Joseph A. Banken, M.A., Ph.D., HSPP Associate Professor Director of Research, Antenatal & Neonatal Guidelines Educa

1. The Impact of Mental Health Telemedicine on Patients’ Cost Savings Joseph A. Banken, M.A., Ph.D., HSPP Associate Professor Director of Research, Antenatal & Neonatal Guidelines Education and Learning System (ANGELS) University of Arkansas for Medical Sciences Department of Obstetrics and Gynecology Little Rock, Arkansas

2. Key Presentation Themes • Growing demand for more cost-effective ways of delivering accessible behavioral healthcare • Telemedicine can assist addressing the high costs associated with behavioral health illnesses in days missed from work • Behavioral health telemedicine provides a possible solution to barriers for needed treatment • Telemedicine Defined: - Employment of telecommunications and information technologies for the clinical care of patients and patient counseling

3. The Rural Hospital Program Interactive Video Network University of Arkansas for Medical Sciences

4. Reaching the Hard to Reach: Barriers for Access to Healthcare Target area for the UAMS Telehealth Project: • East Arkansas Delta • Seven counties, rural population • More than 131,000 residents - 51% are minority African American - Some of poorest counties in Arkansas - Medically Underserved Areas (MUAs) - Health Professional Shortage Areas (HPSAs)

5. Barriers for Access • System Barriers • Lack of providers, insurance, educational, transportation • Travel Costs - Need to travel long distances for medical care • Culture Barriers • Feeling of distress, anxiety by idea of traveling to health professionals in large urban areas - Prefer familiar surrounding for healthcare - Family and social support in own community • Individual Barriers • Lack psychological, physical, financial resources to travel to healthcare settings • Patient avoiding travel - Depression, anxiety, substance misuse

6. The UAMS Rural Hospital Telehealth Project • Developed in 1998, ended in 2003 • Delivered specialty telemedicine consultations at distant sites • Served a poor, underserved, rural population in the East Arkansas Delta • Project Objective: • Increase rural residents’ access to specialty medical services across the life-span using Telemedicine • Funded by the Office for the Advancement of Telehealth, HRSA, DHHS • Provides payment for medical consultations for patients without insurance

7. Telemedicine Technology: Polycom View Stations, ELMO-400 Document Cameras, T1 Telephone Lines(2003)

8. Purpose of Study • Evaluate patients’ cost savings with participation in behavioral health telemedicine consults in the UAMS Telehealth Project during 1998-2003 • Differences in patients’ cost savings were assessed by demographic and socioeconomic variables

9. Cost Variables The variables examined for patients’ cost savings with telemedicine: • Travel mileage for medical care, based on current 2003 standard - 32 cents per mile • Missed days at work • Family expenses

10. Demographic & Socioeconomic Variables • Gender • Ethnicity • Education • Occupation • Income • Insurance • Household Size • Community Size

11. Significance of Study • Results can be used to determine strategies for improving cost savings with behavioral health telemedicine among subgroups of patients in Arkansas • No other comparable study for behavioral health telemedicine

12. Methods • Post-use survey • Behavioral health telemedicine patients • Rural East Arkansas Delta population • Telehealth Project during 1998-2003 • 186 consults • Data collected - March 1998 to August 2003

13. Procedures • Primary care providers from distant, healthcare sites in the East Arkansas Delta requested behavioral health telemedicine consults through the project coordinator • Primary care provider/site facilitator presented patient to the consultant in brief telemedicine interaction • Consult sessions • Patient interviews, MSEs, behavioral health treatment • 45- minute session • Follow-up care and instructions provided for the patient and site facilitator • Patient privacy remained paramount • Developed behavioral health protocols for urgent care • Interactive compressed video technology • Infrequent technical disruptions

14. Instruments • Patient Post–session Evaluation: • Patients’ cost savings - Travel - Missed days at work • Patient Master Record - Demographic and socioeconomic data • Data de-identified for study purposes - Family expenses

15. Data Analysis • Statistical Package for Social Sciences (SPSS) • Chi Square Test of Independence • Evaluated differences between proportion for two or more groups in the master data set - Assess differences in patients’ cost savings with behavioral health telemedicine by demographic and socioeconomic variables

16. Results: Characteristics ofResearch Population • N = 186 consults (N = 73 patients) • Response Rate = 68%-72%, cost savings variables • Female 58% • Adults 19-78 years of age 58% • African-American 43% • Less than High School Education 31% • Unemployed/Retired 46% • Income < $25,000 57% • No Health Insurance 63% • 1-2 Persons in Family 55% • Resided in Smaller Rural 47% • Communities (population 50-1,506)

17. Results: Patients’ Cost Savings for Behavioral Health Behavioral Health Care • WITHOUT Telemedicine • 90% of patients would travel greater than 70 miles for care • 59% would miss one day of work • 56% would spend $75-$150 for family expenses 2003 Expense Costs

18. Patients’ Cost Savings with Behavioral Health Telemedicine • With telemedicine: • 96% of patients traveled <30 miles • 3% traveled 31-50 miles • 87% saved a travel distance of at least 40 miles (40-60 miles)

19. Patients’ Cost Savings with Mental Health Telemedicine • With telemedicine: • 87% of patients saved $32 in fuel costs by saving a travel distance of 100 miles for a round trip (2003 fuel expense data) • 56% saved $75-$150 in family expenses

20. Patients’ Cost Savings with Behavioral Health Telemedicine • Assuming an average annual income of $25,000 - Behavioral health telemedicine patients, this translates to a daily income of $100 • Assuming the cost of missing one day of work is $100 - 59% saved $100 in wages by avoiding one day of missed work with telemedicine

21. Patients’ Cost Savings with Behavioral Health Telemedicine: Demographic and Socioeconomic Variables • With Telemedicine: • 95% of Medicaid patients saved $32 in fuel costs • 78% of Medicaid patients saved $75-$150 in family expenses

22. Medicaid Patient’s Cost Saving for Travel and Family Expenses with Telemedicine Percent

23. Travel Distance Saved With Telemedicine by Education • Patients with a college education were more likely to save a distance of at least 40 miles (40-60 miles) with telemedicine • Compared to patients with a high school degree or less (p = 0.043)

24. Travel Distance Saved 40 – 60 Miles with Telemedicine by Education Percent of Patients

25. Family Expenses Without Telemedicine by Income • More likely to have family expenses over $150 without telemedicine - Patients in households with annual incomes of $25,000 or less (p = 0.001) Patients in households with annual incomes over $25,000

26. Family Expenses Over $150 Without Telemedicine by Household Annual Income Percent of Patients

27. Family Expenses Without Telemedicine by Education • Patients with a College Education • Significantly more likely to have family expenses over $150 without telemedicine - Patients with a high school degree (p = 0.002)

28. Family Expenses Over $150 Without Telemedicine by Education Percent of Patients

29. Missed Days at Work Without Telemedicine by Income Although not significant (p = 0.080) • Patients in households with annual incomes of $25,000 or less (63%) • More likely to miss one day of work without telemedicine - than patients in households with annual incomes over $25,000 (39%)

30. Conclusions The study findings suggest that behavioral health telemedicine patients in rural Arkansas: • Saved on travel for medical care • Missed fewer days of work • Saved on family expenses • Saved an average of $282 in travel fuel costs, family expenses, and wages by avoiding travel and missed work days (2003 Fuel data) Significant differences in patients’ cost savings with telemedicine were found by health insurance status, education, and income

31. Limitations • Post-use survey of self-selected mental health telemedicine patients - Convenience sample • Non-respondents for demographic and socioeconomic variables were higher than desired • Self-reported data extrapolated (2003) for patients’ cost savings with behavioral health telemedicine • Study design limited the ability to determine the cost-effectiveness of program methods

32. Implications for Clinical Practice • Study findings demonstrated that behavioral health telemedicine is serving a useful purpose for a poor, underserved rural population in the East Arkansas Delta • Improve cost savings with behavioral health telemedicine among subgroups of patients by program methods that address patient’s needs regarding travel for medical care, missed days at work, and family expenses • The findings provide evidence for third-party payers regarding patients’ cost savings with behavioral health telemedicine

33. Implications for Future Research • Decrease the sample of non-respondents for demographic and socioeconomic variables • Instructions for patients, train site facilitators: - Completion of all instrument items for demographic, socioeconomic variables

34. Implications for Future Research • Future studies - Compare mental health telemedicine programs and face-to-face mental healthcare on patients’ cost savings • Assess patients’ cost savings with behavioral health telemedicine in small, remote rural communities in other states and among different ethnic groups - Assess hospitalizations - Treatment adherence - Emergency Department Visits - Consider involvement of high-risk patient groups

35. Acknowledgements • Ann Bynum, EdD • Cathy Irwin, RN, PhD • Narissa Perry