Resource - Indiana Rural Health Association

Telemedicine and Health Reform
Jonathan Neufeld, PhD
Clinical Director
Upper Midwest Telehealth Resource Center
• Links to all TRCs
• National Webinar
• Reimbursement,
Marketing, and
Training Tools
UMTRC Services
• Presentations & Trainings
• Consultation
• Technical Assistance
• Connections with other programs
• Program Design and Evaluation
• Information on current legislative and
policy developments
Definitions and Concepts - I
Telehealth and Telemedicine
• Sometimes used interchangeably
• Two types of distinctions •
Telemedicine = billable interactive clinical
Telehealth =
Broader field of distance health activities (CME, etc.)
Clinical remote monitoring (usually at home)
Basic Concept
Explosion of Health Services
• Patients, doctors, hospitals, pharmacies
• Nursing homes
• Specialty hospitals, surgery centers, etc.
• Purchasers, wellness services
• Internet, PDAs, cell phones
• Lifestyle drugs and services
• Social networks, ubiquitous communication
Any service, any place, any time.
Historical Snapshot of Telemedicine
Used at Nebraska Psychiatric Institute in 1955
Developed extensively by NASA in 1960’s
VA started in 1990’s – CCHT Program
Pilot in VISN 8 in 2003 – 63% reduction in ER
visits, 88% reduction in SNF days
2012 Utilization: 0.5 M patients; 1.5 M episodes
Added by Medicare in 1996 (multiple updates)
Regulations requiring Medicaid and commercial
coverage in states began about the same time
Wave of equipment and program grants, projects
Definitions and Concepts - II
TM is not a service, but a delivery
mechanism for health care services
Most TM services duplicate in-person care
Some are made better or possible with TM
Reimbursement equal to “in-person” care
Definitions and Concepts - III
New payment model conundrum
Many of the benefits of TM are only
available under new payment models
Motivations of FFS are “unaligned”
Example: Home Monitoring
Increase adherence
Reduce re-hospitalizations
Improve outcomes
*** Billing FFS for monitoring fails ***
Getting “Value” from Telehealth
Strategies Dependent Upon:
Revenue Stream
Cost Avoidance
Shared Savings
Improved Quality
**Each may appeal to different stakeholders
Recent Headline
“Telemedicine helps hospitals
double revenue.”
A Better Type of Value
Triple Aim:
Better Care – Better Health – Lower Cost
• Patients have a better experience
• They (all) get healthier
• It all costs less (to everyone)
Future Health Care
Outcome goal: population health
Measure: inpatient days per 1000
Overall and within target sub-populations
Healthier people stay out of the hospital
Intervention targets:
Patient engagement in self-care, bio trends
Pt knowledge, skills, attitudes, behaviors
Future Health Care
Providers will be accountable for
patient behaviors
(or at least patient engagement)
How does Telemedicine fit in?
Telemedicine Reimbursement (FFS)
Limited CPTs
Rural areas
IN, IL, MI yes; OH no (but possible soon)
Private Payers
Most provide coverage similar to Medicare
New Models of Reimbursement
Direct Contracts
Managed Care
Work Site Clinics
Vertical Integration
Re-ordering the Clinical Enterprise
Three Basic “Types” or Domains
Hospitals & Specialties
Specialists see and manage patients remotely
Integrated Care
Mental health and other specialists work in
primary care settings (e.g., PCMH’s, ACO’s)
Transitions & Monitoring
Patients access care (or care accesses
patients) where and when needed to avoid
complications and higher levels of care
“Value” Varies by Domain
Hospital & Specialty Care
• Market aggregation, using the long tail
Integrated Primary Care and Health Homes
• Service aggregation, one stop shopping
• Continuity, engagement, momentum
Right service, right place, right time.
New Challenge
“Right service, right place, right time.”
Right for what? Or for whom?
Right Goal? Right Outcome Measure?
Maybe research can tell us…
Research Context
• 20+ years of rigorous research (varies)
• 11 current standards/guidelines documents
Summary of Findings:
When used appropriately, medical care delivered
via telemedicine is
as effective
as satisfactory (to patients and providers)
as efficient
as the same services delivered via traditional inperson medical care.
Research Context
1. Every telemedicine program is different
2. Some telemedicine services are novel
(most are not)
3. Some services offset other services
4. Not all medical treatments are effective
(but we still provide them)
“Value” Factors
1. Payment: FFS vs. Risk-based/Alternative
2. Medical Staff: Salaried vs. Independent
3. Treatment Focus: Chronic vs. Acute Care
4. Temporal Horizon: Present vs. Future
Federal Telemedicine Law & Policy
Professionals are regulated at the state level
(doctors, nurses, counselors, etc.)
Medicare: Pays for certain outpatient
professional services (CPT codes) for
patients accessing care in rural counties and
HPSAs in rural census tracts.
*No regs; only conditions of payment.
Medicaid: Telemedicine is “a cost-effective
alternative to the more traditional face-to-face
way of providing medical care…that states
can choose to cover.”
Indiana Telemedicine Law & Policy
Medical Board/Licensure
• Indiana medical license includes:
“Providing diagnostic or treatment services to a
person in Indiana when the diagnostic or
treatment services: are transmitted through
electronic communications; and are on a
regular, routine, and non-episodic basis or
under an oral or written agreement to regularly
provide medical services.”
Indiana Telemedicine Law & Policy
Except in institutional settings, on-call situations, cross-coverage
situations, and [when supervising NPs],
a physician shall not prescribe, dispense, or otherwise
provide, or cause to be provided, any legend drug that
is not a controlled substance to a person who the
physician has never personally physically examined
and diagnosed
unless the physician is providing care in consultation
with another physician who has an ongoing
professional relationship with the patient, and who has
agreed to supervise the patient's use of the drug or
drugs to be provided.
Indiana Telemedicine Law & Policy
Medicaid Reimbursement (April 1, 2007)
• The member must be present and able to participate
in the visit.
• The audio and visual quality of the transmission must
meet the needs of the physician located at the hub
• When ongoing services are provided, the member
should be seen by a physician for a traditional clinical
evaluation at least once a year, unless otherwise
stated in policy. In addition, the hub physician should
coordinate with the patient’s primary care physician.
Indiana Telemedicine Law & Policy
Medicaid Reimbursable Codes
• Consultations – 99241 to 99245 and 99251 to 99255
• Office or other outpatient visit – 99201 to 99205 and
99211 to 99215
• Individual psychotherapy – 90832 to 90840
• Psychiatric diagnostic interview – 90791, 90792
• End stage renal disease services (ESRD) – G0308,
G0309, G0311, G0312, G0314, G0315, G0317, and
• 90862 deprecated; replaced by E&M codes
Indiana Telemedicine Law & Policy
1. Documentation must indicate the services were
rendered via telemedicine.
2. Documentation must clearly indicate the location of
the hub and spoke sites.
3. All other IHCP documentation guidelines for
services rendered via telemedicine apply, for
example chart notes and start and stop times.
Documentation must be available for post-payment
Indiana Telemedicine Law & Policy
4. Providers must have written protocols for
circumstances when the member must have a
hands-on visit with the consulting provider. The
member should always be given the choice between
a traditional clinical encounter versus a telemedicine
visit. Appropriate consent from the member must be
obtained by the spoke site and maintained at the
hub and spoke sites.
Indiana Telemedicine Law & Policy
Medicaid Special Conditions
• IHCP reimburses for telemedicine services, only
when the hub and spoke sites are greater than 20
miles apart.
• Federally Qualified Health Centers (FQHC) or Rural
Health Clinics (RHC) are only reimbursed for handson services and are therefore not permitted to bill for
telemedicine services.
Indiana Telemedicine Law & Policy
EA 554 (effective July 1, 2013)
• Medicaid will reimburse home health
agencies for “telehealth services”
“Use of telecommunications and information
technology to provide access to health assessment,
diagnosis, intervention, consultation, supervision, and
information across a distance.”
• Medicaid will reimburse FQHCs and RHCs
for telemedicine services
• Medicaid will reimburse regardless of
distance between provider and patient
Review of Key Points
• TM is a delivery mechanism, not a service
• TM usually replicates in-person care
• TM provides multiple types of value
• TM value is embedded in larger
movements in health care
• Reimbursement is now available for
Indiana RHCs and FQHCs (awaiting regs)
• Licensed home health agencies will be
reimbursed for “telehealth” (monitoring)
Contact Information
Jonathan Neufeld, PhD
(574) 606-5038
[email protected]

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