Value of telebehavioral health integration. Phil Hirsch President and CEO Access Psychiatry Solutions LLC

Transcription

1 Value of telebehavioral health integration Phil Hirsch President and CEO Access Psychiatry Solutions LLC

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4 The problem is NOT fundamentally one of workforce shortage It is a fundamental mal-distribution of resources and ineffective delivery of potentially effective treatment

5 Specialty track vs. primary care 90 Efficacy, effectiveness and adherence - Depression Bar = Specialty track Arrow = Primary or medical specialty clinic Percent Effectiveness Efficacy RTC Detection Concordance Compl-apts (12 weeks) Compl-meds (24 weeks) Adhere-meds Druss, BJ Miller, CL Rosenheck, RA Shih, SC Bost, JE (2002).Mental health care quality under managed care in the United States: A view from the Health Employer Data Set (HEDIS). Am J Psychiat 2002; 159: Dolnack DR, Treating patients for comorbid depression, anxiety disorders, and somatic illnesses. J Am Osteopath Assn May; 106. Krupnick J, Sotsky S, Simmens S, Moyer J, Elkin I, Watkins J, Pilkonis P (1996). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology l64(3): Pingnone, MP, Gaynes, BN, Ruston, JL, Burchell, CM, Orleans, CT, Mulrow, DC & Lohr, KN (2002).. Screening for Depression in Adults: A Summary of the Evidence for the U.S. Preventive Services Task Force. Anals of Internal Medicine, 36(10),

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7 Telepsychiatry (TBH) A really good solution

8 How telepsychiatry works $1 $1 Psych Rental

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10 Three pillars Safety Quality Cost

11 Why now? Suicide Mortality Detection Adherence Outcomes Co-morbidity Productivity Disability Safety Quality Cost

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14 Value Prop. for Health Centers Component Screening Specialty case consult/second opinion Treatment algorithms Specialty tx (about 30%) Imp. care - chronically ill Revenue (pt) retention Shared savings Transport and staff costs Re-allocated physician time Effect Almost double detection/case finding Increase diagnostic accuracy and confidence superior outcm. Increase EBP concordance Expertise for complex/refractory cases Improve chron. illness mgmt and reduce costs $ p/m Improve bottom line Improve bottom line days; K mi; $ gas Time spent with other patients

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21 Phil Hirsch, PhD Access Psychiatry Solutions

22 National Association of Community Health Centers Community Health Institute 2011 TeleBehavioral Health: Legal and Regulatory Considerations presented by: Marcie H. Zakheim, Esq. Partner of

23 Telemedicine Defined Telemedicine use of modern telecommunication and information technologies to deliver health care services at a distance Telemental health provision of mental health services via telecommunication systems that enable two-way interactive real-time communication between patient and provider Because of its nature, telemental health tends to be provided through live telecommunication platforms, such as video conferencing 2

24 Common Models Health center directly provides and bills for behavioral health services, which is provided by health center staff Example patient is located at health center site; behavioral health provider is employed by health center and is located at a different health center site (or a distant facility included in health center s scope as a contracted site) Health center provides and bills for behavioral health services through formal written agreements, including contracts to purchase services/capacity (i.e., lease of behavioral health providers) Example patient is located at health center site; behavioral health provider contracts with health center and is located at a different health center site (or distant facility included in health center s scope as a contracted site) 3

25 Common Models Health center refers patients to distant referral provider Health center is responsible for the treatment plan and will provide appropriate follow-up care BUT Health center will NOT provide or bill/pay for behavioral health services rendered by referral provider 4

26 Key Terms: Lease of Behavioral Health Provider Health center purchases capacity of behavioral health providers to provide services at distant site (which may be a health center site) Patients are considered health center s patients Health center assumes financial, clinical and legal responsibility for services provided by contracted behavioral health provider Contracted behavioral health provider furnishes services in accordance with health center s Section 330 grant Applicable health care and personnel policies, procedures and standards (e.g., clinical guidelines, productivity and QA standards, standards of conduct, record-keeping) Contracted behavioral health provider meets health center s licensure and professional standards and qualifications, including credentialing and privileging 5

27 Key Terms: Lease of Behavioral Health Provider Health center Executive Director (with the CMO) maintains ultimate authority for monitoring/evaluating performance of contracted behavioral health personnel Health center retains right to terminate contract (or assignment) of any contracted behavioral health provider who fails to meet qualifications, is non-compliant with policies and procedures, performs unsatisfactorily or provides sub-standard care Health center is responsible for billing and collecting from third parties/patients, retains all revenue secured for services provided by contracted behavioral health provider, and provides fair market payment to behavioral health provider 6

28 Key Terms: Referral Arrangement Distant referral provider (DRP) agrees to furnish behavioral health services to health center patients who are referred by health center DRP retains control and liability Patients are considered DRP s patients DRP assumes financial, clinical and legal responsibility for services it provides DRP policies/procedures/standards govern DRP bills and collects from patients and third party payors for services rendered, and retains all revenue Apparent Authority: court may hold health center liable for negligence of DRP if DRP appears to be under oversight or control of health center Health center should obtain assurances from DRP regarding licensure and professional qualifications Health center MUST distinguish between the DRP and health center If including referral arrangement in-scope, must have formal written agreement that meets PIN requirements 7

29 General TeleBehavioral Health Structure 1) Patient and behavioral health provider are located at two different health center sites 2) Patient is located at a health center site and behavioral health provider is located at a distant location 8

30 Scope of Project Considerations Health center may need to obtain prior approval for change in scope of project to provide services via telemedicine New service New site (either patient s location or clinician s location) At a minimum, services provided via telebehavioral health must be in scope for FQHC benefits to apply (e.g., cost-based reimbursement) NOTE: Advisable to describe telemedicine services clearly in Section 330 grant application narrative (along with including on scope forms, as applicable) 9

31 Scope of Project: Adding New Site The 4 Conditions for a Health Center Site : Providers generate face-to-face encounters patients Query would service via telemedicine qualify as face-to-face Providers exercise independent judgment in providing services to patients Services are provided directly by or on behalf of health center health center board retains control and authority over provision of the services at health center location (regular health center site or contracted facility) Services are provided on a regularly scheduled basis 10

32 Scope of Project: Adding New Service Services will be included in the health center s scope of project if delivered directly by the health center or through a formal written agreement, such as a purchase agreement Must request prior approval to add service to scope of project if health center has been providing behavioral health services through referral arrangement and wishes to provide the service directly or through formal agreement (and vice versa) Formal referral arrangement with behavioral health provider is within health center s scope of project, but actual service provided by behavioral health provider is not included in health center s scope of project Regardless of how they are furnished, all in-scope services must be Readily available and reasonably accessible to all patients equally regardless of ability to pay Offered on a sliding fee / discount schedule 11

33 Interstate Licensure Considerations To date, there is no single or universal licensure statute for telemedicine arrangements that may cross state boundaries Behavioral health providers are generally required to obtain licenses in order to provide services to patients in other states using electronic communications Behavioral health provider should obtain license in state where health center is located Depending on the state, there may be a special licensure option specifically for telemedicine For more information, consult your state s Board of Medical Examiners 12

34 Reimbursement Considerations: Medicaid Trend is to provide reimbursement if care would be covered if it were provided in-person Rapid expansion in the area of behavioral health For Medicaid beneficiaries, check State Plan Amendment to ensure that behavioral health services are covered Over 25 states provide some level of reimbursement for services delivered via telemedicine for interactive consultations to Medicaid recipients Services are coded and billed just like regular in-office services 13

35 Reimbursement Considerations: Medicare Limitations related to geographic location and originating site Patient must be in an originating site, such as a health center, that is located in a HPSA or in county not classified as Metropolitan Statistical Area (unless the health center is part of a federal telehealth demonstration project) Interactive telecommunications system (audio and video allowing for real time communication) is required as a condition of payment Patient must be present and participating in the telehealth visit 14

36 Reimbursement Considerations: Medicare Limitations related to coverage and payment for eligible telehealth services Consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system Remote telehealth services can be furnished by a physician, NP, PA, nurse midwife, diatitian, clinical psychologist or a clinical social worker to eligible individual paid same amount as clinician providing the service would have been paid if service had been furnished without use of a telecommunications system Clinical psychologists and social workers cannot bill for psychotherapy services that include medical evaluation and management services Limitations on number of telehealth services/sessions For additional information, see Medicare Benefit Policy Manual, Chapter 15 Covered Medical and Other Health Services 15

37 Reimbursement Considerations: Private Insurers Regulations for reimbursement by private insurers are set by States At least 5 States have enacted laws requiring that services provided via telemedicine must be reimbursed if same service would be reimbursed when provided in person Some programs cover specific telehealth services (e.g., behavioral health) State waivers or special programs offering remote diagnostics or remote monitoring for specific diseases entities or for particular populations, allow additional coverage of telemedicine services 16

38 Federal Tort Claims Act Coverage Considerations FTCA eligible persons Health center grantees, and their board members, officers, and full-time and part-time employees (regardless of the number of hours worked) Individual contractors working in the fields of general internal medicine, general pediatrics, family practice, ob/gyn ( primary care fields), regardless of the number of hours worked Other individual contractors so long as they work for the health center an annual average of 32 ½ hours per week Contract must be directly between the health center and the individual health professional 17

39 Federal Tort Claims Act Coverage Considerations Must be able to demonstrate that individual is registered as health center patient consistent with FTCA policy Patient accesses care for initial or follow-up visit at health center site Applies even if patient is not permanent resident of service area or is receiving care temporarily Health center triage services are provided via telephone or in-person patient is not yet registered with health center (bit intends to register) Health center should apply to HRSA for a determination of coverage if it is unsure whether a telemedicine activity falls within the scope of services covered by FTCA 18

40 Fraud and Abuse Considerations Health center may receive funding to support costs and/or in-kind donations of telemedicine technology and maintenance of links provided by a hospital or behavioral health provider Anti-kickback statute concern: prohibits any person or entity from knowingly or willfully soliciting or receiving anything of value (remuneration) in exchange for patient referrals May be protected by a safe harbor 19

41 Anti-Kickback Safe Harbor for Section 330 Grantees Health Center Grantee Safe Harbor: final OIG rule issued October 4, 2007 [42 C.F.R (w)] Protects from anti-kickback prosecution certain arrangements between health center grantees and providers/suppliers of goods, items, services, donations and loans Must contribute meaningfully to health center s ability to maintain or increase the availability, or enhance the quality, of services provided to health center s medically underserved patients Must meet all requirements of the safe harbor, including (but not limited to) patient freedom of choice, maintenance of provider judgment, availability to all patients 20

42 Anti-kickback Safe Harbor for EHR Technology Electronic Health Record (EHR) Technology Safe Harbor: final OIG rule issued October 10, 2006 [42 C.F.R (y)] Hardware, software, and IT and training services necessary and used predominately to create, retrieve, transmit or receive EH records is deemed not to constitute prohibited remuneration in violation of the anti-kickback statute Distant provider can provide health center with telemedicine hardware or software provided that System if fully interoperable, Receipt of items or services is not a condition of doing business with distant provider, and Donation of the goods or services is not based on the volume or value of health center s referrals 21

43 Patient Information Privacy & Security Considerations HIPAA Security Rule Requires covered entities to ensure the confidentiality, integrity, and availability of electronic PHI it receives, maintains or transmits Administrative safeguards Physical safeguards Technical safeguards Implement policies and procedures to prevent, detect, contain and correct security violations Work closely with IT personnel to identify most appropriate means of transmission Identify vulnerabilities in the security procedures Install physical and technical security safeguards (i.e., software passwords, data encryption, digital signatures to authenticate sender, backup systems, disaster recovery plan) 22

44 Patient Information Privacy & Security Considerations HIPAA privacy standards set a federal floor regarding patient privacy They do not preempt state laws with stricter standards Stricter federal laws take precedence 23

45 Federal e-health Initiatives Office for the Advancement of Telehealth (OAT) within HRSA Works with DHHS Office of the Assistant Secretary for Planning and Evaluation to: Identify privacy, confidentiality and security concerns unique to telemedicine Lead, coordinate and promote use of telehealth technologies by administering telehealth grant programs, providing technical assistance, and developing policy initiatives From Oct 2006 through Sept 2008, OAT administered 93 telehealth/telemedicine projects 24 were awarded funds totaling more than $6.1 million 24

46 Questions? Marcie H. Zakheim, Esq. Feldesman Tucker Leifer Fidell LLP th Street, NW Washington, DC (202)