The Telemedicine Opportunity Presented By: Marybeth McCall, MD
1962 Episode of the The Jetsons
Presentation Objectives Identify telemedicine utilization projections Describe New York s Telemedicine Mandate Identify potential use cases of telemedicine for members and provider teams 3
Are Your Patients Driving Telemedicine Consumerism?
Why Use Telemedicine? Members want to get their health care online 3 of 4 patients want their doctor to offer online services 1 1 Advisory Board Telemedicine and Concierge Care: Trends in Consumerism and Non-Traditional Primary Care Delivery, 2014 5
US Telehealth Utilization Projections 12
Employers need it Towers Watson predicts telemedicine could save U.S. employers $6 billion 2 $$$ 6 billion $6b 2 Towers Watson, Current Telemedicine Technology Could Mean Big Savings, August 11, 2014 7
Rapid Adoption Rapid Adoption 2015 08 10 ME C A O R WA N V ID UT AZ MT WY C O NM N D SD NE KS O K MN IA MO A R WI IL MS MI IN TN K Y AL O H G A W V SC PA VA N C NY VT NJ DE DC RI CT NH MA MD TX LA FL Full Services Video + Phone Services Limited to Video Services Limited to Phone Alaska Hawaii Services Temporarily Suspended Arkansas: Services temporarily suspended in Arkansas due to differing interpretations between respective state medical boards and MDLIVE over state regulations that govern telemedicine. MDLIVE is engaged in dialogue with Arkansas board and hopes to return comprehensive telemedicine in Arkansas as soon as possible. This map is not a legal opinion. It represents MDLIVE's understanding of state telemedicine regulations and the applicability to MDLIVE's program. Please seek the advice of counsel for a legal opinion as to specific state regulations. MDLIVE reserves the right to revise this document at anytime in its sole discretion
NY Telemedicine Mandate Overview
General Information New York state quasi mandate Effective for policies issued, renewed or modified on or after 01/01/2016 Applies to municipal cooperative health benefit plans (Article 47 Plans); fully insured individual, small group and large group policies, Essential Plan and Child Health Plus products Expands coverage under Medicaid products Does not change any existing requirements for Medicare products Does not apply to self-funded (other than Article 47 Plans)
Commercial Line of Business Requirement: Telemedicine services may not be excluded from coverage if the services provided are otherwise covered under the policy Definition: Telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider Generally no restrictions on type of provider No limitations on places that services may be performed
Medicaid Line of Business Requirement: Must provide coverage for telemedicine as defined below Definition: Telemedicine includes: Telemedicine virtual visits Store and forward technologies Remote patient monitoring Telemedicine providers are limited to: o o o o A licensed physician, physician assistant, nurse practitioner, dentist, podiatrist, optometrist, psychologist, social worker, speech language pathologist or audiologist, midwife Certified diabetes educator, asthma educator, or genetic counselor Hospital, home care services agency, hospice Licensed registered professional nurse only when the nurse is receiving patient specific health information or medical data at a distant site by means of remote patient monitoring
Medicaid Line of Business (Cont d) Distant site: A site at which a telemedicine provider is located while delivering health care services by telemedicine Originating site*: A site at which a patient is located at the time health care services are delivered to him/her by means of telemedicine * Originating sites are limited to NY-licensed hospitals, hospice, facilities for the mentally disabled, private physicians offices located in New York. When a patient is receiving services by means of remote patient monitoring, the patient s home located within New York or other temporary location located within or outside of New York.
Medicare Advantage Product The new law does not apply to Medicare Advantage Products Coverage is consistent with fee-for-service Medicare requirement: o Must cover specific set of CPT and HCPCS codes via telemedicine Definition: Telemedicine is the use of an interactive audio and video telecommunications system that permits real-time communication between patient and provider
Medicare Advantage Product (Cont d) Providers are limited to: Physicians, nurse practitioners, physician assistants, nurse midwives, clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists and clinical social workers (with some limits); registered dieticians or nutrition professionals Originating site: The place an individual receiving telemedicine services is located but must be located in a rural Health Professional Shortage Area located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract; or a county outside of a MSA. The site must be a provider office, hospital, critical access hospital (CAH); rural health clinic; federally qualified health center; hospital-based or CAH-based renal dialysis center (including satellites); skilled nursing facility or community mental health center Distant site: Any site the provider is located
Coding, Documentation and Corporate Medical Policy
What Documentation is Required? The following documentation is required to participate in a telemedicine session: The patient must give verbal authorization/consent for his/her doctor to use telemedicine, which the doctor then documents and generates a patient s medical record The presentation site submits forms to carrier to describe what telemedicine events have been performed The presentation site (if a facility or office) and specialty location submit claim forms to the carrier for payment of the telemedicine consultation 17
Coding Use of code 99444 online medical evaluation Or evaluation and management (E/M) code with use of the modifier, may use time-based care and counseling Modifier -GT for synchronous -GQ for asynchronous
Corporate Medical Policy Corporate Medical Policy 1.01.49, updated 10/28/15 CPT Codes 99441-99443 Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment (code range) CPT Code 99444 Online evaluation and management service provided by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient or guardian, not originating from a related E/M service provided within the previous seven days, using the Internet or similar electronic communications network
Telemedicine Use Cases
Telemedicine Products & Services Opportunities Health Records Telemedicine Behavioral Health Triage & Redirection Life Coach Secure Messaging Second Opinion Symptom Checker Nurse Advice Medically- Trained Service Center Telemedicine: Connecting Patients with Participating Providers Connected Devices In-Office Scheduling Price Transparency
Telemedicine Use Cases Urgent non life threatening symptom virtual visits ED and urgent care avoidance / DSRIP Chronic disease management Diabetic control Specialty long distance or shortage consultation Newborns, movement disorders Store and forward images Dermatology/retinal images Home health oversight and consultation Post discharge, prevention of readmission Quick check of home environment and patient status Care management 22
Pediatric Cardiology Circa 1995 (via Integrated Services Digital Network Line) Problem: Distressed newborns transferred to Level 4 nursery right after birth, separated from mother and family (one hour away) 10 times per month Solution: Obtain pediatric echocardiogram and electrocardiogram; have telemedicine connection for pediatric cardiologist to view baby and decide whether transfer is needed urgently or not Result: Reduced transfers by 80 percent 23
Insulin Pump Management Problem: Joslin Clinic patients with insulin pumps and long distances for visits Solution: Pulaski Clinic developed ability to send diabetic monitor information and allow face to face via telemedicine Result: Diabetic members were able to obtain high-quality visits, despite distance and weather 24
Movement Disorder Subspecialty Problem: Patient with Huntington s Chorea and Parkinson's Disease has difficulty with transportation Solution: Movement disorder specialist does video virtual visit with member from home on a scheduled basis and adjusts medication as needed Result: Member has reduced stress and visits are more productive and comfortable 25
Diabetic Retinal Evaluation (DRE) Problem: HEDIS scores for DRE are low due to documentation in the record Solution: High-definition cameras are placed in the primary care office and images are transmitted to retinal specialist and the retinal physician interprets the image and returns a report to the primary care physician. Result: Improved screening for diabetic changes, hopefully, reducing blindness 26
Competitive Competitive Forces Forces National vendors direct to consumer Pharmacy-sponsored programs o Walgreens Supermarket moves o Wegmans o Price Chopper Major Medical Organizations o University of Pittsburgh Medical Center, Mass General, Cleveland Clinic
Questions? Marybeth K. McCall, MD, MMM, FACP, CPE, CPC Chief Medical Officer, Utica Region Excellus BlueCross BlueShield 12 Rhoads Drive Utica, NY 13502 315 798 4388 office 315 794 5038 cell MaryBeth.McCall@excellus.com