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TelemedicineA Swiss Army Knife Approach

Why Telemedicine & Patient Engagement Matter

Cameron M. Cox, III, MHA, FACMPE

Telemedicine – Common Beliefs, Myths, Comments, Feelings, Emotions, Concerns and Boogie Boos

• It’s EHR all over again…I’m being forced to do this.

• Nobody pays for this.

• MY patients only want to see me in the office.

• I’m not looking for ways to work more.

• It is sub-par medicine.

• I can’t document these visits effectively.

• I need to see the patient for the best diagnosis.

• It is a HIPAA violation/threat.

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Telemedicine VS EHR

Electronic Health Record

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Telemedicine

Industry Movement

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Telemedicine Growth

16million

virtual visits in 2015

10%of patients are willing to

switch

Telemedicine Usage and Preferences

64% 70% 67%

Source: Centric Digital LLC 2015

of Americans would bewilling to have a video

visit with a doctor

of consumers wouldprefer an online videovisit to a physical one in

order to obtain aprescription

of medical professionalsare either using some

form of telemedicine now,or are planning to in the

coming years

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Industry Trends

$2.9 trilliontotal national health expenditures

29 states and DCrequire private insurers to cover telemedicine

28%of people with employer-based insurance skipped seeing a doctor

$20 millionawarded to telemedicine programs by USDA

$5 billionsavings from eVisits compared to cost ofin-office physician visits

1 in 6doctor visits will bevirtual this year

Over 50%of all U.S. hospitals now use some form of telemedicine

247 millionHealth care app downloads

75%of mobile subscribershave a smartphone

Sources: Center for Disease Control and Prevention; American Telemedicine Association; Becker’s Health IT & CIO Review; Computerworld

Will continue to grow…

• 350,000 in 2013

• Projected 7,000,000 in 2018

• Global market to hit $34 Billion by 2020

Source: IHS Technology

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Regulatory Environment

LicensureInterstate Medical Licensure Compact

Source: http://www.licenseportability.org/

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AMA Position

• Recently approved “ethical guidance” in use of telemedicine

• Developed compact to make it easier for physicians to obtain licenses in multiple states

• Encouraging telemedicine to be core competency within medical school education

Reimbursement

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Let me predict your next question…

Payers are starting to pay…BCBSNCTelehealth 96150, 96151-Health behavior assessment 98969, 99444-Online evaluation and management, established patient 99201, 99202, 99203, 99204, 99205-New outpatient evaluation and management 99212, 99213, 99214, 99215-Established outpatient evaluation and management 99241, 99242, 99243, 99244, 99245-- Outpatient consultation evaluation and management 99499 Unlisted evaluation/management G0108, G0109-Diabetic training G0406, G0407, G0408-Inpatient telehealth consult G0425, G0426, G0427-Telehealth consult ED 0188T, 0189T-Remote real time critical care evaluation and management Modifier GQ—(Via asynchronous telecommunications systems). Service codes noted above will not be allowed when modifier –GQ is appended. Modifier GT—(Via interactive audio and video telecommunications systems). Service codes noted above will be allowed when modifier –GT is appended, and when the provisions under telemedicine and online medical evaluation reimbursement guidelines in this policy are met. See also Corporate Reimbursement Policy titled, "Modifier Guidelines " Online evaluation and management services: GT/GQ modifier is not required for online medical evaluations for established patients, reported by CPT codes 99444, 98969. Online evaluation and management (online medical evaluations) for new patients should be reported with an Unlisted evaluation and management code (CPT 99499) with modifier –GT appended to indicate the telehealth service. Online evaluation and management (online medical evaluations) should not be reported with New outpatient evaluation and management (CPT 99201-99205, Established outpatient evaluation and management (CPT 99212-99215), or Office consultation codes (99241- 99245) unless an intervening provider is present with the patient. 

https://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/telehealth.pdf

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SC….Interesting approach…

Blue CareOnDemand is provided using telehealth technology available from American Well® (www.americanwell.com), a company headquartered in Boston. American Well is an independent company that administers Blue CareOnDemand on behalf of BlueCross and BlueChoice.

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Anthem Reimbursement Policy

Source: https://www11.anthem.com/provider/noapplication/f0/s0/t0/pw_e243709.pdf?refer=ahpmedprovider&state=mo

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Medicare

• Beginning to authorize reimbursement for more specialties

• Currently focused on rural medicine

• Reimbursement is based on originating site of provider being in a HPSA

• Several types of visits are reimbursable• https://www.cms.gov/Outreach-and-Education/Medicare-

Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf

Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act of 2017

• Part of most recent budget deal

• Medicare will put more money towards telehealth usage for treating chronically ill patients

• Encourages ACO’s to further utilize telemedicine

• Legislation asks HHS to expand upon which services are best under telehealth

http://www.modernhealthcare.com/article/20180209/NEWS/180209899

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Medicaid• 2005 – only 24 states had some form of telehealth

coverage

• 2018 – All Medicaid agencies had some form of telemedicine coverage

• Missouri specifically : “Despite the ubiquitous adoption of smartphones nationwide, Idaho, Missouri, New York, North Carolina and South Carolina prohibit the use of “cell phone video” to facilitate a telemedicine encounter”

• Quite simply: No two states are alike….classic healthcare

https://higherlogicdownload.s3.amazonaws.com/AMERICANTELEMED/3c09839a-fffd-46f7-916c-692c11d78933/UploadedImages/Policy/State%20Policy%20Resource%20Center/2017%20NEW_50%20State%20Telehealth%20Gaps%20%20Analysis-%20Coverage%20and%20Reimbursement_FINAL.pdf

Current Industry Thoughts on Reimburesment

• CBO doesn’t see “value” in telehealth in saving dollars

• MedPAC sees value in three areas: Medicare Advantage, bundled payments and ACO’s

• Medicaid managed care regulations see value in use of telemedicine to meet “network adequacy” criteria

• Commercial payers seem to be moving faster

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Future Reimbursement

FFS• Many commercial carriers reimburse,

including Medicare Advantage

• Chronic Care Management

• (99490, 99091)

• Management of Rural Patients

– (CPT codes with GT modifier)

• Medicare Next Generation ACO

Initiative (removes rural restrictions)

Value Based• Access to Care

• Timely Appointments

• Patient Satisfaction

• Health Promotion and Education

• Pharmacy Management

• Readmission Prevention

• Preventative Health

• Care Management

• Care of At-Risk Populations

Expense Control

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Expense Concepts

• Opportunity Costs

• Maximizing Use of Resources (Capital, Facilties, HR)

• Maximizing Profitable Services

Consider this…your practice is a business.

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Managing Profit

Revenue Side

• Commonly being covered by Employers

• Insurers beginning to recognize coverage as well

• High Deductible plans…think volume over price

Expense Side

• Lower labor costs

• Maximize use of resources

• Lower potential opportunity costs associated with no shows

Other Business ThoughtsStrategy, Marketing, and Customer Service

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Strategy

• SWOT Analysis – Particularly External Analysis– What are the threats in your area?

– Hospitals

– Retail Clinics

– Urgent Care Centers

– Other providers

– What are the Opportunities in your area?– Population Growth

– Customer Analysis

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http://ir.teladoc.com/news-and-events/investor-news/press-release-details/2018/Teladoc-Announces-Full-Year-and-Fourth-Quarter-2017-Results/default.aspx

Marketing Concepts

• Complementary Service – Enhancing what the practice has to offer

• Patient Engagement – Give them what they want

• Technology Edge

• Not consumer…CUSTOMER

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Give them what they want…

– E-prescribing

– Pre-surgical consults

– Post op appointments

– Chronic disease management

– Direct to consumer specialties

Why don’t practices do it? According to a recent MGMA survey….

• Physician buy in

• Reimbursement concerns

• Lack of need in my specialty

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Trends…Now and To Come

• Demographics are changing

• Technology is driving new expectations of convenience….yes, even in healthcare

• Facilitative Model of Care – Patient Engagement

• High Deductible Plans continue to mature

• Employers continue to drive value for dollars spent

• Bundled and Risk (merit) based models

Is this healthcare’s “last mile”?

Sucharita Mulpuru of Forrester Research refers to the last mile as “the moment that matters.”

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Key to this in the end…

See and think differently

Telemedicine…

…a spectrum of opportunities

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Thank You

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www.msochealth.com

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