Telemedicine: Helping Meet Health Care Challenges

Debbie Voyles, MBADirector of TelemedicineF. Marie Hall Institute for Rural and Community Health

October 2011

Four Core Programs

• Telemedicine –community-based telemedicine in Texas; one of 2 correctional programs; one of longest running programs in nation; 45,000+ consultations

• Rural Research – Project FRONTIER, TARC, Alzheimer’s Disease

• Health Education – West Texas Area Health Education Center (WTAHEC), Hot Jobs, Double-T Health Service Corps, region-wide community health needs assessment

• Electronic Health Records – West Texas Health Information Technology Regional Extension Center (WTxHITREC)

Texas Tech University Health Sciences CenterF. Marie Hall Institute for Rural and Community Health

• Unique challenges for Rural Health Care• What is Telemedicine• Benefits to using Telemedicine• Challenges/Barriers to Telemedicine• Critical Steps to Implement Telemedicine• Reimbursement

Today’s Discussions:

US 2010 Census• Population = 308,745,538

• 9.7% increase from 2000

• 83.7% live in the nations 366 metro areas (population over 50K)

• 10.0% live in the nations 576 micro areas (population between 10K and 50K)

• 6.3% live in rural areas (population less than 10K)

US Department of Commerce Population Distribution and Change: 2000 to 2010

Current Challenges in Rural Health Care

• Workforce shortages

• Geographic isolation – limited transportation

• Diminishing community economics

• Low healthcare margins

• Difficulty recruiting physicians

• Increasing dependence on specialty and expensive technologies

• Demand for quality

Is this the Future of Healthcare?

Health Professional Shortage Areas

HPSA – Mental Health Designated Populations

HPSA – Dental Health Designated Populations

Reported Reduced Access to Care

• In 2009 11.4% of population reported they did not get or delayed medical care due to cost – up from 8.3% in 1997

• In 2009 8.4% of population reported they did not get prescription drugs due to cost – up from 4.8% in 1997

• In 2009 13.3% of population reported they did not get dental care to due the cost – up from 8.6% in 1997

US Census Bureau, Current Population Survey, 2009

Ratio of Providers per 100,000 Population

Primary Care

Doctors

Physician Assistants

Nurse Practitioners

RNs LVNs

U.S., 2000 69 14.4 33.7 780.2 240.8

Texas, 2005 (2000)

68.5 (56)

14.7 (11.9)

17.7 (24.4)

628.6 (603.4)

269 (280.9)

West Texas, 2005

41.7 16 13.4 364.5 424

West Texas/Border, 2005

25.7 15.2 18.4 230.7 183.3

Nurse Practitioner Share of Primary Care Workforce by County, 2009

September 2010 Document by K. Strange, PhD and D. Sampson, PhD, FNP-BC, APRN

Physician Care Share of Primary Care Workforce by County, 2009

September 2010 Document by K. Strange, PhD and D. Sampson, PhD, FNP-BC, APRN

Family Practice Physicians in Rural Counties

Texas Counties Without a Pharmacists

Source: Texas Department of Rural Affairs, August 2010

HoodHoward

Presidio

BrewsterVal Verde

CulbersonHudspeth

Jeff Davis

El Paso

Crane

Pecos

Reeves

Crockett

Terrell

Upton Reagan

Andrews

Ward

Loving Winkler MidlandEctor Glasscock

Martin

Bandera

Jim Hogg

La Salle

Webb

Starr

Zapata

Dimmit

ZavalaMaverick

Kinney Uvalde

Frio

Medina

Nueces

Brooks

Hidalgo

Duval

Kenedy

Willacy

Cameron

Jim Wells

Kleberg

Wilson

McMullen

Bexar

Atascosa

BeeLive Oak

San Patricio

Karnes

GuadalupeGonzales

Mason

McCulloch

Edwards

Sutton

Schleicher

Kerr

Real

Kimble

Menard

Nolan

Tom GreenIrion

Mitchell

SterlingCoke

Runnels

Concho

Coleman

Taylor Callahan

Bell

Blanco

Kendall

Comal

Gillespie

Llano

Travis

Hays

Caldwell

BurnetWilliamson

Comanche

Mills

San Saba

Brown

Eastland

Hamilton

Lampasas

Coryell

Erath

Bosque

Somervell

Swisher

Randall

Hockley

Gaines

Yoakum

Cochran

Dawson

Terry Lynn

Lubbock

Deaf Smith

Bailey

Parmer

Lamb Hale

Castro

Hartley

Oldham Potter

Moore

Dallam Sherman

Knox

Kent

ScurryBorden

Garza

Crosby Dickens

Fisher Jones

King

Stonewall Haskell

Hall

MotleyFloyd

Briscoe

Hardeman

CottleFoard

Childress

JackYoung

StephensShackelford

Throckmorton

ParkerPalo Pinto

Wise

Baylor Archer

WilbargerWichita

ClayMontague

GrayCarson

Armstrong Donley

Hutchinson Roberts

Wheeler

Collings-worth

Hemphill

OchiltreeHansford Lipscomb

Jefferson

Trinity

Brazos

Lavaca

VictoriaGoliad

Refugio

De Witt

Calhoun

Aransas

Jackson

Wharton

Milam

Bastrop

Fayette

Lee

Austin

Colorado

Burleson

Washington

Robertson

Waller

Brazoria

Matagorda

Fort Bend

Harris

Galveston

Chambers

Montgomery

Walker

Grimes

Madison

Jasper

Liberty

Hardin

Polk

San Jacinto

Tyler

Anderson

Ellis

Falls

McLennan

Hill

Freestone

Limestone

Leon

Navarro

Henderson

DallasTarrant

Johnson

Denton

Kaufman Van Zandt

Collin

Rockwall

Hunt

Smith

Cherokee

Houston

Nacogdoches

Angelina

Rusk

Shelby

Panola

Franklin

RainsWood

Hopkins

Marion

Gregg

Upshur

Harrison

Titus

CampMorris Cass

Newton

Orange

San AugustineSabine

FanninCooke Grayson

Delta

Lamar Red River

Bowie

Dentists in Rural Counties

ACCESS

Hospital:

Clinics:

Physicians:

Nurses:

P.A.s:

0

1

.5

2

.5

(nearest 85mi.)

Presidio, TX

Presidio to Lubbock: 398 mi. / 7.5 hrs.

El Paso to Lubbock: 343 mi. / 7 hrs.

Population:

Medicaid Enrolled:

4167

705

We know a need exists

What is Telemedicine?

Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patient’s health status.

Telemedicine began…

• In 1924, when the concept was introduced of a physician seeing his patient over the radio using a television screen and an RCA Victor style speaker

• First wave of telemedicine programs started in the 1950’s

• Now in the third wave

The Radio Doctor – Maybe!

How it Works

• Video conference system

• Various medical peripherals

• High-speed T-1 phone lines

• DSL

• Cable

• Wireless

• Satellite

Telemedicine Components

• Equipment standardization

Electronic Stethoscope

General Exam Camera

Otoscope

Electrocardiogram (ECG)

Emerging Technology Applications

Service Lines•Burn/Wound Care•Dermatology•Genetics•Infectious Disease•Mental Health•Neurology•Nutritional•Orthopedics•Primary Care•Pulmonology

• Cardiology

• Endocrinology

• Geriatrics

• Internal Medicine

• Nephrology

• Oncology/Hematology

• Pharmacy

• Pulmonology

• Urology

Telemedicine Philosophy

• Telemedicine does not alter the practice of medicine.

• It is only a tool.

Telemedicine AccessResponse to:• Fewer physicians in rural/frontier communities• Fewer specialists throughout region• Technology advancements• Changes to state rules• Services w/out taking too much time off from work/school• Reduces escalating (spiking) personal travel costs• Another way to see a health care professional; comparable to face-to-face

care…• Meeting increasing need for specialties due to increasing chronic illnesses

(diabetes, obesity, psychiatric, geriatric, cognitive…)• Expand benefits that health services bring to rural and frontier

communities• …and patients like telemedicine

Benefits to Using Telemedicine

• Improved access to specialty services and care – “care closest to home”

• High patient satisfaction – • improved access, • reduced travel costs (mileage and travel time)• reduced time away from home/school/work

• Improved patient outcomes – earlier interventions, reduced complications, consistent use of evidenced based medicine

• Healthy People/Healthy Communities - better relationships with rural communities – create, improve and maintain local access to appropriate high quality care

Challenges/Barriers to Telemedicine

• Keeping up with changes in technology

• Investment in equipment and training

• Credentialing/licensing (especially across state lines)

• Limits on reimbursement from insurance companies, Medicare, Medicaid

• Connectivity issues

• Regulatory Restrictions

• Systems implementation and interoperability

• End user adoption and training

Three Links to Effective Telemedicine• Referring providers• Technology• Specialists

• We have a handle on the technology link – challenge is connecting the other two

Critical Steps to Implementation

• Community Assessment – in person

• Be clear on goals – what are you trying to achieve?

• Identify a telemedicine team – find champions

• Determine how telemedicine will fit into the organizational structure

• Develop a plan for educating and training

• Continually educate senior leadership, medical staff, community and state leaders, on performance and advances

Community-Based Participatory Assessment

• Communities• What health care services are available• What health care services are needed• Demographics• Sustainability• Acceptance and use

• Will telemedicine make a difference?

• Will the community embrace telemedicine?

• Will the current healthcare providers embrace telemedicine?

• Are there limitations on connectivity?

Treat Telemedicine The Same As Any Other Practice of Medicine

• Apply same protocols, techniques, standards and style

• Treat patient in the same manner as if they were presented in the same room

Licensure

• State licensing – does not require a different license

• Physician must be licensed in the same state the patient is located

• Federal licensing proposal

Telemedicine Credentialing and Privileging Requirements

• If seeing patients in a hospital setting must be credentialed with facility as if seeing the patient in person

• New CMS rule, which applies to all hospitals that participate in Medicare, and inpatients at critical access hospitals, upholds The Joint Commission's current practice of allowing the hospital or CAH to utilize information from the distant-site hospital or other accredited telemedicine entity when making credentialing or privileging decisions for the distant-site physicians and practitioners.

Effective July 5, 2011

Confidentiality and Consent Forms

• Employee confidentiality forms

• Patient consent to treatment form – same as if being seen face to face

• Release of medical records forms

Telemedicine Reimbursement•Medicare

•Medicaid

•Third-Party

•Private Pay

MedicareEligible areas include:• Health Professional Shortage Area (HPSA)• County that is not included in metropolitan statistical area (MSA)

Eligible sites include:

• Office of physician or practitioner• Critical access hospital (CAH)• Rural health clinic (RHC)• Federally qualified health clinic (FQHC)• Hospital• Skilled nursing facility (SNF)• Hospital-based or CAH-based Renal Dialysis Centers (including satellites)• Community mental health center (CMHC)

MedicarePractitioner who may bill:• Physician• Nurse practitioner (NP)• Physician assistant (PA)• Nurse midwife• Clinical nurse specialist (CNS)• Clinical psychologist (CP) and clinical social workers (CSW)

(CPs and CSWs cannot bill for psychotherapy services that include medical evaluation and management services under Medicare. These practitioners may not bill or receive payment for Current Procedural Terminology (CPT) codes 90805, 90807, and 90809)

• Registered dietitians or nutrition professionals

Medicare

Eligible Medical Services• Consultations (CPT codes 99241-99255)• Office or other outpatient visits (CPT codes 99201-99215)• Individual psychotherapy (CPT codes 90804-90809)• Pharmacologic management (CPT code 90862)• Psychiatric diagnostic interview examination (CPT code 90801)• End stage renal disease related services included in the monthly capitation payment

(CPT codes 90951, 90952, 90954, 90955, 90957, 90958, 90960 and 90961)• Individual Medical Nutritional Therapy (HCPCS codes G0270, and CPT codes 97802,

and 97803)• Neurobehavioral status examination (CPT code 96116)• Follow-up inpatient Telehealth consultations (HCPCS codes G0406, G0407 and G0408)

Medicare

Distant site physicians and practitioners submit claims for Telehealth services using the appropriate CPT or HCPCS code for the professional service along with the Telehealth modifier GT, “via interactive audio and video telecommunications system.

Medicare

Originating sites are paid an originating site facility fee HCPCS Code Q3014. The originating site facility fee is a separately billable Part B payment.

Current fee is $24.10

Telemedicine Reimbursement Medicaid

35 States Reimburse for Telemedicine Alabama, Alaska, Arizona, Arkansas, California, Colorado, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, North Carolina, North Dakota, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, Wyoming

Texas Medicaid Reimbursement

Texas Medicaid• Started reimbursing in 1998• One of the first states in the country• Must be “face to face” interactive video, no

store and forward, except for Tele-radiology• Patient site bills for a facility fee –

• Code Q3014

• Must use GT modifier, indicating it was a telemedicine visit

Texas Medicaid Reimbursement

•Eligible areas include:•Rural county – less than 50K

•Medically Underserved Area (MUA) or Medically Underserved Population (MUP)

• Patient Site Location•State hospital•State school•Physician office•Hospital•Rural Health Clinic (RHC)•Federally Qualified Health Center (FQHC)•Intermediate care facility for persons with mental retardation (ICF/MR) that is not a state school•Community Center as defined in Health and Safety Code 534.001 or outreach site associated with a community center•Local health department

Texas Medicaid Reimbursement

•Patient site presenter:• Licensed or certified in this state to perform health care services

• Qualified mental health professional (QMHP)

•Eligible Medical Services• Consultations• Office or other outpatient visits• Psychiatric diagnostic interview• Pharmacologic management• Psychotherapy

Private Payers

• States with government mandated legislation• California, Colorado, Georgia, Hawaii, Kentucky, Louisiana,

Maine, New Hampshire, Oklahoma, Oregon, Texas, Virginia

• All prohibit payers from excluding services solely because they are delivered via telemedicine

Private Payers Providers

Texas Insurance Code (Chapter 1455) generally requires health care coverage providers to treat telemedicine consults as if they had occurred in a face-to-face environment.

JUST BILL THEMJUST BILL THEM

Self Pay

Patients are billed at a discounted rate similar to what they would be billed if seen in person

Texas Tech Telemedicine

Q&A

Contact information:

Debbie Voyles, MBA

TTUHSC Telemedicine

debbie.voyles@ttuhsc.edu

806-743-4440