March 28, William T. Johnson, J.D., LL.M., CEO, Telemedicine Centers USA

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1 March 28, 2016 Strategic Business Case for Telemedicine Technology Partnership Focused on Providing Multicultural Sensitive Health Care to Underserved Community Residents William T. Johnson, J.D., LL.M., CEO, Telemedicine Centers USA We are five years into the Affordable Care Act (ACA), and the numbers of the US population with unmet critical health care needs and suffering from both undiagnosed and poorly managed multiple chronic conditions are still increasing. The costs in fines, penalties and provider s losses in patient billing and payments within the US health care system s hospitals, health insurers, managed care plans, and physician practices are becoming permanent pain points. Too many providers are still unable to integrate patient centered primary care services with behavioral care management, or are ill equipped to reduce excessive hospital readmissions and avoidable ER use. Hence, poor post-discharge care transitions and inadequate capability to manage or support coordinated integrative community facing provider access to patient s ambulatory care needs now reaches in excess of $400 billion annually. Plainly, the business models guiding the operations of the health care delivery apparatus conflates a number of different financial, social and economic issues absent the focus of historical facts resulting in systemic US health disparities, and the academic research lens disclosing that each patient and their care situation is not identical or lends itself to SOP. The fact is we evolved from the first US hospital openings in 1747 to today s 5546 hospitals in the 21 st century supported by 992 thousand US doctors, tasked to care for the fast growing, aging and vastly dispersed 341 million populations. This is a significant access and timely services delivery challenge for a health care system that has to serve the interests and needs of a multiracial and multilingual society also still stratified and divided by social and income factors, while much of the residents face health education and literacy barriers, and technology challenges. With more than half of the total population suffering from multiple chronic care conditions and behavioral treatment issues, there is no doubt this critical situation requires a shift in the paradigm of hospital. As noted by the Centers for Disease Control, medical and health policy scholars, the Institute of Medicine, and even the American Hospital Association itself; the public is alarmed that hospitals have now become the third leading cause of death in the US. This exacerbates a widely acknowledged lack of trust by the public and patients of hospitals, doctors and insurers, as well as creates and feeds the fear that provider s focus on profit self-incentives over-ride patient s interests. This also compels care delivery system reforms implementing affordable technology-driven care supported by trusted community integrated resource partnerships offering transparency, patient care participation, community health education and access to affordable provider choices especially so in serving multicultural communities. 1

2 Black and Multicultural Population Excessive Hospital Readmissions, High Avoidable ER Use and Preventable Deaths, Require Lean Thinking and Patient-Community Partnerships In 2011, the United States placed last among 16 high-income, industrialized nations when it comes to deaths that could potentially have been prevented by timely access to effective health care according to a Commonwealth Fund study. According to the study, other nations lowered their preventable death rates an average of 31 percent between and , while the U.S. rate declined by only 20 percent, from 120 to 96 per 100,000. At the end of the decade, the preventable mortality rate in the U.S. was almost twice that in France, which had the lowest rate 55 per 100,000. Former US Surgeon General Satcher before his retirement lamented that the existing US racial health care disparity gap between Black and white Americans is still increasing despite promises by US health system providers to self-improve, and that unless dramatic changes in equal access and treatments and reforms in health care delivery for Black people occur, close to 90,000 Black low-income underserved residents will die preventable deaths annually. Since then, after the ACA, it was believed as providers increasingly are held accountable for the total health status of their patients, new approaches, including the use of "population heath management" technology, would be playing a bigger role in improvement. While many said technology can be helpful to improve lives, five years after passing the ACA, there is ample evidence supporting why some remain skeptical that digital innovators are aligned with patient and provider needs. In a keynote address in 2015, U.S. Surgeon General Vivek Murthy said that in his travels around the country he hears "a sense of disempowerment that is deeply disturbing to me." Technology has the potential to help create a culture of prevention by giving people the tools to help them regain that lost power over their lives, he said. "I believe that technology can actually help us tackle so many problems in health that we see as insurmountable," Murthy said. The key challenges for those in the health innovation space, Murthy said, are: Making healthy choices more compelling and accessible; Developing ways to reduce health disparities; and Designing tools so the pursuit of health is a "team sport" to maintain motivation and reduce emotional isolation. Given the need for urgency in responding to and ameliorating the increasing gap in health disparities for millions of US low income Black and multicultural immigrants that can use innovative technology for delivering improved provider access and health care services impacting performance outcomes; serious concerns are being raised with respect to existing health system provider s failure to encourage, initiate and support introduction of care services 2

3 delivery innovations that address the fragile fast growing elderly Black and multicultural and multilingual sufferers of complex chronic conditions in critically underserved areas. In this context, from 2013 through 2015, ACA audits confirm that more than half of US hospitals experienced excessive readmissions rates and a sizable proportion of that number was particularly adverse to their underserved Black patients. Also this population more heavily resorted to costly ER care, and accounted for a higher proportion of preventable deaths. At the same time, US venture capital investments supporting new entrant health care entrepreneurs offering technology innovations introduced apps and services exceeded $10 billion. However, these product introductions for the most part are proving to not be aligned with the underserved community patient and provider needs. There exists a need for a new health care delivery services model aimed at supporting coordinated and remote management for this sector that is affordable, overcomes provider/patient technology barriers, and is private. Telemedicine Centers USA is a first mover telemedicine services integrator and care delivery company specifically focused upon the underserved multicultural patient population that substantially reside in rural and urban neighborhoods and communities lacking timely access to affordable and culturally competent providers. This 21% of the US population represents 2/3 rd of the total US $3.7 trillion dollar annual health care cost expenditures for the 341 million US populations. The nearly 40+ million US Black population account for an annual $37 billion in health care spend [not counting the Medicare/Medicaid direct expenditures paid to providers]. Importantly, low-income consumers are harder to reach and to serve in the traditional model of face-to-face care during typical working hours. They are more likely than others to lack stable housing, transportation, and if employed, many don t have work schedule flexibility. Many lack facility in English, and some are socially isolated. People in the safety-net population tend to have less consistent access to WiFi, which is increasingly becoming a necessity for connecting with education, health, and human service. The ACA encourages and support reimbursement and payments to health care providers that embrace innovative technologies that have been successful in connecting with underserved populations, including text messaging, home and community based patient-centered live and doctor video visits with PHI collection, remote management using integrated platforms for primary care and mental health services. WinterGreen Research in a 2015 report on the telemedicine market said: Telemedicine in the home is cheaper than the consequent emergency room visits and hospitalizations that occur if chronic conditions are ignored. With the transition underway from fee-for-service to provider performance documented value care service delivery supporting patient outcomes; there has been some provider movement to reach out to the underserved by adopting health apps, virtual access to free online doctorson-demand vendors using cell phones, and sprinkling into some underserved areas the access to branded or partnered staffed mini-er/urgent Care outlets for minor health care concerns. However, these episodic offerings do not address the huge minority and mostly multicultural populations suffering from multiple chronic conditions that are part of the 1.25 billion non- 3

4 institutionalized ambulatory patient visits that can t all be treated and managed in mini-ers or by a stranger doctor on a cell phone that has no way to appropriately manage their care. Telemedicine Centers USA complement providers that have established relationships to their patients for home direct doctor-to-patient supervised care visits. We install and monitor remote patient s vitals and telementry PHI into EMRs, support community based access to health care providers within population convenient locations to those residents without a usual place of care. Too often providers make assumptions about vulnerable populations' needs and capabilities, including the patients technological capabilities. Some interventions fail because they assume populations have more consistent access to WiFi or data than they have, and sometimes it might even be cost-effective for providers and health plans to pay for users' connectivity in some interventions-particularly where provisions for this cost is granted within ACOs, PCMHs and CMS authorization. Therefore costs to use technology are not the obstacle. Telemedicine Centers USA focus includes health literacy and language literacy. One anecdote in the WinterGreen report concerns a bilingual patient who mistook the English adjective "once" for the Spanish number "once" and took 11 pills more than her doctor prescribed. By the Telemedicine Center being anchored in the underserved communities and embed within trusted community institutions; it exist independently outside of the hospitals. This is especially important for health system providers to build the trust of underserved individuals, who might have concerns flowing from a personal history of bad experiences with government and social support programs that don't follow through. Hence, a Telemedicine Center working through and with the local community assets, including church leaders, educators, and with multicultural doctors, can help bridge the way to regain that trust from within this population. Clearly, there must be an inclusion of multicultural participation in fashioning what the AHA said needed to be a shared vision and renewed effort for achieving health care system services and access change in order to assure that lessons learned from the US health system s discriminatory past history is driving results today. Research answered the often ignored question: Is Race a Risk Factor in Hospital Readmissions? Findings from two studies published in the Journal of Hospital Medicine indicate that hospital patients who are African American and/or on Medicaid are at an increased risk of being readmitted to a hospital within a month of discharge. Also in 2011, it was revealed elderly Medicare black patients have a higher 30-day hospital readmission rate than white patients for several conditions including congestive heart failure and pneumonia, according to findings published in the Journal of the American Medical Association. Little wonder the health diversity gaps continue to increase annually. "Reducing readmissions has become a policy focus because it represents an opportunity to simultaneously improve quality and reduce costs, yet little is known about racial disparities in 4

5 this area" wrote the authors. Moving from hospital-centric transitional care models to home based and community care supported by technology innovations, and use of team management and coordination through partnering with community facing resources that can sustain the patient over time, demonstrably saves lives and health system costs. According to research, differences in hospital readmission rates are more closely linked to the patient socio-demographic and community factors than to poor hospital performance. Abundant evidence exists that poverty is strongly associated with poor health status and more hospital readmissions. These areas are often rural and urban environments with complex populations and dense zones of poverty, or broad regions of poverty, both with extremely high healthcare needs. While everyone living in the last mile is not poor, making better care available based upon ability to pay to access or gain use of the means deployed is contrary to the notion of equal access and opportunity for all to benefit from the massive subsidies and incentives being advanced to improve care for everyone community-wide. Already, health policy experts are now musing, despite strong evidence is compelling that patient-centered home and community based care delivery is best where PCPs make home visits to manage care for elderly and multiple chronic conditions sufferers: maybe this isn t worth the PCP s efficient use and cost of time to do this for everyone except for wealthy and Concierge patients willing to pay for it! It s of real concern to the millions of Black and immigrant multicultural underserved rural and urban residents that could easily be affordably supported by use of innovative technology entrepreneurs efforts that affordable cost telemedicine technology applications are not being implemented for their use. Other than one minority owned Midwest telehealth virtual doctorto-patient home service contract vendor, with investment capital from a health system; there are no telemedicine service providers in these critically medical underserved communities acting in partnerships with hospitals, health plans and ACO, PCMH provider organizations. There are several pay-as-you-receive-doctor-home-care visit vendors, like Heal and Mend, operating in selected areas across the nation. These home visit doctors have contracts supporting health plans/medicare Advantage and commercial health programs to lower the claims payment risks for this segment of the population that would otherwise cost a lot to serve in hospitals or by delayed doctor travel visits. Importantly, now that the ACA added expanded health insurance coverage to the underserved s millions of new insureds in the Medicare and Medicaid insurance programs eligible to participate in the value care performance payment arrangements [just like what nonblack insureds receive with identical health risks and status]; those newly launched doctor-to-patient home vendors are primarily focused upon healthy clients and serving selected patients in limited geographic communities. This is the same 5

6 redlining and two-tier discriminatory access system that undermine fairness and support the historical beliefs justifying distrust of providers and of the entire US health care system. Unless the health care system recognizes that its failure to introduce telemedicine technology delivery services into and for use by Black and multicultural low-income underserved community residents that can lower US health care system costs, prolong life and adherence to treatment plans, actually multiply by four the time use and efficiency of health providers [that both lowers provider care delivery cost and boosts the revenue opportunity from the increased number of patients that can be served]; there is danger of repeating the failed practices and discriminatory conduct of the well documented past contributing to the rising health disparity. US health care system executives and provider organizations should accept industry and governmental health policy experts urgings, supported by volumes of academic research that describe what is well known: without building trust in the underserved communities and with the patients that are unable to obtain access and provider services; health care disparity increases. A study in JAMA makes it clear that distrusted hospitals and providers that ignore these core facts when considering serving Black and multicultural communities and residents act at great risk of community indifference and wastefulness if provisions for multicultural competence, integrative community presence with trusted partners and multicultural providers and health workers and community resources in care delivery is not created and deployed. Our findings confirm the importance of racial and cultural factors in the patient-physician relationship and reaffirm the role of black and Hispanic physicians in caring for black and Hispanic patients. Improving cultural competence among physicians may enhance the quality of health care for minority populations. Racial inequalities in health care may be partly attributable to racial, cultural, and communication barriers between minority patients and white health care providers. Such barriers might arise from cultural or linguistic incongruity between patient and physician, from lack of mutual trust, or from racial discrimination. If these barriers existed, one might expect patients and physicians of similar racial or ethnic background to have better communication and more salubrious relationships than those of dissimilar background. Better relations might in turn lead to greater patient satisfaction and more effective use of the health care system. Now is the time to support millions of multicultural residents in the rapidly expanding majorityminority communities, including multicultural health providers burdened because of market competition and high cost to provide care under the ACA, and the difficulty in accessing affordable technology for ACOs and PCMHs for value care performance to play a larger role. 6