Expanding Urologic Practice Through Telehealth Great Lakes SUNA Chapter Spring Conference Chad Ellimoottil, MD, MS Assistant Professor of Urology Director of Telemedicine, Department of Urology ehealth Business Infrastructure team University of Michigan
AGENDA What is telehealth? If telehealth is so great, why don t more people use it? Telehealth at Michigan Medicine
AGENDA What is telehealth? If telehealth is so great, why don t more people use it? Telehealth at Michigan Medicine
Hello! Meet Susan 55-year old elementary school teacher Medical history: Recurrent kidney stones Management: Every 6 months for stone surveillance and post-op visits
Saginaw Ann Arbor
Saginaw August 28, 2017 CONSULTATION: 15min DRIVE: 2hr and 30min (round trip) WAITING, ROOMING, LINE: 60min TOTAL: 3.5hrs Ann Arbor
TELEHEALTH HAS THE POTENTIAL TO RADICALLY CHANGE CARE DELIVERY FOR PATIENTS LIKE SUSAN Phone Internet Email Video App The remote delivery of health care services and clinical information using telecommunications technology
In January 2016, Blue Cross Blue Shield of Michigan began to reimburse for video visits from home In April 2016, I conducted my first video visit Since then, we have conducted hundreds of similar visits Video visits are a form of telehealth
INTEGRATING TELEHEALTH INTO CLINICAL CARE HAS POTENTIAL BENEFITS FOR ALL Benefits Susan: 3.5 hours, 174 miles, able to teach her class Michigan Medicine: Faster patient turnover improved access for new patients Blue Cross Blue Shield: Better compliance Susan has fewer ED visits for stones
TELEHEALTH USE IS RAPIDLY GROWING NATIONALLY 20% annual growth in global telemedicine market 30+ bipartisan bills in Congress that address telemedicine expansion, and resolution of medical problems through secure email 2,000 telehealth encounters at Michigan Medicine in the last 12 months
BROAD CATEGORIES OF TELEHEALTH SYNCHRONOUS (REAL-TIME) ASYNCHRONOUS (STORE-AND-FORWARD) PROVIDER PROVIDER PROVIDER PATIENT
BROAD CATEGORIES OF TELEHEALTH SYNCHRONOUS (REAL-TIME) ASYNCHRONOUS (STORE-AND-FORWARD) PROVIDER PROVIDER TeleICU Remote tumor board econsults (PCP sends urologist a specific question about microhematuria) PROVIDER PATIENT Video visits Remote patient Monitoring evisits (Patient submits a photo of a rash)
AGENDA What is telehealth? If telehealth is so great, why don t more people use it? Telehealth at Michigan Medicine
USE CASES 1. Metabolic stone follow up 2. Post-endoscopic surgery 3. Medication management follow up (e.g., BPH drugs) 4. New patient pilot (e.g., referrals for complex surgery)
WORKFLOW Eligible? 1. Commercial insurance* or Post-operative (global) 2. Smartphone Patient is scheduled for a video visit by front desk, surgery schedulers or call center Scheduler sends message to Telemedicine Inbox Patient and provider connect on day of appointment Patient receives call to enroll in the Portal and download app
TELEHEALTH AT MICHIGAN MEDICINE Patient appears on IPAD mini IPAD stand from Amazon Information available to me on EMR
WE HAVE END-TO-END EPIC INTEGRATION
CYCLE TIME IS SIGNIFICANTLY REDUCED WITH VIDEO VISITS 80 70 60 50 40 30 20 10 0 75min Standard visit Cycle time = Check in, waiting room, rooming, physician time, standing in line, checkout 24min Video visit
AGENDA What is telehealth? If telehealth is so great, why don t more people use it? Telehealth at Michigan Medicine
IF TELEHEALTH IS SO GREAT, WHY DON T MORE PEOPLE USE IT? 0.3% Of Medicare beneficiaries have used telemedicine 108,000 beneficiaries 0.7% of rural beneficiaries MedPAC meeting September 2017 Utilization of Telemedicine (JAMA, 2016)
BARRIERS TO TELEHEALTH EXPANSION Knowledge gaps Institutional Policy State Federal General Medicare Private Medicaid
THERE ARE SIGNIFICANT KNOWLEDGE GAPS RELATED TO TELEHEALTH Does telehealth impact my rapport with patients? Will telehealth impact quality of the care I deliver? Which patients should I target? Can telehealth improve my bottom line?
COMMENTS FROM OUR SEMI-STRUCTURED INTERVIEWS AFTER VIDEO VISITS I'd missed a lot of days from work and when they offered the video visit, I didn't have to take off of work. It would have been nice to visit face to face, but the video visit was acceptable. Saved me some time and energy, but I would like to meet face to face.
BARRIERS TO TELEHEALTH EXPANSION Knowledge gaps Institutional Policy State Federal General Medicare Private Medicaid
MANY HEALTH SYSTEMS DO NOT HAVE THE EXPERTISE OR MOTIVATION TO INVEST How do I prioritze telehealth efforts? How do I keep the momentum despite failures? How do I know that I am not violating a law? Will Medicare ever start reimbursing?
BARRIERS TO TELEHEALTH EXPANSION Knowledge gaps Institutional Policy State Federal General Medicare Private Medicaid
THERE ARE SIGNIFICANT BARRIERS FOR MEDICARE TELEMEDICINE REIMBURSEMENT PLACE OF SERVICE GEOGRAPHIC LOCATION OF SERVICE SERVICES THAT CAN BE BILLED
THERE ARE SIGNIFICANT BARRIERS FOR MEDICARE TELEMEDICINE REIMBURSEMENT Origination site requirement PLACE OF SERVICE GEOGRAPHIC LOCATION OF SERVICE The patient must travel to an eligible medical facility to connect (physician s office, hospital) SERVICES THAT CAN BE BILLED
THE MAJORITY OF RURAL AMERICANS CAN CONNECT FROM HOME
THERE ARE SIGNIFICANT BARRIERS FOR MEDICARE TELEMEDICINE REIMBURSEMENT PLACE OF SERVICE GEOGRAPHIC LOCATION OF SERVICE Area (HPSA). SERVICES THAT CAN BE BILLED Non-metropolitan statistical area (<50K population) OR Health Professional Shortage
THERE ARE SIGNIFICANT BARRIERS FOR MEDICARE TELEMEDICINE REIMBURSEMENT PLACE OF SERVICE GEOGRAPHIC LOCATION OF SERVICE SERVICES THAT CAN BE BILLED Select CPT codes (ED, outpatient visits, nutrition) No store-and-forward and remote patient monitoring
BARRIERS TO TELEHEALTH EXPANSION Knowledge gaps Institutional Policy State Federal General Medicare Private Medicaid
STATES HAVE WIDELY DIFFERENT POLICIES IN THE FOLLOWING AREAS 1. Definition of telemedicine/telehealth - Many have real-time in def 2. Licensing -9 states requires special license 3. Informed consent -29 states require consent 4. Online prescribing -Some states require a physical exam 5. Site transmission fee for orginating site -31 states reimburse a facility fee 6. Location -Home vs medical facility -Non-MSA vs anywhere in the state 7. Type of service -48 states reimburse for live video -22 states reimburse for RPM -13 states reimburse for S&F http://www.cchpca.org
MEDICAID COVERAGE FOR TELEHEALTH VARIES BY STATE CMS give states the ability to determine their own policies related to telehealth Live-video conferencing is the most common telehealth modality that is reimbursed Store-and-forward telehealth is only reimbursed in nine states Only three states allow the patient s home to be the originating site (DE, CO, OH)
COMMERICAL PAYER REIMBURSEMENT VARIES BY STATE BUT IS OFTEN THE MOST LIBERAL COMPARED TO OTHER PAYERS COVERAGE PARITY LAWS: 34 states (and DC) require that private insurers cover telehealth as long as it meets the same standards of care as a inperson visit This does not mean there needs to payment parity -Full parity vs partial parity Medical policy vs benefit -BCBSM may cover it, but the patient s employer may not include the benefit
Expanding the science behind telehealth at the University of Michigan
TELEMEDICINE RESEARCH INCUBATOR Awarded grant from Institute of Healthcare Policy and Innovation at UM to study the impact of telehealth on six outcome domains Patient experience Quality Clinical efficiency Access Disparities Spending
PATIENTS CAN SERVE AS ARCHITECTS Themes -Trust and rapport -Sensitive topics -Inclusion of caretakers and staff members (e.g., nurses) -Value over other modalities -Security Focus group conducted by Ellimoottil & White et al. (2016)
CALL TO ACTION POLICY ADVOCATES -Encourage deregulation of telehealth RESEARCHERS -Understand and inform clinicians, policymakers and administrators about the knowledge gaps related to telemedicine ALL -Start a pilot program that addresses a very specific problem
Technology is capable of doing great things. But it doesn t want to do great things. It doesn t want anything. That part takes all of us. Tim Cook, CEO Apple
Thank you Chad Ellimoottil, MD, MS @chadellimoottil cellimoo@med.umich.edu
CURRENT FEDERAL LEGISLATIVE EFFORTS (n=33) Bill (House or Senate) Medicare Telehealth Parity Act of 2017 CONNECT for Health Act of 2017 Evidence-Based Telehealth Expansion Act of 2017 Telehealth Innovation and Improvement Act of 2017 Telehealth Enhancement Act of 2017 Description Through a 4 year phased approach, Medicare will allow telehealth to be reimbursed in MSAs with pop. > 100K Home as an originating site for mental and behavioral health only Remote patient monitoring for chronic conditions (90-day payment) Store and forward for chronic conditions Can expand list of originating sites after 4 years at HHS discretion Effective Jan 1, 2018, telehealth restrictions can be waived for Medicare under certain circumstances These include: geographic requirements, originating site requirement, store-and-forward technology, remote patient monitoring, healthcare providers, codes Circumstances: mental health, ACOs (two-sided), Medicare advantage, special waivers, bundled payments or global payments Waivers if telehealth can reduce spending without reducing quality Gives secretary ability to waive any restriction related to telehealth if the secretary and CMS actuary rule that the telemedicine or telehealth service either reduces spending without reducing quality of care or improves quality of care without increasing spending. To require the CMMI to test the effect of including telehealth services in Medicare health care delivery reform models without geographic and originating site restrictions. Flexibility in ACO coverage for telehealth Adds home as an originating site for hospice, dialysis Status Introduced in House (5/2017) 17 cosponsors, referred to W&M SOH Introduced in Senate (5/2017) 15 sponsors, Introduced in House (5/2017) 21 cosponsors, referred to W&M SOH Introduced in House (7/2017) and referred to W&M SOH Introduced in Senate (3/2017) Introduced in House (7/2017), referred to E&C SOH