AMERICAN HOSPITAL ASSOCIATION JANUARY 2015 TRENDWATCH

The Promise of For Hospitals, Health Systems and Their Communities

elehealth increasingly is vital services have shown that: telehealth reflects a changing T to our health care delivery system, • 74 percent of U.S. consumers would landscape with a move toward integrated enabling health care providers to connect use telehealth services; delivery and new payment models. Also with and consulting practitio- • 76 percent of patients prioritize access spurred by consumer demand, telehealth ners across vast distances. Hospitals are to care over the need for human interac- is viewed increasingly as an efficient and embracing the use of telehealth technolo- tions with their health care providers; 2 cost-effective care delivery vehicle. gies because they offer benefits such as • 70 percent of patients are comfortable This two-part American Hospital virtual consultations with distant special- communicating with their health care Association TrendWatch series will ists, the ability to perform high-tech providers via text, e-mail or video, in examine first the promise of telehealth, monitoring without requiring patients to lieu of seeing them in person; and focusing on how telehealth is being used leave their homes, and less expensive and • 30 percent of patients already use com- by hospitals and the benefits for patients more convenient care options for patients. puters or mobile devices to check for and providers. The second part of the Telehealth has moved into the medical or diagnostic information.3 series will analyze the significant legal mainstream. In 2013, 52 percent of Telehealth has many guises, from and regulatory challenges posed by the hospitals utilized telehealth, and another remote monitoring programs used by use of telehealth technologies, including: 10 percent were beginning the process hospitals for post-discharge monitoring • licensure, of implementing telehealth services.1 to reduce readmissions, to hospital emer- • scope of practice, Consumer interest, acceptance and con- gency departments using remote video • liability, fidence in telehealth are growing as well. consultations to enable patients to receive • privacy and security, and Recent studies on the use of telehealth telepsychiatric screening. Increased use of • fraud and abuse considerations.

What are Telemedicine and Telehealth?

Medicare, state Medicaid programs to describe a narrower range of health • The American Telemedicine and technology advocates have used two care services, while the term “telehealth” Association (ATA), an advocacy terms, sometimes interchangeably, to has been used to refer to a broader organization that promotes the use of describe the use of technology to provide scope of health care services, including advanced remote medical technolo- health care services – telemedicine and non-clinical services such as training gies, defines telemedicine as the use telehealth. Each program or definition and education that are provided at of medical information exchanged identifies the scope of services, the types a distance. from one site to another via electronic of technologies and the locations where Various entities involved in tele- communications to improve a ’s patients can receive telehealth services. health describe or define telehealth in clinical health status, including an Generally, “telemedicine” has been used different ways: increasing variety of applications and THE PROMISE OF TELEHEALTH FOR HOSPITALS, HEALTH SYSTEMS AND THEIR COMMUNITIES TRENDWATCH

services using two-way video, email, • Medicare regulations cover a range This flexibility offered by the smart phones, wireless tools and of “telehealth” services, such as the Medicaid program has led to variation other forms of telecommunications use of telecommunications and infor- in the 51 different state laws and technology. mation technology (IT) to provide regulations that affect who can fur- • The Federation of State Medical access to health assessment, diagnosis, nish these services and how they are Boards (FSMB) defines telemedicine intervention, consultation, supervi- reimbursed by Medicaid and private as “the practice of medicine” using elec- sion and information across distance.4 payers. States differ in their defini- tronic communications, information However, Medicare does not reimburse tions or regulations, which in turn technology or other means between a for training or education and limits can create a confusing environment licensee in one location, and a patient reimbursement to a relatively small set for hospitals, health systems, physi- in another location with or without an of enumerated services when provided cians, other clinicians and insurers, intervening healthcare provider. This in rural areas. particularly when caring for a patient definition was included in FSMB’s • Medicaid views telemedicine as a across state lines. As the telehealth “Model Policy for the Appropriate Use cost-effective alternative to the more sector continues to mature, a standard of Telemedicine Technologies in the traditional face-to-face way of provid- definition may emerge. For purposes Practice of Medicine.” The purpose of ing medical care (e.g., face-to-face of this TrendWatch series, the term the model policy is to issue guidance to consultations or examinations between “telehealth” will be used broadly to state medical boards for regulating the provider and patient). The federal describe the delivery of health care use of telemedicine technologies in the Medicaid program encourages states to services, education and information practice of medicine and the appropri- use the flexibility inherent in federal via telecommunications technology, ate standards of care in the delivery of law to create innovative payment including: videoconferencing, remote medical services directly to patients via methodologies for services that incor- monitoring, electronic consults and telemedicine technologies. porate telemedicine technology.5 wireless communications.

The definition of telehealth varies by state, impacting how services are paid for by payers.

Chart 1: Examples of State Law Definitions of Telehealth

State Definition of Telehealth

California “‘Telehealth’ means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care while the patient is at the originating site and the health care provider is at a distant site. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.” CAL. BUS. & PROF. CODE § 2290.5(a) (6) (2012).

Missouri Telehealth is “the use of medical information exchanged from one site to another via electronic communications to improve the health status of a patient.” MO. REV. STAT. § 208.670 (2012).

Pennsylvania Telemedicine is the use of real-time interactive telecommunications technology that includes, at a minimum, audio and video equipment as a mode of delivering consultation services. Pa. Dept. of Public Welfare, Medical Assistance Bulletin 09-12-31, 31-12-31, 33-12-30 (May 23, 2012).

Texas Telemedicine is the use of health care information exchanged from one site to another via electronic communications for the health and education of the individual or provider, and for the purpose of improving patient care, treatment, and services. 25 TEX. ADMIN. CODE § 412.303.

2 THE PROMISE OF TELEHEALTH FOR HOSPITALS, HEALTH SYSTEMS AND THEIR COMMUNITIES TRENDWATCH

The Three Traditional Modalities of Telehealth

Telehealth traditionally encompasses care when providers are not otherwise to a treating physician.7 three main modalities, each with available locally. This modality also is Increasingly, information from these distinct applications within the broader used for providing services to patients devices and applications will become telehealth industry. in other countries. linked to the health information managed One telehealth modality is A third telehealth modality, Remote by health care providers. For example, Real-Time, a live, two-way interaction Patient Monitoring, involves collection Apple is marketing its Health app to between a patient (or the patient’s of a patient’s personal health and medi- patients, allowing them to aggregate per- caregiver) and a health care provider cal data via electronic communication sonal health information on their Apple using audiovisual technology. Real-time technologies. Once collected, the data is devices and link those data to mobile telehealth services can be used to transmitted to a health care provider at a health applications that work with the consult, diagnose and treat patients. different location, allowing the provider Apple platform through HealthKit. At Another telehealth modality is to continue tracking the patient’s data the same time, Apple is partnering with Store-and-Forward, involving transmis- once the patient has been released to his/ providers and sion of a patient’s recorded health his- her home or another care facility. companies to determine how the tool tory (e.g., pre-recorded videos or digital In addition to these traditional can be used in health care settings. images such as X-rays and photos) telehealth modalities, a growing number Similarly, mobile platforms, such as through a secure electronic communica- of mobile health, or mHealth, technolo- smartphones, will likely become a more tions system to a health care provider, gies, applications and online services significant part of the telehealth platform usually a specialist. The information is are being sold directly to patients, such over time.8 Easy access to smartphones, used to evaluate a patient’s case or, in as wearable devices to track health tablets and other communicative devices some cases, render a service outside of a and wellness. The market for wearable is a critical component enabling patients real-time interaction. Store-and-Forward devices is expected to increase from $1.5 to more fully embrace the mHealth technologies have the advantage of billion in 2014 to $6 billion by 2016.6 applications. Between 2011 and 2016, providing access to patient data after it Patients will be able to benefit from the number of Americans with smart- has been collected, and are particularly tools such as wearable electrocardiogram phones is expected to grow two-fold beneficial to patients requiring specialty (EKG) monitors, which deliver readings from 93.1 million to 192.4 million.9

Telehealth provides multiple methods for patients and providers to interact.

Chart 2: Three Modalities of Telehealth

Real-Time Store & Forward Remote Monitoring Provider and patient Digital images, video, Patient uses a system that communicate via live video- audio, clinical data are feeds data from sensors conferencing. Used often in captured and stored and monitoring equipment to , telehomecare, on a patient’s computer or an external monitoring center telecardiology and remote mobile device and then trans- so that health care profes- consults (teleconsults) with mitted securely to a provider sionals can monitor a patient specialists, primary care for later study or analysis. remotely. Used to monitor physicians, counselors, social Used often in chronic conditions such as workers and other health care and . heart disease, diabetes professionals. and asthma.

3 THE PROMISE OF TELEHEALTH FOR HOSPITALS, HEALTH SYSTEMS AND THEIR COMMUNITIES TRENDWATCH

Telehealth platforms provide the potential to offer many hospital services remotely.

Chart 3: Hospital-Based Telehealth Platforms

Platform Description

Telestroke Remote evaluations, diagnoses and treatment recommendations are transmitted to emergency medicine doctors at other sites using advanced telecommunications technologies.

Teleradiology Images and associated data are transmitted between locations for the purpose of primary interpretation or consultation and clinical review.

Tele-ICU Networks of audiovisual communication and computer systems are linked with critical care physicians and nurses to ICUs in other, often remote hospitals.

Telemental Health Mental health and substance abuse services are provided from a distance (e.g. using videoconferencing and other advanced communication technologies).

Telepathology The practice of pathology is performed at a remote location by means of video cameras, monitors, and a remote-controlled microscope.

Cybersurgery Surgeons use surgical techniques with a telecommunication conduit connected to a robotic instrument to operate on a remote patient.

Remote Monitoring Patients are subject to continuous or frequent periodic clinical monitoring via advanced communication technologies.

Telepharmacy Pharmaceutical care for patients (or supervision to technicians) is provided at a distance using advanced telecommunications technology.

Consultations Remote consults are conducted with remote specialists, primary care providers, counselors, social workers and other health care professionals.

Applications of Telehealth by Hospitals and Health Systems

Hospitals can provide the base from which gaps in subspecialist care. and make transfer decisions concerning telehealth services are offered, thereby is another way to offer patients the their most complex patients. Tele-ICU expanding access to care for a wider popu- convenience of remote drug therapy programs can help hospitals supplement lation. Some examples of hospital-based monitoring, authorization for prescrip- clinician staffing of their ICU beds. platforms include telestroke, tele-ICU, tions, patient counseling and monitoring In addition to improving access, patients cybersurgery and remote monitoring. patients’ compliance with prescriptions. are increasingly expecting levels of con- With a nationwide shortage of psychia- venience in health care similar to what is Improving Access to Health Care and trists, telepsychiatry can assist patients in available in the retail and banking sectors.14 Convenience for Patients in Rural Areas need of behavioral health services who Telehealth, regardless of geographic loca- Approximately 20 percent of Americans may otherwise have to drive hours to see tion, can foster a patient’s ability to connect live in rural areas where many do not have mental health providers. Telepsychiatry with a primary care physician or health easy access to primary care or specialist services allow psychiatrists to speak to and system on a more flexible basis and often services. The availability of telehealth ser- evaluate patients in need of mental health without an in-person visit. Patients are able vices to these areas facilitates greater access services through videoconferencing. to receive services at a distance by using to care by eliminating the need to travel Rural and critical access hospitals secure online video services or through long distances to see a qualified health (CAHs) are often in need of critical care secure email, often with the added benefit care provider. Telehealth also can fill clinicians to diagnose, manage, stabilize of reducing travel to health care facilities.

4 THE PROMISE OF TELEHEALTH FOR HOSPITALS, HEALTH SYSTEMS AND THEIR COMMUNITIES TRENDWATCH

The North Carolina Telepsychiatry Network12

Twenty-eight counties across North will also participate in the program. likelihood of returning for treat- Carolina do not have a psychia- The North Carolina program was ment. The study also found fewer trist, leading many people to seek modeled after South Carolina’s use of involuntary commitments to state treatment in their local hospital telepsychiatry that has increased access psychiatric hospitals and higher sat- emergency departments (EDs). The to care for rural communities. It also isfaction for telepsychiatry patients. North Carolina General Assembly has contained costs by reducing the Specific findings include: in July 2013 established the state- number of people admitted to state • The length of stay for patients in wide telepsychiatry system, which institutions from hospital emergency EDs waiting to be discharged to was launched in January 2014. The rooms. From 2010-13, the average inpatient treatment declined from legislature appropriated $2 mil- number of patients treated using tele- 48 hours to 22.5 hours. lion for the program for Fiscal Year psychiatry grew from 8.7 to 12.3 per • The percentage of patients who had (FY) 2013-14 and $2 million for day. The length of stay in EDs while to return for treatment within 30 FY 2014-15. The NC Statewide waiting for treatment decreased from days at one hospital declined from Telepsychiatry Program is adminis- 48-72 hours in 2010 to less than six 20 percent to 8 percent. tered by East Carolina University’s hours in 2013. • The number of involuntary com- Center for Telepsychiatry and In a March 2014 study of the mitments to local hospitals or state e-Behavioral Health. All hospitals program, the North Carolina psychiatric hospitals decreased licensed to operate in North Carolina Center for Public Policy Research by 33 percent. are allowed to participate. Of North found that the use of telepsychia- • Eighty-eight percent of patients Carolina’s 108 hospitals, 49 already try so far in the state shows that agreed or strongly agreed that they are providing telepsychiatry. By July patients spend less time waiting were satisfied with the telepsychia- 2015, the remaining 59 hospitals in hospital EDs and have a lower try services they received.

Improving Quality of Care and were associated with better survival rates Consultant for Telehealth Services for Patient Satisfaction for patients and reduced hospital lengths the VHA, reported that telehealth servic- There is a growing body of research of stay.15 Significant improvements in the es in its post-cardiac arrest care program illustrating that use of telehealth can quality of care for seriously ill and injured resulted in a 51 percent reduction in significantly improve the quality of children treated in remote rural EDs hospital readmissions for heart failure patient care. Research conducted in 2013 also were achieved by using telehealth and a 44 percent reduction in readmis- on nearly 120,000 adult patients from consultations with pediatric critical-care sion for other illnesses. In addition to 56 ICUs in 32 hospitals belonging to 19 medicine physicians at the University of improved patient care, veterans reported U.S. health-care systems concluded that California, Davis Children’s Hospital.16 patient satisfaction levels of 84 percent ICU telehealth interventions, especially For several years, the Veterans for the home telehealth services provided those that increase early intensivist case Health Administration (VHA) has used through the program. VHA’s Clinical involvement, improve adherence to ICU telehealth for home health monitoring Video services with real-time video con- best practices, reduce response times to to track vital signs and conditions for ferencing between VA medical centers alarms and encourage the use of per- patients with chronic diseases or who and VA Community Based Outpatient formance data. In addition, the overall have been released recently from the Clinics also were rated highly, with effects of ICU telemedicine programs hospital. Adam Darkins, former Chief a 94 percent patient satisfaction rate.17

5 THE PROMISE OF TELEHEALTH FOR HOSPITALS, HEALTH SYSTEMS AND THEIR COMMUNITIES TRENDWATCH

Partnership Extends Medical University of South Carolina Care to ICU Patients in Rural Counties

In August 2013, the Medical to MUSC from the state of South present a patient’s condition to a University of South Carolina Carolina. Through the partner- MUSC physician in real time via (MUSC) launched a telemedicine ship, telemedicine and tele-ICU sophisticated video conferencing partnership with Advanced ICU care is provided at community and equipment.13 MUSC board-certified Care. The partnership with the rural hospitals to help patients with critical care doctors, also called nation’s largest tele-intensive care life-threatening conditions in rural intensivists, virtually treat the unit (ICU) provider was made pos- counties. Medical staff on-site at patients without needing to trans- sible in part by a $12 million grant the rural hospitals are able to port them to another hospital.

Telehealth Growth and Expansion Telemental Health Center to patients at (CMMI) for the purpose of testing Applications of telehealth technologies 53 sites in 16 Veterans Integrated Service “innovative payment and service delivery are filling the need for critical health Networks and 24 states. The scope of the models to reduce program expenditures care services in a variety of specialty areas VHA’s telemental health services includes …while preserving or enhancing the and across diverse patient populations. all mental health conditions with a focus quality of care” for those individuals who Some of the most common conditions on post-traumatic stress disorder, depres- receive Medicare, Medicaid, or Children’s for which patients seek telehealth services sion, compensation and pension exams, Health Insurance Program (CHIP).20 are acute respiratory illnesses and skin bipolar disorder, behavioral pain and One of the models being evaluated is problems, but the list of possible uses of evidence-based psycho­therapy.19 It can be the Medicare Shared Savings Program telehealth technologies continues to grow. assumed that the need for these services (MSSP), which focuses on coordination As patients become more proactive in will continue to grow as more veterans and cooperation among providers to their health care delivery choices, utiliza- with physical and behavioral health care improve the quality of care for Medicare tion of telehealth services will increase needs return from Afghanistan, Iraq and fee-for-service (FFS) beneficiaries and from an estimated 250,000 patients in other military operations. reduce unnecessary costs. Eligible 2013 to an estimated 3.2 million patients providers, hospitals and suppliers may in 2018.18 Advancing Telehealth through participate in the MSSP by creating or As previously mentioned, the VHA New Health Care Delivery Models participating in an Accountable Care has been a leader in implementing and The Affordable Care Act (ACA) Organization (ACO). Participating extensively using telehealth across 151 has accelerated the use of telehealth ACOs are encouraged to use telehealth VHA Medical Centers and over 700 technologies by incentivizing Medicare- technologies and remote monitoring as Community Based Outpatient Clinics. participating hospitals and other a means to help them meet the goals of In FY 2013, more than 600,000 patients providers to test and implement vari- improving quality and reducing costs. participated in 1,700,000 telehealth ous types of clinically integrated care On Dec. 1, 2014, the Centers for episodes of care. This included 2,893 models. Congress created the Center Medicare & Medicaid Services (CMS) video encounters by the VHA National for Medicare and Medicaid Innovation issued a proposed rule that would

“Telehealth services in the Veterans Health Administration post-cardiac arrest care program reduced hospital readmissions by 51 percent for heart failure and 44 percent from“ the ” field for other illnesses.” – Adam Darkins, former chief consultant for Telehealth Services, Veterans Health Administration

6 THE PROMISE OF TELEHEALTH FOR HOSPITALS, HEALTH SYSTEMS AND THEIR COMMUNITIES TRENDWATCH

update and improve policies governing a more narrow view. It imposes geographic therapist, physical therapist or speech the MSSP and reinforce the agency’s restrictions to care and limits on provid- language pathologist. It also would have commitment to the use of telehealth ing telehealth services at home or other extended Medicare coverage to remote technologies. In the rule, CMS proposes locations, such as walk-in health clinics.22 patient management services for certain requiring an ACO to describe in its Legislative and regulatory changes are chronic health conditions. In addi- application how it will encourage and needed to reconcile current Medicare law tion, the legislation would have autho- promote the use of technologies such and the ACA’s encouragement of using rized additional sites to be covered by as telehealth services to improve care telehealth health services to help to reduce Medicare, removing many of the current coordination for Medicare beneficia- Medicare care costs. geographic barriers. ries. Noting that ACOs currently have It should be noted that several flexibility to use telehealth services as Congressional legislative proposals have Employer-driven Telehealth they deem appropriate for their efforts been introduced that address Medicare Employers also are driving the growth to improve care and avoid unnecessary coverage of telehealth services. In the of telehealth services. Some employers costs, CMS is seeking information from 113th Congress, for example, the are choosing to offer their employees ACOs and other stakeholders about Medicare Telehealth Parity Act of access to telehealth services, such as those the use of such technologies, particu- 2014 (H.R. 5380) was introduced by offered by Teladoc, Inc., a telehealth larly the specific telehealth services and Rep. Mike Thompson (D-Calif.). The provider with a national network of functions that might be appropriately bill would have authorized additional physicians who are U.S. board-certified adopted by ACOs.21 telehealth providers, including a certified in internal medicine, pediatrics and fam- Current Medicare law governing the diabetes educator or licensed respira- ily medicine.23 Employees may contact FFS (traditional) Medicare program takes tory therapist, audiologist, occupational physicians via telephone or online video

Mayo Clinic’s Plan to Bring a Medical Kiosk to its Employees

Mayo Clinic has launched a pilot up to the kiosk without scheduling more-affordable care.” program to bring health care provid- an appointment and be treated for The pilot project is expected to ers into the workplace using tele- minor, common health conditions “decrease absenteeism, lower costs health kiosks. The first “Mayo Clinic by doctors, nurse practitioners and and increase wellness, a win-win for Health Connection” kiosk is located physician assistants from both Mayo employers and employees,” Bernard on the Mayo Clinic Health System Clinic and Mayo Clinic Health said. Initially, the kiosk system will campus in Austin, approximately 40 System,” said Matt Bernard, M.D., be available to approximately 2,000 miles west of Mayo’s main campus Southeast Minnesota region Primary Mayo employees and their depen- in Rochester, Minn. The planning Care Service Line chairman. “Mayo dents. Negotiations are underway for the pilot program began in early is committed to reducing health care with other organizations interested 2014, and the first patients will be expenses for employees and employ- in using the Mayo Clinic Health seen by the end of 2014.27 ers by improving access to medical Connection to help drive down their “Patients can conveniently walk services through convenient and health care costs.

“Patients can conveniently walk up to the kiosk without scheduling an appointment and be treated for minor, common health conditions by doctors, nurse practitioners and physician from“ the ” field assistants from both Mayo Clinic and Mayo Clinic Health System.” – Matt Bernard, M.D., Mayo Clinic regional primary care service line chairman

7 THE PROMISE OF TELEHEALTH FOR HOSPITALS, HEALTH SYSTEMS AND THEIR COMMUNITIES TRENDWATCH

for diagnosis, recommended treatment reducing the time taken by employees offer telehealth services, and an additional and prescribing medication for many to see physicians in person.24 Employers 37 percent of employers expect to offer common, non-emergent medical issues. also save money on primary care or ED such services to employees by 2015.25 U.S. Employers that offer employees access to visits, and costs related to these health care employers could save up to $6 billion per telehealth services have an opportunity encounters. Almost a quarter of employers year by making these telehealth technolo- to increase employee productivity by with 1,000 or more employees currently gies available to their workforces.26

Coverage and Payment for Telehealth Services

Few obstacles present greater challenges services provided via telehealth the same geographic area or a predefined list of for providers seeking to improve patient way they would for services provided qualified services.30 care through telehealth technologies in-person. than coverage and payment for tele- Virginia and New Mexico are two Medicaid health services. Whether public and states that have created a regulatory envi- A 2014 report by the Center for private payers cover telehealth services ronment that encourages the availability Connected Health Policy noted that and adequately reimburse hospitals and and provision of telehealth services, 46 state Medicaid programs, both other health care providers for providing including providing telehealth coverage fee-for-service and Medicaid managed those services is a complex and evolving for their state employee health plans. care, have some form of coverage for issue and, as a result, a possible barrier Two additional states – Arizona telehealth services, such as for remote to adopting such services. Providers that and Colorado – have enacted partial patient monitoring (13 states). Live also have their own health plans may parity laws that require coverage of and video is the most frequently covered find it easier to deploy telehealth because reimbursement for telehealth services. telehealth service, while store-and- they control their coverage guidelines However, coverage is limited to a certain forward services are defined and and can benefit from the cost savings. A baseline question with respect to provider payment for telehealth services Twenty states and the District of Columbia have enacted is whether the payer covers telehealth parity laws requiring insurers to cover telehealth services. services at all. On the public payer front, inconsistencies exist. For example, Chart 4: Private Payer Coverage and Reimbursement for Telehealth Services Medicare’s policies for coverage and payment for telehealth services lag far behind other payers due to its restric- tive statutes and regulations. Many state Medicaid programs cover telehealth services to some extent, although the criteria for coverage vary widely from state to state. On the private payer side, by contrast, there has been significant expansion with many states passing laws requiring private payers to provide coverage for telehealth services.

Private Payers According to the ATA, 20 states and the District of Columbia have enacted “parity” laws, which generally require health insurers to cover and pay for Full Parity Partial Parity No Parity

8 THE PROMISE OF TELEHEALTH FOR HOSPITALS, HEALTH SYSTEMS AND THEIR COMMUNITIES TRENDWATCH

UVA Center for Telehealth

The University of Virginia’s (UVA) technology, UVA specialists meet to care with innovative solutions. Center for Telehealth (part of virtually with patients to discuss the Among these solutions are mobile the University of Virginia Health best treatment plans.28 telehealth applications and patient System) has grown rapidly since its The center has measured its monitoring programs.” Financially, inception in 1994. Currently, the success via patient satisfaction data the center has a nearly sustainable Center partners with 132 hospitals, by the number of miles of travel program from patient consult reve- clinics, Community Service Boards avoided by patients and clinical nues and video-teleconferencing sup- (CSBs), health department sites, process metrics. To date, the center port fees. “If you factor in reduced schools, federally qualified health has provided 40,884 total telehealth penalties for hospital readmissions or centers (FQHCs), skilled nursing services and saved 14,789,738 miles downstream revenues from patient facilities (SNFs), dialysis facilities in travel for patients. Furthermore, transfers, the institution is more and a home telehealth company. hospital readmissions have decreased than made whole by the program,” These networks have supported more through UVA’s Care Coordination explained Rheuban. than 40,000 patient encounters in Remote Patient Monitoring program Public policies have helped to more than 45 sub-specialties across by more than 40 percent. better integrate use of telehealth the Commonwealth of Virginia. As the center’s programs con- services into mainstream health care UVA’s health partners send impor- tinue to develop, its director, Karen in Virginia by allowing for reim- tant health information directly to Rheuban, M.D., anticipates even bursement from the state’s Medicaid UVA specialists, who review the more robust growth. “With favorable program and a legislative mandate information before meeting with public policies in our state, we are in requiring parity of third party pay- patients. Using teleconferencing a position to greatly increase access ments for telehealth services.29

reimbursed by only a handful of state in, or who use telehealth systems in, (such as physicians, nurse practitioners Medicaid programs. State Medicaid eligible facilities located in rural Health and clinical psychologists) can provide programs rarely cover e-mail, telephone Professional Shortage Areas, either the services. and fax consultations, unless they are located outside of a Metropolitan • Medicare provides coverage only for a used in conjunction with some other Statistical Area (MSA) or in a rural small, defined set of services (including type of communication. Twenty-four census tract, as determined by the consultation, office visits, pharmaco- states pay providers either a transmis- Office of Rural Health Policy within logical management and individual sion or a facility fee, or both. A few the Health Resources and Services and group diabetes self-management states have adopted the Medicare policy Administration (HRSA); or in a training services).32 that restricts coverage to only telehealth county outside of an MSA. For services that meet these crite- services that are provided in rural or • Medicare does not cover telehealth ria, hospitals are paid a facility fee of underserved areas.31 services provided via store-and- approximately $25 for each claim to forward technology, except in Alaska cover services provided to patients in an Medicare and Hawaii. inpatient or hospital outpatient clinic Medicare’s restrictive coverage and reim- • Telehealth services will be covered only setting. Off-site hospital-owned sites bursement policies for telehealth services if the beneficiary is seen at an approved also are considered “facilities” in the result from the program’s narrow defini- “originating site” authorized by law context of a facility fee.33 Professional tion and scope regarding telehealth: (including physician offices, hospitals fees for provision of telehealth ser- • Telehealth services may be provided and skilled nursing facilities). vices are the same as those paid for an only to Medicare beneficiaries who live • Only Medicare-eligible providers in-person encounter and are based on

9 THE PROMISE OF TELEHEALTH FOR HOSPITALS, HEALTH SYSTEMS AND THEIR COMMUNITIES TRENDWATCH

Geisinger Remote Patient Monitoring Reduces Readmissions and Cost of Care

Geisinger Health Plan (GHP), enabling them to quickly identify and significant reductions in all-cause a regional full-service managed care focus on those patients facing greater admissions, 30-day and 90-day read- organization serving patients residing needs on a given day. With the near missions, and cost of care. In a given mainly in rural central Pennsylvania, real-time data collected via the tele- month of the study, patients enrolled developed and has operated a focused monitoring program, case managers in the program were 23 percent less heart failure telemonitoring program are able to identify biometric readings likely to experience a hospital admis- since March 2008. The program is or IVR responses that are out of sion. The odds of experiencing a used to help extend the case manager’s specified ranges and send an alert to 30-day readmission were 44 percent reach for monitoring individuals at the patient’s primary care provider. lower and the odds of experiencing a risk of heart failure. The case manager then collaborates 90-day readmission were 38 percent GHP gives patients Advanced with the primary care team to address lower than patients not enrolled in Monitored Caregiving Bluetooth the situation, which may include the telemonitoring program.35 scales with an Interactive Voice setting up follow-up appointments, Also, implementation of Response (IVR) system that is activation of a patient-specific medi- the program was associated with used with landline or cellular phone cation management plan, reinforce- approximately 11 percent cost service to transmit weight measure- ment of self-management activities savings during the study period. ments and to take the IVR calls. such as diet, or other updates to the The estimated return on investment The IVR system includes a list of care plan as necessary. associated with the telemonitor- questions specifically designed to GHP researchers reviewed claims ing program was approximately detect changes in physical condi- data for patients enrolled in the heart $3.30 return in terms of cost savings tion indicating exacerbation, such as failure telemonitoring program from accrued to GHP for every $1 spent shortness of breath, swelling, appetite January 2007 through October 2012.34 to implement the program. and prescription management. Even though the telemonitoring These findings suggest that One of the key elements of case program officially started in March the GHP telemonitoring program management is timely follow-up and 2008, the study period included one provides a potentially useful tool appropriate touch points with the year prior to the official start date for disease and case management patients. The telemonitoring program to capture any baseline trends and of those patients who are likely to is an important asset to case manag- preintervention claim patterns. The benefit from frequent and regular ers, increasing their efficiency by results of the claims review indicate monitoring by health care providers.

the Medicare physician fee schedule. psychotherapy services, extended Medicare’s intention to expand its cover- Beginning Jan. 1, 2015, Medicare will office visits, chronic care management age for telehealth services, but significant cover and pay for several additional and remote patient monitoring of geographic restrictions remain. However, services when provided via telehealth, chronic conditions. These additions changes to the geographic restrictions including certain wellness visits, to the list of telehealth services show require Congressional action.

“The tool that we’re introducing into your everyday life is a direct communication line to your care team … your case manager is going to get the information that’s being collected through from“ the ” field this call, or when you step on the scale.” – Doreen Salek, Geisinger health plan’s director of population management operations

10 THE PROMISE OF TELEHEALTH FOR HOSPITALS, HEALTH SYSTEMS AND THEIR COMMUNITIES TRENDWATCH

Provider-based Health Plans Kaiser Permanente Northern California has offered virtual visits Generally, provider-based health plans to enhance access to care and service to patients. are more favorable to telehealth strategies because they are not subject to private Chart 5: In-Person and Virtual Patient-Physician Visits, Kaiser Permanente or public payer coverage rules. Further, Northern California, 2008–13 cost savings that are realized from telehealth

accrue to the provider-based health plan. 20 Office Visits Virtual visits (telephone and secure e-mail) For example, in 2008, Kaiser Permanente of Northern California (KPNC) imple- 15 mented an inpatient and ambulatory care electronic health record system for its 3.4 million members and developed patient- 10 friendly telehealth tools using phone, email Millions of visits and video. The number of virtual “visits” 5 grew from 4.1 million in 2008 to 10.5 million in 2013. KPNC has found that the 0 advantages resulting from the telehealth 2008 2009 2010 2011 2012 2013 technologies have been central to its efforts to achieve superior quality and service while 36 Source: Internal data from Kaiser Permanente Northern California. Note: Virtual visits are encounters via telephone or keeping costs competitive. secure e-mail; they do not include video visits. aEstimated values based on data for the first three quarters of the year.

Conclusion

Hospitals and health systems are adopt- date, there is no consensus on criteria improve their performance and pro- ing telehealth technologies to provide or reimbursement rates for telehealth vide greater convenience and value to convenient access for patients and services, while payers are concerned patients. As new health care delivery these technologies hold great promise that paying for virtual visits in a fee- and payment models evolve, and the to increase access and patient satisfac- for-service system may increase volume systems to support the use of new tion. However, implementation has and costs.37 technologies improve and become less been hampered by operation challenges, The implementation and effective costly, telehealth offers the potential as well as the confusion caused by the use of Internet, mobile and video to improve the efficiency, convenience patchwork of reimbursement rules and technologies offer hospitals, physi- and cost-effectiveness of our health rates for public and private payers. To cian groups and health plans ways to care system.

POLICY QUESTIONS

Legal and regulatory barriers affect the ability of hospitals to initiate • What state insurance, state medical board or Medicaid or expand their telehealth services. Hospitals can work with federal policy changes are needed to allow clinicians in addition to and state policymakers to address how to remove these obstacles. physicians, such as advanced practice nurses and physician Hospitals also need to fully analyze other legal and regulatory chal- assistants, to provide telehealth services? lenges implicated by the use of telehealth technologies, many of • How can hospitals encourage states to enact full parity laws which are addressed in the second part of this TrendWatch series. that require private health insurers to pay for services provided • How can Medicare accelerate its coverage of telehealth via telehealth the same way in-person services are paid? services to address increased demand? • How can hospitals and health systems collaborate with state • How restrictive are state Medicaid policies regarding policymakers to develop effective telehealth networks to increase coverage of and payment for telehealth services? access to limited health care services, such as telepsychiatry?

11 ENDNOTES

1. AHA Annual Survey, Health Information Technology Supplement. (2013) 21. Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations, 2. NTT Data, Trends in Telehealth (2014), available at http://americas.nttdata.com/ CMS-2014-0155-0001, 12/02/2014 Industries/Industries/Healthcare/~/media/Documents/White-Papers/Trends-in-Telehealth- 22. Pub. L. No. 111-148 (Mar. 23, 2010), as amended by the Health Care and Education White-Paper.pdf; Survey: 76% of Patients Would Choose Telehealth Over Human Reconciliation Act of 2010, Pub. L. No. 111-152 (Mar. 30, 2010). As amended by Contact, available at http://hitconsultant.net/2013/03/08/survey-patients-would-choose- ACA, Section 1899(b)(2)(G) of the Social Security Act provides that ACOs “shall define telehealth-over-human-contact/. processes to promote evidence-based medicine and patient engagement, report on 3. Survey: 76% of Patients Would Choose Telehealth Over Human Contact, available quality and cost measures, and coordinate care, such as through the use of telehealth, at http://hitconsultant.net/2013/03/08/survey-patients-would-choose-telehealth-over- remote patient monitoring, and other such enabling technologies.” human-contact/. 23. Telehealth Special Report: Health Care and Business, Teladoc Inc, June 14, 2012 4. 42 CFR 410.78 http://www.teladoc.com/employers/resource/telehealth-special-report-health-care- and-business/ 5. Medicaid.gov description of Telemedicine http://www.medicaid.gov/medicaid-chip- program-information/by-topics/delivery-systems/telemedicine.html 24. Caryn Freeman, Analysts say Telemedicine Can Cut Costs, Boost Productivity by Reducing Doctor Visits, Bloomberg BNA (Sept. 2014), available at http://www.bna.com/ 6. NTT Data, Trends in Telehealth (2014), available at http://americas.nttdata.com/ analysts-say-telemedicine-n17179894561/. Industries/Industries/Healthcare/~/media/Documents/White-Papers/Trends-in-Telehealth- White-Paper.pdf. 25. Jonah Comstock, Employer Use of Telemedicine to Rise 68 Percent by 2015, Mobi Health News (Aug. 2014), available at http://mobihealthnews.com/35737/ 7. NTT Data, Trends in Telehealth (2014), available at http://americas.nttdata.com/ employer-use-of-telemedicine-to-rise-68-percent-by-2015/. Industries/Industries/Healthcare/~/media/Documents/White-Papers/Trends-in-Telehealth- White-Paper.pdf. 26. Towers Watson, Current Telemedicine Technology Could Mean Big Savings, available at http://www.towerswatson.com/en-US/Press/2014/08/current-telemedicine- 8. Akanksha Jayanthi. The Rise of mHealth: 10 Trends. Becker’s Health IT and CIO Review technology-could-mean-big-savings. 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