Telepsychiatry: Importance, Opportunities and Challenges of Remote Care Steven E. Locke, MD, Chief Medical Officer, ihope Network, Inc.

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3 6 MPS Bulletin - September 2016 Telepsychiatry: Importance, Opportunities and Challenges of Remote Care Steven E. Locke, MD, Chief Medical Officer, ihope Network, Inc. PART TWO Continued from July/August Newsletter Reimbursement Issues Telemedicine cannot get significant traction without third-party reimbursement and CPT codes and fee schedules or active adoption by ACOs. Many payers, including MassHealth, have no strategic plans to create or enable CPT codes for telecare. Instead they prefer to shift the treatment innovation options to value-based payment and alternative payment contracts with networks of providers. How that will impact the few remaining solo practitioners (mostly psychiatrists) remains unclear but could be problematic. These reimbursement deficiencies threaten to exacerbate the problems contributing to unacceptable disparities in access to and quality of care in at-risk populations. The telemedicine reimbursement landscape is extremely complex and dynamic and the only way to get an up-to-date snapshot is to review the monthly updates provided by the Center for Connected Health Policy and the website of the American Telemedicine Association Some private payers are beginning to reimburse for telemedicine and because of federal and state parity legislation, they must also reimburse for telemental health as well. The first payer in Massachusetts to begin reimbursement for telemedicine is BCBS of Massachusetts (BCBSMA). They created a telemedicine modifier GT which when used with select CPT codes could be submitted for reimbursement. Providers need to register their practice with BCBSMA as offering telemedicine using a Practice Status Update form available on the Provider Central website. On January 1, 2016 codes were turned on for psychiatrists as well as social workers, psychologists and licensed mental health counselors (LMHCs). As of July 1, these permitted codes have been expanded and are listed in Table 1. As a matter of policy, the level of reimbursement has been set at 10% lower for face-to-face telemedicine treatment than for in-person treatment. BCBSMA explains that this is to take into account lower projected operating costs for providers of telemedicine. BCBSMA members are being advised of how they can access telemedicine. On their website it says that members and their families who have Telehealth benefits can see doctors and therapists in the Blue Cross Blue Shield of Massachusetts network who choose to offer the service. To see if you are covered for Telehealth, log in to Member Central at to review your plan benefits. Depending upon your plan design, you may be billed your cost share after your visit. If you are having trouble finding a doctor who offers Telehealth, you can try one of the following options: Ask your local doctor if he or she offers Telehealth. Find a local provider who offers Telehealth through the Telehealth providers tab above. Visit now with one of our national providers through our partner, American Well, an independent company. Firsttime users, enter Service Key: BCBSMA when registering to make sure you receive coverage. Harvard Pilgrim Health Care has carved out their mental health benefit to a managed behavioral healthcare organization, United Behavioral Health, or Optum Behavioral Health. Optum will reimburse for telemedicine. However, Optum-credentialed providers must apply for authorization to be able to submit claims for telemedicine practice. ope-provexpr/us/en/clinical-resources/tmh.html For further information, contact UBH/Optum Provider Relations. In May of this year, members of the MPS Healthcare Systems and Finance Committee met with Steven Kozak, LICSW, Director of Behavioral Services at Tufts Health Plan. We learned that THP is currently reviewing the issue of telemedicine reimbursement in MA but no timeline for a decision is currently known. Tufts does currently reimburse for telemedicine in NH in their Tufts Health Freedom Plan. Although MassHealth has no current plans to reimburse for telemedicine, the Group Insurance Commission which provides health insurance for MA state employees is monitoring a new innovation initiative of the Health Policy Commission, the Telemedicine Pilot Initiative. This month eligible carriers and health care providers submitted proposals for initiatives intended to implement telemedicine-based services to enhance access to behavioral health care for any of the following populations in Massachusetts with unmet behavioral health needs: 1) children and adolescents; 2) older adults aging in place; 3) individuals with substance use disorders. Platforms The Telemental Health Institute (San Diego, CA) has a comprehensive list of the various potential providers of secure videoconferencing solutions for telemedicine and telepsychiatry. See: Some vendors who have offered free programs in the past now provide a subscription service along with a BAA for HIPAA-compliant, secure videoconferencing (e.g., Skype for Business). I use VSee because my usage level is low enough that I fall within the free subscription allowance. I have signed a BAA with VSee. VSee is also the videoconferencing engine for a vendor called Secure Video which is a subscription service, uses a BAA, and offers some nice features like a waiting room where the patient can log in and park while awaiting for you to log in and start the session. ihope Network, for which I am the CMO, uses SecureVideo. Here are several popular HIPAA-compliant videoconferencing platforms: 1. Zoom 2. Vidyo 3. VSee (Free*) 4. SecureVideo 5. Doxy.me (Free*) Support: You and/or the patient may need some technical support when things don t go according to plan. What if the video keeps freezing, or the program crashes? Or there is not enough bandwidth for full video and audio? You need to discuss these issues with your vendor and know what your support options are. Consider purchasing a subscription support option if needed, either from the vendor or from a technology support vendor like the Geek Squad (BestBuy) or similar service. (continued on page 7)

4 (continued from page 6) Informed consent: The standard of care has not been established with regard to informed consent for the use of telemedicine. Unfortunately, it may ultimately be determined by case law, rather than by statute or regulations. Patients do have the right to be informed of the risks and benefits of a treatment and both are present for telepsychiatry. The MPS should consider providing a sample ICF that can be adapted for use by individual practitioners. Attorney James Hilliard, who represents the MPS, has a sample informed consent for use in telemedicine. Training: As you have been learning, there are some unique aspects to providing telecare, especially for telemental health. There are training resources that you should consider. The San-Diego based Telemental Health Institute (Marlene Maheu, PhD, founding director) offers an extensive online training curriculum. See: The William James College ( edu/), formerly Massachusetts School of Professional Psychology, is preparing to offer training in telemental health. WJC is planning a symposium, Telemental Health: Expanding the Frontier at the Newton Marriott on Friday, September 23, 2016, from 8:30 AM-3:30 PM. Information will soon be posted on their website. Barriers to Adoption Several additional barriers to telemedicine adoption have been identified. 1) Rapport Building and Adherence Challenges: Some mental health clinicians have expressed concern that telemental health solutions interfere with the ability to build a therapeutic relationship with their patients. They worry that this could translate into less effective treatment and reduced patient adherence to their treatment plans. They worry that computer-guided or tele-delivered treatment will be superficial. There is, however, no empirical evidence to support this. Furthermore, as tele-mental health is integrated into population health management, it will facilitate the delivery of structured, behavioral treatments as well as psychodynamic treatment. 2) Impact on Workflow, Productivity and Office Cost: Clinicians worry how telemedicine will affect office routine, require workflow changes and how productivity would be impacted as they accommodate both face-toface and tele-mental health patient encounters. In addition, the demands of understanding the technology to make informed purchasing decisions and acquiring the knowledge to master and maintain the hardware and software for tele-mental health practice, are another source of concern ) Licensure, Credentialing and Reimbursement: Telemental health practitioners need to be licensed in the state where they physically practice as well as in the state where each patient resides. Further, they must be credentialed in each hospital or clinic where they see patients. State laws differ, and navigating through a complex web of state and federal credentialing regulations can be confusing, expensive and time consuming. Legislation and regulation governing telemedicine practice are very dynamic. The shifting environment imposes a burden on the individual practitioner. Therefore, membership in organizations such as the American Telemedicine Association, the American Association for Technology and Psychiatry and the Telemental Health Institute to keep current is quite useful for those interested in telepsychiatry and for those anticipating and preparing for modern practice. Risk Management Issues Treating patients remotely involves both legal and clinical risks. First you must determine if an additional medical license is required if you are treating an out-of-state patient. Some states (e.g., Washington, Ohio) do not require a clinician licensed in another state to obtain a license to practice telemedicine in their state as long as the out of state clinician does not have an office in their state. I am currently treating two patients using telemedicine who have moved to states where this is the case. I have another patient moving to California, where I am licensed and she prefers to continue in treatment with me rather than change to a new psychiatrist. I will establish a collaborative care relationship with her new PCP. There can be serious consequences (including insurance coverage issues) if you are found to be practicing medicine without a license in another state. Courts are ruling that medical services are rendered where the patient is physically located, so you will need to check with the patient s state medical board, as well as your own medical board, to determine what is required for you to legally treat the out of state patient. You also need to check with your malpractice insurance carrier to be certain that you are covered for practice out of state. Another issue involves your ability to deliver good clinical care and meet the standard of care at a distance. For example, how could you arrange for hospitalization in an emergency if your patient is in crisis? Utilizing telemedicine does not alter the standard of care to which you will be held it is the same standard that would apply if the patient was seen in your office or fac Risk Management Advice 1. Determine licensure requirements from your state medical board as well as the medical board for the state where the patient is located (if different from your state and if you are not licensed in the patient s state). 2. Ensure compliance with all relevant states laws and guidelines related to telemedicine. 3. Engage in thoughtful patient selection. This is critically important. 4. Obtain and document informed consent. 5. Verify the patient s location. 6. Have a plan to response to technology failures. 7. Have a plan to respond to clinical emergencies. 8. Become familiar with the local clinical resources. 9. Understand that technology is a tool that can partially restore the lost abilities to evaluate and treat patients at a distance, but that by itself technology cannot completely restore all abilities. (continued on page 8) 27th Annual Psychopharmacology Update Saturday, October 22, 2016 MMS, Waltham MA Visit to register and view the detailed program brochure

5 8 (continued from page 7) Conclusion: Telehealth, including telepsychiatry and telemental health, is growing rapidly. While it is still a wild frontier, with all the opportunity and danger associated with new worlds, there is broad agreement that telemedicine is an important part of the future of healthcare. And that includes the future of psychiatry. If integrated, collaborative care is where psychiatry ought to be headed, technology is what will transport us to that future. That is how we go from treating a small portion of the population suffering from mental illness to embracing a population health approach capable of addressing the 80% of persons with mental disorders who never seek treatment. Hopefully this article provides a guide to encourage you to explore this new world. MPS Bulletin - September 2016 RESOURCES Blue Cross Blue Shield of Massachusetts Fee Schedule for Telemedicine Effective July 1, To view the BCBSMA Fee Schedule, please log on to the MPS website at and click the Newsletters tab, Featured Columns. Ternullo JL, Locke SE. Tackling changes in mental health practice: the impact of information age health care. In: Maheu MM, Drude K, Wright S, editors. Career Paths in Telemental Health. New York: Springer, Locke SE, Gorrindo T. Technology in treatment and physicianpatient communication. In: Greenberg DB, Fogel B, editors. Psychiatric Care of the Medical Patient. 3rd edition. New York: Oxford University Press, Risks Associated With Specific Internet Activities: A Guide For Psychiatrists. InternetBook_16Update.pdf. Accessed: June 4, John MacIver, MD November 18, 1923 June 8, 2016 John MacIver, MD, aged 92, died of pulmonary fibrosis on June 8 at Broad Reach Rehabilitation Center in North Chatham. Dr. MacIver was born in Irvine, Scotland in 1923 and emigrated, the youngest of four children, with his family in 1927, and grew up in Dorchester. Dr. MacIver attended Boston Latin School for middle and high school and matriculated at Harvard College, Class of 1945, studying Philosophy. He was then drafted in 1943 into the 8th Armored Division at Fort Polk, La. After scoring at the top of his Battalion in a medical/dental school aptitude test, he was sent to Columbia University College of Physicians and Surgeons where he earned an MD in After medical school, he specialized in Psychiatry in a residency at Yale University, where he also earned a Master s Degree in Public Health in 1953, and pursued a fruitful and innovative career in corporate medicine, most lately at the United States Steel Corporation. In 1972, Dr. MacIver opened a private practice in Hyannis, taking up residence at the family home in North Chatham. He found great fulfillment in the variety of clinical work he experienced on staff at Cape Cod Hospital as well as his leadership roles with the Massachusetts Medical Society and the Southeastern Massachusetts Psychiatric Society. Husband of the late Shirley MacIver, MD, who he shared a happy and fulfilling marriage for 57 years until her death in 2007 from Alzheimer s disease. Dr. MacIver is survived by two sons, John Robertson (Rob) and Janet Riggs of Voorhees, N.J.; Mathew and Diane of Hingham; four grandchildren, Andrew, Megan, Anne and Gregory; and many nieces and nephews. He is also survived by his companion Janice Wilson of Newmarket, N.H., with whom for the past 7 years he had enjoyed a devoted and fulfilled relationship, extended by her loving care. Attending Psychiatrists Hospital Practice Psychiatry, Inc (HPP), a division of Polaris Healthcare Services, Inc., and in conjunction with the Southeast Area of the Massachusetts Department of Mental Health (DMH), seeks Board Certified or Board Eligible psychiatrists for full -time Attending Psychiatrist positions in general adult care psychiatric facilities. These facilities provide acute and continuing care treatment for DMH-eligible patients. Candidates should have a commitment to a recovery-based model and community first. All facilities are Joint Commission Accredited (JCAHO) and are located in Brockton, Fall River, Pocasset and Taunton, Massachusetts. As public sector acute and intermediate care facilities, HPP/Polaris psychiatrists do not experience the pressures of managed care. This provides a unique opportunity for psychiatrists interested in providing treatment to a diverse population of psychiatric patients with severe and persistent mental illness in an acute and continuing care environments. The psychiatrist is the leader of a multidisciplinary team, and a wide range of treatment modalities are valued, including psychopharmacology, group therapy emphasizing skill-building, insight-oriented and cognitive behavioral psychotherapy, family interventions, and Dialectical Behavior Therapy. The psychiatrist group is energetic, well trained, welcoming and very collegial. Most have trained in Boston-area psychiatric residency programs, including the Harvard/Cambridge Hospital, the Harvard/Longwood programs, Tufts University School of Medicine, and Boston University School of Medicine. These outstanding opportunities offer competitive compensation packages and include an attractive employee benefit program. Night/weekend call is not required but is available for additional compensation if desired. Interested candidates should send a Letter of lnterest and CV to William Pariseau at: bill@polarishealthcare.com.