Telehealth Development & Status in New York State

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1 NYS Bar Association Symposium Telehealth and Telemedicine: Progress and Barriers in New York September 17, 2014 Telehealth Development & Status in New York State Al Cardillo Executive Vice President Home Care Association of New York State 1

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3 History Preliminary Provider innovation/vision in home telehealth; the catalyst Led to and was further bolstered by grants and demonstrations funded under the state budget, Health Care Reform Act (HCRA) and 3621 public health law to further test and promote HCRA initiative provided up to $2 million per year beginning in 2004 for telemedicine demonstration, through 2008 (with residual funding rolling into 2009), along with additional grant support in budget 3

4 History Enactment of Telehealth Statute New York State Home Telehealth Reimbursement Law Enacted in 2007 Developmental grants an important step; but next needed was a mechanism for operational support, in order to bring telehealth into a mainstream role in conjunction with other home health services Mechanism was created through 2007 statute, developed through HCA led effort, and support of Administration and Legislature 4

5 History Enactment of Telehealth Statute HCA 2007 meetings with State Administration and Legislature led to HCA staff and Board development and submission of telehealth legislative language Compelling HCA provider/board testimony and further presentation of HCA provider data and experience reinforced validity and momentum Administration (Spitzer) and Legislature (Senators Hannon/Bruno, and Assemblymen Gottfried/Silver) further negotiated final language and enacted into law along with the 2007 state budget 5

6 Home Telehealth Statute Home Telehealth program and reimbursement rate under Medicaid was codified as Public Health Law c Established programmatic provisions, provider participation, patient targeting criteria, framework for reimbursement The statute directed the Department of Health (DOH) to establish telehealth rates to ensure the availability of telehealth services The Department was directed to establish the telehealth rate or rates by October 1,

7 Home Telehealth Statute The statute provides for a rate that is to reflect costs on a monthly basis, accounting for daily variation in the intensity and complexity of telehealth service needs The statute sets forth the cost components which are to be reflected in the rates, including monitoring of vitals, patient education, medication management, equipment maintenance, review of patient trends and/or other changes in condition necessitating professional intervention, and other 7

8 Home Telehealth Statute Statute stipulates eligible providers to be: Certified Home Health Agencies (CHHAs), Long Term Home Health Care Programs (LTHHCPs) and Licensed Home Care Services Agencies (LHCSAs) under contract with CHHAs or LTHHCPs Statute further sets forth patient criteria for program: General criteria are to assist in the effective monitoring and management of patients whose medical, functional and/or environmental needs can be appropriately and cost effectively met at home through telehealth intervention 8

9 Home Telehealth Statute Further targeting criteria are the need for frequent monitoring or service use, where telehealth can appropriately reduce service need; specific conditions are listed as examples of targeted patients, including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), wound care, polypharmacy, mental/ behavioral problems, technology dependent care such as total parenteral nutrition, enteral feeding, ventilator care, oxygen 9

10 Telehealth Program Implementation 10

11 Telehealth Program Implementation Following enactment, some of the critical steps in the implementation process included: Collaborative process for implementation of statute; DOH (led by Mark Kissinger, Rebecca Fuller Gray) working with HCA, wide information/data gathering Development of additional program guidelines Additional patient targeting criteria; development and requirement of risk assessment tool Prior approval of providers before commencement 11

12 Telehealth Program Implementation Development of multi tiered methodology and initial rates Tier I: Tier 1 Class 2 Medical Device that is FDA approved with interoperability ($270/month; $50 installation) Tier II: Tier 1, plus a standard interconnection with a home care point of care system ($310/month; $50 installation) Tier III: Tier 2, plus a standard interconnection with electronic health record and statewide health information network for New York 12

13 Telehealth Program Implementation In 2010, DOH moved to a daily rate for telehealth of $ /day, and an installation rate of $50 In 2012, DOH implemented an Episodic Payment System (EPS) for CHHA Medicaid reimbursement, paying a 60 day episodic rate for services (based on 2009 base year expenditures), replacing fee for service payment, except in certain cases that remain FFS; EPS was not applied to LTHHCP Upon EPS, DOH stipulated that telehealth reimbursement (at its 2009 expenditure levels) was now also subsumed under the single/overall EPS payment, except for those case types kept under FFS 13

14 Examples of Telehealth Performance 14

15 Examples of Telehealth Performance Simione Healthcare Consultants, Innovative Home Care Models: Five Profiles in Cost Savings, Care Transitions 15

16 Examples of Telehealth Performance Lourdes At Home Results 11.2% of ACH rate is due to Heart Failure 2.2% for Heart Failure Patients on Telehealth 25.8 of ACH is due to Respiratory Diagnoses 1.5% for Respiratory Patients on Telehealth Source: Rochelle Eggleton, Director of Home Health Lourdes at Home Program, Vestal, NY Presentation at HCA Clinical Conference, November

17 Examples of Telehealth Performance Source: Debbie Bobé RN, Associate Director of Business Development, Jewish Home Lifecare, Bronx, NY Telehealth Nurse Certification Program Presentation at HCA Clinical Conference, November

18 Examples of Telehealth Performance Source: Debbie Bobé RN, Associate Director of Business Development, Jewish Home Lifecare, Bronx, NY Telehealth Nurse Certification Program Presentation at HCA Clinical Conference, November

19 Examples of Telehealth Performance Veterans Administration studies showed patients receiving home telehealth in conjunction with coordinated care experienced: 40% reduction in emergency room visits, 63% reduction in hospital admissions, 64% reduction in nursing home visits Virtually healthy: Chronic disease management in the home. Meyer, Kobb, & Ryan. (2004). 19

20 Current Status, Opportunities & Challenges 20

21 Current Status, Opportunities & Challenges Telehealth continues to demonstrate effectiveness, growing recognition of value in achieving patient/system goals, and potential for new and innovative applications Telehealth is an element of the state s new health care delivery/finance models, including the DSRIP (Delivery System Reform Incentive Program) / PPS (Performing Provider System) initiative; it is also a natural fit to the coming FIDA (Fully Integrated Duals Advantage) programs and other integrated care, care transitions and care management models 21

22 Current Status, Opportunities & Challenges There are immediate, critical challenges to be addressed to support the current and growing role of telehealth Capital Investment/Financing Need for mechanisms and sources for capital investment and financing for home care telehealth and technology infrastructure Reimbursement Issues Need to explore methodological adjustments within EPS and managed care premium structure (as well as under Medicare and commercial reimbursement) to adequately support telehealth and technology integration, including staff training, program implementation and coordination with partners 22

23 Current Status, Opportunities & Challenges Policy Flexibility for Evolving Field Need to ensure that the current statutory and policy structure has adequate flexibility or ease of update to accommodate evolving directions, technology development and innovations in the field Dislocation from State Policy Shift from FFS to Managed Care Remedy is urgently needed to address inadvertent dislocation and adverse impacts to telehealth from the state s policy shift from fee forservice to managed care 23

24 Current Status, Opportunities & Challenges State implementation of this policy shift has introduced major continuity challenges, access barriers and erosion to telehealth In 2012, there were over 100 providers of the Medicaid telehealth program and about 5,000 statewide recipients under this program; plus additional providers and Medicare/commercial patients (totals not available) in telehealth Today, many providers report erosion of up to 50 percent occurring in Medicaid Telehealth program/patients due to effects of the state policy shift 24

25 Current Status, Opportunities & Challenges Background In 2011 the state adopted a policy mandating the transfer of services and reimbursement for Medicaid and Medicare Medicaid patients (including home care patients needing 120+ days of service) to managed care The policy effectively phases out direct admission and service of these patients in an agency, replacing it with enrollment in a managed care plan, which in turn authorizes and reimburses services through provider contracts 25

26 Current Status, Opportunities & Challenges The continuity challenges to telehealth in this transition are exacerbated by DOH s accelerated pace of the policy shift and pace of the ensuing program/ patient/service transfers that began in 2012 Other than a 90 day transition period for rates and service authorizations for all home care services (including telehealth) which was instituted by the state, no ongoing transition plan has been put into place specifically for continuity of the telehealth program under the managed care shift 26

27 Current Status, Opportunities & Challenges DOH has separately adopted a policy for mainstream Medicaid managed care requiring telehealth coverage and service consistent with c home care telehealth provisions, but this has not been done for managed long term care The lack of a policy transition or continuity plan has pr0mpted the noted erosion, program instability and current uncertainty in the Medicaid telehealth program 27

28 Current Status and Challenges Many outstanding issues need to be addressed in order for continuation, new authorization and reimbursement of telehealth to work under the state s new managed care home care policies, including: The adequacy of telehealth s inclusion in premiums paid to managed care plans; Appropriate provider reimbursement levels and workable framework/procedures for authorization; Carryover of c finance and service provisions into managed long term care 28

29 Newness of service under managed care, and needed learn curve; Alignment of incentives; Other Current Status and Challenges HCA has been working to develop and advance administrative, legislative and industry level solutions to these and the array of telehealth needs and emerging opportunities 29

30 Current Status and Challenges DOH plans a rebasing of EPS for 2015; HCA has recently recommended a base adjustment for home care technology, and a similar adjustment to managed care premium for home care technology Legislature has made telehealth continuity and transition a charge to the state s Workgroup on Home and Community Based Care Regulatory Reform; workgroup has provided recommendations, and DOH response/action is pending 30

31 Current Status and Challenges Legislature has also advanced a number of additional legislative proposals in support Telehealth Continuity and Integration Act S.4956 Young/A.7440 Morelle Continues Home Telehealth Program per c Provides for c telehealth under Managed LTC Provides transitional timeframe and readiness for telehealth incorporation within Managed LTC 31

32 Current Status and Challenges Telehealth/Telemedicine Coverage S.7852 Young, A.9198 A Russell Requires that commercial insurance policies make available coverage for telehealth/telemedicine Adds telehealth coverage to services covered under LTC insurancepolicies Provides for telemedicine coverage under Medicaid and requires that home telehealth coverage be at a minimum as required under c 32

33 Current Status and Challenges Telehealth/Telemedicine Development Act S.4023 Valesky Coordinates telehealth and telemedicine policy and administration with the State Department of Health Requires an annual policy plan to identify barriers, promote access and innovation and research Provides for capital and research grants 33

34 Current Status and Challenges New Directions/Opportunities as development and application of telehealth technology continues in new and innovative ways, it gives rise to new opportunities and benefits HCA has also begun examining statutory and payment parameters so that the regulatory and fiscal framework for telehealth is able to evolve in concert with new potential 34

35 Next Steps 35

36 Next Steps Further support and resolution of issues are needed Further action anticipated Latest policies, emphases in the marketplace and health system trends continue reinforce need, opportunity and potential of telehealth 36

37 Questions? Comments? Al Cardillo Executive Vice President Home Care Association of New York State