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Telehealth Advocates Respond to CMS ‘Virtual Visit’ Proposal

July 16, 2018
by David Raths
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To get around legal restrictions on telehealth reimbursement, CMS expands its definition of ‘communication technology–based services’

Among all the proposed changes the Centers for Medicare and Medicaid Services (CMS) rolled out last week, ones related to telehealth drew considerable interest. Although it can’t use its regulatory power to change the laws that restrict telehealth services paid for by Medicare to rural settings, the agency has instead defined new “communication technology–based services” that could be used for virtual visits with established Medicare patients regardless of such patients’ location, effective Jan. 1, 2019.

In its proposed rule about virtual visits, CMS is seeking comment on whether telephone interactions are sufficient or whether interactions enhanced with video or other kinds of data transmission should be required. CMS also proposes to create a new code to permit separate Medicare payment for store-and-forward technology such as when a dermatologist examines an image of a patient’s skin asynchronously.

The CMS proposal brought a mix of enthusiasm and concerns from groups advocating for greater usage of telehealth. “What they have done is creative and brilliant, and it goes further than CMS has ever gone previously to ensure that seniors have services everyone else in the marketplace has,” said Krista Drobac, executive director of the Alliance for Connected Care. On the other hand, she expressed concern that CMS paying for brief e-visits is going to create an environment where providers are going to weigh whether it is worth it to invest in telehealth systems. “What they will probably find is that the reimbursement is not enough to transform their practice and make telehealth part of their work flow,” she said.

Drobac believes CMS has gone as far as it can go within the existing law. She said Congress needs to give the Secretary the authority to waive the telehealth restrictions on all provider codes. “On the one hand, I am excited about the progress; on the other hand, it makes me even more determined that Congress act. CMS has gone as far as any of us could have asked on a regulatory level.”

Drobac also noted that CMS has plans to make the program budget-neutral by cutting base payments for providers to counter increased spending on virtual visits. “The more this gets used, the lower those E&M code reimbursements might be,” she said.

Aside from actual proposal itself, Mei Wa Kwong, executive director of the nonprofit Center for Connected Health Policy, was intrigued by the reasoning CMS used for how they can make this proposal and not face the same limitations other telehealth services do. “That raises the question: are we creating two separate things, communication technology vs. telehealth. Are they going to be separate? They started down this path a few years earlier with chronic care management and remote patient monitoring,” she said.

The way the virtual check-in proposal stands now stands, providers would have to have a telehealth system set up. “But CMS asked for comments on whether they could be done on the phone, which I think would be a lot more common,” Kwong said. “The reimbursement for that proposal is $14 per check-in. People have asked me whether physicians would see that as worthwhile to go through the administrative tasks and I don’t have an answer. There are still a lot of questions.”

In its proposal, CMS noted that the virtual visit service could be used as part of a treatment regimen in follow-up visits for patients on medication-assisted therapy for opioid use disorders. “We have been very active on that issue on Capitol Hill,” Drobac said. “We have been an advocate for the e-TREAT Act, which is part of the Senate opioid bill. That would lift the telehealth restrictions for substance use disorders. It would give CMS even more authority to work in the substance use disorder area. We are pushing for Congressional action on that.”

Kwong said virtual visits could be very useful for patients, “but there are a bunch of policy complications related to medication-assisted therapy. It might not be as widely used as they hope.”

Overall, how the proposed rule is tweaked could make a big difference, she added. If the asynchronous store-and-forward service can be used for new patients, that would benefit the direct-to-consumer companies, she said. “Is CMS policy going to be that you can establish a patient-provider policy this way? If so, it could have a wider impact. Or if they allow the patient check-ins via phone, that could have a wider impact.”
 
Other provider organization and informatics group represenatives weighed in on the subtle nuances of the proposal:

“I think all types of patients can benefit from a policy like this, as it gives them an opportunity to touch base with a provider without having to schedule an office visit,” said Darryl Drevna, director of regulatory and public policy at the American Medical Group Association (AMGA). “Previously, the way that telehealth was paid was if an office visit was scheduled and then the payment would get wrapped up in that office visit. Here, you can look at the film or have a call with your patient, as sort of a triage, and if you don’t end up having to schedule an office visit, you’ll still get reimbursed for that. So, this is a positive; this is something that we’ve long supported, to expand the use of telehealth as a program.”

“Telehealth advocates have been clamoring for CMS to jump in with both feet on reimbursement of telehealth, and I think this proposal does that,” said Jeff Smith, vice president of public policy at the Bethesda, Md.-based American Medical Informatics Association (AMIA). “Whether or not they are jumping six feet in the water or have both toes in the water is up for debate. But I think telehealth advocates will score this as a major win, and it is a major win.”

“It’s always good when things like telemedicine are expanded and there are more options to treat patients, but what we’re going to be looking at with a proposal like this is: what are the criteria and what is the payment amount?” said Anders Gilberg, senior vice president, government affairs, for the Medical Group Management Association (MGMA). “Some of those additional flexibilities and additional codes for telemedicine can be quite useful, as long as the complexity and the rules and the hoops you have to jump through are not overwhelming so that the return on investment to even provide those [telemedicine services] is there.”

 

 

 

 


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KLAS: EHR Integration, Enterprise Scalability Key Challenges Facing Telehealth Vendors

December 11, 2018
by Heather Landi, Associate Editor
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Healthcare organizations report high satisfaction with their telehealth virtual care platforms (VCPs), however there are significant differences in how broad the various platforms are and in the quality of the vendors’ service. What’s more, integration with electronic health record (EHR) systems is a key challenge facing every telehealth vendor, according to a KLAS report.

In its report, “Telehealth Virtual Care Platforms 2019: Which Telehealth Vendors Have the Scalability Customers Need?,” KLAS evaluates some of the top telehealth companies including American Well, MDLive and Epic, and analyzes what capabilities will set vendors apart as more healthcare organizations adopt virtual health technology solutions.

Most virtual care platform vendors receive positive performance ratings, but the depth and breadth of their capabilities vary, and this can impact scalability for organizations looking to grow, according to KLAS. No two vendors are alike in their capabilities, offering different combinations of functionality and experience.

Of the companies KLAS evaluated, the most common type of visit varied—most of American Well’s visits were on-demand urgent care, while the majority of Epic’s visits were associated with virtual clinic visits.

A key factor of scalability is the ability to support multiple visit types, KLAS researchers note. While multiple vendors offer support for all three visit types (on-demand or urgent care, virtual clinic visits and telespecialty consultations) no single vendor has a large proportion of customers using all three (only 12 respondents across all vendors said they were doing so).

American Well, a market share and mindshare leader, and MDLIVE, two of the vendors used most frequently for multiple visit types, receive generally positive—but lower than average—performance scores. Vendors more specialized in specific visit types or component layers (e.g., Vidyo and Zipnosis) have high scores but narrower expectations from customers.

No one vendor meets all needs equally well, but several are reaching for “all-purpose” status with internal development and/or recent acquisitions (American Well acquired Avizia; InTouch acquired TruClinic), according to the report.

KLAS’ analysis also uncovered a general trend of poor integration. In most cases, the addition of a virtual care platform also means the introduction of a second EHR into the clinician workflow.

“Although integration between EMRs is generally understood to be important for care quality, patient safety, efficiency, and productivity, few interviewed VCP customers have full bidirectional transfer in place. Most say that they are too early in their virtual care programs to pursue integration or that it simply costs too much,” KLAS researchers wrote.

Only American Well, Epic, and MDLIVE have more than half of interviewed customers currently on an integrated path, KLAS found. Epic has placed virtual care capabilities directly into their top-rated MyChart patient portal, which many patients already use. Epic integration means clinicians are able to stay within their existing workflow environment as well.

Many provider organizations are in the early phases of their virtual care programs where showing an ROI is an important milestone and one that organizations want to achieve as soon as possible, KLAS notes. “A key promise from vendors is that their technology and accumulated expertise will result in a fast start and continuous acceleration. When this comes at significant cost or progress is slower than expected, provider organizations can experience disappointment,” the KLAS researchers wrote.

When it comes to getting their money’s worth and achieving desired outcomes, Epic and InTouch are rated highest among fully rated vendors, and swyMed and Vidyo perform well among their smaller groups of respondents, KLAS researchers note.

“For each vendor, the current value proposition is somewhat narrow but well understood: Epic’s use is limited to existing patients of Epic EMR customers; InTouch is used primarily for consults; swyMed is used by respondents primarily for mobile, first responder needs; Vidyo delivers video-conferencing tools,

which are typically combined with other VCP solutions. SnapMD is seen as a low-cost option, but some customers say the impact has been limited. Commentary from VSee customers suggests a similar experience,” KLAS researchers wrote in the report.

Many healthcare organizations are early on in their virtual care journeys, and their ability to achieve desired results depends on guidance from vendors. According to KLAS’ analysis, swyMed and InTouch receive the most praise for taking initiative in proactively guiding customers and also in quickly responding to support problems.

While respondents praise American Well’s platform scalability, some customers blame the vendor’s “exponentialgrowth for staffing shortages that have led to implementation holdups and backlogged service requests. Some SnapMD customers say hard-to-beat pricing comes with a support model that is spare in terms of providing tailored guidance, according to the KLAS report.

Most vendors offer two additional options that can help accelerate customers’ expansion and growth—supplemental services, including added-cost advisory and outsourced services, and tools that automate patient-facing tasks that traditionally require additional staff. I

KLAS found that few customers mentioned these options in top-of-mind conversations. “Respondents who spoke of their vendor’s supplemental services most often referred to marketing support or strategic planning services from vendors American Well, MDLIVE, or Zipnosis. Those who referred to task automation report patient-self-service capabilities around check-in, scheduling, surveys, and/or patient flow from InTouch Health (TruClinic), Epic, MDLIVE, or Zipnosis,” the KLAS researchers wrote.

 

 

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Study: Neonatal Telehealth Reduces Hospital Transfers, Saves Money

December 11, 2018
by Heather Landi, Associate Editor
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Neonatal video-assisted resuscitation reduces transfers from hospitals without newborn intensive care units and provides significant cost savings, according to study published in the November issue of Health Affairs.

The study authors, led by Jordan Albritton of Intermountain Healthcare, examined a newborn telehealth program implemented at eight Intermountain Healthcare community hospitals in November 2014–December 2015 and the impact on the transfer of newborns from those eight hospitals to level 3 newborn intensive care units.

Studies show that 10 percent of newborns require assistance breathing at birth, and 1 percent require extensive resuscitation. At Intermountain Healthcare, approximately 1–2 percent of all babies born in suburban and rural hospitals are transferred to newborn intensive care units (NICUs) for higher-level care, according to the study.

In response to the need to improve outcomes for complex newborn patients, an innovative telehealth program was established at Intermountain Healthcare in 2013 to provide synchronous, video-assisted resuscitation (VAR), bringing a neonatologist to the bedside. As a result, access to specialized neonatal services in rural and suburban settings is no longer limited to telephone calls or the arrival of a neonatal transport team, the study authors wrote.

While telehealth can facilitate video connections between neonatologists at tertiary care centers and providers at smaller hospitals, there is little empirical evidence about the benefits of telehealth programs for neonatal resuscitation, according to the study authors.

Although Intermountain Healthcare began using telehealth technologies in 2013, the current VAR program was implemented in the period November 2014–December 2015. Today, neonatologists from four level 3 NICUs provide VAR support for nineteen referring hospitals.

As part of the study, the researchers evaluated eight hospitals that contained either well-baby (level 1) or special care (level 2) nurseries staffed by physicians, advanced practice clinicians, nurses, respiratory therapists, and other health care professionals. T

The study found that video-assisted resuscitation was associated with a reduction of 0.70 transfers per facility-month and a 29.4 percent reduction in a newborn’s odds of being transferred. Annually, this resulted in 67.2 fewer transfers and an estimated cost savings of $1.2 million per year.

The study authors conclude that reducing transfers keeps families closer to home, increases community hospital revenue, and reduces risk associated with transfers.

“This program helps keep newborns in level 1 or 2 nurseries, which in turn allows families to stay closer to home, improves social support, and increases the revenue of community hospitals while reducing costs and risks associated with transfers,” the study authors wrote. “Payers should consider reimbursement for pediatric subspecialty telehealth consults for neonates in level 1 and 2 nurseries. Through improvements in care quality and cost savings, this service would likely pay for itself many times over.

However, the authors also note that lack of reimbursement for telehealth services limits widespread implementation.

“Policy changes are necessary to align payment incentives and promote the use of telehealth services,” the study authors wrote.

Related Insights For: Telehealth

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Can Telehealth Slow the Traffic Between Nursing Homes, Emergency Departments?

December 6, 2018
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The RUSH Act seeks to reduce the 1.3 million transfers from skilled nursing facilities to emergency rooms each year

There are 1.3 million transfers from skilled nursing facilities (SNFs) to emergency rooms each year, and CMS estimates that two-thirds of those are avoidable. The result is as much as $40 billion in unnecessary spending. Could telehealth be part of the solution?

That question led Timothy Peck, M.D., formerly chief resident in the Emergency Department at Beth Israel Deaconess/Harvard, to co-found a startup company, Call9, and become an advocate for legislation, the RUSH (Reducing Unnecessary Senior Hospitalizations) Act of 2018, to support reimbursement for connecting emergency physicians and SNFs.

Peck has spent considerable time studying the issue. “I didn’t know much about nursing homes when I started,” he said.  “I went and lived in one for three months. I wound up sleeping on a cot in a conference room.”

Peck was trying to understand nursing home finances and operations and why the patients are being transferred. They usually have things like urinary tract infections or pneumonia, which could be treated in the outpatient setting, but the SNFs aren’t equipped with the right tools to be able to treat these patients. Those patients come in without their families and 43 percent have dementia, he said. “Most become delirious upon transfer. We don’t have much information about them so we order every test under the rainbow, driving up the bill unnecessarily. We put them in hallways. They get bedsores. We inevitably admit these patients for an average of $15,000 to $20,000 per admission.”

The two-thirds of transfers that are avoidable represent about $40 billion in unnecessary spending for something that harms patients,” he said. “We are spending money on hurting patients.”

Peck zeroed in on three operational issues:

• First, on average, nurse to patient ratios in nursing homes are 1 to 36. If one patient becomes acutely ill and spikes a fever, that nurse does not have time to take care of that patient when they have 35 other patients to take care of. Also, most nursing home nurses are trained to handle chronic care, not emergency or acute care. It is a mismatch of skills, not a people problem in any way, he said.  

• Second, diagnostic equipment is sparse, and EKGs and lab tests take 24 hours to 48 hours to come back. That doesn’t work well for acute care.

• Third, physicians are not present in nursing homes. “When I was living in that nursing home and walking the halls weekends and nights, I never once saw another physician. Long-term care patients are seen once a month by their primary care doctors.”

Peck described the Call9 service: They embed 24x7 a paramedic or EMT or a nurse with emergency experience in the SNF. They go to the patient’s bedside and connect to a remote emergency physician who is available 24x7 and working from home. They can see a patient in nursing home A with a paramedic by the bedside and then jump to nursing home B and see a patient there with a first responder with them. “It makes the physician a scalable resource,” Peck said. “Believe it or not, they are our least expensive resource because they get scaled.”

Call9 has full integration with the three most commonly used EHRs in the SNF world. The solution also deploys a suite of mobile diagnostics and can return lab test results in a few minutes. It offers real-time telemetry and real-time ultrasound.

After treating a few thousand Medicare Advantage patients, he said the model has shown that it can save payers more than $8 million per nursing home per year. That allowed Call9 to get involved with Medicare shared savings value-based contracts with several payers nationally. But he notes that 60 percent of patients in nursing homes are Medicare patients. “We took that data to CMS and showed it to them,” Peck said. “The Ways and Means Committee in the House of Representatives got ahold of the data and got excited and started writing the Rush Act.”  He stressed that Call9 is not the only organization creating a program like this. There are others working on similar solutions.

Peck said CMS is interested in using telehealth in this way, he said. “But they don’t have any way to change payment mechanisms in a quick manner. They would have to ask CMMI to run demos, which takes years. But Congress could pass new legislation.” He described the RUSH Act as creating a value-based shared savings arrangement with Medicare where 50 percent of the savings goes back to Medicare, and 37.5 percent goes to a company like Call9 or a physician group or medical staffing group that administers the program and 12.5 percent goes to the nursing home, aligning all stakeholders, he said. “The bill has been introduced by a bipartisan group, because it is a nonpartisan issue.” With time running out in this session, he said, the bill still has strong support among Democrats set to take over House leadership in 2019.

Besides bipartisan sponsors in Congress, the bill also has support from patient advocacy groups such as the Alzheimer’s Association, Michael J. Fox Foundation for Parkinson’s Research, American Heart Association, the National Alliance on Mental Illness, and the American Telemedicine Association. “They are saying that the patients need it; the taxpayers benefit; why are we not doing this?” Peck said.

As someone who has seen family members and friends make that repeated, disruptive round trip from nursing home to emergency room, I concur.  

 

 

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