19 th Annual Western Regional Conference Women in Government May 21, 2016 Seattle, WA

Transcription

1 TELE TODAY 19 th Annual Western Regional Conference Women in Government May 21, 2016 Seattle, WA cchpca.org Mei Wa Kwong, JD Senior Policy Associate & Project Director

2 DISCLAIMERS Any information provided in today s talk is not to be regarded as legal advice. Today s talk is purely for informational purposes. Always consult with legal counsel. CCHP has no relevant financial interest, arrangement, or affiliation with any organizations related to commercial products or services discussed in this program.

3 CCHP is an independent, public interest organization that strives to advance state and national telehealth policies that promote better systems of care improved health outcomes and provide greater health equity of access to quality, affordable care and services.

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5 TELE STATE-BY-STATE POLICIES, LAWS & REGULATIONS Current Laws, Regulations, Pending Bills State & Federal Interactive Policy Map

6 WHAT IS TELE?

7 WHAT IS TELE? A doctor's diagnosis "by radio" on the cover of the February, 1925 issue of Science and Invention magazine

8 WHAT IS TELE? Telehealth is a means of enhancing health care, public health, and health education delivery and support using digital telecommunication technologies.

9 Live Video Patient & provider interact in real time. Variety of high-speed digital telecommunications. Outpatient or inpatient specialty consultation. Most commonly used. Store-and-Forward Not in real-time. Often low bandwidth, still images, can store video clips. Best used in dermatology, ophthalmology, pathology, and radiology. Exploring new avenues, such as psychiatry.

10 Remote Patient Monitoring Hospital emergency departments, intensive care units, and skilled nursing facilities. At-home management of patients with chronic conditions. Keeping people healthy and at home. May or may not be in real-time. Mobile Health (mhealth) Health care, public health, and health education. Supported by cell phones, tablet computers, PDAs, and other mobile communication devices. Can be targeted (promoting healthy behavior and disease management) to wide-scale (disease outbreak alerts).

11 CHANGING LANDSCAPE OF CARE Affordable Care Act More people w/health care Mandates, penalties & bonuses Focus on quality Pay for performance Aging/Sicker Population One or more chronic diseases Those who just entered health care market tend to be sicker Limited Resources Limited Workforce Cost pressures Telehealth? Technology More access to broadband Better technology Greater innovation Patient Is More Informed Consumer more access to information More concern about their health Consumer has insurance

12 FEDERAL

13 MEDICARE HISTORY OF FEDERAL TELE Balanced Budget Act of 1997 Benefits Improvement & Protection Act 2000 Medicare Improvements for Patients & Providers Act, 2008 Various Changes Made Administratively Medicare beneficiaries in rural HPSAs may receive care via telehealth Practitioner required to be w/patient during consult Consulting & Referring physicians share fee (75/25) Included non-msa sites Eliminated fee sharing Expanded eligible services for reimbursement Expanded list of facilities that may act as an originating (patient location) site Credentialing & Privileging Regulations Increase in number of codes reimbursed Redefinition of rural Inclusion of Chronic Care Management Codes Medicare telehealth policy very limited & has not changed much in recent years

14 MEDICARE SOCIAL SECURITY ACT OF 1835(m) or 42 USC 1395m Only Live Video reimbursed Store & Forward (Asynchronous) only for Alaska & Hawaii demonstration pilots Specific list of providers eligible for reimbursement Limited to rural HPSA, non-msa, or telehealth demonstration projects Limited types of facilities eligible Limited list of reimbursable services, but CMS decides what can be delivered via telehealth and reimbursed

15 MEDICARE ELIGIBLE PROVIDERS Physicians Nurse practitioners Physician assistants Nurse midwives Clinical nurse specialists Certified registered nurse anesthetists Clinical psychologists & clinical social workers Registered dietitians or nutrition professionals ELIGIBLE SITE (FACILITY) Offices of physicians or practitioners Hospitals Critical Access Hospitals Rural Health Clinics Federally Qualified Health Centers Hospital-based or CAH-based renal dialysis centers (including satellites) Skilled Nursing Facilities Community Mental Health Centers

16 MEDICARE REIMBURSED SERVICES SERVICE HCPCS CODE CPT CODE Telehealth consultations, emergency department or initial inpatient G0425 G0427 Follow up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs G0406 G0408 Office or other outpatient visits Subsequent hospital care services, w/limitation of 1 telehealth visit every 3 days Subsequent nursing facility care services, w/limitation of 1 telehealth visit every 30 days Individual and group kidney disease education services G0420 G0421 Individual & group diabetes self management training services w/min. 1 hour of in person instruction in initial year training period to ensure effective injection training G0108 G0109 Individual & group health & behavior assessment & intervention Individual psychotherapy , Telehealth Pharmacologic Management G0459 Psychiatric diagnostic interview examination ESRD related services included in the monthly capitation payment , , , ESRD related services for home dialysis per full month for patients <2 years to 19 includes monitoring for nutrition, growth & development & counseling of parents ESRD related services for home dialysis per full month patients 20 & older Individual & group medical nutrition therapy G Neurobehavioral status examination Smoking cessation services G0436 G Alcohol and/or substance (other than tobacco) abuse structured assessment & intervention services G0396 G0397

17 MEDICARE REIMBURSED SERVICES Annual alcohol misuse screening, 15 minutes Brief face to face behavioral counseling for alcohol misuse, 15 minutes Annual depression screening, 15 minutes High intensity behavioral counseling to prevent sexually transmitted infection; face to face, individual, includes: education, skills raining & guidance, performed semi annually, 30 minutes G0442 G0443 G0444 G0445 Annual, face to face intensive behavioral h therapy for cardiovascular disease, individual 15 minutes G0446 Face to face behavioral counseling for obesity, 15 minutes Transitional care management services w/moderate medical decision complexity (face to face w/in 14 days of discharge Transitional care management services w/high medical decision complexity (face to face visit w/in 7 days of discharge) Psychoanalysis Family psychotherapy w/o the patient present Family psychotherapy (conjoint psychotherapy w/patient present) Prolonged service in office or other outpatient setting requiring direct patient contact beyond the 99354, usual service; first hour & additional 30 minutes Prolonged service in inpatient or observation setting requiring unit/floor time beyond usual service, first hour & each additional 30 minutes Annual Wellness Visit, first visit & subsequent visit G0447 G0438, G , Approximately 80 codes reimbursed if provided via telehealth out of 10,000 possible codes

18 Federal Legislative Landscape 2016 HR 2066 (Rep Harper) Telehealth Enhancement Act of 2015: Authorizes an Accountable Care Organization to include coverage of telehealth and remote patient monitoring as supplemental health care benefits to the same extent as in a Medicare Advantage plan Recognizes telehealth services and remote patient monitoring in the national pilot program on payment bundling Includes additional originating sites for TH care (but without receiving payment of a facility fee), any critical access hospitals, sole community hospitals, home telehealth sites, as well as others HR 3081 & S 1778 (Rep Nunes) TELEmedicine for MEDicare Act of 2015: Allows a Medicare participating physician to provide services across state lines via telehealth to a Medicare beneficiary without being licensed in the beneficiary state, as long as the provider holds a valid license in their own state. S 2484 (Senator Schatz) The CONNECT for Health Act: Would require telemedicine or RPM bridge demonstration waivers Would eliminate some of the current Medicare restrictions for bridge demonstrations HR 2948 (Rep Thompson) Medicare Telehealth Parity Act of 2015: Phased-in approach to expand eligible facilities and eliminate geographic restrictions Expand eligible providers and services

19 OTHER FEDERAL Federal Drug Administration (FDA) Issuance of guidelines for mobile health software Federal Trade Commission (FTC) North Carolina Board of Dental Examiners v. Federal Trade Commission Supreme Court case that ruled in favor of FTC and found that the make-up of licensing board can have unfair trade practices implication. FTC Comment letter on Alaskan State legislation SB 75 FTC comments indicated that by allowing out-of-state providers to have equal capabilities of in-state providers (in this situation prescribing), it would create better competition, cost savings and more options for consumers FTC also questioned the fairness in the medical board writing standards targeted at telehealth providers if the standards differed from what was required in-person for no good reason FTC comments stopped short of saying these were unfair or anti-competitive practices

20 TELE IN THE COURTS Planned Parenthood of the Heartland, Inc. & Jill Meadows v. Iowa Board of Medicine: Board of Medicine requirement that an MD must conduct an in-person examination and be physically present prior to administering an abortion inducing drug and at the follow-up visit--- Ruled against by State Supreme Court Current court case in Idaho Teledoc, Inc v. Texas Medical Board: Antitrust suit filed against the TX Medical Board on the basis that recently passed regulations requiring an MD face-toface visit before physicians may prescribe medication illegally limits competition--- Case moving forward. Plaintiff s case based on Supreme Court Case

21 STATE

22 NO TWO STATES ARE ALIKE! 42 states have a definition for telemedicine 32 states (and DC) have a definition for telehealth 3 states Alabama, New Jersey and Rhode Island have no definition for either As of March 2016

23 MEDICAID REIMBURSEMENT BY SERVICE MODALITY Live Video 47 states and DC Store and Forward Only in 9 states Remote Patient Monitoring 16 states As of March 2016

24 PARITY IN PAYMENT WITH IN-PERSON 33 states and DC have telehealth private payer laws Some go into effect at a later date. This is the most common policy change at the state level! Parity is difficult to determine: -Parity in services covered vs. parity in payment -many states make their telehealth private payer laws subject to the terms and conditions of the contract As of March 2016

25 LEGISLATION IN telehealth related bills introduced in 30 states Most common legislation addresses: Reimbursement Telehealth professional standards (need for in-person exam, prescribing, etc.) Cross-State Licensing All Incremental Approaches to Needed Change As of March 31, 2016

26 MISSOURI TELE MO Medicaid will reimburse for: Limited set of providers (physicians, advance NP, psychologists) Live Video Only Limited set of services Distant Site Provider may bill codes: Consultations (CPT codes ) Office or other outpatient visits (CPT codes ) Originating site receives facility fee Limited eligible originating sites Office of a physician or health care provider Hospital Critical Access Hospital (CAH) Rural Health Clinic (RHC) Federally Qualified Health Center (FQHC) Missouri State Habilitation Center or Regional Center Community Mental Health Center Missouri State Mental Health Facility Missouri State Facility MO Private Payer Law If the service was provided via in-person, it must be covered if provided via telehealth. Parity in payment. Pending legislation to increase Medicaid reimbursement.

27 CALIFORNIA TELE MEDI-CAL (Medicaid) No geographical restrictions, but DHCS does limit the location facility wise, though they are not statutorily required to Larger list of eligible providers, again not statutorily limited, but DHCS does Limited list of services they will reimburse for Informed consent required (can be verbal or written) Will reimburse for store-and-forward for dermatology, ophthalmology, narrow set of optometry services & dental Private Payers Cannot require in-person contact to occur before payment is made, subject to terms and conditions Pending legislation to increase reimbursement for S&F & private payers

28 IDAHO TELE Medicaid Only reimburses for two-way live video services Only a limited set of services reimbursed and there must be a referral by a primary care provider Private Payer No private payer law, but Idaho one of the medical licensure compact states. Pending legislation to increase reimbursement.

29 HAWAII LEGISLATION SB 2395 Mandates reimbursement in Medicaid & private payers Most explicit and expansive definition of telehealth includes mobile health Explicit inclusion of the home Explicitly requirements parity in payment Clarification on establishment of patient-provider relationship via telehealth Touches upon malpractice liability

30 RESOURCES Center for Connected Health Policy Telehealth Resource Centers Center for Medicare & Medicaid Services Telehealth Fact Sheet Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf

31 THANK YOU!