Leveraging Telemedicine to Improve Care

Megan Douglas, JDAssociate Project Director, Health IT Policy

National Center for Primary CareMorehouse School of Medicine

Overview• Define telemedicine• Telemedicine in practice• Policy issues– Licensure– Reimbursement– Scope of Practice

• Teladoc v. TMB

• Discussion

Learning Objectives

• Define telemedicine• Describe how telemedicine is being used to improve

clinical outcomes• Identify policies that create barriers or facilitate the

use of telemedicine

What is telemedicine?

“Use of medical information exchanged from one site to another via electronic communications to improve

a patient’s clinical health status”

-American Telemedicine Association, www.americantelemed.org

Includes:• Patient consultations via video conferencing• Transmission of still images• E-health (including patient portals)• Remote monitoring of vital signs• Continuing medical education

Prevalence of telemedicine

• 200 telemedicine networks– 3,500 service sites

• Over 50% of hospitals use some form of telemedicine

• Nearly 1 million patients use remote cardiac monitors

• 300,000 remote consultations by Veterans Health Administration (2011)

Telemedicine in Practice

Primary Care– Consultations– Medication

management– School-based health care– Public health programs– Healthcare for the

Homeless

Emergency Medicine– Stroke

Specialty Care– Mental health– Dermatology

Remote Patient Monitoring– Chronic disease

management– Post-surgical monitoring

Equipment

Why telemedicine?• Increased access

– Rural– Underserved communities

• Efficiency– Financial– Staff– Travel

• Quality– Supplement– Substitute– Health Equity

• Consumer empowerment– Convenience

Cost“[Hospital at Home] program achieved savings of 19% over costs for similar inpatients...predominantly derived from lower average length-of-stay and use of fewer lab and diagnostic tests”Cryer L, Shannon SB, Van Amsterdam M, Leff B. Costs for 'hospital at home' patients were 19 percent lower, with equal or better outcomes compared to similar inpatients. Health Aff (Millwood). 2012 Jun;31(6):1237-43.

“The simulation predicted savings of $4.3 billion per year if hybrid telehealth systems were implemented in emergency rooms, prisons, nursing home facilities, and physician offices across the United States”Pan E, Cusack C, Hook J, Vincent A, Kaelber DC, Bates DW, Middleton B. The value of provider-to-provider telehealth. Telemed J E Health. 2008 Jun;14(5):446-53.

School-based health clinics“[I]ncreased communication across the school and specialty mental health systems and facilitated greater input across child, parent, school personnel, and mental health professionals”Nelson EL, Duncan AB, Peacock G, Bui T. Telemedicine and adherence to national guidelines for ADHD evaluation: a case study. Psychol Serv. 2012 Aug;9(3):293-7.

“[R]esulted in improvements in asthma symptom control and quality of life similar to improvements reported in face-to-face encounters provided by specialists”Romano MJ, Hernandez J, Gaylor A, Howard S, Knox R. Improvement in asthma symptoms and quality of life in pediatric patients through specialty care delivered via telemedicine. Telemed J E Health. 2001 Winter;7(4):281-6.

Stroke“[U]tilization facilitated rapid transfers and followed recommended clinical protocols for patients needing serious and/or urgent attention (e.g. stroke symptoms, chest pain)”Ward MM, Ullrich F, MacKinney AC, Bell AL, Shipp S, Mueller KJ. Tele-emergency utilization: In what clinical situations is tele-emergency activated? J Telemed Telecare. 2015 May 29.

“Fifty-two percent of the telemedical group achieved excellent outcome compared to 43% of the neurologist on-site group (P = .30)”Fong WC, Ismail M, Lo JW, Li JT, Wong AH, Ng YW, Chan PY, Chan AL, Chan GH, Fong KW, Cheung NY, Wong GC, Ho HF, Chan ST, Kwok VW, Yuen BM, Chan JH, Li PC. Telephone and Teleradiology-Guided Thrombolysis Can Achieve Similar Outcome as Thrombolysis by Neurologist On-site. J Stroke Cerebrovasc Dis. 2015 Jun;24(6):1223-8.

Discussion

• What have been your personal experiences using and/or observing telemedicine?

• What patient safety issues are involved with the delivery of health care through telemedicine?

• What are some barriers and/or facilitators to implementing telemedicine into a medical practice?

Policy Issues – Reimbursement

Medicare - 1999• Health Professional Shortage

Areas (HPSA)• Fee-for-service only• Limited CPT codes• NO home monitoring• 75%/25% fee split for originating

and distant sites• Estimated expenditures: $60

million-$690 million• Actual expenditures: $20,000

(301 encounters)

Medicare - 2015• HPSA, non-MSA• $24.83 originating site fee• Limited (but expanded from

original) CPT codes• No ACO reimbursement• Actual expenditures (2012):

$5 million

Whitten P, Buis L. Private payer reimbursement for telemedicine services in the United States. Telemed J E Health. 2007 Feb;13(1):15-23.

Neufeld JD, Doarn CR. Telemedicine Spending by Medicare: A Snapshot from 2012. Telemed J E Health. 2015 Apr 3.

Policy Issues – Reimbursement

Medicaid• Varies from state-to-state• 46 states reimburse for telemedicine– Limitations similar to Medicare (specific CPT codes,

providers, geographic location)

• 10 states reimburse for store-and-forward• 13 states reimburse for remote patient monitoring• 24 states reimburse for facility fee (originating site)

Policy Issues - ReimbursementMedicaidUtilization (2008-2009): 0.1% of all claims for telemedicine

ICD-9 Codes Frequency Percent ICD-9 Codes296 33,684 29.7% bipolar314 23,866 21.0% ADD/ADHD/Hyperkinetic disorder295 9,186 8.1% Schizophrenia309 6,647 5.9% Depression/Anxiety/PTSD304 5,339 4.7% Drug addiction300 5,280 4.7% Anxiety311 4,989 4.4% Depression 313 4,731 4.2% Child/Adolescent emotional disturbance312 3,518 3.1% Socialization/Manias299 2,203 1.9% Autism/PDD

113,425 telemed claims

Policy Issues – Reimbursement

Private Payers• Varies from state-to-state• Parity: requires private payers to reimburse same

amount for telemedicine as for in-person encounters• 24 states have private payer parity laws for

telemedicine– Similar limitations as Medicare (geographic location,

provider, CPT codes)

Policy Issues – Licensure

• Ability to practice across state lines varies from state to state– Federal initiatives discussed, but no action yet

• State policies:– Physician delivering services must be licensed in state in

which patient is located– Special purpose license or telemedicine license

• 10 states

– Exemption:• Emergency or natural disasters

Policy Issues

• Informed Consent– 28 states

• Telepresenter– Qualifications of individual located with patient

• Scope of Practice/Practice Standards– Different standards for in-person vs. telemedicine

encounters– Physician-patient relationship

• Most common: Patient must be an established patient of the physician or has had an in-person physical examination from that provider

• Acceptable methods of establishing relationship

Discussion

• Which of the policy issues mentioned incentivize providers to adopt telemedicine?

• Which of the policy issues mentioned pose the largest barriers for providers interested in adopting telemedicine into their practice?

Teladoc• Offers services to individual consumers, insurance

carriers, health care organizations• According to http://www.teladoc.com:

2010TMB issues

new rule requiring in-

person physical

exam prior to prescribing medications

2011TMB letter to

Teladoc claims physicians failed to properly establish

Dr-patient relationship

Teladoc sues TMB for improper rulemaking –

Teladoc wins on appeal in 2014

2014TMB issues emergency

ruling requiring in-person encounter

2015TMB rule effective

Teladoc sues TMB on federal antitrust claims –

Injunction issued

Teladoc v. Texas Medical Board

Teladoc v. Texas Medical Board

22 TAC § 190.8. Violation Guidelines.

(1) Practice Inconsistent with Public Health and Welfare. Failure to practice in an acceptable professional manner...includes, but is not limited to:

(L) prescription of any dangerous drug or controlled substance without first establishing a defined physician-patient relationship.

(i) A defined physician-patient relationship must include, at a minimum(II) establishing a diagnosis through the use of acceptable medical practices, which includes documenting and performing:

a) patient history;b) mental status examination;c) physical examination that must be performed by either a face-to-face visit or in-person evaluation

http://www.sos.state.tx.us/texreg/pdf/backview/0206/0206emer.pdf

Teladoc v. Texas Medical Board

Teladoc’s claims:TMB’s conduct has harmed competition, competitors, and consumers:1. New Rule 190.8 Would Harm Patients By Raising Prices And

Reducing Supply of Physician Services2. New Rule 190.8 Would Harm Public And Private Payors By

Raising Prices And Reducing Choice3. New Rule 190.8 Is Not Reasonably Necessary Or Narrowly

Tailored to Any Legitimate Objective4. New Rule 190.8 Will Cause Irreparable Harm to Plaintiffs

Teladoc v. Texas Medical Board

Patient Safety

Consumer Choice

Questions?