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Making Inroads into Telehealth: How One “Sub-Sector” of Healthcare Continues to Evolve (Part 1)

June 13, 2018
by Rajiv Leventhal
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One industry expert feels strongly in a healthcare future in which telehealth is simply “health”

Last September, the U.S. Senate unanimously passed the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017, bipartisan legislation that expands telehealth services for chronic care patients in Medicare. As Healthcare Informatics reported at the time, the legislation’s overarching goal is to transform how Medicare works for seniors who suffer from chronic illnesses by including provisions such as expanding access to telehealth services.

Indeed, currently, there are several restrictions regarding reimbursement for telehealth services under Medicare, such as patients may only be located at certain clinical sites or within certain rural areas, and only Medicare-defined physicians and practitioners can provide telehealth services. The bill, which received favorable response from health IT stakeholders, is just one example of various recent and forthcoming policies and regulations that will make telehealth more mainstream and “open up” reimbursement avenues for providers, says Sean Sullivan, an attorney in the healthcare practice group of Atlanta-based law firm Alston & Bird.

Sullivan notes that there are lots of different telehealth policies that fall into a few different buckets.  For one, there is a “licensure obstacle,” in that every state has their own licensure requirements. Generally, the servicing physician has to be licensed in the state where the patient is located. “So you can’t just have a telemedicine company that has 25 doctors sitting in a bunker somewhere in some city, calling patients and taking care of patients all over the U.S.,” he says. “Each patient might be in different states and each physician might only be licensed in one or a few states. And it gets really difficult when you try to have a large-scale telemedicine platform because you have to have coverage and licensures for all the states you are covering. It’s the main barrier right now,” he says.

Sean Sullivan

As far as breaking down those barriers, Sullivan points to the Interstate Medical Licensure Compact, an initiative which just recently officially began accepting applications from qualified physicians who wish to obtain multiple licenses from participating states. Currently, 18 states have adopted the Compact and eight additional states and the District of Columbia have introduced legislation in support of a pathway for license portability.

“That’s a huge relief,” Sullivan attests, speaking to the Compact. “It’s been fairly slow, though it is picking up momentum. But it is still not a one-sized-fits-all solution; doctors can’t sign up and get licensed in every state, but they can certainly apply to all the states where they think they will serve,” he says. And that brings up another key question, says Sullivan: Is there a different standard of care throughout different states and is it even necessary to have that state-by-state licensure?

Indeed, licensing providers across state lines has long been a challenge. Clinicians who want to treat patients in another state have historically had to apply for and pay for licenses in those states, a costly and time-consuming process. Some state boards have sought to prevent or limit the expansion of telehealth, citing patient safety concerns.

For Sullivan, state-by-state variances simply do not make a lot of sense. “A person with a cold, broken bone or any illness in Alabama is probably going to have the same issues and be treated the same way as if he or she was in Oregon. But the main obstacle is that these individual state medical boards want to and need to have a feeling of control. And it’s also a source of revenue in getting those individual licenses from each physician,” he explains.

What’s more, telehealth practitioners have also long been prevented from being able to treat patients until they have established an in-person patient-doctor relationship. But now, in almost every state, that relationship can be created via telemedicine, with Texas being one of the last holdouts for this particular issue.

Still, there continues to exist a confusing landscape of state laws and regulations. Sullivan notes that every state decides on how they the physician-patient relationship can be established, how telemedicine will be treated, whether or not consent is required, what might be required within that consent, what the limitations might be for providing prescriptions, and what the limitations might be for providing licensures.

Nonetheless, Sullivan believes that current and future regulations and policies will help remove some of these barriers, and that telehealth roadblocks will continue to dissipate each year. This will open up telehealth to service new areas—not just rural areas, he says. “Ultimately, all of us will be seeking to get healthcare and technology will simply be a part of it. Telehealth now is its own industry, but the end goal is that healthcare will include telehealth and the ‘tele’ part will go away. But more legislation ends to happen, as well as more regulation and guidance from CMS [the Centers for Medicare & Medicaid Services].”

Sullivan does believe in one key factor that will continue to push the sub-sector forward, however: hospital buy-in. To this end, he says most of his clients are hospitals that are either affiliated with physician groups or have them as subsidiaries. These hospitals are setting up telehealth programs where a big or medium-sized hospital will reach out to smaller hospital and provide telehealth specialist services through their physician groups, he explains. “They may have a subsidiary physician group that has specialists in neuroscience, orthopedics or some other specialty that smaller hospitals might not have available, so they will contract with the bigger hospitals who are putting together telemedicine platforms,” Sullivan explains. That enables the small organizations to keep the patients at those locations. “It can be a lifeline for them,” he adds.

And on the reimbursement front, Sullivan acknowledges that providers are quite frustrated as they want to make sure they are getting paid for the services they provide. But in Sullivan’s point of view, physicians are thinking about the reimbursement challenge in the wrong way. “I try to get them to think about reimbursement not as the top priority, but instead to think about telemedicine as improving quality and improving access to healthcare for people who can’t access it. Then, ultimately, if you get those things in place, the reimbursement will flow. If you are doing things right, healthcare in the U.S. will get better and you will get your reimbursement,” he says.


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Key Questions Before Partnering With Telehealth Specialty Providers

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For primary care clinics, especially those in rural areas, establishing solid relationships with organizations that provide specialty telehealth services can vastly improve the number of services they can offer their patients. But building and maintaining those relationships so that they make sense financially and in terms of quality and patient satisfaction takes a lot of work.

I hadn’t realized how complex that relationship-building could be until yesterday, when I got a chance to hear an online presentation by the California Telehealth Resource Center (CTRC) detailing 20 questions clinics should ask specialty telehealth providers when vetting different offerings. The speaker was Kathy Chorba, CTRC’s executive director, who has 20 years of telehealth program development experience, beginning with establishing and growing the UC Davis Telemedicine program, incorporating 80 sites and 35 specialties, and directing the Telemedicine Learning Center. 

Chorba began by noting that the work of assessing these partnerships should begin only after you have done a needs assessment, identified the kinds of specialties you want to engage (dermatology, psychiatry, etc.), and the volume you expect to generate. You should also have established physician buy-in and identified your telehealth team. Once you have done these things, then you are ready to start establishing partner relationships, she said.

I won’t go through all the questions Chorba suggested clinics ask of specialty provider groups, but just the following sampling of them might help those of us who are not in the telehealth trenches everyday better understand some of the logistical issues involved.

• What specialties are available through this provider group? Chorba noted that some specialty provider groups offer one specialty only (such as behavioral health) while others offer a wide variety of specialties.  She added that some clinics prefer the “one-stop shop” for all their specialty needs, because it simplifies the contracting, credentialing, referral process and workflow, while other clinics prefer to shop around and find the best price for each specialty.

• Does the provider group contract with your payer(s), bill you by the hour or block of time or patient seen? Specialty provider groups use different payment mechanisms, and you have to find one that is mutually beneficial. Chorba added that before you negotiate, you should know how many referrals you think you will have for each specialty and how soon you will be able start. “This will help determine the financial model that fits your program,” she said.  The speciality provider will know if they have capacity.”

• What are the rates for live video and store and forward and are they the same for adult and pediatric? Rates will vary depending on the specialty services needed, as well as volume and modality. Rates for store-and-forward specialties such as dermatology will typically be lower than live video specialties, and new patient appointments may be more expensive than follow-up appointments, Chorba said. Also, rates may vary according to the volume of patient referrals you anticipate sending to the specialty group. Each specialty also tends to have a different timeframe for visits. Dermatology visits may take 20 minutes, while psychiatric visits take an hour. “One rule of thumb is 40 minutes for new visits and 20 minutes for followup visits,” she said. Clinics have to structure their appointment strategy to afford the specialists’ time. “When does a $250-per-hour specialist cost less than a $200-per-hour specialist? When the $250 specialist can fit more patient visits into that hour,” she said.

CTRC offers clinics a sustainability worksheet to help them understand all their costs involved in purchasing blocks of time from telehealth specialists. Initially they may expect to lose some money because all the patients are new and the visits are longer, but as you move into the growth phase, and the specialists are seeing more follow-up patients, you can fit more patients into an 8-hour day. “The bottom line is you are not losing money anymore,” Chorba said. About seven months into the program, you should hit the maintenance phase, where you are keeping your patient no-show rate down and overall costs down.  

• Does the specialty provider group have referral guidelines for each specialty? Besides specifying the time required for new and follow-up patients, these guidelines also state what information or tests are needed prior to the consult (labs, chart notes, etc.). Chorba added that the tests required could be unavailable or too expensive for your patients or not covered by their health plan. “Just knowing the referral guidelines and tests rquired prior to a consult,” she said, “may help you decide that is a provider you don’t want to work with.”

• What level of technical support will the specialty provider group provide? While most primary-care clinic sites have some technical support staff available, few clinics have staff that are able to troubleshoot telemedicine video and peripheral equipment and/or broadband connectivity issues. Some specialty provider groups provide a basic level of technical support or troubleshooting assistance in order to make sure services are provided as scheduled. Chorba said clinics should make clear what type of support it can provide.

This is just a subset of all the questions Chorba raised with webinar attendees. It helps explain why Federally Qualified Health Centers and other small clinics need consulting help to get their telehealth programs up and running. In closing she mentioned that the CTRC is now working on its next set of guidance on how to keep that relationship with specialty providers healthy once you have chosen a group to work with. With so much emphasis on the potential for telehealth these days, it is important for all of us to remember that the transition to telehealth and the hand-offs between providers involves a lot of complexity!

 

 

 

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AMIA Supports NIST Efforts to Secure Telehealth RPM Ecosystem

January 9, 2019
by Heather Landi, Associate Editor
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Back in November, the National Cybersecurity Center of Excellence at NIST, the National Institute of Standards and Technology, issued a draft paper outlining a project it plans to undertake to provide a reference architecture addressing the security and privacy risks for healthcare delivery organizations leveraging telehealth capabilities, such as remote patient monitoring.

Traditionally, patient monitoring systems have been deployed in healthcare facilities, in controlled environments. Remote patient monitoring (RPM), however, is different in that monitoring equipment is deployed in the patient’s home, according to NIST’s NCCoE. NIST is housed within the Department of Commerce.

These new capabilities, which can involve third-party platform providers utilizing videoconferencing capabilities, and leveraging cloud and internet technologies coupled with RPM devices, are used to treat numerous conditions, such as patients battling chronic illness or requiring post-operative monitoring. As the use of these capabilities continues to grow, it is important to ensure the infrastructure supporting them can maintain the confidentiality, integrity, and availability of patient data, as well as ensure the safety of patients, according to NCCoE.

To address these security, privacy and safety concerns, NCCoE aims to provide a practical solution for securing the telehealth RPM ecosystem. The NCCoE project team will perform a risk assessment on a representative RPM ecosystem in the laboratory environment, apply the NIST Cybersecurity Framework and guidance based on medical device standards, and collaborate with industry and public partners. The project team will also create a reference design and a detailed description of the practical steps needed to implement a secure solution based on standards and best practices, according to the organization.

This project will result in a publicly available National Institute of Standards and Technology (NIST) Cybersecurity Practice Guide, a detailed implementation guide of the practical steps needed to implement a cybersecurity reference design that addresses this challenge.

The NCCoE sought public feedback on the project, which was detailed in a draft released in November called “Securing Telehealth Remote Patient Monitoring Ecosystem.”

The American Medical Informatics Association (AMIA) is one industry organization that has voiced support for the NCCoE project to develop guidance around security and privacy risks associated with remote patient monitoring.

In written comments about the project, AMIA president and CEO Doug Fridsma says he “foresees a future of care delivery and disease management that will rely heavily on RPM,” due to a “confluence of shifting and/or diminished reimbursement, aging and chronically ill population growth, and continued depopulation of rural areas.”

Securing these systems and ensuring trust in the data generated by these systems is an utmost priority, and is at the heart of consumers’ ability to obtain care and manage their health, Fridsma noted in the written comments.

Among its recommendations, AMIA advises the NCCoE to leverage existing mobile infrastructure and health IT standards.

“The ultimate spread, scale, and usage of these RPM tools will likely depend more on the commercial marketplace than the short-and long-term plans of healthcare institutions. Further, patients/consumers will use the tools that they are familiar and fits best into their individual ‘workflows.’ Securing the existing mobile infrastructure where individuals perform most of their day-to-day living will improve the likelihood that healthcare specific tasks will succeed,” Fridsma noted.

Fridsma also noted that AMIA recommends NIST focus on data security and integrity that provides data provenance and supports consistent semantic meaning of the data across RPM manufacturers.

 

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Michigan Becomes 25th State to Join Interstate Medical Licensure Compact

January 9, 2019
by Rajiv Leventhal, Managing Editor
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Michigan Governor Rick Snyder signed two bills into law on the last day of December, making Michigan the 25th state to enact the Interstate Medical Licensure Compact (IMLC), an initiative that offers an expedited pathway to licensure for physicians wishing to practice in multiple states.

In 2017, the Interstate Medical Licensure Compact officially began accepting applications from qualified physicians who wished to obtain multiple licenses from participating states. The Compact has been expected to expand access to healthcare, especially to those in rural and underserved areas of the country, and facilitate the use of telemedicine technologies in the delivery of healthcare.

Licensing providers across state lines has long been a challenge, as clinicians who want to treat patients in another state have historically had to apply for and pay for licenses in those states—a costly and time-consuming process. Some state boards have also sought to prevent or limit the expansion of telehealth, citing patient safety concerns.

But under this agreement, licensed physicians can qualify to practice medicine across state lines within the Compact if they meet the agreed upon eligibility requirements. As of December 31, 4,511 medical licenses have been issued and 2,400 applications processed through the IMLC.

The Compact legislation was supported in Michigan by Ascension Michigan, Trinity Health, Michigan Health & Hospital Association, American Society for Dermatologic Surgery Association, and AARP Michigan, among others.

“Ascension Michigan applauds the passage of legislation providing for the state of Michigan to join the Interstate Medical Licensure Compact,” Sean Gehle, chief advocacy officer, Ascension Michigan, said in a statement. “We believe that not only will the Compact facilitate increased access to healthcare for patients in underserved areas of our state, allowing them to more easily connect to medical experts through the use of telemedicine, but also provide for a more streamlined and expeditious process for recruitment of physicians to these same underserved areas.”

Michigan joins 24 states, Guam and the District of Columbia in enacting legislation to join the Compact. These states include Alabama, Arizona, Colorado, Idaho, Illinois, Iowa, Kansas, Maine, Maryland, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Hampshire, Pennsylvania, South Dakota, Tennessee, Utah, Vermont, Washington, West Virginia, Wisconsin and Wyoming.

The initiative remains under consideration in Kentucky, New Mexico and South Carolina.

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