Telehealth proof before payment- an antiquated barrier to care

     Telemedicine (tmed) has moved from technology to an opportunity for care.  Where there is limited access to experts (eg...rural stroke care), it is compensated- the right person at the right time can make all the difference.  However, widespread adoption of has been limited by two critical issues. First, licensure issues limit providers from crossing state lines.  Second, and more importantly, payment models are complex.  The same rural service delivered may not be paid for across town in a city.  Additionally, reimbursement for virtual care may be possible for one condition but not another in the same rural hospital.
    Parity legislation attempts to simplify these issues. In short, parity legislation requires, in fact mandates for private insurers, that the same billing codes apply whether the patient is seen is an office or on a computer. Almost every State is considering some form of this legislation.  Unfortunately, “mandate”  equates to cost for many legislatures and most insurers.  Mandate is viewed as a 4 letter word.

    In an effort to slow parity legislation, payers have suggested there needs to be proof tmed’s value related to specific clinical scenarios before payment.  Although this makes sense new drugs and devices, I am less certain it applies to tmed.
    Ultimately, healthcare "value" depends on 2 people- the provider and the patient.  The provider needs to be comfortable they can adequately assess the patient. This may require a physical exam, but more often providers need to see the patient and hear their concerns.  For most patients, a visit to the doctor is about reassurance, getting a sense that their cough isn't cancer, that the pain they feel is normal or worthy of further investigation.  If the provider or the patient feel a virtual visit is insufficient, either can choose to have the visit become an in person experience.  For the cost of one emergency room visit,  we could buy 50 to 100 virtual visits.  Access manages disease before it requires expensive tertiary care. Value is not determined by physical presence, but rather the communication, relationship and ultimately the patient’s outcome.      
    Virtual care offers an additional advantage over the standard office practice.  By eliminating physical barriers, care coordination can improve.  Many chronically ill patients have between 12-18 providers, most whom never meet or talk about the patient.  Leveraging mobile devices, care teams could be together, reducing costs and improving care.

    An alternative approach to no proof/no payment might be a stage introdcution for virtual serivces.  Allow reimbursed, but set a limit for a certain number per month per patient.  This would enable providers and patients to discover the most cost effective virtual alternatives while limiting the perceived financial risk to the payer.      Allow market forces to determine the best possible solutions rather than stifling innovation.  To compare tmed to traditional care would take years of work and thousands of patients.  And in the end we would be left with an ever evolving, and confusing landscape for virtual reimbursement.
    Healthcare in America is in transition.  We are moving from transactional care and reimbursement, get paid for what you do,o shared risk, wellness model.  Virtual care is one of the many tools that can help improve the care/cost curve moving forward.  Hopefully antiquated thinking will not limit tomorrow's possibilities.

Developing a Collaborative Strategy for Patient and Community Engagement

Sally Trnka, Senior Program Coordinator

Health care is about taking care of patients; ensuring that your community members are healthy and taking care of them when they are not.   That much we know.  After all, that’s why many of us got into health care to begin with.  What we don’tknow fully, however, is how to most systematically and effectively ensure that our goal of keeping our community healthy can be achieved. 

The regulators are telling us, through the release of regulations for Stage 2 of Meaningful Use (along with the proposed Stage 3 measures), that we need to develop a plan for exactly how to engage our patients and communities in their health through patient portals and the usage of electronic health records (EHRs). Stage 2 of Meaningful Use ramps up on initial efforts laid out in Stage 1 and will require 50 percent of a provider’s patients to be given access to online health information for viewing, downloading and or/transferring through a patient portal.  Further, providers must have 5 percent of their patients accessing their electronic health information online and must engage in secure, two-way messaging with their provider through the portals. 

That’s a BIG leap from Stage 1, imploring facilities and providers to develop a strategy for how they will implement their portal, how they will educate providers and staff, how to communicate with patients and, ultimately, how to encourage patients and communities to recognize the value of this interaction with their own health.  The common criticism of these provisions is that it places a lot of responsibility for patient engagement in the hands of facilities and providers.  Another perspective is that healthcare providers are held accountable for the level of patient involvement in their own care.

We know that two out of three people would consider switching to a physician who offers access to medical records through a secure Internet connection[1]. We know that 80% of American who have access to their health information in electronic health records use it and 65% who don’t have it, say it’s important to[2]. We know that people who are more engaged in their health actually get better health care[3].

So, where to start?  With the myriad of rules and regulations that seem overwhelming to leadership, how do you prioritize the development and implementation of a comprehensive patient engagement strategy?  The answer lies in the foundational concept of the regulations—it needs to be a COMMUNITY approach.  Health care facilities and providers need to be talking with their patients and community members, local businesses and governmental leadership, regional extension centers and health information exchanges (HIE), and rural health networks to develop a comprehensive strategy.  By developing something collaboratively that is owned by the community reduces the burdens on the individual facilities and empowers patients to utilize something that they helped to create.

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^[1] 2011 Survey of Health Care Consumers in the United States; Key Findings, Strategic Implications. Deloitte Center for Health Solutions, Washington, DC, 2011.

^[2] National Partnership for Women and Families. Making IT Meaningful: How Consumers Value and Trust Health IT. 2012.

^[3] Institute for Health Technology Transformation