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Electronic Visits: Going Mainstream?

August 18, 2010

The AMA recently reported that they are in favor of reimbursement for telehealth.  Can you believe it? For those of us who have been toiling in the fields of Connected Health for many years, this is an amazing statement.  I dare say many of us never thought we’d be able to say or write it.  The Center for Connected Health is issuing a media advisory on this today.  In essence this represent a huge symbolic step in the adoption of telehealth.

A quick review of history:  until the late 90s, the Centers for Medicare and Medicaid Services did not reimburse for care unless patient and provider were in the same physical location.  They then dipped their toe in the water, largely due to pressure from politicians representing rural states, allowing providers caring for patients in ‘non-metropolitan statistical areas’ to bill Medicare for videoconferencing-based telehealth activities.  Earlier in the current decade, some commercial payers began reimbursing for ‘secure clinical message’ exchange between patient and provider.  These e-visits are reimbursed at the rate of ~$35/message.  With some minor exceptions that has been the state of remote health reimbursement for some time.

So for the AMA to suggest the payment for telehealth services should be broadened is wonderful news at first glance.  For at least the last 15 years, I’ve attended talk after talk where the same slide is shown with ‘barriers to adoption’ and tops on the list is ‘lack of reimbursement’.

But is it good news?

Perhaps you think I’ve gone soft – had too much time off this summer. How could it not be good news???

The caveat is that the AMA’s endoresement comes at a time when health care providers are being asked to engage in serious dialogue about the rising cost of health care and their responsibility to be part of the solution.

The reason that all manner of payers were reluctant to reimburse for telehealth all of these years is because they feared increases in utilization and redundancies would result.  I’m a dermatologist. What if  your primary care doctor sent me an image of your mole.  I look at it and decide that I really need to see you in person to be sure, but I bill for both the image review and the in-person visit.  If we simply reimburse telehealth on a fee for service reimbursement will those of us billing for services simply become part of the problem of rising health care costs?

Payment reform is in the air.  The day is not far off when insurers will be paying us in bundles and asking us once again to take financial risk for the care of our patients (capitation).  Connected Health advocates are bullish that remote care contributes to cost reduction by allowing for just-in-time care, allowing for spur-of-the-moment consultation and by minimizing redundancies and uneccessary office visits, emergency room visits and hospital admissions.  As an example, we’ve looked at the readmission rate for our heart failure patients on our telemonitoring program and it is about half the rate of non-monitored patients.

So maybe what the AMA should be advocating for is alternative care models to go hand in hand with alternative payment models, i.e. pay us for quality and outcomes and leave the delivery of services (in-person or remote) to us health care providers.

Kudos to the AMA for taking this important first step. But, we still have more work to do.

What do you think?

10 Comments leave one →
  1. Ed Childs permalink
    August 18, 2010 1:46 pm

    Excellent comments,

    You are right on mark with purchaser and consumer long-term goals of provider reimbursement based outputs and value, rather than inputs and sophisticated coding.

    The basic building blocks are almost in place for a Platform for Value-based Buying™. Necessary components are:
    1-Patient enrollment and choice of a single physician clinical team leader.
    2-Plan sponsor release of benefit plan, reimbursement, network, etc. data.
    3-Patient centered reporting of diagnosis, acuity, severity of illness, etc.
    4-Use of an EMR, single concurrent-clinical care plan, with advanced nurse navigators.
    5-Electronic comparative profiles of all referral physicians by outcomes,
    resources-consumed, and patient satisfaction.
    6-Gainsharing- reimbursement for patient and medical team.
    7- Performance-based medical team reimbursement, through selection and
    non-selection of existing referral and admission choices, will secure necessary adjustments
    in fees, utilization, quality, outcomes, overall cost and patient satisfaction.

    Parallel-Vested Interest(TM) and completion for “paying referrals” is far superior in modifying practice pattern variation than any third party reimbursement scheme.

    Ed Childs

    • August 18, 2010 2:36 pm

      this is an interesting checklist for us all to consider as we move forward

  2. Maryalice Jordan-Marsh permalink
    August 18, 2010 7:18 pm

    Many excellent pieces on the checklist, but personal health record component is missing or hidden. Really restructuring means giving patients more access to information. Too often patients get to the next expert and the image/xray/lab result is not available. If it is posted on a patient access page, around the world, patients and their providers can make informed decisions. Yes, some risks, but think of the risks and costs in our current system.

    Also, the time is past when AMA is the sole arbiter. So much talk about telehealth tosses ecosystem around, now is when we need to really take a fully sociecological and physical feature environment view. Nursing and social work professional organizations need to be at the table and in the blogosphere! The Continua Alliance (http://continuaaliance.org) is a vital partner as well.

    • Ed Childs permalink
      August 19, 2010 2:15 pm

      Maryalice,

      The EHR is an interface option with the EMR through the Nurse Navigator who maintains contact with patients on a PRN basis with visits, phone calls, e-mail, i-mail etc.

      EHR electronic downloads to the nurse would be interpreted and entered into the EMR. Certainly any data formated from the patient, updating key metrics would be welcome and a patient portal for this input as well as lab results and prescription data from the EMR captured electronically from PBM’s and labs, via the LOINC Code transmissions,would be a natural outflow of the EMR to automatically update the EHR, just as claims status could be updated from TPA,s.

      The Nurse Navigator would serve as an Advanced Nurse patient advocate for communications between the clinical care team and the patient and other ancillary support providers.

      I appreciate your comments. Patient-centered, primary care centered clinical team collaboration drive the check list implementation.

      Ed Childs

      e

  3. August 19, 2010 1:33 pm

    Two things I agree with: Glad the AMA recommended virtual visits (and what took them so long) and yes payment and care reform are still fundamental issues. It is a reasonable fear that payers will grab this solely a cost reduction under fee for service or a tool to force capitation.

    However the bigger picture still remains, how can connected health expand our ability to care for people in their homes, in “rural” areas as an adjunct and for pocketed groups of elderly (and families) in conjunction with a nurse practitioner or other mid-level provider. Are we looking at the expanse of care a PCP can provide with small remote investment to have immediate and timely consults with specialists?

    The ability to treat and care for the patient as a person in a timely manner with quality care is the goal. That in modifying the workflow and adopting new technology and treatment processes/monitoring actually may be more cost effective is a benefit. That the change and new technologies may provide better care for the patient needs to remain the focus

  4. Antoine Poppe permalink
    August 20, 2010 12:55 pm

    Also in Belgium, Telemedicine applications are being progressively adapted by the large medical insurance companies (mutualities).
    Specifically concerning ” virtual visits”: they make only sense if a visit is the follow up of an alarm coming from the patient’s online wireless monitoring devices ( ECG, glucose level,blood pressure, weight etc). When alarm levels are reached, the GP and/or medical specialists concerned, will receive in the Electronic Health Record of the patient, an alarm signal so that there is a concrete measured indication that the patient has to be visited or eventually brought to the hospital.
    Such medical value chain creates huge advantages for all parties in the chain:
    1. For the patient:
    – a longer life,
    – important clinic and nursing savings,
    – cheaper insurance costs,
    – longer mobile and outdoor happy life at your proper home,
    – secure comfort feeling because of online control,
    2. For the insurance company:
    – important savings on the insurance contracts of their
    insured high risk groups for heart attacks,
    – potentiality to lower the price for insurance contracts for
    the lower and non risk groups,
    – differentiation of contract pricing according to acceptance
    or non-acceptance of the on-line monitoring by the client of
    the insurance company.
    3. For the social security and the society in general
    – drastic reduction in hospitalization and surgery costs
    (prevention is 80 % cheaper than curative treatment after an
    accident)
    – survival and normal social and/or economical life in case of
    prevention of a heart attack,
    – important financial savings for the economy and industry
    4 . For medical sector and clinics.
    – The time saving for the patient is a question of life and death: the detection in time and in advance of an imminent heart attack will save the life of the person concerned; the non detection in time means death for 50 % of the persons suffering from a heart attack
    – This prevention leads towards preventive treatment in time so that there is a much higher efficiency in the treatment of heart patients by medical sector
    – Our technology will give correct medical information of the patient for specialists and medical personnel so that heart accidents will be more and more prevented instead of cured

    Toon Poppe,
    Heart Link & Diabetes Link Online

  5. Karen Heffernan FNP-c RD MPH permalink
    August 22, 2010 10:48 am

    Have the team considered starting an Association with UT School of Rural Public Health.
    Social forces there could make telemed attractive

    1 20% of Americans live in small communities + More than 1/3 of our kids in many states
    2 MD retention is low
    3 Specialists are scarce
    4 Occupational injuries, tobaccoism, & depression are prevalent
    5 An attitude of self reliance may make rural patients good partners for newer projects

    Karen Heffernan

  6. Greg Merriman permalink
    August 26, 2010 10:46 am

    I attended the Academy Health meetings in Boston recently and I recall one HIT session in particular where ‘real world’ practicing physicians (obviously with interest in this/research/etc) were hopping all over and around this during Q&A. And it got into the weeds, and fairly contentious, pretty quickly (the mole example and then some, but from the MD’s perspective). For these folks – the average physician/practitioner who must (! or at least can’t help but) worry about logistics/the weeds – and, particularly, $/reimbursement – lack of reassurance, lack of comfort, anxiety, etc., is a BIG deal.

    For the average practitioner, the endorsement by AMA is going to be a big deal as time and technology marches on. Maybe mine are all obvious statements, and maybe, at a high level, we assume it will all just work out because it ‘has to,’ but the anxiety about this (similar to anxiety about EHR perhaps/any technology and how they relate to time and money) remains high. For these folks to be able to turn to the AMA’s words/position – even if the next step is to pick it apart (as should be done), determine their remaining areas of concern (or new ones), discuss with colleagues – I think is a good thing. It’s something in a place where there has been very little.

    The average practitioner will, to some extent, place faith in their group to help the right things happen – we know this, looking back, well, many practitioners are so busy in the weeds that s/he just does not have time to get up and out of them and have a look around at what’s going on – and when they do – out of a sense of urgency sometimes – it may be/is so far along that it is challenging to grasp, step in and stand for what they think is right (in spare time), and on and on. This will help the masses and at least reassure them that the AMA is engaged and willing to take a stand, and that the stand is fairly reasonable.

    I think a lot about patient-related outcomes and how to evaluate them; right in the middle of the technology and the patient is the practitioner (well, and the payer :/ ). No buy in there (no confidence/comfort/endorsement even if it is related to reimbursement and has nothing to do with the technology) –> outcomes/results that lean toward the null.

    Anyhow, I do hope that the word spreads/continues to spread…

    Greg Merriman

  7. September 5, 2010 6:23 pm

    You pose an excellent question, Joe K: Which trends in technology-enabled healthcare will end up as the real game-changers? It’s always wise to hem and haw and qualify predictions every which way from Sunday, of course, so please consider the following statements hedged. That said, here’s what I expect to see:

    • Growth in the health-to-medicine ratio. In other words, the resources – money and time — we devote personally to staying healthy are going to expand a lot faster than the resources we hand over to medical professionals towards the same end. Technology-assisted doctors’ work will grow in absolute terms (due to population aging) but technology-assisted self-help will take a growing share of the total market.

    • Health technology that goes beyond mobile to embedded and ubiquitous. Sensors and electrodes will collect data and generate feedback whenever and wherever we choose to locate them — in, on and around the body, and on objects both mobile and immobile.

    • Breakthroughs in what we might call compliance engineering. What comes to mind is some combination of Sunstein’s and Thaler’s description of choice architecture; Christakis’ and Fowler’s dissection of the influence of social networks; and – on an even grander scale – the British inquiries into the health effects of social class. For the next ten years we’re going to be teasing out causative effects and attempting to neutralize them. Many of the compliance features we engineer will be technology-based and self-engineered, with opt-ins and opt-outs galore. But often compliance engineering will amount to social engineering, which means there will be political reverberations (see below).

    • Physical structures and transportation vehicles built to be not only “green” but “blue” – conducive to good health. As an aspect of compliance engineering, architects, planners and designers will lay out smart buildings, campuses, public spaces and public services, one that encourage physical exertion and monitor and measure results, though individuals will be able to opt in or opt out.

    • Neuroscience that changes everything. We’ve just started to plumb the results of fMRIs and other tools for studying the brain. My favorite finding of the moment comes from “How the Opinion of Others Affects Our Valuation of Objects” in this past July’s issue of Current Biology. Campbell-Meiklejohn et al report that the mere experience of agreeing with experts and authority figures lights up the brain’s ventral striatum – that is, confers psychic rewards. With findings like these, neuroscientists will begin to color in the outline we have of human decision-making and motivation. If we make radical progress in understanding technology’s users – that would be us – technology will have to change radically as well.

    • Health data that ends up in siloes. Doctors will adopt electronic health records, no question, but the feds will continue to redefine the NHIN out of existence, and institution-specific EHRs will never catch up with the numbers generated by the various technologies referenced here.

    • Payment systems that treat most of connected health IT as infrastructure or overhead. Today’s concerted push by vendors to wrangle specific fee-for-service reimbursement for uses of their products will largely fail, supplanted by a common-sense view of IT as part of healthcare’s woodwork. IT expenditures, in other words, will be treated not as add-on services but as business expenses, to be covered by global or capitated payments. This is by far the best way to ensure that such expenditures either reduce costs or enhance outcomes — if they don’t, capped providers won’t lay out the money for them.

    • Re-alignments of responsibility and risk. We will all navigate uneasily between the science of decision-making (above), where personal volition is provisional but still matters, and genomics and other disciplines focused on disease predisposition, where the influences beyond our personal control rank high. In the end, driven by financial worries and cultural norms, the public will acquiesce to rate-setters and payers — insurers, employers and governments – who routinely differentiate in their charges between insureds with healthy habits and insureds without. As each of us does what we can to land in the right camp, connected health technology will thrive.

    • Technology trend smash-ups occasioned by all of the above. The Nanny State tint to some of the technology developments I’m talking about will breed continuous popular ambivalence and periodic popular eruptions. As health care professionals and technologists, we need to prepare ourselves for the distinct possibility of political black swans – low-incidence but trend-ending disruptions in the public mood. In hindsight such disruptions will appear understandable, even inevitable, but when they’re happening they will seem inexplicable. Trends will arrive, trends will disappear, and every so often, connected health technology will get caught up in the mishegas.

    • September 6, 2010 9:29 pm

      thanks, MIke for such a thoughtful addition to the blog

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