Connected Health - The small matter of price - Nick van Terheyden, MD
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Transcript of Connected Health - The small matter of price - Nick van Terheyden, MD
© 2002-2014 Nuance Communications, Inc. All rights reserved
mHealth Reimbursement – Who Will PayNick van Terheyden, MD (aka @drnic1)HIMSS mHealth CommitteeCMIO, Nuance Communications, Inc.http://DrNick.vanTerheyden.com
© 2002-2014 Nuance Communications, Inc. All rights reserved
Agenda
– mHealth Reimbursement– Telehealth Technology Players– Use Cases for mHealth – Preventing Readmissions– The Healthier Workforce
© 2002-2014 Nuance Communications, Inc. All rights reserved
“The good physician treats the disease; the great physician treats the patient who has the disease.”
Sir William Osler
© 2002-2014 Nuance Communications, Inc. All rights reserved
Chronic Disease
– Today, 133 million Americans – 1/3 of the total population suffer from at least one chronic disease.
– 70% of all deaths result from chronic diseases.– 85% of all healthcare dollars go to treatment of chronic
diseases.– More than 2/3 of Medicare dollars are spent on patients
with 5 or more chronic diseases.
© 2002-2014 Nuance Communications, Inc. All rights reserved
mHealth Reimbursement
– 1 January 2015– Final 2015 Physician Fee Schedule
– Physicians can bill Medicare for “non-face-to-face” chronic care management (CCM)
– Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensating, or functional decline; comprehensive care plan established, implemented, revised, or monitored.
© 2002-2014 Nuance Communications, Inc. All rights reserved
mHealth Reimbursement3 Core Requirements
– Secure the eligible beneficiary’s written consent
– Have five specified capabilities needed to perform CCM
– Provide 20+ minutes of non-face-to-face care management services per calendar month
© 2002-2014 Nuance Communications, Inc. All rights reserved
mHealth Reimbursement
– Third party payers are now starting to reimburse for telehealth (video conferencing) but only for certain specialties:
– dermatology, mental health, etc– Reimbursement chronic disease
– Multiple Doctors, only one can bill for fee per month– Problems with reimbursement
– licensing issues for providers– limitations for populations covered (for example Medicaid
approves telehealth only for certain jurisdictions mostly rural)
© 2002-2014 Nuance Communications, Inc. All rights reserved
5 Fallacies of Remote Patient Monitoring
– All remote monitoring is the same– All remote monitoring is reimbursed– Patients and physicians will welcome and embrace
remote monitoring– Remote monitoring should be totally automated– Remote monitoring is only for recently discharged patients
© 2002-2014 Nuance Communications, Inc. All rights reserved
Secretary Burwell Establishes Clear Goals for Value-Based Payment
Medicare Reforms and the Transition to Risk
Source: Burwell, S, “Setting Value-Based Payment Goals — HHS Efforts to Improve U.S. Health Care,” New England Journal of Medicine, March 5, 2015; Health Care Advisory Board interviews and analysis.
1) Alternative Payment models include ACOs, bundled payments, patient-centered medical homes, demonstration projects for those dually eligible for Medicare and Medicaid.
HHS Commits to Payment Transformation
2014 2016 2018
80%85%
90%
"This is the first time in the history of the program that explicit goals for alternative payment models and value-based payments have been set for Medicare."
Sylvia M. Burwell, Secretary of Health and Human Services
Medicare Payments Through Alternative Payment Models1
Medicare FFS Payments Tied to Quality or Value
2011 2014 2016 2018
0%
20%
30%
50%
~
Slide courtesy:Dr Kavita Patel
© 2002-2014 Nuance Communications, Inc. All rights reserved
mHealth Reimbursement Resources
– More Info Center for Connected Health Policy– http://cchpca.org/state-laws-and-reimbursement-policies
– AAFP Summary of Medicare Fee Schedule– http://www.aafp.org/news/government-medicine/
20141105finalfeeschedule.html– CMS 1612 FC – Final Rule plus details
– http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1612-FC.html
© 2002-2014 Nuance Communications, Inc. All rights reserved
Social Security Act Sec. 1834(m) [42 C.F.R. § 410.78]
“(T)he Secretary shall pay for telehealth services that are furnished via a telecommunications system by a physician (as defined in section 1861(r)) or a practitioner (described in section 1842(b)(18)(C)) to an eligible telehealth individual enrolled under this part notwithstanding that the individual physician or practitioner providing the telehealth service is not at the same location as the beneficiary.”
• Medicare covered services• Approved telehealth services• Medicare Part B beneficiary• Authorized clinician• Authorized patient site• Separate physical locations• Interactive audio and video system (federal demo sites in AK and HI may use store-and-forward
technology)
Medicare Telehealth Benefit
© 2002-2014 Nuance Communications, Inc. All rights reserved
Source: Medicare Telehealth Services Fact Sheet
Service HCPCS/CPT Code Telehealth consultations, emergency department or initial inpatient HCPCS G0425–G0427 Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs HCPCS G0406–G0408 Office or other outpatient visits CPT 99201–99215 Subsequent hospital care services, with the limitation of 1 telehealth visit every 3 days CPT 99231–99233 Subsequent nursing facility care services, with the limitation of 1 telehealth visit every 30 days CPT 99307–99310 Individual and group kidney disease education services HCPCS G0420 and G0421 Individual and group diabetes self-management training services, with a minimum of 1 hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training HCPCS G0108 and G0109
Individual and group health and behavior assessment and intervention CPT 96150–96154 Individual psychotherapy CPT 90832–90834 and 90836–90838 Telehealth Pharmacologic Management HCPCS G0459 Psychiatric diagnostic interview examination CPT 90791 and 90792
End-Stage Renal Disease (ESRD)-related services included in the monthly capitation payment CPT 90951, 90952, 90954, 90955, 90957, 90958, 90960, and 90961
Individual and group medical nutrition therapy HCPCS G0270 and CPT 97802–97804 Neurobehavioral status examination CPT 96116
Smoking cessation services HCPCS G0436 and G0437 and CPT 99406 and 99407
Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services HCPCS G0396 and G0397
Annual alcohol misuse screening, 15 minutes HCPCS G0442
Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes HCPCS G0443
Annual depression screening, 15 minutes HCPCS G0444
High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes HCPCS G0445
Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes HCPCS G0446
Face-to-face behavioral counseling for obesity, 15 minutes HCPCS G0447
Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge) CPT 99495
Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge) CPT 99496
Psychoanalysis* CPT 90845
Family psychotherapy (without the patient present)* CPT 90846
Family psychotherapy (conjoint psychotherapy) (with patient present)* CPT 90847
Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour* CPT 99354
Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes* CPT 99355
Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) first visit* HCPCS G0438
Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) subsequent visit HCPCS G0439
*Effective for services furnished on and after January 1, 2015
© 2002-2014 Nuance Communications, Inc. All rights reserved
Source: CMS, as reported to the Center for Telehealth and eHealth Law
Medicare Telehealth Claims
15
© 2002-2014 Nuance Communications, Inc. All rights reserved16
Potential Barriers• Largely limited to fee-for-service (Note: CAH service subscriptions)
• Patients must travel to an eligible originating site
• Originating site eligibility can change year-to-year (HPSA or MSA updates)
• Originating site fee copay makes telehealth more expensive (~$5)
• Approved services list isn’t exhaustive; extensive and lengthy process to add services
• Limited clinical outcomes data for some services
• Clinician state licensure limitations (Note: FSMB interstate compact)
• Specialist credentialing/privileging required at each hospital originating site
• Most of U.S. can’t use store-and-forward to better utilize specialists’ time
• Clinician-to-clinician consultations aren’t billable
• RHC and FQHC distant site prohibition
• Different coverage policies than other payers (e.g., Medicaid, insurers)
• Some equipment is still expensive
• Transmission speeds, reliability, and costs
© 2002-2014 Nuance Communications, Inc. All rights reserved
Medicare Telehealth Services Fact Sheet http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf
Medicare telehealth regulations http://www.ecfr.gov/cgi-bin/text-idx?SID=89f51d919ffc5b375f126c606b5b5cd3&node=se42.2.410_178&rgn=div8
Medicare Telehealth Payment Eligibility Analyzer http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx
Medicare telehealth webpage http://www.cms.gov/Medicare/Medicare-General-information/telehealth/index.html
Medicare Benefits Policy Manual Chapter 15 (Sec. 270) http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf
Medicare Claims Policy Manual Chapter 12 (Sec. 190) http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
Medicaid telemedicine webpage http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html
Resources
17
© 2002-2014 Nuance Communications, Inc. All rights reserved
mHealth Use CasesPreventing Readmissions
© 2002-2014 Nuance Communications, Inc. All rights reserved
mHealth Value Proposition
– Early intervention for people at risk of congestive heart failure (CHF) - the leading cause of hospitalization in the U.S. - could save from $5 to $7 billion per year by expanding telehealth services.
– Telehealth documented itself to be efficacious as a tool for early intervention
– Miley, Madeline L., et al. "The state of emergency stroke resources and care in rural Arizona: a platform for telemedicine." Telemedicine and e-Health 15.7 (2009): 691-699
– Deployment of an mHealth Patient Monitoring Solution for Diabetes: “Improved Glucose Monitoring Leads to Reduction in Medical Expenditure”
– http://www.touchendocrinology.com/articles/deployment-mhealth-patient-monitoring-solution-diabetes-improved-glucose-monitoring-leads-r
© 2002-2014 Nuance Communications, Inc. All rights reserved2009 Continua Health Alliance Brigitte Piniewski, MD2008 21
0 25 65Age
Illness
Pre
-Illn
ess
Welln
ess
Unpredictable Health
Predictable (Rules-based) Health Death
60-80% Lifestyle
Modifiable Health
© 2002-2014 Nuance Communications, Inc. All rights reserved2008 22
0 25 65 AgeIll
ness
Pre
-Illn
ess
Welln
ess
Death
To put it another way….
Fun
No Fun
2009 Continua Health Alliance Brigitte Piniewski, MD
Annual medical costs for people who are obese were $1,429 higher than those of normal weight.
Annual medical costs for people who are obese were $1,429 higher than those of normal weight.
Centers for Disease Control and Prevention (2009)
Centers for Disease Control and Prevention (2009)
© 2002-2014 Nuance Communications, Inc. All rights reserved
Fort Healthcare has run with it!(Still in progress)
Fall 2011Six weeks
605 players (four employers)
> 222 million steps
1,368 players
365 million steps (so far)
64 teams (341 players)
3,781 pounds lost
Spring 2012Four months
Fall 2012Six weeks
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Columbia was up for the challenge
Columbia Slimdown Challenge
3,586 Participants
(75+ local employers)
11,505 pounds lost(winner lost 23% of body
weight)
36 sponsors(starting at
$2,500)13 week long weight loss challenge
“Thank you so much for the opportunity to lose weight in such a fun way….. Several of us are hoping the contest can continue (lose more weight!) or restart (add new people).”
—Slimdown participant
© 2002-2014 Nuance Communications, Inc. All rights reserved
Making a difference, changing lives
~ 5.2 BILLION steps taken
~ 76,770
pounds lost(equivalent to the weight
of an 18 wheeler)(equivalent to walking
around Earth ~40 times)
26,518 lives changed
23 competitions completed
© 2002-2014 Nuance Communications, Inc. All rights reserved
Nuance Just Completed their First Challenge
Since March over 800 employees have been tracking their steps, food and sleep to manage their health and earned over 337,710 points redeemed for 10,359 entries into the May 31st sweepstakes. We are pleased to announce that we have our first set of winners.
© 2002-2014 Nuance Communications, Inc. All rights reserved
Single Individual
– 149,000 steps which is equivalent to 70 miles
Firstly I would like to thank your team for the Jiff Challenge. Being
motivated to compete for the Apple Watch resulted in me
losing 21 pounds in 28 days! I’d say the program is a huge
success.
He sacrifice sleep, changed vacation plans to go to hike mountains instead of visiting family, walked every chance he got morning afternoon and late into the night. He would watch shows on his treadmill and go to the gym and just walk. He didn’t even sleep the last day of the challenge he walked every chance he got.
© 2002-2014 Nuance Communications, Inc. All rights reserved
Recognizing New Channels for Growth
Established Provider
Care Delivery Network
Relationship-Based Referring Physician
Cost-Conscious Referring Physician
Price-Sensitive Consumer
Entrenched Payer
Vulnerable Payer
Activated Employer
Exchange Operator
Custom Network Builder
Secure Enrolled Lives Win Share of VolumesTraditional Growth Channels
Key Decision-Makers in Traditional and New Growth Channels
Individual Insurance Shopper
Accountable Physician Entity
New Growth Channels
Slide courtesy:Dr Kavita Patel
© 2002-2014 Nuance Communications, Inc. All rights reserved
Nick van Terheyden, MD CMIO, Nuance CommunicationsTwitter http://twitter.com/drnic1LinkedIn http://www.linkedin.com/in/nickvtVoice of the Doctorhttp://drvoice.blogspot.com/My Activityhttp://DrNick.vanterheyden.comAboutMe http://about.me/obiwanFaceBook http://profile.to/[email protected], [email protected] (301) 355-0877
QuestionsWhere You Can Find Me