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Legislation to Modernize VA Health System Includes Telehealth Licensing Provision

December 6, 2017
by Heather Landi
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U.S. Senators John McCain (R-Ariz.), chairman of the Senate Armed Services Committee, and Jerry Moran (R-Kan.), chairman of the Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and Related Agencies, introduced new legislation designed to modernize the Department of Veterans Affairs (VA) healthcare system and includes a provision that would allow physicians to practice telemedicine across state lines.

The Veterans Community Care and Access Act of 2017 (S. 2184) would better integrate VA services and existing VA community care programs, such as the Veterans Choice Program, into an efficient and high-performing healthcare system, the Senators wrote in a press release.

This legislation would ensure that veterans are the primary decision-makers concerning when and where they receive care. In addition, the bill would require the VA to use objective data on healthcare demand to set standards for access and quality, and to identify and bridge gaps in veterans’ care – whether in VA or community facilities. Importantly, the bill would ensure the VA promptly pays community providers, offers access to walk-in clinics, offers telemedicine, increases graduate medical education and residency positions for employees, and improves its collaboration with community providers and other federal agencies.

Specifically, a section of the bill would expand authority fo rVA health care professionals to practice in any state, including by telemedicine, notwithstanding the location of the health care provider or the patient. This section would specifically invoke Federal supremacy to prevail over any general or specific provisions of law, rule, or regulation of a state that are inconsistent with the federal legislation. It would also prohibit any state from denying or revoking the license, registration, or certification of a VA health care professional who otherwise meets the requirements of the state for such license, registration, or certification, on the basis of practicing under this authority.

Covered health care professionals would include VA employees who are authorized to furnish health care. Additionally, under the legislation, the VA would be required to submit a report to Congress within one year of enactment on VA’s telemedicine program, including provider and patient satisfaction, the effect of telemedicine on wait-times and utilization, and other measures.

A standalone bill and bipartisan legislation, the Veterans E-Health and Telemedicine Support Act of 2017 (VETS Act), also aims to expand telehealth services provided by the VA and that bill passed the House last month.

“In the wake of the scandal in care at VA hospitals in Phoenix and around the country, we vowed to guarantee our veterans timely access to quality treatment,” Sen. McCain said in a statement. “The Veterans Choice Program was the first step in delivering on that promise, but much more needs to be done to provide all veterans a choice in when and where they receive care. Our bill would strengthen and improve the core elements of Choice by consolidating and streamlining the VA’s community care program. Moreover, the bill would deliver long overdue, critical reforms to the VA, including commonsense reporting standards that ensure cost-efficient care to our nation’s veterans. It’s time we transform the VA into a 21st century health care system, one that respects the dignity of our men and women in uniform and provides all veterans the quality health care they deserve.”

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The Role of Health IT in Caring for Rural America

January 23, 2019
by Betty Rabinowitz, M.D., chief medical officer, NextGen Healthcare, Industry Voice
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According to the US Census Bureau, approximately 60 million, or one in five Americans, live in rural areas. Rural areas are sparsely populated, have low housing density, and are far from urban centers, and these factors create unique and complex challenges when providing healthcare to this population.

After completing their training, physicians and nurses often gravitate to urban areas. The patient-to-primary care physician ratio in rural areas is only 39.8 physicians per 100,000 people, compared to 53.3 physicians per 100,000 in urban areas, according to data from the U.S. Department of Health and Human Services (HHS). This discrepancy makes access to care more difficult, and data collected by the Rural Health Information Hub indicates that this negatively impacts care outcomes and even life expectancy in rural areas. Due to the scarcity of specialists such as mental health providers, dentists, and oncologists, patients must often travel significant distances to seek these types of care.

Compounding the impact of the shortage of primary care physicians and in parallel to it, access to care has further been impacted by an increase in closures of rural community hospitals.  According to the Government Accountability Office’s (GAO) analysis, 64 rural hospitals closed from 2013 through 2017. This represented approximately 3 percent of all the rural hospitals in 2013 and more than twice the number of closures of the prior 5-year period. The GAO's analysis further shows that rural hospital closures were more prevalent in the South, among for-profit hospitals, and among hospitals that received the Medicare Dependent Hospital payment designation, one of the special Medicare payment designations for rural hospitals. The national shift to ambulatory care, which resulted in reduced hospital occupancies, worsened the financial burdens of these rural hospitals, resulting ultimately in their closure. These closures often inevitably portended the decline in other medical services that depended on these hospitals for their livelihood, for example ambulance services, home health services and outpatient laboratories. 

The opioid epidemic has had a significant, disproportionate impact on rural America as well. The rate of opioid overdose deaths is 45 percent higher in rural than in metro areas, according to data from the National Rural Health Association. This is likely multifactorial: a combination of socioeconomic factors and reduced access to mental health providers, pain treatment, and addiction treatment centers and specialists. Because of the geographical realities in rural areas, access to emergency services is not as readily available and many more overdose cases result in death due to unavoidable delays in arrival of emergency teams capable of pharmacologically reversing an impending lethal drug overdose. 

Rural healthcare providers face significant challenges, and the resulting provider burnout and health outcome disparities are real. Developments in health information technology (HIT) offer some needed hope.

Widely available telemedicine capabilities enable rural health systems to overcome the impact of geographic distance and resource scarcity. Patients meeting virtually with their providers can significantly decrease the burden of travel and consequent poor access. Mental health services are well suited for virtual visits, as are follow-up visits after surgical procedures or monitoring patients with stable chronic conditions.

Rural health providers often practice solo or in small groups and, at times, are professionally isolated. Health IT tools offer great promise in reducing this isolation by providing video consults with specialists. Rural providers can even do live consults with colleagues in real time—an empowering and helpful option. 

As an example, the University of Washington Division of Pain Medicine offers weekly TelePain sessions, a videoconference with specialists with expertise in the management of challenging chronic pain problems. The UW TelePain program significantly increases access to experts who provide real-time support in the care and treatment of the most challenging chronic pain patients.

Mounting evidence shows that poverty and other social determinants of health significantly and negatively impact health outcomes. According to the Rural Health Information Hub, rural residents tend to be poorer, with about 25 percent of rural children living in poverty. On average, per capita income in rural areas is lower, and the disparity in income is even greater for minorities in these areas. The negative health impact of poverty is often mediated through lack of health insurance or under-insurance, which may deter these individuals from seeking medical care and from adhering to care recommendations.

Smoking rates are also higher in rural areas, as are deaths from motor vehicle accidents and youth suicide. Chronic conditions such as diabetes and COPD (chronic obstructive pulmonary disease) are more prevalent, and when present, less well controlled, adding further burden to rural providers’ already thinly stretched resources.

Contributing to this complex healthcare landscape, higher percentages of older adults also live in rural areas. Many of the healthcare challenges faced by residents of rural areas are amplified significantly in the elderly.  Geographical distance, access to care, poverty, isolation, the scarcity of food programs such as Meals on Wheels, elder day care and long-term care programs, all impact healthcare complexity and outcomes in this vulnerable population. 

Healthcare provider organizational are increasingly leveraging technology to address the social factors that impact rural patients’ health. As example of one innovative approach to reducing disparities in access to care is the effort by the Patient Access to Pharmacists’ Care Coalition which is working to enact federal legislation to enhance access to care for Medicare beneficiaries in underserved communities. The coalition is proposing an amendment to Medicare rules that would increase medically underserved seniors’ access to health care through pharmacist-provided care. Since nearly 95 percent of the U.S. population lives within 5 miles of a pharmacy, according to data from the National Association of Chain Drug Stores, and improving access to pharmacist’s services by creating appropriate Medicare reimbursement rules holds significant promise. 

Dr. Betty Rabinowitz is the chief medical officer of NextGen Healthcare. She has more than 25 years of extensive clinical experience and expansive knowledge of population health and value-based practice transformation.


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Stanford Children’s Health Expanding Telehealth Services

January 22, 2019
by David Raths, Contributing Editor
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Pediatric health system launches service that offers digital second opinion consultations

Telehealth specialty services continue to increase in pediatrics, especially in neurology, psychiatry, cardiology, neonatology and critical care, according to a 2018 report by SPROUT (Supporting Pediatric Research on Outcomes and Utilization of Telehealth), a telehealth research network. Some health systems are expanding the types of telehealth services they offer. For instance, in a January 2019 story on its website, Stanford Children’s Health described its plans to more than double its number of telehealth appointments — from 1,100 visits in 2018 to 2,500 visits in 2019. 

Until this year, Stanford Children’s telehealth visits have largely been offered to patients for follow-up appointments. The report noted that some of those are clinic-to-clinic visits, in which a nurse practitioner at a primary-care office connects with a physician at a specialty clinic. The nurse practitioner at the remote clinic examines the child while a high-resolution camera and microphone let the physician at the specialty clinic see and hear exactly what the nurse practitioner does.

Through the Stanford Children’s Health MyChart patient portal, patients and families can connect with their physicians remotely using phones and tablets. Vandna Mittal, director of digital health services at Stanford Children’s Health, is quoted as saying such virtual visits are popular among teen behavioral health patients who go away to college but want to maintain a close relationship with their mental health provider at Stanford.

Stanford Children’s Health also offers clinic-to-school visits, in which physicians can connect remotely with a patient in a school nurse’s office. For instance, a physician caring for a child with Type 1 diabetes can communicate directly with the school nurse and the patient’s parent through a telehealth visit at the nurse’s office, minimizing the need for the parents and the child to travel to the doctor’s office and enabling the doctor and the school nurse to interact.

Telehealth is also being used within Packard Children’s Hospital. From inpatient units, on-call doctors are evaluating patients in the emergency department via telehealth before they are admitted; in some cases, specialists are able to advise ED care teams on the most appropriate transfer methods for patients, according to the Stanford Children’s report.

In November 2018, Stanford Children’s Health launched a new service in conjunction with Stanford Health Care that offers digital second opinion consultations from Stanford physicians. Through the program, called Grand Rounds, patients don’t have to visit the hospitals or clinics for this service. Rather, people can create an account through the Stanford Children’s website and pay a $700 fee; Stanford will collect all of their medical records for them (if the records are in the United States). An expert from Stanford will then review the medical information and send a written second opinion, usually within two weeks.




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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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