Driving Telehealth Adoption Through the Triple Aim Jonathan Neufeld, PhD, HSPP Ohio SORH Annual Conference November 21, 2014 1
Outline UMTRC and National TRC Program Aspiring to the Triple Aim Some Helpful Concepts and Definitions Key Factors That Drive Success Examples and Models Questions 2
telehealthresourcecenters.org Links to all TRCs National Webinar Series Reimbursement, Marketing, and Training Tools
UMTRC Services Presentations & Trainings Individual and Group Consultation Training and Technical Assistance Connections with other programs Program Design and Evaluation Information on current legislative and policy developments
The Triple Aim In business, three things matter: Quality, Performance, and Price. You can pick any two. 6
A Realistic Approach Services done right will improve Patient Experience (Better Care) Providing the right services will improve Population Health Better Health will lead to Lower Cost 7
Telehealth in a Triple Aim Context The right tool changes everything 8
Telehealth/Telemedicine A Tool In Search of a Problem 9
Telemedicine - The Standard Model Rural originating site Specialist at distant site Facility Fee (Part B) Professional Fee (Part B)
Hub & Spoke Telemedicine Providers at the hub Patients at the spoke Spoke receives services Hub receives payment Examples: Specialty Consults, MH in ED
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Three Domains of Telehealth Hospital & Specialties Specialists see and manage patients remotely Integrated Care Mental health and other specialists work in primary care settings (e.g., PCMH s, ACO s) Transitions & Monitoring Patients access care (or care accesses patients) where and when needed to avoid complications and higher levels of care **Value proposition differs among these types** 14
Hospital and Specialty Care 15
Three Domains of Telehealth Hospital & Specialties Specialists see and manage patients remotely Integrated Primary Care Mental health and other specialists work in primary care settings (e.g., PCMH s, ACO s) Transitions & Monitoring Patients access care (or care accesses patients) where and when needed to avoid complications and higher levels of care **Value proposition differs among these types** 16
Integrated Primary Care 17
Hub and Spoke Telemedicine pt pt pt pt pt Spoke pt pt pt pt Spoke pt pt pt pt pt Spoke pt pt pt pt pt pt Spoke MD NP pt pt pt pt pt Spoke MD MD HUB DO MD MD PhD pt pt pt pt pt Spoke
Peer-to-Peer Telemedicine MD MD NP MD CSW PhD pt pt pt pt pt pt pt pt pt pt pt pt pt pt pt pt CHC pt pt pt pt pt pt pt pt pt pt pt pt pt pt pt NP DO
Peer-to-Peer Telemedicine Peer-to-Peer Model Clinicians anywhere Patients anywhere Patient site bills, receives payment Clinician gets paid by patient site (as an employee or contractor) Clinicians anywhere Patients anywhere Patient site bills, receives payment Clinician gets paid by patient site (as an employee/contractor) Telecommuting (IN & IL)
Three Domains of Telehealth Hospital & Specialties Specialists see and manage patients remotely Integrated Care Mental health and other specialists work in primary care settings (e.g., PCMH s, ACO s) Transitions & Monitoring Patients access care (or care accesses patients) where and when needed to avoid complications and higher levels of care **Value proposition differs among these types** 21
Transitions and Monitoring 22
Telehealth Technology Specialized Telemedicine equipment and hardware is being replaced by generic videoconferencing or remote collaboration equipment and software Many companies are making videoconferencing simpler and cheaper Generic software can be adopted by a larger market, driving down costs 23
Equipment Standard Video End Point ($5,000+) LifeSize Passport 32 HDTV (monitor + speakers) Desktop stand or rolling cart Web-based System ($1,000+) Software (Zoom, Vidyo, etc.) Mini computer + HD webcam 26-32 HDTV monitor + speakers Desktop stand or rolling cart
Equipment Web-based System ($500) All-in-one desktop computer HD webcam Software package
Peripherals Exam Camera Dermatology, wound evaluation Tremendous detail, resolution, lighting options Unnecessary for many applications Stethoscope Several very good models available Bluetooth (wireless) connections, excellent audio Otoscope Multiple models available Modular, easy to use 26
Basic Peripherals Stethoscope 27
Basic Peripherals Otoscope 28
P2P Network(s) 3 CMHC 1 RHC 2 FQHC 1 LTC (plus MD/NP site) 2 CAH 1 Admin (Grantee)
P2P Putting Rural in Charge Rather than connecting with a large health system, rural CHCs can hire/contract directly with the clinicians/services they need CHC drives the project CHC chooses clinicians/services/format CHC bills for services CHC pays clinician CHC maintains ownership/control 30
Telemedicine Policy & Payment Regulations: Professionals are regulated at the state level (doctors, nurses, counselors, etc.) Medicare: Pays for certain outpatient professional services (CPT codes) for patients accessing care in rural counties and HPSAs in rural census tracts. *No regs; only conditions of payment. Medicaid: Telemedicine is a cost-effective alternative to the more traditional face-to-face way of providing medical care that states can choose to cover.
Medicare Telemedicine Billing Medicare pays for a limited set of HCPCS/CPT codes when provided: By an eligible Medicare provider Physicians, NPs, PAs, CNMs, CNSs, CPs, CSWs To a member at an eligible originating site Hospital, Office, Clinic, CMHC, SNF, Hospital-based Dialysis Centers In a rural (non-msa) county 32
Update to HPSA Rural Designation Effective January 1, 2014: Otherwise eligible sites in health professional shortage areas (HPSAs) located in rural census tracts of MSA counties will be eligible originating sites. (RUCA codes 4-10, also 2-3 in counties over 400 sq. mi., <35/sq. mi. density) Eligibility Lookup Tool http://datawarehouse.hrsa.gov/telehealtha dvisor/telehealtheligibility.aspx
Medicare Reimbursement Published Annually 6 pages All allowable codes, providers, and locations
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Many services can be billed multiple ways Most basic are usually allowed Many screening and prevention services allowed 36
Coverage for Transitional Services Effective January 1, 2014: CPT codes 99495 and 99496 added Communication (direct, telephone, or electronic) with the patient and/or caregiver within 2 business days of inpatient discharge Medical decision making of at least moderate (or high) complexity during the service Follow up face-to-face (in-person) visit within 14 (or 7) calendar days of discharge
New CMS Telehealth Codes for 2015 90845 (psychoanalysis) 90846 (family psychotherapy without the patient present) 90847 (conjoint family psychotherapy with patient present) 99354 (prolonged service in outpatient setting; first hour) (list separately in addition to office or other outpatient E&M Code) 99355 (prolonged service in outpatient setting; each additional 30 minutes) (list separately in addition to code for prolonged service) G0438 (annual wellness visit; includes a personalized prevention plan of service, initial visit) G0439 (annual wellness visit, includes a personalized prevention plan of service, subsequent visit)
Chronic Care Management - CCM GXXX1 chronic care management services furnished to patients with 2 or more chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline 20 minutes or more; billable once every 30 days Patient does not need to be present Any staff with indirect supervision from clinician Must use electronic registry or data management system Must be furnished during the 30-day billing interval Proposed reimbursement rate: $41.92/month
Basic Billing Model Professional fee (CPT-based) goes to Specialist ( remote site ) Facility fee goes to Clinic ( originating site ) Originating site facility fee (Q3014) is a separately billable Part B service NOT the same as facility fee in Part A Billed as Q3014 (revenue code 780) Currently $24 per encounter
OH Medicaid Covered Services (Now) Alcohol & Drug Abuse Services Case Management Individual Counseling Group Counseling (6:1 ratio) Mental Health Telepsychiatry Medication Services Therapy & Counseling Community Psychiatric Support OAC 5122-29-03, 5122-29-04, 5122-29-05, 5122-29-17, 4732-17-01
Medicaid Rule Timeline Current draft rule May 2014 Submission to Common Sense Initiative May-June 2014 (public comment period) JCARR filing October 2014 Public hearing November 2014 JCARR hearing Final File Effective date January 2015 11/10/2014 42
Definition Telemedicine is limited to interactive, realtime audio and video (synchronous) telecommunication between an originating site and a distant site Not covered: Delivery of service via email, phone, fax Conversations between practitioners without patient present eicu (management of ICU via telemedicine) 11/10/2014 43
Originating Site The office of a physician or optometrist, a hospital, clinic, or nursing facility Responsible for documenting medical necessity of the service getting consent from patient developing and maintaining progress notes Either an evaluation and management fee or a telemedicine originating fee not both No institutional claims 11/10/2014 44
Distant Site 11/10/2014 Distant site provider must be physician or licensed psychologist (or one of these located at an FQHC) Entitled to professional payment no facility payment Notes must be sent to originating site Must be outside a five mile radius from the originating site except for medical emergencies 45
RHC Billing Requirements Site Services Consultations: 99241 99245 and 99251 99255 Office/Outpatient Visits: 99201 99205 and 99211 99215 Psychotherapy: 90832 90840 Psychiatric: 90791 and 90792 Interactive Complexity add-on code: +90875 Use Modifier GT to denote telemedicine services 46
SPOKE Billing Considerations Bill HCPCS Q3014 with the GT modifier Revenue code 780 (telemedicine services) If multiple services were provided on the same date as the SPOKE service, bill Q3014 as a separate line item from other professional services 47
Telecommuting An agreement between an employer and an employee or contractor There is only one billing entity The FQHC/RHC bills as for any valid encounter The provider does not bill as they are an employee/contractor of the FQHC/RHC 48
Some Important Considerations Assumes all of the following are true: The physician is contracted by the Clinic and compensated for the services under a contractual arrangement ("under agreement"). Services rendered are covered by the Medicaid program and have a valid HCPCS code on the list of recognized encounter codes The FQHC bills the Medicaid program for the service (and the provider does not) 49
Peer-to-Peer Telemedicine MD MD tele-commuters NP MD CSW PhD pt pt pt pt pt pt pt pt pt pt pt pt pt pt pt pt CHC pt pt pt pt pt pt pt pt pt pt pt pt pt pt pt NP DO
Triple Aim - Volume vs. Value Still early in the Transition to Value Only 11% of dollars linked to value today Volume still drives most of sustainability Keeping patients healthy and out of the ED is a key goal of primary care Main strategy: Driving utilization 51
Driving Utilization 1. Drive from high cost to high effectiveness Away from ED (to Primary Care) Away from No Care (to Primary Care) **To Primary Care** 2. Actively find patients 3. Reduce gaps, dropouts, lost to follow up 52
ED Mental Health Evaluations Driving utilization away from the ED Improving efficiency of ED Reduced boarding Reduced lost costs for self-pay patients 53
Hours in Emergency Department Hours Spent in Emergency Department Range Mean (SD) Median Order to Consult*** Before TM 0.5-52.9 16.2 (13.2) 14.2 Using TM 0.02-25.1 5.4 (6.4) 2.6 Door to Consult *** Before TM 6.3-56.6 22.7 (12.6) 19.6 Using TM 1.7-50.9 10.5 (10.2) 5.9 Length of Stay*** Before TM 12.6-65.9 31.7 (14.1) 26.3 Using TM 3.0-69.5 17.0 (18.0) 8.2 Note. ***p<.001 54
Observed Utilization-Estimated Costs Inpatient Days Cost ($1,382/day) Nursing Hours Cost ($30/hr) Pre-Telemedicine 31.7 $43,809 668 $20,040 Avg Per Case (24) 1.3 $1,825 28 $835 Telemedicine 26.9 $37,175 646 $19,380 Avg Per Case (38) 0.7 $978 17 $505 55
Estimated Savings Item Unit Cost/Savings Per Year Annual Total COSTS Technology Telemedicine Unit $3,300 1 $3,300 Maintenance $1,500 1 $1,500 Bandwidth $6,000 1 $6,000 Training Nursing Time $30 10 $300 Evaluations Evaluation Charge $100 60 $6,000 TOTAL COSTS $17,100 SAVINGS Hospital Nursing Time $330 60 $19,800 Payer Hospital Inpatient Days $847 60 $50,820 TOTAL SAVINGS $70,620 ROI: 1+((70,620 17,100)/17,100) = 4.13 56
Example Valley Professionals (FQHC) Mental health (LCSW and Psychiatrist) hired to see patients onsite (from home) Could be used for any provider type Clinicians can see patients at multiple sites Requires change of scope (but not reevaluation/adjustment of PPS rate)
Example Capabilities Clinic (RHC) Needed specific mental health services for its target/core population of developmentally disabled adults Hired MD and NP to provide outpatient mental health ( telecommuting ) Clinic also opened to the public ~4 hours/wk psychiatry scheduled onsite
Example Oaklawn (CMHC) Service locations in Goshen, Elkhart, and South Bend (2 counties) 2+ hours from Chicago; 3+ from Indy Established 3 telemedicine clinic sites and 3 provider home offices 2 in Chicago, 1 in Indianapolis Chicago providers do on-site clinics also
Other Potential Service Areas LTC/SNF Integration Geriatric Primary Care Geropsychiatry Community Paramedicine Urgent Care replacement More expensive, but also more effective (proactive) 60
Key Factors That Drive Success Clear Vision (with a sustainable model) Technological Openness Among Staff Can we meet by video? Good Information (rules, systems, etc.) Solid Partners & Partnerships Testing and Rehearsal (per Schedule) 61
Other Factors Than Contribute Stable Internet Connectivity 3 Mbps, cable or fiber, unshared (ideal) Right-sized Technology Procedural Flexibility/Creativity Basic Planning and Follow Through 62
Process Team Development Needs Assessment Readiness Assessment Program Development/Implementation Testing and Evaluation Expansion (back to the top) 63
QUESTIONS Jonathan Neufeld, PhD, HSPP Clinical Director Upper Midwest Telehealth Resource Center jneufeld@umtrc.org (574) 606-5038 64