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Legislation that Would Expand Telehealth Use, Access Passes Easily in Senate Committee

May 19, 2017
by Rajiv Leventhal
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Several provisions in the bill are related to providing ACOs the ability to expand the use of telehealth services

The Senate Finance Committee, with unanimous approval, has passed bipartisan legislation that would expand telehealth services for chronic care patients in Medicare. The bill will now move to the full Senate.

The Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017 (S.870), introduced in April by Sens. Orrin Hatch (R-Utah), Ron Wyden (D-Ore.), Mark Warner (D-Va.),  Johnny Isakson (R-Ga.), and others, has the overarching goal to transform how Medicare works for seniors who suffer from chronic illnesses by including provisions such as expanding access to telehealth services. 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.

But as Sen. Wyden noted in a statement yesterday, announcing the Senate Finance Committee’s passing of the bill, “The CHRONIC Care Act will mean more care at home and less in institutions. It’ll expand the use of life-saving technology. It places a stronger focus on primary care. It gives seniors, however they get Medicare, more tools and options to receive care specifically targeted to address their chronic illnesses and keep them healthy. Those are all important steps forward in updating the Medicare guarantee.”

Indeed, under Title III of the bill, expanding innovation and technology, there are several provisions related to enhanced telehealth access and use, including: increasing convenience for Medicare   Advantage enrollees through telehealth; providing accountable care organizations (ACOs) the ability to expand the use of telehealth.; providing home remote patient monitoring for dialysis therapy; and expanding the use of telehealth for individuals with stroke.

Providing ACOs the ability to expand the use of telehealth services is an especially noteworthy component of the legislation, as most existing Medicare reimbursement policies only cover limited telehealth services. Specifically, however, this bill calls for the inclusion of the home as an originating site for telehealth services and for no application of geographic limitations. However, eligible ACOs in this provision must take on two-sided risk.

In response to the bill, the National Association of ACOs president and CEO Clif Gaus said, “I am encouraged by the Senate Finance Committee’s success in moving the bipartisan CHRONIC Care Act of 2017. The legislation includes a number of provisions that provide greater flexibility to several ACO models. NAACOS is pleased that the CHRONIC Care Act would allow for greater use of telehealth services for two-sided ACO risk models, would allow all ACOs to opt in to prospective beneficiary assignment, and would create a Beneficiary Incentive Program, providing clinicians with more tools in the toolbox to get patients to primary care appointments which will improve health and lower Medicare costs. While NAACOS would like to see these same allowances expanded to all ACO models, this legislation is a significant step in the right direction.” 

Meanwhile, the Congressional Budget Office (CBO) graded the bill favorably in its preliminary cost estimate, noting that expanding telehealth to the home for Medicare dialysis treatment would be budget neutral. Also of note, expanding the use of telestroke would add about $180 milling to spending over the next decade, while adding telehealth to ACOs will cost some $100 million, per the agency’s estimations. But, CBO estimated, savings would be seen by increasing convenience for Medicare Advantage enrollees via telehealth ($80 million) and by eliminating the Medicare and Medicaid Improvement Funds ($375 million). This is the first time that CBO has scored telemedicine legislation since 2001.

 

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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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