6th Annual Georgia Partnership for TeleHealth

Spring Conference MARCH 25-27

Savannah, GeorgiaMario Gutierrez

Executive Director

Center for Connected Health Policy • 877-707-7172

cchpca.org

TELEHEALTH POLICY & PRACTICE

We seek to advance state and national telehealth policies that:

• promote better health & health systems

• provide greater health equity

• Established in 2006, funded by the Office for the Advancement of Telehealth

• Twelve regional centers

• One national technology assessment center

• Collectively form a network of telehealth program expertise and experience

• Independently serve a designated region

TelehealthResourceCenter.org

One National Policy Resource Center - CCHP

What Is Telehealth?

Telehealth is a means for enhancing health care, public

health, and health education delivery and support using digital telecommunication technologies.

Telehealth?

A doctor's diagnosis "by radio" on the cover of theFebruary, 1925 issue of Science and Invention magazine

Why Telehealth is Essential to

the Future of Health Care

Advances in telecommunications technologies can help redistribute health care expertise to where and when it

is needed, and create greater value

Live VideoVariety of high-speed digital telecommunications

Outpatient or inpatient specialty consultation

Most commonly used

Store-and-Forward

Often low bandwidth, still images, can store video clips.

Best used in dermatology, ophthalmology, pathology, and radiology.

Exploring new avenues, such as psychiatry

TELEHEALTH MODALITIES

Remote Patient Monitoring

Hospital emergency departments, intensive care units, and skilled nursing facilities

At-home management of patients with chronic conditions

Keeping people healthy and at home

Mobile Health (mHealth)

Health care, public health, and health education

Supported by cell phones, tablet computers, PDAs, and other mobile communication devices

Can be targeted (promoting healthy behavior and disease management) to wide-scale (disease outbreak alerts)

TELEHEALTH MODALITIES

Remote Monitoring & M-

Health

Healthy Living

Chronic Conditions

AgingAcute Care,

ICU

End of Life

Cue provides molecular diagnostic capability in the home.

Apple Watch will display blood glucose levels from the Continuous Glucose Monitor

Handheld cellphone-based

Otoscope

12

Health Chair incorporates

a vast array of biosensors to measure basic vital signs:

Weight Blood Pressure Temperature ECG Auscultation of Heart and

Lung Sounds Blood Oxygen Saturation Motion Analysis Reflex Response Time

Incorporates communication unit with remotely controlled camera

Berkeley “Tricorder”Remote monitoring of multiple health functions in an

unobtrusive, wearable wireless device

• Combines accelerometer,

ECG, stethoscope, pulse-

oximeter, myography, and

other functions

• Bluetooth radio with

connectivity to PC and

smart phone

• 2 GB data storage

capacity: two days of

continuous monitoring

Monitoring Rx Adherence

FDA-Approved Digestible Microchip

FEDERAL & STATE POLICIES

Telehealth State-by-State Policies, Laws, &

Regulations

Interactive Policy Map

LawsRegsPendingBillsState & Federal

• Definition of telemedicine/telehealth

• Reimbursement for: live video

store-and-forwardremote patient monitoringemail/phone/faxtransmission/facility fees

• Consent issues• Location of service provided• Online prescribing• Private payer laws• Cross-state licensure

11 Telehealth Policy Areas

Current State Telehealth Policies:

Every State is Different!

Definition

• 43 states have a definition for “telemedicine”

• 28 states & DC have a definition for “telehealth”

• 2 states have no definition for either

Reimbursement

• 46 states & DC reimburse for live video

• 14 states reimburse for remote patient monitoring

• 9 states reimburse for store-and-forward

• 24 states and DC have telehealth private payer parity laws

Provider/Location Restrictions

• Most common reimbursements: consultations, mental

health, and radiology

• Most common providers reimbursed: physicians and

nursesAs of Feb. 2015

More State Telehealth Policy

DifferencesLooking Beyond the Medical Professions

• Some Medicaid programs reimburse for: home health, dental, speech-

speech-language pathology, physician assistants, physical therapists,

therapists, dieticians, genetic counselors, behavioral health

Additional Telehealth-Related Policy Practices

• 28 states require some form of informed consent

• Most states don’t consider an online questionnaire adequate to

establish a patient-provider relationship needed for prescribing.

Licensing

• 10 state medical boards issue special licenses related to telehealth.

• 11 additional states make allowances for contiguous states or make

exceptions for practicing on an infrequent basis.

As of Dec 2014

Florida and Georgia

Georgia: Medicaid

Reimbursement

• Live video reimbursement only!

• Eligible services include:

– Office visits; Pharmacologic management,

limited office psychiatric and radiological

services; A limited number of other physician

fee schedule services.

• Written informed consent required

Georgia: Other Policies

• Insurers required to cover telemedicine,

subject to terms and conditions.

(regulation, not law)

• GA Medical Board adopted practice

standards for the practice of medicine

through “electronic means”-strict and very

detailed!

Georgia: Medicaid

Reimbursement

Eligible Originating & Distant

• Provider offices;

• Hospitals;

• Critical Access Hospitals

• Rural Health Clinics (RHC);

• Federally Qualified Health Centers (FQHC);

• Skilled nursing facilities;

• Community mental health centers;

• GA public health clinics;

• School-based clinics

Eligible Sites

• Provider offices;

• Hositals;

• Critical Access Hospitals

• Rural Health Clinics (RHC);

• Federally Qualified Health Centers (FQHC);

• Skilled nursing facilities;

• Community mental health centers;

• GA public health clinics.

Florida: Medicaid

Reimbursement

• Live video reimbursement only!

• Eligible providers:

– Physicians

• Originating site must be:

– Hospital outpatient setting

– Inpatient setting

– Physician’s office

• Limited consultation codes reimbursed

• No facility or transmission fee

Florida: Medicaid

Reimbursement

• Other requirements

– Referring practitioner must be present during telemedicine consultation.

– Both distant and originating site must be located in FL.

– Documentation requirements:• Explanation of why services were not provided

face-to-face;

• Documentation of telemedicine service provided; and

• Patient consent

Florida: Other Policies

• No private payer parity law or

regulations

• Telemedicine Practice Standards

adopted by FL Board of Medicine &

Board of Osteopathic Medicine.

– Allows for the establishment of a physician-

patient relationship by telemedicine.

– Controlled substances cannot be

prescribed through telemedicine.

Florida TaxWatch

• “Time for Telehealth” 11/2014 Report: “Florida lawmakers need to act quickly to connect patients with higher quality, timely care by using telehealth to bring the state's health policies into the 21st century”

Study shows that hospital charges could be reduced by more than $1.2 billion annually based on hospitalization charges alone.

Evidenced-based Research coupled with Consumer Advocacy can be a powerful combination for change

Federal MediCare

Reimbursement for Telehealth

MEDICARE TEHEHEALTH POLICY:

OUTDATED!• Reimbursement is available for only a

limited number of Medicare Part B

services

• Reimbursement limited to live video

only substituting for in-person

encounter

• Can only occur when the originating

site is in:

• a Health Professional Shortage Area

(HPSA),

• a county outside of any Metropolitan

Statistical Area (MSA), or

• an AK/HI demonstration project

Federal Landscape 2015

FEDERAL LEGISLATION

• Proposed draft bill 21st Century CURE Bill in House Energy & Commerce

Committee includes provisions for Medicare to waive some telehealth

restrictions if certain conditions met-SEEMS TO HAVE BIPARTISAN SUPPORT!

• Previous Congressional Session bills :

HR 5380 (Thompson, Harper & Welch)

For Medicare, phased in increase of eligible geographic locations;

adding home as eligible site; reimbursing for RPM; reimbursing for

Store &Forward

HR 3306 (Harper, Nunes, Thompson & Welch) & S 2662

For Medicare, expand list of eligible originating sites including the

home; small expansion of S&F to CAHs & sole community hospitals;

for liability and licensing purposes services furnished at the

provider’s location; allows for the use of RPM in specialty medical

homes contracts

HHS/CMS

• Movement toward Accountable Care Organizations as part of the ACA

• President Obama sets goal of 90% of Medicare payments tied to VALUE---not fee for service

• CMS approves more Medicare tele-psych codes for reimbursement

• New code for “non-face to face” chroniccare management & coordination

Next Generation ACO

• Greater access to home visits, live telehealth services, and skilled nursing facilities;

• “benefit enhancements” allow circumvention of Medicare rules that go beyond benefits that Medicare Advantage (MA)

• Would allow ACOs to utilize the technology regardless of a patient’s geographic location.

Other Federal Activities

• Federal Communications Commission-Net

Neutrality & Protecting Connected Care

• Federation of State Medical Boards –

Licensing Compact/Interstate Licensure

FUTURE TRENDS IN TELEHEALTHPOLICY & PRACTICE

The Changing Healthcare

Landscape: 2015

Aging/sicker population

Primary care/specialist shortage

More newly insured with

Obamacare

Rising health care costs:

$3 trillion/year

Making Change Happen

Health Systems Policy Private Payers

Evidenced-based Research

Technology Changes

Consumer Demand

Federal And State Policy:

Volume-to-Value

Value‐based

• Pay for results

(quality/efficiency)

• Shared risk

• Partnerships and

collaborations

• Continuum of care

• Community health

improvement (HIT)

• Wellness care

Volume‐based

• Pay for service (volumes)

• Cost‐based reimbursement

• Hospital/physician

independence

• Inpatient focus

• Stand-alone care

systems

• Illness care

Team-based, Person-Centered Care

Everyone Working at the Top of Their License

Out of the “Box” of Health Care

Mercy Virtual Care Center-St. Louis

Opening Summer, 2015

Will accommodate nearly 300 physicians, nurses, specialists, researchers and support staff. Care will be delivered 24/7 via audio, video and data connections-3 million telehealth visits in first 5 years.

Virtual Care Anywhere

• 75 million Virtual Medical Visits in N. America-2014

-Deloitte

© 2014 Kaiser Permanente

Kaiser Permanente Leading the Way

Improved engagement, quality, and satisfactionMember retention My Health Manager users were 2.6 times

more likely to remain members 1

Quality of care improved 2.0 to 6.5% improvement - glycemic

(HbA1c), cholesterol, and blood pressure

screening and control2

Refill improves outcomes (LDL) 3

High patient satisfaction 85% rated encounters 8 or 9 on a 9 pt

scale4

1 Turley, Marianne; Garrido, Terhilda; Lowenthal, Alex; Zhou, Yi Yvonne, “Association Between Personal Health Record Enrollment and Patient Loyalty,” Am J Manag Care. 2012;18(7):e248-e253 (web exclusive)

2 Zhou, Yi Yvonne; Kanter, Michael H; Wang, Jian J; Garrido, Terhilda, “Improved Quality at Kaiser Permanente Through E-Mail Between Physicians and Patients,” Health Affairs, Vol 29, No 7 (2010); 1370-1375.

3 Sarkar, Urmimala, Lyles, Courtney; Parker, Melissa; Allen, Jill, et al., “Use of the Refill Function Through an Online Patient Portal is associated With Improved Adherence to Statins in an Integrated Health System,”

Medical Care, Vol 00, No 00 (2013)

4 Internal KP study, “Harvesting Value: Early Findings from Kaiser Permanente HealthConnect™” presented to Center for Information Therapy by T Garrido, C Serrato, J Oldenburg (1/15/2008)

45

US Healthcare Practitioners Who Currently Provide or Plan to Provide Telemedicine

Services*, Oct 2014*healthcare services via telephone, video or webcam visits Note: n=759; Source: Academy of Integrative Health & Medicine (AIHM) survey as cited

in press release, Nov 11, 2014

33%

Yes

29%

No-but planning to in the next few

years

38%

Noimmediate

plans

Even if

you’re on

the right

track…You’ll

get run over

if you stand

still!

Thank You!