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
806-743-4440
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