Connected Health - The small matter of price - Nick van Terheyden, MD

© 2002-2014 Nuance Communications, Inc. All rights reserved

mHealth Reimbursement – Who Will PayNick van Terheyden, MD (aka @drnic1)HIMSS mHealth CommitteeCMIO, Nuance Communications, Inc.http://DrNick.vanTerheyden.com


Agenda

– mHealth Reimbursement– Telehealth Technology Players– Use Cases for mHealth – Preventing Readmissions– The Healthier Workforce


“The good physician treats the disease; the great physician treats the patient who has the disease.”

Sir William Osler


Chronic Disease

– Today, 133 million Americans – 1/3 of the total population suffer from at least one chronic disease.

– 70% of all deaths result from chronic diseases.– 85% of all healthcare dollars go to treatment of chronic

diseases.– More than 2/3 of Medicare dollars are spent on patients

with 5 or more chronic diseases.


mHealth Reimbursement

– 1 January 2015– Final 2015 Physician Fee Schedule

– Physicians can bill Medicare for “non-face-to-face” chronic care management (CCM)

– Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensating, or functional decline; comprehensive care plan established, implemented, revised, or monitored.


mHealth Reimbursement3 Core Requirements

– Secure the eligible beneficiary’s written consent

– Have five specified capabilities needed to perform CCM

– Provide 20+ minutes of non-face-to-face care management services per calendar month


mHealth Reimbursement

– Third party payers are now starting to reimburse for telehealth (video conferencing) but only for certain specialties:

– dermatology, mental health, etc– Reimbursement chronic disease

– Multiple Doctors, only one can bill for fee per month– Problems with reimbursement

– licensing issues for providers– limitations for populations covered (for example Medicaid

approves telehealth only for certain jurisdictions mostly rural)


5 Fallacies of Remote Patient Monitoring

– All remote monitoring is the same– All remote monitoring is reimbursed– Patients and physicians will welcome and embrace

remote monitoring– Remote monitoring should be totally automated– Remote monitoring is only for recently discharged patients


Secretary Burwell Establishes Clear Goals for Value-Based Payment

Medicare Reforms and the Transition to Risk

Source: Burwell, S, “Setting Value-Based Payment Goals — HHS Efforts to Improve U.S. Health Care,” New England Journal of Medicine, March 5, 2015; Health Care Advisory Board interviews and analysis.

1) Alternative Payment models include ACOs, bundled payments, patient-centered medical homes, demonstration projects for those dually eligible for Medicare and Medicaid.

HHS Commits to Payment Transformation

2014 2016 2018

80%85%

90%

"This is the first time in the history of the program that explicit goals for alternative payment models and value-based payments have been set for Medicare."

Sylvia M. Burwell, Secretary of Health and Human Services

Medicare Payments Through Alternative Payment Models1

Medicare FFS Payments Tied to Quality or Value

2011 2014 2016 2018

0%

20%

30%

50%

~

Slide courtesy:Dr Kavita Patel


mHealth Reimbursement Resources

– More Info Center for Connected Health Policy– http://cchpca.org/state-laws-and-reimbursement-policies

– AAFP Summary of Medicare Fee Schedule– http://www.aafp.org/news/government-medicine/

20141105finalfeeschedule.html– CMS 1612 FC – Final Rule plus details

– http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html

http://cchpca.org/state-laws-and-reimbursement-policies

http://cchpca.org/state-laws-and-reimbursement-policies

http://www.aafp.org/news/government-medicine/20141105finalfeeschedule.html

http://www.aafp.org/news/government-medicine/20141105finalfeeschedule.html

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html





Telehealth Technology Players



Social Security Act Sec. 1834(m) [42 C.F.R. § 410.78]

“(T)he Secretary shall pay for telehealth services that are furnished via a telecommunications system by a physician (as defined in section 1861(r)) or a practitioner (described in section 1842(b)(18)(C)) to an eligible telehealth individual enrolled under this part notwithstanding that the individual physician or practitioner providing the telehealth service is not at the same location as the beneficiary.”

• Medicare covered services• Approved telehealth services• Medicare Part B beneficiary• Authorized clinician• Authorized patient site• Separate physical locations• Interactive audio and video system (federal demo sites in AK and HI may use store-and-forward

technology)

Medicare Telehealth Benefit


Source: Medicare Telehealth Services Fact Sheet

Service HCPCS/CPT Code Telehealth consultations, emergency department or initial inpatient HCPCS G0425–G0427 Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs HCPCS G0406–G0408 Office or other outpatient visits CPT 99201–99215 Subsequent hospital care services, with the limitation of 1 telehealth visit every 3 days CPT 99231–99233 Subsequent nursing facility care services, with the limitation of 1 telehealth visit every 30 days CPT 99307–99310 Individual and group kidney disease education services HCPCS G0420 and G0421 Individual and group diabetes self-management training services, with a minimum of 1 hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training HCPCS G0108 and G0109

Individual and group health and behavior assessment and intervention CPT 96150–96154 Individual psychotherapy CPT 90832–90834 and 90836–90838 Telehealth Pharmacologic Management HCPCS G0459 Psychiatric diagnostic interview examination CPT 90791 and 90792

End-Stage Renal Disease (ESRD)-related services included in the monthly capitation payment CPT 90951, 90952, 90954, 90955, 90957, 90958, 90960, and 90961

Individual and group medical nutrition therapy HCPCS G0270 and CPT 97802–97804 Neurobehavioral status examination CPT 96116

Smoking cessation services HCPCS G0436 and G0437 and CPT 99406 and 99407

Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services HCPCS G0396 and G0397

Annual alcohol misuse screening, 15 minutes HCPCS G0442

Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes HCPCS G0443

Annual depression screening, 15 minutes HCPCS G0444

High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes HCPCS G0445

Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes HCPCS G0446

Face-to-face behavioral counseling for obesity, 15 minutes HCPCS G0447

Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge) CPT 99495

Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge) CPT 99496

Psychoanalysis* CPT 90845

Family psychotherapy (without the patient present)* CPT 90846

Family psychotherapy (conjoint psychotherapy) (with patient present)* CPT 90847

Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour* CPT 99354

Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes* CPT 99355

Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) first visit* HCPCS G0438

Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) subsequent visit HCPCS G0439

*Effective for services furnished on and after January 1, 2015


Source: CMS, as reported to the Center for Telehealth and eHealth Law

Medicare Telehealth Claims

15

© 2002-2014 Nuance Communications, Inc. All rights reserved16

Potential Barriers• Largely limited to fee-for-service (Note: CAH service subscriptions)

• Patients must travel to an eligible originating site

• Originating site eligibility can change year-to-year (HPSA or MSA updates)

• Originating site fee copay makes telehealth more expensive (~$5)

• Approved services list isn’t exhaustive; extensive and lengthy process to add services

• Limited clinical outcomes data for some services

• Clinician state licensure limitations (Note: FSMB interstate compact)

• Specialist credentialing/privileging required at each hospital originating site

• Most of U.S. can’t use store-and-forward to better utilize specialists’ time

• Clinician-to-clinician consultations aren’t billable

• RHC and FQHC distant site prohibition

• Different coverage policies than other payers (e.g., Medicaid, insurers)

• Some equipment is still expensive

• Transmission speeds, reliability, and costs


Medicare Telehealth Services Fact Sheet http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf

Medicare telehealth regulations http://www.ecfr.gov/cgi-bin/text-idx?SID=89f51d919ffc5b375f126c606b5b5cd3&node=se42.2.410_178&rgn=div8

Medicare Telehealth Payment Eligibility Analyzer http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx

Medicare telehealth webpage http://www.cms.gov/Medicare/Medicare-General-information/telehealth/index.html

Medicare Benefits Policy Manual Chapter 15 (Sec. 270) http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

Medicare Claims Policy Manual Chapter 12 (Sec. 190) http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

Medicaid telemedicine webpage http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html

Resources

17

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf



http://www.ecfr.gov/cgi-bin/text-idx?SID=89f51d919ffc5b375f126c606b5b5cd3&node=se42.2.410_178&rgn=div8

http://www.ecfr.gov/cgi-bin/text-idx?SID=89f51d919ffc5b375f126c606b5b5cd3&node=se42.2.410_178&rgn=div8

http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx

http://www.cms.gov/Medicare/Medicare-General-information/telehealth/index.html

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf



http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf



http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html


mHealth Use CasesPreventing Readmissions


mHealth Value Proposition

– Early intervention for people at risk of congestive heart failure (CHF) - the leading cause of hospitalization in the U.S. - could save from $5 to $7 billion per year by expanding telehealth services.

– Telehealth documented itself to be efficacious as a tool for early intervention

– Miley, Madeline L., et al. "The state of emergency stroke resources and care in rural Arizona: a platform for telemedicine." Telemedicine and e-Health 15.7 (2009): 691-699

– Deployment of an mHealth Patient Monitoring Solution for Diabetes: “Improved Glucose Monitoring Leads to Reduction in Medical Expenditure”

– http://www.touchendocrinology.com/articles/deployment-mhealth-patient-monitoring-solution-diabetes-improved-glucose-monitoring-leads-r


Healthier Workforce

© 2002-2014 Nuance Communications, Inc. All rights reserved2009 Continua Health Alliance Brigitte Piniewski, MD2008 21

0 25 65Age

Illness

Pre

-Illn

ess

Welln

ess

Unpredictable Health

Predictable (Rules-based) Health Death

60-80% Lifestyle

Modifiable Health

© 2002-2014 Nuance Communications, Inc. All rights reserved2008 22

0 25 65 AgeIll

ness

Pre

-Illn

ess

Welln

ess

Death

To put it another way….

Fun

No Fun

2009 Continua Health Alliance Brigitte Piniewski, MD

Annual medical costs for people who are obese were $1,429 higher than those of normal weight.

Annual medical costs for people who are obese were $1,429 higher than those of normal weight.

Centers for Disease Control and Prevention (2009)

Centers for Disease Control and Prevention (2009)


Fort Healthcare has run with it!(Still in progress)

Fall 2011Six weeks

605 players (four employers)

> 222 million steps

1,368 players

365 million steps (so far)

64 teams (341 players)

3,781 pounds lost

Spring 2012Four months

Fall 2012Six weeks


Columbia was up for the challenge

Columbia Slimdown Challenge

3,586 Participants

(75+ local employers)

11,505 pounds lost(winner lost 23% of body

weight)

36 sponsors(starting at

$2,500)13 week long weight loss challenge

“Thank you so much for the opportunity to lose weight in such a fun way….. Several of us are hoping the contest can continue (lose more weight!) or restart (add new people).”

—Slimdown participant


Making a difference, changing lives

~ 5.2 BILLION steps taken

~ 76,770

pounds lost(equivalent to the weight

of an 18 wheeler)(equivalent to walking

around Earth ~40 times)

26,518 lives changed

23 competitions completed


Nuance Just Completed their First Challenge

Since March over 800 employees have been tracking their steps, food and sleep to manage their health and earned over 337,710 points redeemed for 10,359 entries into the May 31st sweepstakes. We are pleased to announce that we have our first set of winners.


Single Individual

– 149,000 steps which is equivalent to 70 miles

Firstly I would like to thank your team for the Jiff Challenge. Being

motivated to compete for the Apple Watch resulted in me

losing 21 pounds in 28 days! I’d say the program is a huge

success.

He sacrifice sleep, changed vacation plans to go to hike mountains instead of visiting family, walked every chance he got morning afternoon and late into the night. He would watch shows on his treadmill and go to the gym and just walk. He didn’t even sleep the last day of the challenge he walked every chance he got.


Recognizing New Channels for Growth

Established Provider

Care Delivery Network

Relationship-Based Referring Physician

Cost-Conscious Referring Physician

Price-Sensitive Consumer

Entrenched Payer

Vulnerable Payer

Activated Employer

Exchange Operator

Custom Network Builder

Secure Enrolled Lives Win Share of VolumesTraditional Growth Channels

Key Decision-Makers in Traditional and New Growth Channels

Individual Insurance Shopper

Accountable Physician Entity

New Growth Channels

Slide courtesy:Dr Kavita Patel


Nick van Terheyden, MD CMIO, Nuance CommunicationsTwitter http://twitter.com/drnic1LinkedIn http://www.linkedin.com/in/nickvtVoice of the Doctorhttp://drvoice.blogspot.com/My Activityhttp://DrNick.vanterheyden.comAboutMe http://about.me/obiwanFaceBook http://profile.to/[email protected], [email protected] (301) 355-0877

QuestionsWhere You Can Find Me


mHealth Reimbursement – Who Will PayNick van Terheyden, MD (aka @drnic1)HIMSS mHealth CommitteeCMIO, Nuance Communications, Inc.http://DrNick.vanTerheyden.com