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Making Inroads into Telehealth: How One “Sub-Sector” of Healthcare Continues to Evolve (Part 2)

July 9, 2018
by Rajiv Leventhal
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A healthcare veteran weighs in on the telehealth landscape and what impact recent developments might have

Editor’s note: In part one of this two-part feature on telehealth, a healthcare attorney examines the changing policy and reimbursement landscape.

It was over 20 years ago when Michael Merson, then-CEO of Baltimore-based MedStar Franklin Square Medical Center, first started learning about and becoming interested in telehealth. At the time, Merson’s organization was part of a Johns Hopkins medicine-led intensive care monitoring pilot initiative that was centered around using virtual technology. 

The beta testing of the technology, from Visicu, a company that was later sold to Philips in 2007—and known for its eICU Program, which tracks ICU patients and provides monitoring of vital information— generated positive feedback from Franklin Square Medical Center’s employees. From there, after Merson left the provider world to become board chairman at Baltimore-based CareFirst BlueCross BlueShield, there was a belief on the payer side that since many smaller hospitals didn’t have dedicated intensivists, leveraging a technology like what Visicu offered could lead to safer care and better outcomes.

At that time, under Merson’s lead, CareFirst BlueCross BlueShield funded the installation of the technology at five rural hospitals in Maryland. Although there were stumbling blocks along the way, such as not getting enough cooperation from regional academic medical centers to provide the real-time monitoring and communication center support, for Merson, the results were startling. “I became convinced that [telehealth] was a way to go and that [folks in] conventional medicine would have a hard time accepting it because it did more than provide a resource for people. People felt threatened; they felt that the fee-for-service [revenue] that they were able to generate, and the teaching of in-house staff and training programs, would either be threatened or eliminated,” Merson recalls.

Nonetheless, the anecdote portrays just how long ago Merson started to feel strongly about telehealth. “In each of the institutions [I have worked in], I have insisted that we had a ‘telehealth task force’ to try to move forward in different areas in which it could be used,” he says. Now, working as a consultant at Yaffe & Company, based in Towson, Md., Merson says he is encouraging all clients, one way or another, to get involved in the sector and have money in their budgets to invest in telehealth. 

Below is a Q&A between Healthcare Informatics and Merson that touches on how recent legislations could impact the telehealth sector, how providers and payers are feeling about telehealth today, all while offering predictions for the future.

How does recent telehealth legislation—such as the CHRONIC Care Act of 2017—land for you? Do you see the bills as meaningful?

They are meaningful. The CHRONIC Care Act has teeth in it, but it’s also like gradually gnawing on a bone as opposed to going all the way by embracing it and doing it quickly. And the other side of it is that, in this fee-for-service to value-based care transition, most physicians are still being paid on the fee-for-service side. Value-based care is still in its infancy and consequently, even with the CHRONIC Care Act that is aimed at Medicare patients, its ability to push and transform the industry is mitigated by the continuation of a very high level of fee-for-service patients. Hence, there is skepticism that telehealth can be implemented on a cost-effective basis, and not be abused.

Michael Merson

Are providers more bullish on telemedicine than they used to be?

I think leading-edge providers and providers who are committed to higher-quality outcomes at lower costs, as well as the highest level of patient safety, are the ones who push it. But to be candid, most of mainstream medicine, whether it’s in nursing homes, home care, hospitals, or elsewhere, is still rendered in a very traditional manner. And most of the people live off the half-life of knowledge that they gained 15, 20 or 30 years ago. With all the emphasis on “keeping up or leading,” looking at the system as a whole, most people are not practicing that way. That’s not to say that nobody is, but it takes first-movers and innovators, and a combination of legislation and some form of financial incentives to really move the market. Things that should be transformational in healthcare generally take way too long.

Clearly, there are policy and reimbursement issues that need to still be worked out. Where do things stand with this?

The government is trying to protect itself, whether at the state or federal level, from excess utilization. But the other side of the equation is that each one of those “protective” measures inhibits innovation.

Are providers and commercial payers negotiating favorably? How are commercial insurers handling telehealth?

In the long term I see commercial payers as an ally. They have to be. Whether dealing with chronic care patients, congestive heart failure patients, or others, even if you cut off Medicare and look at the illness burden for a conventional health plan insuring people up to age 65, it is so high by such a small percentage of the population. And that population’s illness burden is typically filled with chronic care that necessitates ongoing coordination of care and ongoing monitoring of care.

And it is so labor intensive and so inefficient that when [payers] are competing in the marketplace on the price of a health plan, they have to be looking at ways to create efficiency—and much more so in this high-intensity population. In the commercial population, 8 percent of the people spend 65 percent of the [healthcare] dollars. The cost of health insurance is so overwhelmingly in the cost of care, which means utilization and excess utilization of physical medicine.

What are some telehealth predictions you can offer for the near future?

I am hopeful, but not hopeful that companies such as Berkshire Hathaway and Amazon joining forces to “create a health plan” in and of itself will change the market. Frankly, I think that telehealth has evolved small and unknown companies. Amazon and Apple, with the technology, they’re the ones that will have to force the lead, because it’s no longer about sitting in a room with a bank of monitors. Now a radiologist in Israel can be walking the streets and have a caseload of 10 images to review and pass judgement on off an iPhone, and do it accurately. That’s really where this has to go.

Healthcare providers are so slow to move and adapt. Unless disrupters can also disrupt the financing equation, and really force institutions to adopt or adapt to something new, it will take forever. But it shouldn’t be that way. I am hopeful that the bigger players will see interest in this and begin to drive change.


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Senate Passes Opioid Response Bill with Substantial Health IT Elements

September 18, 2018
by Rajiv Leventhal, Managing Editor
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The U.S. Senate yesterday passed The Opioid Crisis Response Act of 2018, which includes numerous important health IT provisions, by a vote of 99-1.

The bill was originally sponsored by Senate Health, Education, Labor and Pensions (HELP) Committee Chairman Lamar Alexander (R-Tenn.) and ranking member Patty Murray (D-Wash.), and includes proposals from five Senate committees and over 70 senators. The House passed its version of the legislation in June and now it’s expected that a committee will be convened to reconcile the differences between the two.

The legislation’s core purpose is to improve the ability of various health departments and agencies—such as the Department of Health and Human Services (HHS), including the Food and Drug Administration (FDA), the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration (HRSA), and the Departments of Education and Labor—to address the opioid crisis, including the ripple effects of the crisis on children, families, and communities, help states implement updates to their plans of safe care, and improve data sharing between states.

There are several key health IT provisions in the legislation, including: enabling the Centers for Medicare & Medicaid Services (CMS) to test various models that provide incentive payments to behavioral health providers for the adoption and use of certified electronic health record (EHR) technology to improve the quality and coordination of care through the electronic documentation and exchange of health information; requiring the use of electronic prescribing for controlled substances within Medicare Part D; facilitating the use of electronic prior authorization within Medicare Part D; and expanding access to telehealth services for substance use disorders.

Regarding telehealth specifically, the Senate version of the bill will allow for payment for substance use disorder treatment services, via telehealth, to Medicare beneficiaries at originating sites, including a beneficiary’s home, regardless of geographic location. It also requires guidance to cover state options for federal reimbursement for substance use disorder services and treatment using telehealth including, services addressing high-risk individuals, provider education through a hub-and-spoke model, and options for providing telehealth services to students in school-based health centers.

Health IT Now's Opioid Safety Alliance—a working group of prescribers, health systems, technology companies, pharmacies and pharmacists, professional societies, and patients advocating for the use of technology to fight illegitimate opioid use—supported the Senate’s passing of the bill. Said Joel White, HITN Opioid Safety Alliance executive director, “We are especially encouraged by the inclusion of commonsense Opioid Safety Alliance-endorsed language in this bill that will remove bureaucratic barriers to vital telehealth services for those suffering from addiction, modernize prescribing practices for controlled substances, and streamline prior authorization claims to improve efficiency while bolstering patient safety. These solutions can make a world of difference both in dollars saved and, more importantly, lives spared."

White did add, however, as Congress convenes a committee to reconcile the differences in the House and Senate-passed bills, lawmakers ought to include the House-passed OPPS Act (H.R. 6082) as part of any final conference agreement, “thereby ensuring that addiction treatment records are no longer needlessly isolated from the rest of a patient's medical history—a practice that has hindered informed decision making and threatened patient safety for too long.”

Indeed, the Senate version of the bill requires HHS “to develop best practices for prominently displaying substance use treatment information in electronic health records, when requested by the patient.”

White also noted, “Additionally, OSA remains concerned about the lack of real-time, actionable data provided to clinicians by states' prescription drug monitoring programs (PDMPs). With lawmakers poised to devote additional resources toward these programs, we should know if taxpayers are getting a return on their investment. We support the inclusion of language that would require an objective study and report on states' use of PDMP technology." 

As stated in the bill, states and localities would be provided with support to improve their PDMPs and "implement other evidence-based prevention strategies.” The bill also “encourages data sharing between states, and supports other prevention and research activities related to controlled substances."

What’s more, another section of the bill reauthorizes an HHS grant program “to allow states to develop, maintain, or improve PDMPs and improve the interoperability of PDMPs with other states and with other health information technology.”

Sen. Alexander, meanwhile, said yesterday he is “already working to combine the Senate and House-passed bills into an even stronger law to fight the nation’s worst public health crisis, and there is a bipartisan sense of urgency to send the bill to the President quickly.”

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Survey: Healthcare Organizations Report Gaps in Disaster Preparedness Plans

September 12, 2018
by Heather Landi, Associate Editor
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As Hurricane Florence churns toward the East Coast this week, disaster preparedness is a timely topic, yet a new survey finds that only 72 percent of healthcare providers believe their organization’s disaster plan is comprehensive enough to cover a variety of disaster scenarios both inside the organization and across the community.

The findings are even more troubling among specialty care providers, such as cardiologists and endocrinologists, who provide critical treatment to individuals with chronic diseases, with just 29 percent reporting that they have a comprehensive disaster plan in place. More than two-thirds (68 percent) of survey respondents were affected by two or more disasters in last five years, according to the survey, yet most respondents doubt their organization’s disaster plans are up to the task.

DrFirst, a provider of e-prescribing and medication management solutions, surveyed 109 healthcare professionals across acute, ambulatory, hospice and home care about disaster preparedness. According to the DrFirst, the results are critical for addressing potential safety issues that affect the health and lives of millions of Americans who are increasingly subject to hurricanes, wildfires, and floods as well as other man-made disasters like digital and criminal attacks.

“The fact that almost 70 percent of the surveyed healthcare providers have been affected by more than two disasters in the last 5 years should be a major wake-up call for the healthcare industry,” G. Cameron Deemer, president of DrFirst, said in a statement. “As we learned in the aftermath of major disasters such as hurricanes Maria and Harvey, natural disasters lead to surging demands for acute and emergency care, especially from the most vulnerable patients who may have been displaced from their homes without medications or critical medical supplies, like oxygen or diabetic testing equipment. We must take measures now to address the critical gaps impacting patient care and safety, such as communication challenges and ready-access to medical records and specialty care providers.”

The survey revealed another key vulnerability—the widespread dependence on disaster communications methods that fail to meet legal requirements for secure communications between medical teams, pharmacies, and patients, according to the survey. Under the federal law known as the Health Insurance Portability and Accountability Act (HIPAA), a patient’s private health information can only be shared with the patient or other providers via secure methods such as password-protected portals and secure messaging.

One-third or more of clinicians surveyed across acute, ambulatory and hospice/home health state that calling by phone is their top method for communicating with pharmacies, EMS units, patients and families, local authorities, and community health providers in times of disaster. Secure messaging and email complete the top three modes of communication.

A striking number of clinicians use regular unsecured text messaging to reach hospitals: more than one-quarter of respondents use this mode to communicate with hospitals during and immediately after a disaster strikes, and 22 percent report using unsecured texting to communicate with patients or their family members. According to the Centers for Medicare and Medicaid Services (CMS), the use of phones for texting of patient health information is only permissible through a secure messaging platform that provides message encryption. Encryption is also required when emailing patient health information.

Healthcare professionals working in hospitals were more aware of the need for secure messaging tools than individuals working in other settings, including specialty care providers. Forty-four percent of hospital-based respondents said that secure, HIPAA-compliant medical messaging is a key requirement of a disaster preparedness plan.

In fact, hospital-based respondents indicated that the only requirements more important than secure messaging were the installation of backup generators in case of power outages (56 percent) and the ordering and maintaining of extra inventory of supplies and medications (52 percent). Yet, specialty providers place the need for including secure messaging at the very bottom of their disaster planning requirements.

Survey respondents also see telehealth is a viable disaster solution, as 45 percent cited telehealth as an effective option to provide care to patients across the community during or immediately after disasters or emergencies. However, more than half expressed concerns that connectivity and other technical issues could impact the reliability of telehealth, and only 27 percent believe their organization has deployed adequate telehealth capabilities.

Another key finding from the survey is that many organizations preparing for an impending disaster still rely heavily on paper, with most advising patients to keep copies of their medical records. Just 40 percent of respondents believe their electronic health record (EHR) has sufficient information available to take care of all patients during a disaster.


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CPT Codes Updated to Reflect HIT Advancements

September 6, 2018
by Rajiv Leventhal, Managing Editor
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The American Medical Association (AMA) announced the release of the 2019 Current Procedural Terminology (CPT) code set, with changes reflecting new technological shifts in the industry.

According to the AMA, there are 335 code changes in the new CPT edition reflecting the CPT Editorial Panel and the healthcare community’s “combined annual effort to capture and describe the latest scientific and technological advances in medical, surgical and diagnostic services.”

Among this year’s changes to CPT include three new remote patient monitoring codes that reflect how healthcare professionals can more effectively and efficiently use technology to connect with their patients at home and gather data for care management and coordination. Also, two new interprofessional internet consultation codes have been added to reflect the increasing importance of using non-verbal communication technology to coordinate patient care between a consulting physician and a treating physician, according to AMA.

“The CPT code set is the foundation upon which every element of the medical community—doctors, hospitals, allied health professionals, laboratories and payers—can efficiently share accurate information about medical services,” AMA President Barbara L. McAneny, M.D., said in a statement. “The latest annual changes to the CPT code set reflect new technological and scientific advancements available to mainstream clinical practice, and ensure the code set can fulfill its trusted role as the health system’s common language for reporting contemporary medical procedures. That’s why we believe CPT serves both as the language of medicine today and the code to its future.”

McAneny added that the AMA has urged the Centers for Medicare and Medicaid Services (CMS) to adopt the new codes for remote patient monitoring and internet consulting and designate the related services for payment under federal health programs in 2019. “Medicare’s acceptance of the new codes would signal a landmark shift to better support physicians participating in patient population health and care coordination services that can be a significant part of a digital solution for improving the overall quality of medical care,” she said.

In July, as part of CMS’ proposed Physician Fee Schedule and Quality Payment Program rule, the agency recommended various provisions that would aim to support access to care using telecommunications technology, such as: paying clinicians for virtual check-ins, paying clinicians for evaluation of patient-submitted photos; and expanding Medicare-covered telehealth services to include prolonged preventive services.

New CPT category I codes are effective for reporting as of Jan. 1, 2019. Additional CPT changes for 2019 include new and revised codes for skin biopsy, fine needle aspiration biopsy, adaptive behavior analysis, and central nervous system assessments including psychological and neuropsychological testing.

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