5055 E. McKinley Ave, Fresno CA 95407 Tel: (559) 251 5038 Info@ CHIA PRESENTATION HANDOUT 2018 CHIA CONVENTION & EXHIBIT SAN DIEGO, CA Transforming Health Care with Connected Health Technology: An Update on Telehealth Policy Trends and Issues Presented by: Mei Wa Kwong, JD Presented on: Wednesday, June 06, 2018 California Health Information Association, AHIMA Affiliate
Transforming Health Care with Connected Health Technology: A Update on State and National Telehealth Policy Trends and Issues Mei Wa Kwong, JD Executive Director Center for Connected Health Policy 2017 California Health 2017 Information California Health Association Information Association Disclaimer 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. 1
About the Presenter Mei Wa Kwong, JD Executive Director, Center for Connected Health Policy Over two decades of policy experience Recognized national expert on telehealth policy Published author on telehealth policy Goals/Objectives or Agenda Gain a clear understanding of what telehealth is---and how its being used Understand the breadth of public policy issues affecting the use of telehealth on the federal and state levels Learn how telehealth policies are being developed and implemented at the state and federal level Become aware of the State of California telehealth policies and issues Gain a better understanding of how technology is changing and improving the delivery of health care and improving health Enhance your vision of how to best harness the power of technology to advance a healthier population 2
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. HEATH POLICY 3
TELEHEALTH STATE-BY-STATE POLICIES, LAWS & REGULATIONS Current Laws, Regulations, Pending Bills State & Federal Interactive Policy Map THE VALUE OF TELEHEALTH Advances in telecommunication technologies can help redistribute health care expertise and resources to where and when it is needed, and create greater value among consumers, public & private payers, and health systems 4
TIMELY ACCESS TO QUALITY CARE Primary and Specialty Care Diagnosis & Treatment (Live or Asynchronous Store & Forward) including Direct to Consumer Acute, Chronic, & Emergency Care Where The Consumer Is Located 5
ENHANCED CONSULTATION/COMMUNICATION Patient/Consumer Health Care Team Uses secure portal for email communication or live video using smart phone, tablet or computer. Directly Connects Consumers to Care Team Primary To Specialist Consultation econsult: a web-based system that allows PCPs and specialists to securely share health information and discuss patient care Improves timely access to specialist while enhancing the PCP knowledge and services using Web-based, asynchronous communication 6
REMOTE MONITORING Management of Chronic Conditions In Home-Aging in Place Acute Intensive Care (Tele-ICU) Bluetooth or broadband connected Remote Monitoring Can Improve Quality & Save Money Congestive heart failure best managed by longterm telemonitoring Obstructive pulmonary disease best treated with telepulmonology that remotely measures lung function Stroke most effectively treated via telestroke methods that prompt early tpa interventions A 2014 Canadian study showed telehomecare saved 14% ($1,613 per patient per year) over traditional care, by reducing hospitalizations by 45%, emergency department visits by 35%, and achieving 50% shorter hospital stays 7
VALUE OF TELE-MONITORING: AGING IN PLACE Close to Family /Social Supports Improves Well- Being Enhances the Care Giver Support Reduces Sense of Isolation-Connected to the World Mobile Connected Health Health care, public health, and health, education & personal health monitoring Supported by mobile phones, tablet computers, and other mobile communication devices Can be targeted (promoting healthy behavior and disease management) to wide-scale (disease outbreak alerts) 8
FEDERAL UPDATE Current Medicare policy Current Legislation MEDPAC/MACPAC Office of the Inspector General Report Recently passed policies Net neutrality MEDICARE - History 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 9
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 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 10
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 99201 99215 Subsequent hospital care services, w/limitation of 1 telehealth visit every 3 days 99231 99233 Subsequent nursing facility care services, w/limitation of 1 telehealth visit every 30 days 99307 99310 Individual and group kidney disease education services G0420 G0421 Individual & group diabetes self management training services w/min. 1 hour of in person G0108 G0109 instruction in initial year training period to ensure effective injection training Individual & group health & behavior assessment & intervention 96150 96154 Individual psychotherapy 90832 90834, 90836 90838 Telehealth Pharmacologic Management G0459 Psychiatric diagnostic interview examination 90791 90792 ESRD related services included in the monthly capitation payment 90951 90952, 90954 90955, 90957 90958, 90960 90961 ESRD related services for home dialysis per full month for patients <2 years to 19 includes 90963 90965 monitoring for nutrition, growth & development & counseling of parents ESRD related services for home dialysis per full month patients 20 & older 90966 Individual & group medical nutrition therapy G0270 97802 97804 Neurobehavioral status examination 96116 Smoking cessation services G0436 G0437 99406 99407 Alcohol and/or substance (other than tobacco) abuse structured assessment & intervention services G0396 G0397 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 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 90845 Family psychotherapy w/o the patient present 90846 Family psychotherapy (conjoint psychotherapy w/patient present) 90847 Prolonged service in office or other outpatient setting requiring direct patient contact beyond the 99354, 99355 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 G0446 G0447 G0438, G0439 99495 99496 99356, 99357 11
OTHER MEDICARE POLICIES Reimbursement for non face-to-face chronic care management - Not considered telehealth 2018 changes: Addition of more codes for reimbursement (Psychotherapy codes, add on codes related to administration and assessment of chronic care management services) Removal of use of GT modifier; use of 02 place of service Establishment of Chronic Care Management codes to be used by RHCs and FQHCs Request for information on ways they can expand telehealth services without a law change, particularly around RPM Unbundling RPM code 99091 FEDERAL UPDATE Current Legislation Opioid bill passes Senate Health Panel Opioid Crisis Response Act of 2018 (S 2680) Makes changes to Ryan Haight Forces DEA to create special registration to prescribe via telehealth without an in-person exam Existing legislation that continues to look at expanding the utilization of telehealth, but has not moved HR 5603 (Matsui) - Access to Telehealth Services for Opioid Use Disorders Act For treatment of SUD waive certain telehealth limitations under Medicare around originating site, geography and S&F. Passed out of committee. VA legislation passed Senate but remains in the House House introduced VA Mission Act of 2018 VA proposed regs became final May 14 allows providers practice across state lines regardless of provider or patient location. RAND ECHO report 12
FEDERAL UPDATE MEDPAC/MACPAC Recent reports from both MEDPAC & MACPAC MACPAC more general recommendations, first report on telehealth MEDPAC continues to express caution in expanding telehealth suggestions mainly for pilots and in Medicare Advantage and ACOs FEDERAL UPDATE Office of the Inspector General Report Reported that $3.7 million in payments that should not have been made Issues were primarily regarding oversight in not disallowing inaccurate payments, certain edits/requirements not put in place and lack of knowledge by providers on what and how to bill 13
MEDICARE ADVANTAGE Beginning 2020 MA plans allowed to provide additional telehealth benefits Treated the same as Medicare fee-for-service option Additional telehealth benefits include: Part B benefits without restrictions Other services identified as clinically appropriate HHS Secretary must solicit comments on types of telehealth services that should be considered additional telehealth benefits by Nov. 30, 2018. Secretary shall establish requirements around: Physician or practitioner licensure Care coordination with in-person services Other areas specified by the Secretary ACCOUNTABLE CARE ORGANIZATIONS Beginning 2020 ACOs have the ability to expand telehealth services by: Including home as originating site Eliminating geographic requirements The Secretary required to conduct study on utilization and expenditures for telehealth by applicable ACOs and report to Congress no later than Jan. 1, 2026. Similar waiver made in: Next Generation ACO Comprehensive Care for Joint Replacement Model 14
ACUTE STROKE AND END STAGE RENAL DISEASE Beginning Jan. 1, 2019, the following sites are eligible originating sites and exempt from the rural geographic requirement, but NOT eligible for the facility fee: ESRD-related visits Renal dialysis facility * Hospital based or CAH based renal dialysis center Home (in-person visit 1/month)* Acute Stroke Treatment Hospital CAH Mobile Stroke Unit* Any site determined appropriate by the Secretary* * Not currently an eligible originating site. FEDERAL UPDATE Net neutrality FCC Roll back of net neutrality is partly in effect Parts of the rollback delayed by the FCC because they say OMB needs to sign off on parts of it. Would need to publish these parts in the Federal Register. More than two dozen states looking to pass own net neutrality state laws Fully in effect June 11, 2018 Likely lawsuits will be filed Senate passed legislation to stop end of net neutrality 15
PROPOSED LEGISLATIVE SOLUTIONS HR 2550 (Thompson & Harper) - Medicare Telehealth Parity Act of 2017 Expands under Medicare eligible facilities and a phased-in approach to eliminate geographic restrictions Allow FQHCs and RHCs to act as distant sites Expand list of eligible providers Include RPM HR 2291 (Duffy) - Helping Expand Access to Rural Telemedicine (HEART) Act of 2017 For Medicare, allow S&F for CAHs, RHCs and sole community hospitals Allow for RPM under certain circumstances Distant site can be an RHC Adds sole community hospital to originating site Expands list of eligible providers to some allied professionals (PT, OT, etc.) HR 3360 - Telehealth Enhancement Act Of 2017 Exempt new sites from Medicare s current geographical restrictions (CAHs, sole community hospitals, home) Allow for S&F for CAHs and sole community hospitals Encourages but not mandates use of telehealth in certain programs such as authority to CMS to contract with State Medicaid agencies to coordinate care through a home health for patients with chronic conditions and requires provider to report a plan for use of RPM States may reimburse for telehealth under Medicaid so as long as the service satisfies federal requirements of efficiency, economy, and quality of care. 16
NO TWO STATES ARE ALIKE 45 states have a definition for telemedicine 1 states Alabama has no definition for either 36 states (and DC) have a definition for telehealth As of October 2017 17
MEDICAID REIMBURSEMENT BY SERVICE MODALITY Live Video 49 states and DC Store and Forward Only in 15 states Remote Patient Monitoring 20 states As of October 2017 PARITY IN PAYMENT WITH IN-PERSON 38 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 October 2017 18
2018 LEGISLATIVE TRENDS 2018 State Legislation So Far 13% 4% 8% 11% Broadband Licensing Miscellaneous 12% 11% Medicaid Reimbursement Pilots Prescribing 6% Practice Standards Private Payer 19% 16% Worker's Comp 2018 BILLS IN STATE LEGISLATURES Connecticut HB 5152: Creates an exception to Connecticut s requirement that no provider is allowed to prescribe a controlled substance through telehealth, allowing for only the prescribing of controlled substances used in medication-assisted treatment of substance use disorders through the use of telehealth. (2/16/18: Joint Committee on Public Health) New Hampshire HB 1471: This bill requires the same rate of payment for services delivered through telehealth, as those delivered in the office or facility as long as the rate doesn t exceed the rate for an in-person consultation at the originating site. (3/2/18: Subcommittee work session) Kansas HB 2674: Establishes telehealth practice standards and coverage parity between in-person and telemedicine-delivered healthcare services and providers (3/1/18: To Senate Committee on Public Health and Welfare.) 19
OTHER COMMON THEMES Allowing schools to be originating sites Prohibiting insurers from limiting reimbursement to a specific technology Allowing telehealth to meet network adequacy standards Pilots related to incorporating telehealth into substance use treatment programs CALIFORNIA TELEHEALTH POLICIES Reimbursement CA has a private payer law, but payers are not mandated to reimburse, only to have a telehealth reimbursement policy Medi-Cal does reimburse for some telehealth delivered services Limited list of live video Store & Forward dermatology, ophthalmology, dentistry No RPM No geographical restrictions Patient location essentially a clinical setting unless provider is w/patient Limited list of providers Not explicitly clear written policies in telehealth provider manual 20
CALIFORNIA LEGISLATION AB 2315: CDE and DHCS will develop guidelines on use of telehealth to provide behavioral and mental health services in public schools. AB 2576: Authorizes the Governor, during a state of emergency, to direct all state agencies to utilize, employ, and direct state personnel, equipment, and facilities for the performance of any and all activities that are designed to allow community clinics and health centers to provide and receive reimbursement for services provided during or immediately following the emergency. Authorizes any agency directed by the Governor to perform those activities to expend any of the moneys that have been appropriated to it. Includes telehealth services. AB 2861: Requires the State Department of Health Care Services to allow a licensed practitioner of the healing arts or a certified substance use disorder counselor to receive Medi-Cal reimbursement for substance use disorder services provided through telehealth in accordance with the Medicaid state plan. OTHER STATE DEVELOPMENTS Medi-Cal Call for Comments Changes to Provider Manual December 2017 call for comments on proposed changes Comments on allowing home as an originating site Increase number of CPT codes eligible for reimbursement California Children Services Changes All CCS and GHPP providers can bill new codes. New codes include approx. 40 new codes Examples include: Genetic counseling Audiology Speech language pathology Physical therapy services Occupational therapy services Physician/Dentist coordinating activities 21
COMMUNITY HEALTH CLINICS STATES MEDICAID - California No specific mention regarding telehealth and FQHCs, but allowed Allow FQHCs bill PPS rate Allow FQHCs bill for S&F Recently considered submitting State Plan Amendment for FQHCs & RHCs, included some changes for how to bill for telehealth As of October 2017 Summary Telehealth Is: An essential tool for improving access, quality and efficiency of health care into the future Becoming more consumer-centric and driven Health technology developing faster than the policy Policymakers are increasingly looking to telehealth Increase in telehealth policy proposals Telehealth being looked to as solution to some of our major health concerns, particularly opioid crisis 22
Question & Answer Open to Questions for attendees Resources www.cchpca.org www.telehealthresourcecenters.org 23