CRESCENT CITY GI, ENDOSCOPY, & LIVER DISEASE UPDATE 2018

Transcription

1 Presented by John D. McKee III, MD FACP CRESCENT CITY GI, ENDOSCOPY, & LIVER DISEASE UPDATE 2018 No conflicts of interest University of Florida Med School & Residency Harvard-Beth Israel Deaconess Advanced Therapeutic Fellowship My niche Underserved area with tremendous opportunity & challenges necessitating adaptive strategies Professional survival hinged on unending study of best practices, team work & tech. Prime example: Telehealth Good news/bad news: None of this stuff is on the Boards! 1

2 Sir William Osler, MD Jason Gorevid, MD CEO of Teledoc Telehealth-Telematics Broader term Devices-Apps Monitoring Variable goals Provider, patient care Administrative Business development Telemedicine Encounters Physician-patient Non-physician-patient Tele Mentoring Remote Site Over sight 2

3 Business Education Customers Features Fleet Management Base Model >$4,000 HD Encrypted Remote login Physician Patient Provider Administrator Transhumanism Venture capital increase funding : 1.1B-4.3B American Well Boston 81M TeleDoc Dallas 50M Doc on Demand SF 21M Brigham & Women s Mayo Clinic Ochsner UPMC Keyser Permanente ACO s 75M visits 300M capacity Price Point: Think deductible Complexity Primary care ICU-Banner 3

4 Apps Ochsner: O Bar Report Card Commercial space Fit Bit Who s watching? Who s getting paid? Who s responsible? AMA snake oil warning, but educating med students on telehealth Large employers telehealth benefit >5,000 employees : 12%-17% Companies planning telehealth benefit : 33%-43% 2018: 96% Wall Street Journal/MarketWatch, March 3, 2014 Healthcare IT News, Sept 17,

5 Not Tele Medicine? Phone Call Freebie? Physician Nonphysician min, 11-20min, 21-30min Documentation, EMR Date, Time Participants Medical decisions made Plans Collection Strategies Up Front Disclosure Legal RVU s Decrease abuse? Simple Fee Annual 25$ Per Visit 5-10$ Like luggage MD/DO call charge 20-50$ Non physician call 20-40$ Originating Sites County outside Metro Statistical Area, MSA Census bureau Rural Health Professional Shortage Area, HPSA Health Resources & Services Administration Federal Telemedicine demonstration project Dec 31, 2000 US Dept. Health & Human Services Audio Visual 2 Way Real Time Store Forward: Alaska & HI Locations Offices physician, providers Hospitals Rural health clinics Federal qualified health centers Skilled nursing facilities Originating site code HCPCS: Q3014 Provider Bill Medical Admin Contractor MAC CMS 2017 Telehealth Update: 2016; 1-7 5

6 Office, outpatient visits CPT: Hospital consults HCPCS: G Hospital, SNF follow-up HCPCS: G Critical care ~ 60 min HCPCS: G Pharmaceutical management HCPCS: G0459 Individual, group nutrition therapy HCPCS: G0270 CPT: ETOH, substance abuse HCPCS: G HCPCS: G0442 Annual misuse screen HCPCS: G0443 Brief 15 min Tobacco HCPCS: G Depression HCPCS: G0444 Obesity HCPCS: G min Prolonged service Out/Inpt CPT: CPT: CMS 2017 Telehealth Update: 2016; 1-7 EDUCATION/PRACTICE Project Echo New Mexico, University Based Ochsner, Gulf Coast Liver disease Clinical presentation & decision making Pro s Broad reach, building relationships Inexpensive Hurdles Glitches Variable participation HOSPITAL & OFFICE Skype-type communication Family discussions Follow up visits Remote consults sight & sounds History Physical findings Rashes Images Radiology EKG Endoscopy Path Givens $$$ Motility $$$ Assessment & Plan Proxy Doc 6

7 IBDMonitoring & Tx Equipment installation vs. texting Design Self reporting Signs, symptoms Weight Treatment response Outcomes + Quality of life Disease awareness Decreased disease activity Fewer hospitalizations More s, calls Hepatitis C Mentoring Tele Echo New Mexico HCV 29 primary providers 90% comfortable treating HCV SVR s Center vs. Rural 58 vs. 57% New territory CHF, HIV & Pulmonary Encephalapp for Cirrhotics N -167 Overt encephalopathy 38% Discriminate activity >90% Procedural Mentoring Live courses Satellite uplink Challenging case Peer to peer feedback Cross. Gastro and Hepatology.2017 ; 4 (23) INDUSTRY INVOLVEMENT International Companies Olympus Japan IRCAD* France Hansen USA Boston Scientific USA RS-ALC Netherlands EOR Kyushu Instit. Japan Invendo Medical Germany Intuitive Neoglide USA Aeroscope GI View Israel Endotics ERA Endo Italy CUHK China Yeung, World J Gastr.2016; Feb PROGRESS REPORT Areas of Focus Standard & Advanced Endoscopy ESD NOTES Challenges Paradoxical motion Hysteresis Multiple approaches in trial Joystick, keyboard Data Small, limited human trials 5-10 x s slower cecal intubation Cater, Am J Robot Surg. 2014;Jun

8 RSC, NETHERLANDS KYUSHI INSTITUTE, JAPAN 8

9 ENDOTICS SRL, ITALY INTUITIVE NEOGLIDE, USA 9

10 MASTER, SINGAPORE HANSEN VIACATH, USA Telemedicine (+) Getting started Business plan Marketing Pro Forma Training Buy In 3 rd Party Payers Patients Employers Providers Telemedicine (-) Legal Licensure StateLaws Intra vs. Interstate International Risk management IT & Tech Support Exit Strategy 10

11 Joint Commission Pullback on federal regs States Legislatures Difficulty keeping pace Federal Telehealth Bill 2015 Pro telehealth Allows for interstate Interstate Licensure compact 17 State agreement Licensure Not credentialing American Telemedicine Association State-by-state assessment Barriers Licensure Informed consent Digital divide affecting poor Malpractice E-prescribing Not encounter based American Telehealth Association: 2017 Annual Report American Telehealth Association: 2017 Annual Report 11

12 Doctors per 100,000 people: (lowest in US) Medical students per 100,000 people: 20.2 (13th lowest) No health insurance: 18.2% (9th highest) Life expectancy: 74.8 years (lowest) Overweight or obesity rate was 68.8% (highest) Diabetes 12.4% (2 nd highest) Colorectal cancer incidence and death (highest) UMC Telemedicine in Delta CRC prevention, detection Diabetes USA: 3.91 per 100,000 FRA: 3.48 per 100,000 AUS: 2.10 per 100,000 CAN: 1.83 per 100,000 GBR: 1.41 per 100,000 Moayeddi et al. American Journal of Gastroenterology 2007, Vol 102 (3);

13 AMA Established Patients only No impairments Functional Interface AV works Suitable Encounter Clinical info Exam A&P Documentation Monetization-Open Teladoc New/Est Pts Annual visits: 1.6M 22.6 million members Doc s: Board certified, avg 20y experience Call back time: 10min Problem solved: 92% Pt satisfaction: 95% Subscription based Physician pay: $40/v Length 10-15m ER recommended <5% Health care rights Globalization Centers of excellence problem: lack of access 18% of Gross Domestic Product on Health Care Telehealth estimates of saving $476/visit, $48 workplace productivity Increasing acceptance: telehealth = good medicine Age of EMR & clinical pathways standardization Barriers likely to come down No human being is constituted to know the truth, the whole truth, and nothing but the truth; and even the best of men must be content with fragments, with partial glimpses, never the full fruition. Sir William Osler MD 13

14 Status quo scenario: Patients with highest needs are the 20% who may account for 80% of medical costs often requiring specialists. Specialists booking: 20 days till appt. which is 20 minutes and takes 2 hours out of the day for the patient. Three trends Selling points Past: Improved access Future: Convenience & costs Diagnosis & Treatment Past: Acute condition Future: Chronic, episodic conditions Sites of Service Past: Clinics & hospitals Future: Mobile & home Dorsey. NEJM 2016; 375: AV tools Informing family post procedure Patients Saves time & money Tech savvy image Unpaid toil Cross Town Traffic 1-2 hour commutes Satellite & Consultant-provider Tertiary care tie-ins sought after Transplant, IBD, & EUS No RVU s in SUV s. Shaun McKee, MD 14

15 Optimal Telehealth Utilization has multiple benefits Professional development Use of best technology Increasing quality of care Improved practice efficiency Improved provider productivity Business competitive edge Reimbursement for providers Decreasing cost The foolishness of yesterday has become the wisdom of tomorrow. Sir William Osler MD 15