trends, strategies, and payment models in telemedicine
TRANSCRIPT
Trends, Strategies, and Payment Models in Telemedicine
Becker’s Hospital Review CIO/HIT + Revenue Cycle Summit
July 21, 2015
2515 McKinney Avenue Suite 1500 • Dallas, Texas 75201 • Telephone: 214.369.4888 • Fax: 214.369.0541
Ben Ulrich, CVA Director – Physician Compensation Valuation
Overview 2
Telemedicine Introduction
Reimbursement Environment
Telemedicine Strategies & Structures
FMV Considerations
Telemedicine Introduction
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Source: “Help Wanted: More US Doctors – Projections Indicate America Will Face Shortage of MDs by 2020” by AAMC
4
Telemedicine Not a new mode of care
Current concept has existed for at least 20 years – 20th annual American Telemedicine Association Conference in May 2015
Certainly expanded with technology development and is continuing to evolve
Short form definition - Leveraging technology to enhance access to care for patients
Telemedicine implementation & expansion is broad
Direct to Patient/Consumer
Provider to Provider
Facility to Facility
Chronic Care Mgmt.
Tele-Monitoring, Remote Diagnostics
Teaching Hospitals
Mobile Health/Apps
International Care
Concierge Medicine
Call Center – 24/7 Access
Source: “Help Wanted: More US Doctors – Projections Indicate America Will Face Shortage of MDs by 2020” by AAMC
5
Telemedicine 3 Overarching Categories or Types of Telemedicine Care
Real-Time Care
Live video conferencing between provider and patient
“Store and Forward”
Digital data (images, records, audio/video, etc.) that are captured and transmitted to a provider for further study or second opinions
Remote Monitoring
Monitoring equipment transmits patient data to healthcare professionals (ex. chronic care management, diabetes, cardiac care, etc.).
Benefits/Strengths of Telemedicine
Access to care that eliminates local market/geographic barriers
Rural coverage in areas with physician shortages
Reduces emergency department stress/overutilization
Network cost reduction
Market expansion, outreach, and integration
Convenience for the patient (i.e. 24/7 access)
School health & employer based programs
Source: “Help Wanted: More US Doctors – Projections Indicate America Will Face Shortage of MDs by 2020” by AAMC
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Telemedicine Challenges
Finding the right vendor or partner – understanding your goals/needs
Efficiently leveraging the technology & managing the system
Medical Board Licensure – state by state
HIPAA & data security issues
Keeping the physicians engaged (ex. lower volume arrangements)
Overcoming patient “technology fear”
Source: “Help Wanted: More US Doctors – Projections Indicate America Will Face Shortage of MDs by 2020” by AAMC
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Telemedicine Predominant Specialties Leveraging Telemedicine
Acute Care –
Stroke
Inpatient & ED Neurology
Critical Care
Inpatient & ED Psychiatry
Outpatient Coverage –
Primary Care / Pediatrics
Behavioral Health
Cardiology
Tele-interpretations
Radiology
EKGs, EEGs
Source: “Help Wanted: More US Doctors – Projections Indicate America Will Face Shortage of MDs by 2020” by AAMC
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Telemedicine Equipment Needed
Patient Site of Service –
Live audio/video connection
Typically a cart, webcam & video monitor
Support staff/physician on site with the
patient & cart to monitor & support
Remote monitoring in some instances
Patient records transmitted
Specialist/Telemedicine Physician –
Internet connection supporting live video
Webcam & microphone
Typically some sort of computer/smartphone
to review any documentation
Telemedicine equipment needs are very dependent on
the goals/needs of the contracting party. More or less
sophisticated technology may be warranted
Reimbursement Environment
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Source: “Help Wanted: More US Doctors – Projections Indicate America Will Face Shortage of MDs by 2020” by AAMC
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Reimbursement Environment
Medicare
“Telehealth” services reimbursed to the same degree as services delivered in the traditional manner. Telehealth does not apply to teleradiology or telepathology (no asynchronous connection)
Covered services limited by the location of the patient, service rendered, provider type and technology utilized. Requirements:
Real-time video & audio – face to face connection between patient & doctor
Phone calls, emails, faxes or one-way video connections are not allowed
Service must be a approved telehealth service
Office/OP visit, consultation, psychotherapy, drug mgmt, transitional care, etc.
Physician must be credentialed with the patient-site facility
Physician must be a authorized provider of the Specialty service
Physicians, PA/NPs, midwives, nurse specialists, psychologists, social workers, dietitians
Patient must be at a facility in a rural market (could be changing)
Health Professional Shortage Area
Patient originating site must be a qualified facility
Source: “Help Wanted: More US Doctors – Projections Indicate America Will Face Shortage of MDs by 2020” by AAMC
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Reimbursement Environment
Medicaid
Reimbursement must follow Medicare conditions for participation but states can decide and elect unique payment policies.
States can elect what technologies to require, provider type, and the actual reimbursement levels
45 states reimburse for some level of telemedicine services – rules vary greatly state to state
Only 10 states provide reimbursement for remote patient monitoring
Source: “Help Wanted: More US Doctors – Projections Indicate America Will Face Shortage of MDs by 2020” by AAMC
12
Reimbursement Environment
Commercial Payors
Parity laws have driven commercial reimbursement for telemedicine
Many states prohibit commercial payors from denying telemedicine reimbursement if they reimburse for traditional on-site care
State policy driven
Source: “Help Wanted: More US Doctors – Projections Indicate America Will Face Shortage of MDs by 2020” by AAMC
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Reimbursement Environment
Private Payors
Typically depends on the parity laws as well
Many payors are starting to establish independent telemedicine coverage (typically through contracted arrangements with vendors) to connect their beneficiaries virtually with providers
Aetna, Cigna, and BCBS all have individual state technology platforms used in this manner
Goal is greater integration, cost reduction and taking on population health initiatives on a grander scale
Telemedicine Strategies & Structures
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Source: “Help Wanted: More US Doctors – Projections Indicate America Will Face Shortage of MDs by 2020” by AAMC
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Telemedicine Strategies & Structures
Rural Coverage & Network Expansion Desire for telemedicine coverage driven from need to provide care in rural
locales
Telemedicine used as strategy for expanding system network & maximizing/integrating delivery of care
Expense reduction
Integrated healthcare
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Telemedicine Strategies & Structures
Telemedicine Delivery of Care Structure Model #1: Hospital needing Specialty Coverage
Patient presents at the Rural Hospital originating site.
Connects with Specialty Physician via telemedicine
Both parties bill for their respective services
Specialty Physicians
Rural Hospital
Telemedicine
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Telemedicine Strategies & Structures
Telemedicine Delivery of Care Structure Model #2: Central Hospital with Specialty Coverage Provides to Spoke
Facilities Spoke facility patients connect with Hub facility physicians via telemedicine
Telemedicine
Physician Coverage
Central Hub
Facility
Spoke
Spoke
Spoke
Telemedicine
Telemedicine
Fair Market Value Considerations
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Source: “Help Wanted: More US Doctors – Projections Indicate America Will Face Shortage of MDs by 2020” by AAMC
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Fair Market Value Considerations
FMV Considerations Favorable OIG Advisory Opinions (98-18, 99-14, 04-07, 11-12) assuming intent to
induce referrals is non-existent
Payment Rates to Physicians for providing coverage Considerations for potential professional reimbursement Payment Structure –
Per-consult (potentially grossed up for availability) Daily availability; Coverage Stipend Combination of these rates $ / annual ED visit Lease rate for equipment hardware/software
Charge Rates to Spoke Facilities
Considerations for potential professional reimbursement Payment Structure –
Per-consult Daily availability (potentially at reduced rates depending on network) $ / annual ED visit Lease rate for equipment hardware/software
Source: “Help Wanted: More US Doctors – Projections Indicate America Will Face Shortage of MDs by 2020” by AAMC
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Questions?
Ben Ulrich, CVA Director – Physician Compensation Valuation
972-616-7798
[email protected] vmghealth.com