Telehealth and the U.S. College Population

Author: George Pantos Executive Director HPM Institute February 2013 Telehealth and the U.S. College Population Connecting Students with Doctors for Better Health

Introduction In the rapidly changing healthcare landscape, new delivery and reimbursement models are transforming the U.S. health system and redefining the traditional patient-doctor relationship. Telehealth, which uses technology and mobile devices to connect patients and physicians for real-time consultations, is one of the delivery models adding a new dimension to healthcare. By fostering virtual patient-doctor interactions for non-urgent medical issues in lieu of costly in-person visits, telehealth is an alternative, affordable and effective way to access healthcare by phone, internet video and e-mail. A looming shortage of primary care physicians, costly office visits and constantly escalating health insurance premiums are driving forces that make telehealth an effective way to help meet the needs of a broad range of Americans, particularly students enrolled in higher education. Despite some resistance from state physician groups, telehealth continues to gain popularity as a viable healthcare alternative for today s college students who rarely are detached from their mobile phones. While the recently enacted Affordable Care Act (ACA) expands healthcare coverage for dependents, the costs associated with keeping students on the family s plan will affect many parents who are struggling to meet tuition and living expenses; and coverage does not equate to access. As a complement to parent and school insurance plans, telehealth which is not insurance provides today s mobile phone- and computer-connected students with direct, quick access to primary care doctors for basic health information, consultation, diagnosis and prescriptions for non-controlled substances. Parents gain peace of mind knowing that their student has ready, aroundthe-clock access to quality, physician care away from home; and schools can expand their campus health services to 24/7 without additional infrastructure or personnel costs. As insurers increasingly reimburse doctors for telehealth services and as colleges forge collaborative relationships with telehealth firms telehealth is expected to continue its steady growth on America s campuses. Major trends are shaping the increasing use of mobile telehealth services within the U.S. s college and university populations: higher costs for parentand school-sponsored health plans; a critical shortage of primary care doctors; and potential reductions in the availability of school health plans due to budgetary constraints. Parents, students and schools need important information about the benefits and limitations of telehealth, how it works and how it can be used to greatest effect. This paper addresses all of those aspects of telehealth s growing penetration in American higher education.

Trends Impacting the U.S. Healthcare System and Telehealth As a new U.S. health system takes shape in the post-aca world, significant trends are converging to impact the healthcare choices of college and university students. These choices, in large part, are driven by innovative patient care delivery models, provider reimbursement options, advances in technology and new modalities of electronic communication. Against this backdrop, we examine telehealth as a viable healthcare option for the higher-education population, along with some practical considerations affecting student telehealth use. High Doctor Office Visit Costs High-cost doctor office visits is a major contributor to spiraling U.S. healthcare costs. While costs vary based on specialty and geography, according to the federal Agency for Healthcare Research and Quality, in 2011 the average rate for a basic office visit with a U.S. primary care physician was $133.00, with three to six minutes of actual doctor participation. i By comparison, telehealth doctor consultations typically come with either a per-call charge of $35 to $40 or unlimited calls for a monthly fee of $10 to $19, with a typical consultation lasting more than 15 minutes. The average telehealth doctor visit is nearly four times longer than a traditional doctor visit and 10 percent to 25 percent of the actual cost. ii Up to 70 percent of doctor office visits and 40 percent of hospital emergency room visits are unnecessary, according to a 2006 national survey. iii While the care was medically necessary, the delivery venue was deemed inappropriate and/or more costly than the level of care required. This suggests that many of the conditions addressed during in-person visits could be handled effectively with a telehealth consultation. Higher Premiums for Family/Dependent Coverage An estimated 3 million young adults including many college and university students have healthcare coverage under a parent s plan, thanks primarily to ACA provisions that extend dependent coverage to age 26. To account for these expanded coverage requirements, major changes to insurance pricing and plan design will make parent plans more expensive. iv The added costs will range from moderate to severe, according to a national survey by human resource consultancy Mercer LLC. v Some surveyed insurers said they are moving away from comprehensive family plan deductibles, which typically cover dependents for a flat fee, and will implement an individual deductible for each family member, making out-of-pocket costs for family coverage significantly more costly. Added costs for expanded coverage are causing some employers to drop family coverage or to reduce their subsidy for dependent coverage. Other employers say they will change premium rate tiers for dependents and impose a higher premium share for all dependents. About two-thirds of college students remain on their parents health insurance, according to a 2008 General Accountability Office survey. vi This figure may drop dramatically if proposed cost hikes are implemented. In 2010, private health plan participants paid on average nearly $4,000 a year toward family coverage, a 14 percent increase from 2009, and implemented before ACA provisions became effective, according to the Kaiser Family Foundation and the Health Research and Education Trust, two non-profit organizations that focus on health policy issues. vii Copyright 2013. All Rights Reserved.

Higher Premiums for School-Sponsored Plans Colleges and universities have long offered school-sponsored health plans, with as many as 3 million students enrolled nationwide. viii These health plans are expected to become more costly as they accommodate ACA s new requirements. Although there have been coverage gains for young adults ages 19 to 25, compliance with ACA s new requirements is likely to drive up costs and jeopardize colleges ability to offer insurance. From a long-term perspective, the ability of colleges and universities to provide appropriate access to healthcare is a major concern, according to the Lookout Mountain Group (LMG), a non-partisan study group of college health professionals. ix Typically, school health plans are limited-benefit, low-cost plans that place strict caps on how much the plan will pay toward medical care. Currently 60 percent of school plans have a benefit cap of $50,000 or less; ACA requires these caps to be phased out by the start of classes in 2014 and for the 2013 to 2014 school years, school plans must cover at least $500,000 in medical expenses. Schools say student premiums for limited-benefit plans will go up roughly tenfold under the new ACA requirements; many are dropping the plans because of this increase. ACA also requires school plans to add prescription drug coverage and offer specified preventive care services at no out-of-pocket cost to enrollees. As a result of these new mandates, and already impacted by budgetary constraints, many colleges and universities are dropping out of the health insurance business entirely. Many are closing their campus health centers or reducing hours of operation. As premiums continue to escalate, users and providers of insurance/healthcare services need to consider all the options, noted a Georgetown Health Policy Institute researcher in a published interview. x A Growing Shortage of Primary Care Doctors The rollout of ACA will add 30 million new insured in 2014; they, plus the 3 million young adults who can continue as insured dependents until age 26, will overtax an already-burdened healthcare system. Primarily, this sudden and significant influx of new patients is expected to exacerbate the existing shortage of primary care physicians. The Association of American Medical Colleges projects a shortfall of about 63,000 physicians by 2015 and expects that number to double by 2025. While individuals typically can access healthcare services during physician shortages, doing so is often slow and difficult, according to a New York Times report. xi Driven by an aging population and the looming doctor shortage, the focus on alternative healthcare delivery modes including telehealth is expected to intensify, particularly for routine, non-urgent medical services. According to a market research study from InMedica, 1.8 million patients will be treated worldwide through telehealth by 2017. xii 3 Copyright 2013. All Rights Reserved.

Hospital Acquisition of Doctor Practices The recent trend of hospital systems acquiring independent, private physician practices is a structural change that is transforming the traditional doctor-patient relationship and contributing to higher healthcare costs for patients. As independent doctors shift to hospital-based practices, they will be reimbursed for services at higher hospital-system rates for identical procedures and tests. For example, imaging scans, formerly done in a private office or other facility, now may be billed as hospital outpatient procedures, more than doubling the cost. xiii Higher fees for hospital-based physicians means insured patients will be subject to higher out-of-pocket costs for certain medical services another factor contributing to the search for alternative healthcare delivery methods. It is interesting to note that while hospital billing rates can drive up costs for office-based services, they are also early adopters of telehealth. The same InMedica study found that in 2012, 308,000 patients were being monitored remotely for a number of conditions, including congestive heart failure, COPD, diabetes and some mental health conditions, usually following an inpatient stay. The intensive, sustained monitoring reduced readmissions, which in turn, lowered costs system-wide. xiv Considerations Impacting Increased Interest in Telehealth in the College Market While it has been common practice for undergraduate students to stay on their parents health insurance plan or to purchase a school plan, the changing healthcare landscape and practical, new considerations may affect the healthcare decision-making process for students in their school home away from home. These considerations include: Availability of reliable information about routine medical conditions/illnesses On-demand access to doctor consultations Availability of doctors outside normal office hours, including weekends and while traveling Time lost from class and the inconvenience of travel to in-person doctor visits High-costs and long waits in emergency rooms and urgent care facilities Access to updated electronic health records for continuity of care with at-home physician and other medical providers Telehealth gives students direct, on-demand access to reliable information and diagnoses from a physician without the high costs and long waits inherent in other care venues. Here are some detailed views of how telehealth addresses each of these considerations: Copyright 2013. All Rights Reserved. 4

Routine Doctor Care: Students who need information about routine illnesses or medical questions can use a cost-effective telehealth consult instead of an emergency room visit, which can be as much as seven times more expensive. xv Dr. Kenneth M. McConnochie, a practicing physician and healthcare author, describes his telemedicine work as follows: The less-demanding [patients] that it serves are the many [students] who have relatively minor, common, acute problems and do not need emergency room, after-hours urgent care center or even an in-person office visit telemedicine is simpler and more convenient because costs of transportation and time are markedly reduced it appears that the model should reduce costs from a societal perspective. xvi Time Saved and Patient Satisfaction. Long waits, travel to office appointments and time missed from work or school are among the obstacles associated with face-to-face doctor visits. Appointments are hard to get and inconvenient: As many as one in three people has trouble seeing their primary care physician and one in four has problems taking time off to see a doctor. Patients overuse emergency rooms: More than one-half of all ER visits are for nonemergency issues because patients cannot get timely office appointments. Patients have difficulty getting information during office visits. More than one-third of physicians do not have time to deliver enough useful information about specific medical issues. xvii A government survey found that one in five people who attempted after-hours contact with their primary care doctor reported it was very difficult or somewhat difficult to reach a clinician. Those who reported less difficulty reaching a clinician after hours had significantly fewer emergency department visits and lower rates of unmet medical needs than people who experience more difficulty. xviii Documented studies report 90 percent of patients say they were very satisfied or satisfied with the telehealth service they received based on greater convenience, time and cost savings. xix Research shows that patients who use telehealth in a non-urban setting can overcome the barriers of time and travel required for in-person doctor visits. A study of telehealth access in a rural setting reported overall patient satisfaction was very high and telehealthcare was rated either excellent or very good. xx Electronic Health Records/Continuity of Care: Electronic health records (EHRs) are invaluable tools that optimize the value of telehealth. Typically, the telehealth physician accesses the patient s record before the consult and updates it after the call. This helps to maintain the most up-to-date information and fosters seamless continuity of care. With permission, the record is made available immediately to the student s other medical providers. HIPAA (The Health Information Portability and Accountability Act) requires that telehealth EHRs must be handled and stored in strict compliance with Federal privacy provisions as they would be during face-to-face encounters. xxi 5 Copyright 2013. All Rights Reserved.

Benefits of Telehealth in the College Space Approximately 2 million college-age students have no health coverage, and 19- to 29-year-olds visit hospital emergency rooms more than any other group below age 75, according to the Young Invincibles, a national advocacy group that focuses on college costs, health insurance and debt affecting young people. xxii Studies show that students without access to a regular source of care can leave them and their families at risk for higher out-of-pocket costs in the event of even minor illness. xxiii A Commonwealth Fund survey found that almost half of all young adults forgo necessary treatments due to cost considerations. xxiv For routine, non-urgent medical issues, telehealth consultations can help students and physicians shift care away from high-cost settings like hospital emergency rooms or urgent care clinics. Additionally, as a complement to other health services, telehealth can help to bridge gaps for insured, under- and uninsured students by offering consultations by phone, email, text and interactive video chat. Telehealth is not health insurance. It is a convenient, affordable way for patients to access medical services for common conditions 24/7/365 from any location using the phone or Internet. Services are provided by a network of participating, licensed medical providers. Some telehealth services rely on nurses, some use physicians exclusively, and others combine the two for different levels of service at different price points. Telehealth physicians can address hundreds of common ailments, including bronchitis, allergies, sinusitis, sore throats, urinary tract and respiratory infections. The benefits of telehealth have been recognized by influential medical groups including the American Heart Association. xxv New research reported in JAMA Internal Medicine compared the quality of care for physician telehealth and in-person doctor visits for patients with sinus infections and urinary tract infections between January 2010 and May 2011. The study found that for both patient groups those treated virtually and those treated in-person 7 percent or less of patients returned for another consultation within three weeks, suggesting similar outcomes for both groups. The JAMA researchers found patients treated through a telehealth visit paid 21 percent less than those treated through an office visit. xxvi Telehealth services need not be limited to physical medicine; many providers include behavioral services and wellness programs for a comprehensive, integrated offering. The behavioral services are of particular interest to college administrators because of the growing incidence of mental health issues among students. According to the American College Health Association, 32 percent of surveyed students reported feeling seriously depressed, 51 percent felt significant anxiety, and 87 percent reported feeling overwhelmed by academic and social pressures at least once during the school year. xxvii These numbers point to a pressing need for accessible student counseling services; telehealth is a viable option to complement existing campus services or as a stand-alone program at schools that do not offer mental health care. Copyright 2013. All Rights Reserved. 6

How Telehealth Works Typically telehealth services offer different types of consultations: On-demand, phone-based physician consultations. Telehealth offers students convenient, direct, virtual access to doctors in the same state where their college or university is located. State-licensed physicians are available 24/7for diagnosis, treatment, referrals to specialists and prescriptions, if necessary. Students also can use their phones to snap and upload photos for better diagnosis. On-demand, web-based physician consultations. Platforms that enable doctors to provide real-time, online access to patients are now a reality. Web-based systems include live streaming video, which enables web-cam-equipped students to see and speak to a physician during a virtual visit. The video connection allows students to show rashes or sore throats to the doctor for better diagnosis. Both types of consultations save time and money and eliminate lengthy waits for appointments. Students can get answers to routine questions quickly and easily. Medically unnecessary visits are reduced because students have a first line of defense and can see a physician only after medical need is established. Generally, the telehealth consultation process follows a standard procedure, although there may be variations among providers. The student must first register with a telehealth firm like CampusMD, a Maryland-based broker of telehealth services for colleges, universities and students that requires payment of a monthly fee. Once the student enrolls in CampusMD, the procedure is as follows: The student calls toll-free the triage nurse at the Customer Care line. The nurse gathers medical information and contacts a network physician to schedule a callback, typically within 20 minutes and guaranteed within three hours. The doctor reviews the student s medical record and calls the studentto begin the consultation via phone or video chat. The doctor discusses the student s symptoms, diagnoses the issues, and prescribes treatment and/or medications as appropriate. If a prescription is required, the doctor calls the Rx to the student s choice of pharmacy. The doctor enters the consultation notes into the student s EHR and forwards a copy to the student and to anyone else the student authorizes. A patient satisfaction survey is sent to the student. Member calls to request consultation Member describes condition Call scheduled with appropriate doctor Doctor reviews the online patient history and calls member How Telehealth Works Member receives follow-up contact Call recoding is posted Doctor updates EMR with consultation notes If prescription is required, doctor calls in Rx to member s choice of pharmacy 7 Copyright 2013. All Rights Reserved.

Provider Reimbursement The American Medical Association has taken direct action to support reimbursement for telehealth services. According to a newly adopted AMA policy, as reported in American Medical News, remote electronic visits should be reimbursed adequately. xxviii Additionally, the Telehealth Advancement Act of 2011 adopted in California states it is the intent of the Legislature to recognize the practice of telehealth as a legitimate means by which an individual may receive healthcare services from healthcare providers without in-person contact with a healthcare provider. xxix A number of states have enacted laws calling for parity by requiring insurers to reimburse equally for telehealth services and in-person doctor services. These states include California, Virginia, Kentucky, Hawaii, Georgia and Maryland. A new Michigan law prohibits health insurers from mandating in-person contact between patients and doctors in lieu of a telehealth consultation. xxx Barriers to Wider Adoption Despite the recent growth of telehealth, several barriers limit wider adoption: Provider liability concerns: To reduce physician liability and costly malpractice suits, many states require that providers establish an in-person relationship before using electronic means to deliver care. State-specific licensing: Licensure fees and restrictions differ from state to state. Doctors who want to practice in more than one state must apply for licensure in each state, although new models are emerging under which a doctor licensed in one state can apply to another state via an abbreviated procedure. Data interoperability: With some exceptions, providers cite cost as a barrier to adopting electronic medical records. Fewer than half of doctors use all the features of a fully functional EHR system; however, e-prescribing is on the rise, along with use of software-as-a-service solution by many providers. Prescribing limitations: Several states have passed laws prohibiting doctors from prescribing during a telehealth visit, except in specified circumstances. The rationale is that doctors should first conduct a physical examination before prescribing medication. Some states limit telehealth prescriptions to certain classes of drugs. Generally, certain types of telemedicine prescriptions are permitted by some states, while other states are concerned about potential prescription drug abuse, particularly for DEA-controlled substances. xxxi While some physician groups have cited specific types of care that should be performed only during inperson visits, the range of medical services deemed suitable for telehealth has expanded significantly. Copyright 2013. All Rights Reserved. 8

An Expanded Role for Telehealth on U.S. Campuses A variety of factors costs, ACA, changes in reimbursement and physician availability is spurring the continued growth and wider adoption of telemedicine in general and specifically within the collegiate space. Telehealth offers a convenient, affordable, flexible way for tech-savvy students to access quality healthcare, and in the process, help them maintain better health and achieve their educational goals. As the digital economy continues to grow, so should telehealth, which is poised to leverage technological and medical advances simultaneously. With more studies confirming its efficacy, quality and cost savings, telehealth can serve millions of students, and by extension, the greater U.S. population seeking new solutions for primary care. 9 Copyright 2013. All Rights Reserved.

Endnotes i Agency for Healthcare Research and Quality, Statistical Brief#318: Expenses and Characteristics of Physician Visits in Different Ambulatory Care Settings 2008. ii BoxerRJ, MD, Telehealth Can Enable Convenient, High Quality and Affordable Care, White Paper (2009). iii National Ambulatory Medical Care Survey 2006 (August 2008). iv Big Changes in College Health Plans, Wall Street Journal, June 2, 2012. v Health Reform--Sizing up the Challenge, 2010 Survey, Mercer LLC. vi General Accountability Office, Most College Students Are Covered Through Employer Sponsored Plans, GAO-08-389 (March 2008). vii Employer Health Benefits Annual Survey, Kaiser Family Foundation and the Health Research and Education Trust (September 2010). viii College Student Health Plans Would Offer More Protections Under Proposed Rules, The Chronicle of Higher Education (February 2011). ix Impact of Healthcare on College Students, Lookout Mountain Group (April 2010). x College Health Plans: Exploring the Options, Kaiser Health News (June 2012). xi Doctor Shortage Likely to Worsen with Health Law, The New York Times (July 2012). xii 1.8 Million Patients Will Use Telehealth Tools by 2017, ihealth Beat Report from Computer World (January 2013). xiii Same Doctor Visit, Double the Cost, Wall Street Journal (August 2012). xiv See Note 12. xv Boxer, RJ MD, Telehealth Can Enable Convenient High Quality and Affordable Care for Children and Their Families (2009). xvi McConnochie, KM MD, MPH. Potential of Telemedicine in Pediatric Primary Care, Pediatric Rev. (Sept 2006). xvii Herrick D. Convenient Care and Telemedicine, National Center for Policy Analysis (2007). xviii Center for Studying Health System Change, After Hours Access to Primary Care Practices Linked with Lower Emergency Room Use, Healthcare Finance News (December 2012). xix Sands,D.Z. MD, MPH. New Platforms and New Business Models for Care-at-Distance, Cisco Internet Business Solutions Group, Beth Israel Deaconess Medical Center and Harvard Medical Center (2010). xx Diamond, RJ MD, et al. Using Telemedicine to Provide Pediatric Subspecialty Care to Children, Pediatrics, Vol. 113 (January 2004). xxi Converging the Silos of Telehealth and erecords: A Workshop of the Challenges, Issues and Strategies, St. Andrews Conference Centre, Toronto, Canada (2007). xxii Do Young Invincibles Need Healthcare Insurance? iinsure Me (2012). xxiii Age Band Compression under Health Care Reform, American Academy of Actuaries, Healthwatch (June 2013). xxiv Collins, S. et al. 2010 Commonwealth Fund Biennial Health Insurance Survey (March 2011). xxv Delivering Care Anytime, Anywhere Telehealth Alters the Medical Ecosystem, California Healthcare Foundation (November 2008). xxvi Physician Study Finds Similar Outcomes for In-Person, Telehealth Consultations, JAMA Internal Medicine, Vol. 173 (Nov. 2012). xxvii National College Health Assessment, American College Health Association (2004). xxviii AMA: Delegates Seek Pay for Care Delivered Via Telemedicine, AMA News (June 28, 2010). xxix California Signs Telehealth Advancement Act of 2011 (AB 415), Health Informatics (October 2011). xxx Epstein,Baker, Green. States Jumping on the Telehealth Bandwagon, Tech Health Perspectives (July 2012). xxxi See Note 20. Copyright 2013. All Rights Reserved. 10

About the HPM Institute The Healthcare Performance Management Institute (HPM Institute) is a research and education organization dedicated to promoting the use of business technology and management principles that deliver better and more cost-effective healthcare benefits for employers who cover their employees. The Institute s mission is to introduce and develop a new corporate discipline called Healthcare Performance Management (HPM) a technology-enabled business strategy that tackles the challenge of controlling healthcare cost and quality in much the same way that enterprises have optimized customer relations, supply chain management and enterprise resource management. Supported by its four key pillars Measure, Manage, Engage and Automate HPM provides organizations with visibility and control over their healthcare benefits spending trends and risk management postures, while protecting individual employee privacy. HPM Institute Board of Advisors Henry Cha President Healthcare Interactive Paul Chang Global Business Strategy Lead, Emerging Technologies IBM Software Group Scott Haas Vice President Wells Fargo Insurance Services Bill Lavis Partner Sitzmann Morris & Lavis Keith Lemer President WellNet Healthcare Group Marcos Lopez President exude Benefits Group Sabrina Orque Vice President of Human Resources Charlie Palmer Group George Pantos Executive Director Healthcare Performance Management Institute Deanna Scott Vice President of Human Resources & Corporate Operations The SCOOTER Store Todd Thompson Chief Technology Officer Lockheed Martin Federal www.hpminstitute.org 4733 Bethesda Avenue, Suite 300 Bethesda, MD 20814 1-888-505-4764