child care. Even if an individual lives in a community where there is no shortage of qualified providers, they may not be able to access these providers when unexpected urgent care needs arise.6

However, this draft adds new language stating that the Department will only pay for telemedicine services located in the same community as a patient if they are located in a federally designated HPSA, ignoring the many barriers Alaskans face in accessing needed care. To better serve these patients, we ask that the Department delete new subsection 7 AAC 110.630 (f).

* * *

Thank you for the opportunity to comment, and please don’t hesitate to contact us with any questions.

Sincerely, Alyson Currey Legislative Liaison Planned Parenthood Votes Northwest & Hawaii

6 mHealth Intelligence, How One Urgent Care Clinic Uses Telehealth to Find Its Niche, https://mhealthintelligence.com/news/how-one-urgent-care-clinic-uses-telehealth-to-find-its-niche