Trends, Strategies, and Payment Models in Telemedicine

Trends, Strategies, and Payment Models in Telemedicine

Becker’s Hospital Review CIO/HIT + Revenue Cycle Summit

July 21, 2015

2515 McKinney Avenue Suite 1500 • Dallas, Texas 75201 • Telephone: 214.369.4888 • Fax: 214.369.0541

Ben Ulrich, CVA Director – Physician Compensation Valuation

Overview 2

Telemedicine Introduction

Reimbursement Environment

Telemedicine Strategies & Structures

FMV Considerations

Telemedicine Introduction

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Source: “Help Wanted: More US Doctors – Projections Indicate America Will Face Shortage of MDs by 2020” by AAMC

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Telemedicine Not a new mode of care

Current concept has existed for at least 20 years – 20th annual American Telemedicine Association Conference in May 2015

Certainly expanded with technology development and is continuing to evolve

Short form definition - Leveraging technology to enhance access to care for patients

Telemedicine implementation & expansion is broad

Direct to Patient/Consumer

Provider to Provider

Facility to Facility

Chronic Care Mgmt.

Tele-Monitoring, Remote Diagnostics

Teaching Hospitals

Mobile Health/Apps

International Care

Concierge Medicine

Call Center – 24/7 Access


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Telemedicine 3 Overarching Categories or Types of Telemedicine Care

Real-Time Care

Live video conferencing between provider and patient

“Store and Forward”

Digital data (images, records, audio/video, etc.) that are captured and transmitted to a provider for further study or second opinions

Remote Monitoring

Monitoring equipment transmits patient data to healthcare professionals (ex. chronic care management, diabetes, cardiac care, etc.).

Benefits/Strengths of Telemedicine

Access to care that eliminates local market/geographic barriers

Rural coverage in areas with physician shortages

Reduces emergency department stress/overutilization

Network cost reduction

Market expansion, outreach, and integration

Convenience for the patient (i.e. 24/7 access)

School health & employer based programs


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Telemedicine Challenges

Finding the right vendor or partner – understanding your goals/needs

Efficiently leveraging the technology & managing the system

Medical Board Licensure – state by state

HIPAA & data security issues

Keeping the physicians engaged (ex. lower volume arrangements)

Overcoming patient “technology fear”


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Telemedicine Predominant Specialties Leveraging Telemedicine

Acute Care –

Stroke

Inpatient & ED Neurology

Critical Care

Inpatient & ED Psychiatry

Outpatient Coverage –

Primary Care / Pediatrics

Behavioral Health

Cardiology

Tele-interpretations

Radiology

EKGs, EEGs


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Telemedicine Equipment Needed

Patient Site of Service –

Live audio/video connection

Typically a cart, webcam & video monitor

Support staff/physician on site with the

patient & cart to monitor & support

Remote monitoring in some instances

Patient records transmitted

Specialist/Telemedicine Physician –

Internet connection supporting live video

Webcam & microphone

Typically some sort of computer/smartphone

to review any documentation

Telemedicine equipment needs are very dependent on

the goals/needs of the contracting party. More or less

sophisticated technology may be warranted


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Medicare

“Telehealth” services reimbursed to the same degree as services delivered in the traditional manner. Telehealth does not apply to teleradiology or telepathology (no asynchronous connection)

Covered services limited by the location of the patient, service rendered, provider type and technology utilized. Requirements:

Real-time video & audio – face to face connection between patient & doctor

Phone calls, emails, faxes or one-way video connections are not allowed

Service must be a approved telehealth service

Office/OP visit, consultation, psychotherapy, drug mgmt, transitional care, etc.

Physician must be credentialed with the patient-site facility

Physician must be a authorized provider of the Specialty service

Physicians, PA/NPs, midwives, nurse specialists, psychologists, social workers, dietitians

Patient must be at a facility in a rural market (could be changing)

Health Professional Shortage Area

Patient originating site must be a qualified facility


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Medicaid

Reimbursement must follow Medicare conditions for participation but states can decide and elect unique payment policies.

States can elect what technologies to require, provider type, and the actual reimbursement levels

45 states reimburse for some level of telemedicine services – rules vary greatly state to state

Only 10 states provide reimbursement for remote patient monitoring


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Commercial Payors

Parity laws have driven commercial reimbursement for telemedicine

Many states prohibit commercial payors from denying telemedicine reimbursement if they reimburse for traditional on-site care

State policy driven


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Private Payors

Typically depends on the parity laws as well

Many payors are starting to establish independent telemedicine coverage (typically through contracted arrangements with vendors) to connect their beneficiaries virtually with providers

Aetna, Cigna, and BCBS all have individual state technology platforms used in this manner

Goal is greater integration, cost reduction and taking on population health initiatives on a grander scale


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Rural Coverage & Network Expansion Desire for telemedicine coverage driven from need to provide care in rural

locales

Telemedicine used as strategy for expanding system network & maximizing/integrating delivery of care

Expense reduction

Integrated healthcare

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Telemedicine Delivery of Care Structure Model #1: Hospital needing Specialty Coverage

Patient presents at the Rural Hospital originating site.

Connects with Specialty Physician via telemedicine

Both parties bill for their respective services

Specialty Physicians

Rural Hospital

Telemedicine

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Telemedicine Delivery of Care Structure Model #2: Central Hospital with Specialty Coverage Provides to Spoke

Facilities Spoke facility patients connect with Hub facility physicians via telemedicine

Telemedicine

Physician Coverage

Central Hub

Facility

Spoke

Spoke

Spoke

Telemedicine

Telemedicine

Fair Market Value Considerations

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Fair Market Value Considerations

FMV Considerations Favorable OIG Advisory Opinions (98-18, 99-14, 04-07, 11-12) assuming intent to

induce referrals is non-existent

Payment Rates to Physicians for providing coverage Considerations for potential professional reimbursement Payment Structure –

Per-consult (potentially grossed up for availability) Daily availability; Coverage Stipend Combination of these rates $ / annual ED visit Lease rate for equipment hardware/software

Charge Rates to Spoke Facilities

Considerations for potential professional reimbursement Payment Structure –

Per-consult Daily availability (potentially at reduced rates depending on network) $ / annual ED visit Lease rate for equipment hardware/software


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Questions?

Ben Ulrich, CVA Director – Physician Compensation Valuation

972-616-7798

[email protected] vmghealth.com

mailto:[email protected]

Health & Medicine

Trends, Strategies, and Payment Models in Telemedicine