Telehealth 101: Key Concepts for Starting and Sustaining

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1 Telehealth 101: Key Concepts for Starting and Sustaining

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3 Telehealth 101 Danielle Louder Program Director NETRC, MCD Public Health Andrew Solomon, MPH Project Manager NETRC Nina Antoniotti, PhD, MBA, RN Executive Director -Telehealth and Clinical Outreach Southern Illinois University School of Medicine Michael Wehner Manager of Telemedicine University of Vermont Medical Center Judy Amour, MA Telemedicine Grant Administrator NETRC, University of Vermont Medical Center

4 About Us

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6 Who do we serve? Academic Institutions National, State, or Regional Associations Federal, State, Regional, or Local Government Agencies Legislators/Policy makers Health Systems Rural Clinics Federally-Qualified Health Centers (FQHC) Critical Access Hospitals (CAH) Community & Urban Hospitals Primary Care Clinics Individual Providers Ambulatory Care Centers Nursing Homes Schools Vendors and many others!

7 We provide: Short and long term technical assistance services for organizations Education for the telehealth workforce Access to educational materials Access to specialized tools + templates Access to telehealth experts willing to share their experiences Monthly newsletter updates and other alerts on telehealth in the northeast Support for collaboration that fosters a favorable environment for telehealth And more!

8 Select Resources Join our newsletter! Telehealth Resource Library Nearly 1,200 publicly available resources Find Telehealth Providers Recently launched to map telehealth in the northeast (complete our survey to promote your sites!) Telehealth Basics Curriculum Developed with the Veterans Rural Health Resource Center- Eastern Region as training for telepresenters Customized Toolkits We are available to create toolkits with resources to fit your needs!

9 Reimbursement for Telehealth Reimbursement depends on the state and the payer Medicare has set specific (limiting) requirements Requirements for reimbursement by Medicaid programs varies greatly Reimbursement by private insurers mandated by law in 29 states and Washington D.C., but language varies Reimbursement should be equal to in-person services

10 Medicare Reimbursement Eligible Originating Sites An Originating Site (where the patient is located) must be in: A county outside of a Metropolitan Statistical Area (MSA); or A rural Health Professional Shortage Area located either outside of a MSA or in a rural census tract Originating Sites may include: The offices of physicians or practitioners; Hospitals; Critical Access Hospitals; Rural Health Clinics; FQHCs; Hospital-based or CAH-based Renal Dialysis Centers; Skilled Nursing Facilities; and Community Mental Health Centers. Source: CMS, CY 2015

11 Metropolitan Statistical Areas (NE) Source: U.S. Census Bureau

12 Eligible Rural Areas in the Northeast Source: Find Telehealth Providers

13 Medicare Reimbursement Additional notes: Originating Site Facility Fee available (about $25) Interactive audio and visual telecommunications system must be used in real-time. Store and forward only available for Alaska and Hawaii demonstration programs. CMS outlines eligible CPT codes (about 73 now) and adds to the list each year. Claims should be submitted using GT modifier. Some signs of slow expansion see Next Generation ACO and some bills pending Source: CMS, CY 2015

14 Private Payers & Medicaid State Private Insurance CT ME MA NH Mandated 3rd party reimbursement (enacted 2015) Mandated 3rd party reimbursement (enacted 2009) Mandated 3rd party reimbursement is limited, legislation under review Mandated 3rd party reimbursement (enacted 2009) Medicaid No reimbursement from Medicaid Limited reimbursement from Medicaid Limited reimbursement from Medicaid Mandated to meet Medicare requirements NJ No mandate, legislation under review Limited to Telepsychiatry, legislation under review NY Mandated 3rd party reimbursement (enacted 2015) Mandated reimbursement from Medicaid RI No mandate, legislation under review No reimbursement from Medicaid, legislation under review VT Mandated 3rd party reimbursement (enacted 2012) Mandated reimbursement from Medicaid

15 States with Parity Laws for Private Insurance Coverage of Telemedicine (2015) Source: American Telemedicine Association

16 Medicaid Overview Live video: Reimbursed by 47 states Remote Patient Monitoring: Reimbursed by 16 states, 2 offer reimbursement through Department of Aging Services Store and forward: Reimbursed by 9 states 29 states provide transmission/facility fee States rarely include , phone, or fax Source: Center for Connected Health Policy, July 2015

17 Connecticut Private payer: See SB 467 signed by the governor in June 2015, effective January 1, Includes live video + store and forward and establishes minimum standards of practice (effective October 1, 2015). Medicaid: Only exception for case management behavioral health services for clients age 18 and under.

18 Maine Private payer: ME HB 740 enacted in 2009 requires reimbursement for interactive audio, video or other electronic media. Does not include telephone, , or fax. Medicaid: Reimburses for live video, but currently requires pre-approval with a compelling benefit. RPM included under Home and Community Benefits for the Elderly and for Adults with Disabilities

19 Massachusetts Private payer: Payers may provide coverage under 2012 health reform bill, but no mandate. Medicaid: No policy, but RPM for home health agencies included in FY2014 State Budget Note: See pending bill HB 267 and new Coalition supporting the bill

20 New Hampshire Private payer: NH Telemedicine Act (415-J) enacted in 2009 for audio, video, or other electronic media and does not include telephone or fax. Medicaid: See SB 112 signed July 2016 requirement Medicaid to meet Medicare requirements.

21 New Jersey Private payer: No mandate, some bills pending Medicaid: Policy for telepsychiatry in mental health clinics and/or hospital providers of outpatient mental health services only.

22 New York Private payer: See AB 2552 signed March 2015, effective January 1, Includes live video, store and forward, and RPM. Medicaid: Mandated in AB See Medicaid Updates for September 2011 and March 2015

23 Rhode Island Private payer: No mandate Medicaid: No policy

24 Vermont Private payer: VT Act 107 enacted in 2012 mandates live video and allows Store and Forward. Medicaid: Included in VT Act 107, but also required to cover RPM by home health agencies. See S 139 signed June 2015 requiring coverage outside of a health care facility.

25 Telehealth Business Models Telehealth is a complex and quickly changing field It offers many potential benefits to a variety of stakeholders Careful research of various business models and strategies is necessary to maximize benefit

26 New Reimbursement Models Direct Contracts Managed Care ACOs Worksite Clinics

27 Model 1 Remote Specialists Traditional Hub and Spoke Tele-cardiology, Tele-stroke, etc. Standard pro-fee payment (CPT-based) goes to the specialist Facility Fee goes to the patient site Called originating site Typically $22-$25 per encounter

28 Model 1 Financials and Value Revenue Stream Patient kept/treated in local hospital Outreach path to specialty hospital Cost Avoidance Travel cost savings for patient AND payer Value Both hospitals raise value position Shared savings

29 Model 2 Specialists Stay Put Site to site within and organization No real hub or spoke Facility fees excluded? Goals Reduced travel Increased capacity Increased efficiency

30 Model 2 Financials and Value Revenue Stream New services added at existing sites Higher billables; great efficiency Cost Avoidance Reduced travel Fewer no- shows and less cost per no-show Value Great range of services in more areas

31 Model 3 Remote Hiring Recruit from anywhere to anywhere Recruit from lower cost locales Retain staff when they move Key consideration: licensure Health care occurs at site of the patient Providers must be licensed at patient s location

32 Model 3 Financials and Value Revenue Stream Existing patients, services, payers Cost avoidance Cheaper (and better) than locum tenens Value Fulfill service obligation Raise client satisfaction Progressive leadership image

33 Model 4 Remote Monitoring Strategies: Cost avoidance: unnecessary admissions Technologies: Low tech: home scales, telephones High tech: cell phones, in-home vitals, video, 3G/4G networks, etc. Key: minimum necessary to get results Potential Savings: Great potential, high success rates

34 Model 4 Financials and Value Revenue stream Direct contracts? SB 554 Cost avoidance Unpaid/unnecessary hospitalizations Value Better patient health; visibility Shared savings for both payer and provider

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