Project: Engaging Your Providers in Your Telehealth Development and Program Presented by: James Dunnick, MD, FACC, CHCQM, CPC, CMDP - The Dunnick Group, LLC Learning Outcome Standard: This program is based on general federal, state, and payer guidelines for telemedicine. Project: Disclosure of Proprietary Interest The Dunnick Group, LLC does not have any proprietary interest in any product, instrument, device, service, or material discussed during this learning event. The Dunnick Group, LLC uses physician led teaching to reduce cost of care, improve outcomes, and reduce audit risk exposure. The education offered by ICAHN in this program is compensated by the HRSA Small Hospital Improvement Program (SHIP) grant, Iowa FY17-18, Contract #5888SH01. Project: Learning Outcomes By the end of this session, attendees should be able to: Describe the history of telemedicine development Exam legal issues affecting use Discuss strategies for breaking down barriers that may inhibit provider participation Develop a global plan for your program 1
Disclaimer: 1. Do NOT assume we are correct, we make mistakes. 2. Read and self educate. 3. CPT books, government manuals, online resources. 4. Obtain professional teaching, from more than one source. 5. Consultant opinions very. 6. Auditor s opinions vary. 7. States vary. 8. Payers vary. 9. Rules change. This is meant as general and initial information only. Telecommunications The Parent Telecommunications Send information via electromagnetic signals 1876 Telephone 1887 Radio 1905 EKGs 1925 Teledactyl 1950 PA radiology 1959 Nebraska Neuro exams to medical students 1964 Nebraska Neuro exams to a distant office 1960s Investment US Government NASA Department of Defense 2
1960s Investment Public Health Department HEW History Telecommunications Telehealth Telehealth All medical services Clinical services Telehealth: A public health app that alerts the public of a disease outbreak A video-conferencing platform for medical education : A mobile app that lets physicians treat their patients remotely via video-chat A software solution that lets primary care providers send patient photos of a rash or mole to a dermatologist at another location for quick diagnosis 3
Project: On Line Company (OLC) Skip the Waiting Room Speak to a Doctor 24/7. Anytime, Anywhere. Feel Better Fast OLC doctors can send prescriptions right to the nearest pharmacy. Great Doctors, Great Results U.S. Board Certified doctors & pediatricians with an average of 15 years of experience. Project: On Line Company Advertised Pluses 15 Minute wait 24/7 Provider employed by the telemedicine company, not your physician s group $49, no insurance On Line Company Doctor visits for Headaches Acne Allergies Flu Nausea Sore throat Respiratory problems Diarrhea Fever Pink eye Ear problems Urinary tract infections. 4
Project: On Line Company 2009 Opened 2015 total 600 patients 2016 total 1,200 patients PROS Access Access Convenience Convenience Reduce cost Definitions Distant or Hub site: Site where the provider is located. Originating or Spoke site: Location of the patient Telepresenter: Personnel at the site to help with transmission Asynchronous : Store and forward Synchronous : Live interaction Eligible Provider: Provider, distant site, providing the service 5
Qualifying Rules Originating Site Health Professional shortage area (HPSA) Originating Site Physician offices Hospitals Critical Access Hospitals (CAH) Rural Health Clinics Federally Qualified Health Centers Skilled Nursing Facilities (SNF) Community Mental Health Centers (CMHC) Hospital-based or CAH-based Renal Dialysis Centers Note: Independent Renal Dialysis Facilities are not eligible originating sites. Notable for its absence is the patient s home. Medicare does not reimburse for telehealthor telemedicine services provided to a patient at home. Effect on mobile health and remote monitoring programs? 6
Eligible Providers Under Medicare, the following healthcare providers can use telemedicine: Physicians Nurse Practitioners Certified Registered Nurse Anesthetists Physician Assistants Clinical Nurse Specialists Clinical Psychologists Nurse Midwives Clinical Social Workers Registered dietitians or nutrition professionals CMS 2001 CMS Reimbursement CBO estimate MC $150 M over 5 years 2015: Claims 373,518 Dollars 22,449,968 2016: Claims 496,396 Dollars 28,748,210 Medical Need 323,000,000 People USA 100,000,000 obese people 86,000,000 pre diabetics 30,000,000 diabetics 3,000,000 baby boomers 1,700,000 cancer diagnoses 700,000 MIs 7
Medical Shortages 45,000 PCPs within 3 years 20/day x 5 days = 100 patients 100 patients x 45,000 = 4,500,000/week ED wait times PCP access times Telepsychiatry Teledermatology Teleopthamology Teleradiology Telepathology Teleobstetrics Telenephrology Teleoncology Telerehabilitation Report Government Accountability Office Highlighted cost savings of telemedicine. BUT VA 12% rate MC 1% rate 8
On the contrary, the most daunting obstacle to date has been a deeply entrenched resistance on the part of providers. http://www.nytimes.com/2010/01/07/health/07chen.html Cons Written consent Technical Pre existing relationship Lack of continuity Impersonal Physician guidelines IBM Providers Held to the same standards of care. Be within the physician s scope of practice. Use evidence-based telemedicine practice. Complete medical records and access. Comply with HIPAA. Written protocol must be established and reviewed. 9
Physician guidelines IBM Verify the identity of the patient Ensure the patient can verify the credentials of all health care providers Knowledge of local medical resources. Able to refer to an acute care facility. Equipment must comply with safety laws and codes. Physician guidelines IBM Type of service Fees/costs sharing if different than in an in-person encounter Financial interests Ensure the patient s ability to amend their information, provide feedback, and to register complaints. The physician must be available either in-person or electronically Cons Largest Barriers Legal Qualifying Rules Quality of Care Payment 10
Physician guidelines IBM Barriers Ensure the patient receives a physical examination, when medically necessary, sufficient for diagnosis and treatment prior to providing treatment via telemedicine The medical interview and physical examination need not be inperson if the telemedicalencounter is sufficient to establish an informed diagnosis as though the medical interview and physical exam had been performed in-person. Barriers Limitations on drugs, services, and technology Physicians using telemedicine in the diagnosis and treatment of a person located in Iowa must have an active Iowa medical license. Medicaid Federal Note that the federal Medicaid statute does not recognize telemedicine as a distinct service. 11
Medicaid State Coverage If a state chooses to cover telemedicine Does not cover certain providers Does not cover certain areas The state must assure access and coverage for face to face visits https://www.medicaid.gov/medicaid/benefits/telemed/index.html New York Telehealth Lack of payment parity language in New York Statute, some commercial insurers pay providers only 50% of the reimbursement rate. Disincentive for providers Effective January 1, 2016, The Insurance Law will require commercial health insurers to cover telehealth. Iowa Parity Law Iowadoes not currently have a private payerparity lawthat would legally require private payers to covertelemedicine. However, several new bills were proposed in the 2015 2017, still no parity law 12
Billing GT Modifier Only certain CPT and HCPCS codes eligible Live telemedicine Identify, track, and reimburse for telemedicine services. Conclusions Huge telemedicine need Barriers are legal and administrative Teams must be developed Project: Learning Outcomes By the end of this session, attendees should be able to: Describe the history of telemedicine development Exam legal issues affecting use Discuss strategies for breaking down barriers that may inhibit provider participation Develop a global plan for your program 13
REFERENCES & RESOURCES https://www.medicaid.gov/medicaid/benefits/telemed/index.html 42 CFR 410.78 https://www.cms.gov/regulationsandguidance/guidance/transmittals/downloads/r1798b3.pdf https://www.cms.gov/outreach-and-education/medicare-learning- Network-MLN/MLNEdWebGuide/Downloads/CEINFO-WE- L10152015QINQIO.pdf QUESTIONS? If you have questions about this education, please contact: Dunnick Group LLC www.dunnickgroup.com info@dunnickgroup.com Or you can contact hthtech@hometownhealthonline.com 14