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Meaningful Use Final Rule

• Final Rule was released last night

• Webinar analyzes the finalized Meaningful Use Stage 2 & 3 rules

• Tuesday, October 20th

12pm CT/1pm ET

Upcoming Webinars: 4 Part Series

Government Regulations & Ramifications • Meaningful Use Audits (Nov. 11th)

• EHR Cloning (Nov. 18th)

• The Dangers of Information Blocking and Its Effect on Interoperability (December)

• HITECH Security and HIPAA (December)

Telemedicine, the Future of Health Care Delivery?

Introductions

Lindsey LanningHealthcare Informatics

Coordinator

Telemedicine, the Future of Health Care Delivery?

Common Questions

Is there a difference between telemedicine and telehealth?

Is reimbursement different for telemedicine services compared to in-person services?

Does telemedicine only consist of live video conversations?

How will wearable technology and mobile health apps affect telemedicine?

Can physicians practice telemedicine across state lines?

Agenda

This session will cover:

• Telemedicine vs. Telehealth

• Elements of Telemedicine

• Modalities and Delivery Mechanisms of Telemedicine

• The Benefits and Obstacles to Telemedicine

Reimbursement

Licensure

• Recent Legislation and it’s Impact on Telemedicine

• The Future of Telemedicine

Highlighting the use of wearable technology and mobile apps

Telemedicine

• Telemedicine is defined as a form of telehealth which is the delivery of clinical health care services by means of real time two-way audio, visual, or other electronic communications.

• This includes the application of secure video conferencing or store and forward technology to provide health care delivery.

Telemedicine vs. Telehealth

Telehealth is different from telemedicine because it refers to a broader scope of remote healthcare services than telemedicine. While telemedicine refers specifically to remote clinical services, telehealth can refer to remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services.

Elements of Telemedicine

1. Its purpose is to provide clinical support.

2. It is intended to overcome geographical barriers, connecting users who are not in the same physical location.

3. It involves the use of various types of communication technology.

4. Its goal is to improve health outcomes.

Telemedicine Modalities

3. Remote patient monitoring

1. Live video

2. Store-and-forward

4. Mobile health

Telemedicine Delivery Mechanisms1. Networked programs that link specialty hospitals,

clinics with outlying clinics, and community health centers in rural or suburban areas.

2. Point-to-point connections using private high speed networks are used by hospitals and clinics that deliver services directly or outsource specialty services to independent medical service providers.

3. Monitoring center uses links for cardiac, pulmonary or fetal monitoring, home care and other related services.

4. Web-based e-health patient service sites that provide direct consumer outreach and services over the Internet.

The Benefits1. Improved Access –Telemedicine improves access to

patients but it also allows physicians and health facilities to expand their reach, beyond their own offices.

2. Cost Efficiencies – Reducing or containing the cost of healthcare is one of the most important reasons for funding and adopting telemedicine technologies.

3. Improved Quality – Studies have consistently shown that the quality of healthcare services delivered via telemedicine are as good those given in traditional in-person consultations.

4. Patient Demand –Using telemedicine technologies reduces travel time and related stresses for the patient.

The Obstacles• There are multiple barriers to the

widespread uptake of telemedicine, but the most prohibitive are regulatory policies at the state level.

• State legislation with the following four elements is needed:

1. Provide a payment parity.

2. Establish the same standard of practice applies whether services are delivered in person or remotely.

3. Prevent the creation of more restrictive licensing requirements by states.

4. Create exemptions for telemedicine with regards to state licensure requirements.

The ObstaclesState of physician telemedicine licensing:

• 49 state boards, plus the medical board of the District of Columbia, require that physicians engaging in telemedicine are licensed in the state in which the patient is located.

• 13 state medical boards issue a special purpose license, telemedicine license or certificate, or license to practice medicine across state lines to allow for the practice of telemedicine. These states are listed below:

Alabama, Louisiana, Montana, Nevada (medical), New Jersey, New Mexico (medical), Ohio, Oregon, Pennsylvania (medical and osteopathic), Tennessee (medical and osteopathic), and Texas.

• 1 state board, Minnesota, requires physicians to register if they wish to practice across state lines.

The Obstacles

• State of Reimbursement: We are all over the map

18 states and the District of Columbia require both private insurance companies and Medicaid to cover telemedicine services to the same extent as face-to-face consultations.

20 states currently require only Medicaid to cover telemedicine services.

9 states do not require any reimbursement parity for telehealth.

22 states and D.C. require state-regulated health plans reimburse for telemedicine services with rates on par with face-to-face consultations.

24 states require private insurers to cover telehealth services in the same way as corresponding in-person services.

Telehealth Coverage• Telehealth coverage laws require health plans to cover

services provided via telehealth to the same extent the plan already covers the services if provided through an in-person visit.

• Telehealth coverage laws also frequently include language to protect patients from cost-shifting. This is reasonable and logical because telehealth is not a separate specialty, but simply a technological conduit through which the physician provides care.

• Most states have elected to expand on telehealth coverage with two additional topics:

Remote patient monitoring

Payment parity

RPM and Payment Parity

• The first concept, remote patient monitoring, includes a variety of patient oversight and communication devices to allow providers a greater ability to monitor patient care needs and immediately respond. Clinical benefits are significant and well-established, particularly for chronic disease management.

• The second concept, telehealthpayment parity, requires health plans to pay providers for telehealth services at the same or equivalent rate the health plan pays the provider when the service is provided in-person.

CMS Medicare/Medicaid• Nearly 20 years after such

videoconferencing technology has been available for health services, less than 1 percent of Medicare beneficiaries use it.

• The Medicare statutory coverage conditions and definitions are restrictive, requiring qualifying originating sites and rural patient locations, and other requirements. Although this year, Medicare did expand telemedicine coverage for mental health services and annual wellness visits.

• At this time, better opportunities for telehealth providers can be seen among Medicaid managed care organizations and Medicare Advantage plans.

Medicaid Reimbursement

• Reimbursement for Medicaid covered services, including those with telemedicine applications, must satisfy federal requirements of efficiency, economy and quality of care. States are encouraged to use the flexibility inherent in federal law to create innovative payment methodologies for services that incorporate telemedicine technology.

• Medicaid guidelines require all providers to practice within the scope of their State Practice Act. Some states have enacted legislation that requires providers using telemedicine technology across state lines to have a valid state license in the state where the patient is located. Any such requirements or restrictions placed by the state are binding under current Medicaid rules.

Medicare Coverage

There have been several bills introduced in Congress that would further increase the use of telemedicine, such as allowing Medicare payments for remote patient monitoring in the home (H.R. 3306), providing Medicare coverage for round-the-clock emergency support via telehealth tools (S. 1549), and expanding the use of telemedicine in the TRICARE veterans’ program (H.R. 2725).

Additionally, effective January 1, 2015, telehealth-based Chronic Care Management (CCM) was introduced as a new service covered by Medicare.

Medicare Telehealth Parity Act

• On July 7, 2015, the Medicare Telehealth Parity Act of 2015 was introduced. The legislation intends to modernize the way Medicare pays for telehealth services. Containing three implementation phases over a four year horizon, the Act proposes changes to Medicare telehealth payment methodologies and expands coverage not only to residents of rural areas, but urban areas as well.

• The Act also includes provisions for Medicare coverage of remote patient monitoring services (RPM) for covered chronic care conditions, and home dialysis services for those with end stage renal disease.

• The 2015 Act represents federal lawmakers’ continued and increasing support for expanding Medicare telehealth reimbursement.

Doc Fix Bill The Act includes specific provisions benefiting telehealth and remote patient monitoring (RPM), particularly for the Medicare program. It states:

• Telehealth and remote patient monitoring are expressly recognized as, and included in the definition of, “Clinical Practice Improvement Activities” along with care coordination, population health management, and monitoring of health conditions.

• New “Alternative Payment Models” may include payment for telehealth services, even if the service is not otherwise covered by the traditional Medicare program (42 U.S.C. 1395(m)).

Other Reimbursement OptionsIf healthcare systems had their own doctors do virtual visits, they’d have to figure out how to pay them for their time. Currently, most groups pay physicians on productivity, so they’d have to change their compensation models.

Behavioral Telemedicine for ACO’s• This program allows ACOs to treat the whole patient, not just

physical symptoms. By offering patients the behavioral healthcare they need, the entire ACO ends up reducing costs due to the many ways mental health impacts physical health.

• The "gold standard" online behavioral telehealth program, at present, does not have a commonly accepted definition, however, it should include the following criteria:

use of evidence-based content;

focus on achieving clinical outcomes;

developed on robust, engaging, secure and responsive technologies;

informed and developed by behavioral health subject-matter experts;

patient-centered and highly personalized; and

have research and evaluation supporting its effectiveness.

Remote Prescribing of Controlled Substances

• Remote prescribing remains an area of concern for state medical boards, and a number of states require an in-person examination of the patient prior to issuing a prescription.

• Federally, remote prescribing of controlled substances is governed by the Ryan Haight Act. The Act and its regulations require a physician to conduct at least one in-person medical evaluation of the patient before prescribing any controlled substances remotely. Once the prescribing practitioner has conducted an in-person exam, the regulations do not set an expiration period or a minimum requirement for subsequent annual re-examinations.

Telehealth Apps and HIPAA• With the 2014 and 2015 changes in

FDA’s guidance on mHealth apps and medical devices, many telehealth app developers appear to be focusing their “regulatory” attention primarily on whether (or not) their app is a “medical device”. Less attention appears to be focused on the privacy and security of their products.

• App developers: Covered Entity, Business Associate, or neither?

• Bottom Line: Addressing privacy and security issues should definitely be on the “to do” list of any telehealth app developer’s business plan.

Wearable Technology

• When clinicians can collect information on patients anywhere and anytime, the increased knowledge can lead to earlier detection of problems, preventing readmission and resulting in better clinical outcomes.

• Another consideration is the amount of data that these devices generate. For payers and providers, while these devices give better insights on a patient's medical condition, more data brings greater risk of data breaches and more responsibility to implement tighter security and access controls.

Physicians will need this data to be integrated into their IT systems, and they will have to change their workflow to accept and use this external data.

Wearable Technology

Gadgets that companies such as Nike, Fitbit, Jawbone and Apple have recently produced and brought to market that can record our heart rate, calories expended, and steps taken are

shifting purpose to help those who truly need it the most: people with chronic medical illnesses such as emphysema,

diabetes, or congestive heart failure. This will lead to remote patient monitoring that couples easy-to-use, plug-in devices

for patients at home, with human and automated intervention on the provider side.

Wearable Technology

What can Wearable Technology Accomplish?

1. Put diagnostic testing of basic conditions into the hands of patients: Close to 42% of physicians are comfortable relying on at-home test results to prescribe medication.

2. Increase patient-clinician interaction: Half of physicians said that e-visits could replace more than 10% of in-office patient visits, and nearly as many consumers indicated they would communicate with caregivers online.

3. Promote self-management of chronic disease using health apps: 28% of consumers said they have a healthcare, wellness, or medical app on their mobile device, up from 16% last year. Nearly 66% of physicians would prescribe an app to help patients manage chronic diseases such as diabetes.

4. Help caregivers work more as a team: 79% of physicians and close to 50% of consumers believe using mobile devices can help physicians better coordinate care.

Mobile Apps

Mobile apps are software programs that run on smartphones and other mobile communication devices. They can also be

accessories that attach to a smartphone or other mobile communication devices, or a combination of accessories and

software.

CafeWell

• Their platform is to include the healthcare consumer by allowing people to aggregate personal data from wearable devices, health and fitness apps, smoking cessation and diabetes management programs and other online tools in a single place.

• They have negotiated contracts with Weight Watchers, FitBit, and dLife.

• Health plans or providers pay to license the content and provide it to their members through an opt-in platform called CafeWell.

The Future of Telemedicine

CVS Health • Announced 8/26/2015 that it is teaming

up with telehealth service providers American Well, Doctor On Demand and Teladoc to further services to CVS customers.

• A CVS pilot test of telehealth through its MinuteClinic chain of in-store clinics ended successfully in July.

Walgreens • Earlier this year, Walgreens said it

planned to expand a telemedicine app it started testing in 2014 that lets people see doctors for minor ailments.

• Walgreens plans to make it available in 25 states and estimates that would allow it to reach about half the U.S. population.

The Future of Telemedicine• The airlines have upgraded their communications technology and

mobile device policies so that nearly every plane is equipped with Wi-Fi and other technologies, allowing both crew and passengers to communicate in real-time with persons on the ground.

Model 1: Contracting with airlines to provide services to the crew

Model 2: Offering in-flight telehealth services directly to passengers

Model 3: Contracting with airlines to provide emergency services to crew and passengers

• Licensure? Privacy and Security?

What Do Physician’s

Think?

Telemedicine Adoption Questions1. Do We Have an Executive Leader Who Will Sponsor a

Telemedicine Initiative?

2. How Will Telemedicine (Virtual, Digital, and Mobile Health) Fit Within Our Portfolio of Services?

3. Can We Have Success With Telemedicine?

4. Are We Stuck In The Past With Our Telemedicine Program?

Physician Buy- In

• In-Depth Education and Training on New Telemedicine Technology.

• Put Quantifiable, TrackableMetrics in Place to Measure Telemedicine Progress.

• Establish Clear Quality Standards for Telemedicine Services.

What will your next doctor’s visit look like?

Questions

• Lindsey LanningHealthcare Informatics Coordinator llanning@Itentive.com 224-220-5621

• Cindi KincadeVice President, Client Solutions ckincade@Itentive.com 224-220-5575

Thank you