The Business of Telemedicine

Transcription

1 The Business of Telemedicine Nancy S. Rowe Associate Director, Outreach Arizona Telemedicine Program Industry Overview Telemedicine is Huge! Success stories abound telemedicine saves lives Direct to consumer services are big: > 330 registered for American Telemedicine Association accreditation (5 accredited so far, more expected by end of year) UnitedHealthcare: Partnered with 3 DTC companies and plans to cover 21 million consumers by 2016 Retail clinics: CVS, Walgreens, Walmart, RiteAid, Whole Foods. Finance: Telehealth & mhealth companies raised $366 million in 2 nd Qtr 2015 (Mercom Capital) Teladoc raised more than $270 million during its IPO July 1,

2 Telemedicine is Growing & Popular! 2 million online consultations this year (per IHS, Inc.) between PCPs and their patients, expected to grow to 5.4 million by 2020 Total number of virtual consults is growing 10% per year (IHS, Inc.) Specialist visits are projected to jump from 14.5 million this year to 21.5 million in 2020 (IHS, Inc.) CVS pilot program found >90% patient satisfaction with telehealth sessions at MinuteClinics (Journal of General Internal Medicine) NPR story on telemedicine expansion, Mercy Virtual Telemedicine Is Affecting Legislation & Policy Private payers: 29 states + DC now have telemedicine parity laws The Office of the National Coordinator for Health Information Technology (ONC) calls for strong mhealth implementation in its justreleased Federal Health IT Strategic Plan for Notes telehealth & remote monitoring technologies help improve healthcare in rural communities Includes maximizing availability of broadband services to all H.R.2066: Telehealth Enhancement Act of 2015 introduced ATA involved in national & state telehealth policy initiatives; Center for Connected Health Policy monitors state & national legislation Getting Started 2

3 Key Steps / Best Practices Conduct Needs Assessment/Readiness Assessment Define Services, Program Model, Technology Model Develop Business Model Develop Detailed Implementation Plan Develop Performance Monitoring Plan TRC Telehealth Program Developer Kit attachments/complete program developer kit 2014 web1.pdf Return on Investment Revenue Patient services reimbursement Medicare facility fees Ability to reach more patients Possible grants & contracts (sustainability plan needed) Possible support by parent organization (sustainability plan needed) Possible user fees (to distribute fixed expenses & use network/equipment) Savings (e.g., physician travel time & costs, patient transports) Penalty avoidance (e.g., fewer hospital readmissions) 3

4 Return on Investment Strategic contributions Patients / providers don t have to travel; providers can see more patients Better access to care: Local, emergency, specialist consults Referring docs learn from specialists Fewer referrals to large healthcare systems Value added, expanded market base Physician recruitment (larger pool) & retention (live where they want) Increased physician continuity Network availability for other services (meetings, education) Better communication, team treatment model Fewer patient no shows Expenses: Technology Who will provide the platform & how much will it cost? (equipment, installation, travel, training) Space Network/transmission Equipment maintenance contracts, upgrades, refresh, license renewal Expenses: Personnel Who will provide tech support (esp. to home based providers)? Your staff Service provider partner Centralized program staff Will additional staff time be needed to cover new/additional workflows? Medical director Program coordinator Site coordinators Technical Clinical Administrative 4

5 Offsetting Costs: FCC Universal Service Fund Rural Health Care Fund: rebates on telecommunications connections for healthcare information, including telemedicine sessions Includes internet access Providers must be eligible 65% flat rebate or the difference between urban and rural rates Applying is cumbersome but well worth the effort Telemedicine Reimbursement Medicare Reimbursement: The Good Covers real time, 2 way interactive video (no phone, , fax) Covers store and forward services such as radiology (not considered telemedicine) Remote patient monitoring for chronic disease management now covered (not rural only, not considered telehealth CPT code 99490) Medicare Telehealth Services fact sheet (& list of HCPCS/CPT codes) 5

6 Medicare Reimbursement: The Good Reimbursement to health professional is same as current fee schedule amount for non telehealth service provided Must use the telehealth modifier GT Pays telehealth originating site facility fee per patient session The lesser of 80% of the actual charge or $24.83 (2015) In addition to the CPT code (separately billable Part B payment) Need to bill it: HCPCS code Q3014 (PATIENT site, not provider, bills) Medicare Reimbursement: The Bad Practitioner must be physician, NP, PA, nurse midwife, clinical nurse specialist, clinical psychologist* or clinical social worker*, or registered dietitian or nutrition professional *Clinical psychologists and CSWs cannot bill for psych diagnostic interview exams with medical services or medical eval and management services Patient must be in a hospital, FQHC, RHC, CAH, practitioner s office, SNF, CMHC, or dialysis center (originating site) Currently, beneficiary must be in a rural HPSA or a county outside a Metropolitan Statistical Area Medicare Telehealth Payment Eligibility Analyzer Back to Finance Medicaid Reimbursement: Overview Medicaid rules for telemedicine & telehealth coverage vary by state 47 states + DC reimburse for live video telemedicine (Arizona does) 16 states reimburse for remote patient monitoring (Arizona does not) 29 states pay a transmission or facility fee (Arizona does not) 27 states require a specific informed consent (Arizona does) Reimbursement for Medicaid covered services must satisfy federal requirements for efficiency, economy, and quality of care. 6

7 ATA State Telemedicine Gaps Analysis Reimbursement: The Good No prior authorizations needed A grade: patient setting/location not specified as a condition of payment Non emergency transportation to/ from spoke site (a.k.a. originating site) for medically necessary consultation is covered American Telemedicine Association, 2015 Medical Policy for AHCCCS Covered Services, Policy 320 I, Telehealth and Telemedicine (p. 178 of PDF) Back to Finance Reimbursement: The Good Covers medically necessary real time services via telemedicine for: Cardiology Pathology Dermatology Pediatrics & pediatric Endocrinology subspecialties Hematology/oncology Radiology Infectious diseases Surgery follow up & consultations Neurology Behavioral health Obstetrics/gynecology Diagnostic consultation & evaluation Psychotropic medication Oncology/radiation adjustment/monitoring Ophthalmology Individual & family counseling Orthopedics Case management Pain clinic 7

8 Reimbursement: The Bad Store and forward limited to dermatology, radiology, ophthalmology & pathology (and subject to review) Provider types: Physician, registered NP, PA, certified nurse midwife, clinical psychologist, LCSW, licensed marriage & family therapist, licensed professional counselor American Telemedicine Association, 2015 Telepresenter requirement: Reimbursement: The Ugly Patient s PCP, attending physician, other medical professional employed by PCP must be present For behavioral health, patient s physician, case manager, BH professional or telepresenter must be present NOT reimbursed unless performing a separately billable service (e.g., EKG, x ray) American Telemedicine Association, 2015 Arizona Parity Legislation, SB 1353: The Good Health insurers must cover services provided through telemedicine if they would be covered as an in person service Insurers may impose deductibles, copays, coinsurance if not > than those for in person Text of law 8

9 SB 1353: The Bad Considered partial parity law Rural only: Enrollee is in: County with < 900,000 persons City or town in a county with > or = 900,000 population at least 30 miles from a city of 500,000 or more (Phoenix and Tucson) American Telemedicine Association, 2015 Eligible services are limited: Trauma, burn, cardiology, infectious disease, mental health disorders, neurologic diseases including strokes, & dermatology Doesn t specifically include payment parity: At least one AZ private payer reimburses tele providers only 80% of the fee for the same service delivered in person Creates a disincentive for providers States with specific payment parity language include VA, DE, NM Telemedicine Report Cards (ATA) Telemedicine Reimbursement: Other Payers DOC and other agencies TriCare & Champus (active military) follows Medicare VA has own system State exchanges, per ACA, are supposed to cover telehealth/telemedicine (part of the alternative payment methods provision effective 2017) Healthcare insurers of federal employees (e.g., BCBS Federal Employee Program) Self pay (popular with DTC telemedicine services) 9

10 Patient Services Reimbursement Insurer billing & collections are still generally not a good primary mechanism to pay for a telemedicine program UNLESS It is a closed or capitated clinical environment where significant cost savings can be realized OR It is viewed as a Loss Leader Regulatory Issues Telemedicine Law All the laws still apply regardless of whether the healthcare service takes place in person or via telemedicine: HIPAA Privacy & security Licensing Anti kickback Liability Standard of care 10

11 Credentialing & Privileging of Tele providers CMS Proxy Credentialing Rule: Allows medical staff of hospital where patient is being treated via telemedicine to rely on the credentialing and privileging done at the Medicare certified hospital where the telemedicine practitioner is located and credentialed Written agreement required Streamlined: Obtaining medical staff privileges at a hospital takes 2 3 months May require hospital bylaw amendment Or retain complete credentialing of all telemedicine providers using existing credentialing process Medical Malpractice & Telemedicine Coverage for telemedicine may not be included in standard medical malpractice policies: ask your insurer Mitigate risk with strong provider credentialing practices and training specific to telemedicine delivery Adopt same quality assurance and peer review practices as with your in person models Stark & Anti Kickback Statutes Stark Law prohibits physicians from referring patients for designated health services to an entity with which the physician has a financial relationship. AKS prohibits offering or soliciting anything of value, directly or indirectly, in return for patient referrals. Telemedicine may be subject to fraud and abuse laws if the use directly or indirectly generates reimbursement from a federal health program. Equipment leases or the provision of free telemedicine equipment to referral sources should be evaluated under fraud and abuse laws. 11

12 Security & Privacy Protect not only the electronic health information, but the physical setting of the encounter Secure the session: HIPAA compliant platform, BAA Encrypt Ensure no one else can enter the call Train patient site staff to understand equipment: Turning off TV does not turn off camera and microphone Keep a lens cover over the camera Set to auto answer mute Arizona Telemedicine Laws: Overview Telemedicine provider must be licensed in Arizona Informed consent is required for telemedicine services Written or verbal (verbal must be documented on patient medical record) Not needed for emergency where unable to give informed consent; transmission of diagnostic images or test results; interactions where patient is not physically present Medicare, FSMB, and AZ allow establishment of physician patient relationship via video (2 way live interactive, IDs, credentials, consents) AZ: This applies to prescribing (SB1339, 2014) TRC State Law & Reimbursement Resource Center for Connected Health Policy Can search each state for specific areas of types of laws & status 12

13 Finding Partners Service Provider Directory Provides detailed information to help you compare possible clinical service provider partners Searchable Listings are vetted: Provides medical or ancillary services via telemedicine Provides services to healthcare and other entities (not only direct to consumer) Visit the directory Service Provider Showcase (SPS) Focuses on linking service provider companies with entities that need their services Nationally known speakers Expo hall For more information 13

14 Questions? Nancy S. Rowe Associate Director, Outreach Arizona Telemedicine Program