Telemedicine: Helping Meet Health Care Challenges

1. Telemedicine: Helping Meet Health Care Challenges Debbie Voyles, MBA Director of Telemedicine F. Marie Hall Institute for Rural and Community Health October 2011

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

3. Today’s Discussions: • Unique challenges for Rural Health Care • What is Telemedicine • Benefits to using Telemedicine • Challenges/Barriers to Telemedicine • Critical Steps to Implement Telemedicine • Reimbursement

4. 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

5. 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

6. Is this the Future of Healthcare?

7. Health Professional Shortage Areas

8. HPSA – Mental Health Designated Populations

9. HPSA – Dental Health Designated Populations

10. 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

11. Ratio of Providers per 100,000 Population

12. Nurse Practitioner Share of Primary Care Workforce by County, 2009 September 2010 Document by K. Strange, PhD and D. Sampson, PhD, FNP-BC, APRN

13. Physician Care Share of Primary Care Workforce by County, 2009 September 2010 Document by K. Strange, PhD and D. Sampson, PhD, FNP-BC, APRN

14. Family Practice Physicians in Rural Counties

15. Lipscomb Dallam Sherman Hansford Ochiltree Hartley Hutchinson Moore Roberts Hemphill Oldham Potter Carson Gray Wheeler Collings- worth Deaf Smith Randall Armstrong Donley Parmer Castro Swisher Briscoe Hall Childress Hardeman Cottle Motley Wilbarger Hale Floyd Bailey Lamb Wichita Foard Clay Montague Lamar Cooke Grayson Red River King Baylor Crosby Dickens Archer Lubbock Cochran Hockley Knox Fannin Bowie Delta Jack Titus Wise Denton Collin Garza Kent Lynn Stonewall Haskell Throckmorton Young Terry Franklin Yoakum Hopkins Hunt Morris Cass Camp Rockwall Rains Tarrant Marion Wood Parker Dallas Palo Pinto Borden Scurry Gaines Dawson Fisher Jones Shackelford Stephens Upshur Kaufman Van Zandt Harrison Gregg Hood Johnson Smith Ellis Eastland Howard Andrews Martin Mitchell Nolan Taylor Callahan Erath Somervell Henderson Panola Rusk Navarro Hill Comanche Bosque Coke Ector Midland Glasscock Winkler Loving Cherokee Sterling Runnels Anderson Shelby Coleman Brown El Paso Hamilton Freestone Nacogdoches McLennan Limestone Ward Mills Hudspeth Culberson Crane Tom Green San Augustine Coryell Upton Reagan Sabine Concho Reeves Houston Irion Leon Angelina Falls McCulloch Lampasas San Saba Trinity Bell Robertson Madison Schleicher Menard Polk Burnet Milam Newton Pecos Tyler Jasper Walker Crockett Mason Jeff Davis Llano Brazos Williamson San Jacinto Grimes Sutton Burleson Kimble Travis Hardin Gillespie Lee Montgomery Blanco Terrell Washington Liberty Orange Bastrop Kerr Hays Waller Presidio Edwards Kendall Val Verde Austin Jefferson Fayette Harris Caldwell Real Brewster Comal Bandera Chambers Colorado Guadalupe Fort Bend Gonzales Bexar Lavaca Galveston Uvalde Medina Kinney Wharton Brazoria Wilson De Witt Jackson Karnes Atascosa Zavala Frio Matagorda Victoria Maverick Goliad Calhoun Dimmit Bee McMullen Live Oak La Salle Refugio Aransas San Patricio Webb Nueces Jim Wells Duval Kleberg Jim Hogg Brooks Zapata Kenedy Starr Willacy Hidalgo Cameron Texas Counties Without a Pharmacists Source: Texas Department of Rural Affairs, August 2010

16. Dentists in Rural Counties

17. Presidio, TX ACCESS Hospital: Clinics: Physicians: Nurses: P.A.s: 0 1 .5 2 .5 Population: Medicaid Enrolled: 4167 705 (nearest 85mi.) El Paso to Lubbock: 343 mi. / 7 hrs. Presidio to Lubbock: 398 mi. / 7.5 hrs.

19. We know a need exists

20. 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.

21. 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

22. The Radio Doctor – Maybe!

23. How it Works • Video conference system • Various medical peripherals • High-speed T-1 phone lines • DSL • Cable • Wireless • Satellite

24. Telemedicine Components • Equipment standardization

25. Electronic Stethoscope

26. General Exam Camera

27. Otoscope

28. Electrocardiogram (ECG)

29. Emerging Technology Applications

30. 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

31. Telemedicine Philosophy • Telemedicine does not alter the practice of medicine. • It is only a tool.

32. Telemedicine Access • Response 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

33. 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

34. 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

35. Three Links to Effective Telemedicine • Referring providers • Technology • Specialists • We have a handle on the technology link – challenge is connecting the other two Patient Technology Access Provider Specialized Care

36. 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

37. 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?

38. 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

39. Licensure • State licensing – does not require a different license • Physician must be licensed in the same state the patient is located • Federal licensing proposal

40. 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

41. 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

42. Telemedicine Reimbursement • Medicare • Medicaid • Third-Party • Private Pay

43. Medicare • Eligible 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)

44. Medicare • Practitioner 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

45. 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)

46. 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.

47. 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

48. 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

49. 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

50. 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