DELIVERING CARE ACROSS RURAL & FRONTIER AMERICA: THE ROLE OF TELEMEDICINE & PARAMEDICINE Charles Milligan CEO, United Healthcare Community plan of NM November 7, 2017

Improving Access to Care There is an increasing shortage of Medicaid providers in rural and frontier communities. The United States will face a shortage of 70,000 physical and behavioral health providers in the next 10 years. Telehealth can create access to health care services in places where access is limited (such as rural or frontier localities) or in situations where individuals are unable to physically travel to a provider. Paramedicine can fill critical gaps in access to care in rural and urban areas and improve utilization patterns. Percentage of Population Living in Designated Health Professional Shortage Area Telehealth is part of the solution for addressing access issues that are only likely to increase with a growing shortage of Medicaid providers – especially in rural and frontier areas. Telehealth is a big bucket, but common modalities include Live Video : Live, two-way interaction between a person and a provider using audiovisual telecommunications technology. Most commonly reimbursed by Medicaid (48 states) Store-and-Forward : Transmission of recorded health history through an electronic communications system to a practitioner, usually a specialist, who uses the information to evaluate the case or render a service outside of a real-time or live interaction. Only 13 states are reimbursing for this Remote Patient Monitoring (RPM): Personal health and medical data collection from an individual in one location via electronic communication technologies, which is transmitted to a provider in a different location for use in care and related support. Around 20 states with reimbursement policies here Mobile Health (mHealth): Health care and public health practice and education supported by mobile communication devices such as cell phones, tablet computers, and PDAs. Applications can range from targeted text messages that promote healthy behavior to wide-scale alerts about disease outbreaks, to name a few examples. Source: 2015 Association of American Medical Colleges study

Telehealth Potential Barriers Medicaid coverage rules Growth in the number of states reimbursing for live video, store and forward and remote patient monitoring (9 states) An increase in the number of states that reimburse for telehealth in which the home serves as the originating site Growth in teledentistry as a specialty and continued interest in telepsych particularly Potential Barriers Medicaid coverage rules Medicare narrow application Health professional licensure rules Provider adoption Connectivity and speed in rural/frontier communities Overarching view: Regulatory flexibility at the state and federal levels that allows for creative reimbursement strategies (value-based purchasing, alternative payment models) to support the widespread use of technology as avenue for seamless care delivery and smart devices to enhance care coordination and management is the ideal. States are increasingly moving to adoption Issues that remain: Provider option Broadband/internet usage and coverage

Paramedicine Function Examples States across the country are leveraging paramedicine to expand access and improve utilization patterns Key Considerations Reimbursement Physician Oversight Scope of Practice System Coordination Evaluation Sustainability Function Examples Assessment Checking vital signs Blood pressure screening and monitoring Prescription drug compliance monitoring Assessing patient safety risks (e.g., risk for falling) Additional assessments Specimen collection Treatment/ Intervention Respiratory treatments Providing wound or ulcer care, dressing changing, identification of infection Patient education Intravenous monitoring Referrals Mental health and substance use disorder referrals Social service referrals Primary care referrals Specialist referrals (such as pharmacists, ophthalmologists) Prevention and Public Health Immunizations Well Baby Checks Asthma management Fluoride varnishing and oral health activities Disease investigation . This new model of care delivery is successfully operating several states including in North Carolina, Colorado, California, Minnesota, Maine, Nevada, New Mexico, Pennsylvania, and Texas where programs have demonstrated that paramedics can be trained to safely and effectively perform in an expanded role. Under these models emergency medical technicians provide outpatient urgent and extended primary care services for patients who might otherwise visit or be transported to an emergency department (ED). For patients with complex medical or behavioral health needs, ED visits can often lead to hospital admissions that might otherwise be avoided by allowing emergency medical technicians to provide coordinated services in patients’ homes. Reimbursement - Minnesota and Nevada have CMS-approved Medicaid state plan amendments for community paramedicine services. In both states’ Medicaid state plans, the services are covered as physician services. They paramedics aren’t independent service providers there must be physician supervision and oversight Physician Oversight – if in state plan as physician services, it needs to be overseen by a provider Scope of Practice – some states are avoiding the physician oversight by developing new provider types. Examples of States that have taken steps to define this new provider and to address regulatory barriers include the following: Minnesota passed legislation in 2011 that formally recognized community paramedics as a distinct provider, and clarified their educational and training requirements. Maine lawmakers removed regulatory barriers by authorizing up to 12 pilot programs throughout the state (2012). In Colorado, the state EMS office is developing a new regulatory framework that provides oversight through a conditional license for community paramedics. Evaluation and Sustainability go hand in hand and are part of anything we do in Medicaid. Understanding the volume of patients and the potential to improve outcomes, utilization and spend are critical to making these programs sustainable long term. We are hearing from states with rural issues and how they have used these two strategies – Telemedicine and Paramedicine – to improve access and the quality of care in their state.

Medicare Announcement on November 2, 2017 From the CMS press release: “To strengthen access to care, especially for those living in rural areas, CMS is transforming access to Medicare telehealth services by paying for more services and making it easier for providers to bill for these services. Improving access to telehealth services reflects CMS’s work to modernize Medicare payments to promote patient-centered innovations.” On November 2, 2017, CMS released its final rule on 2018 physician fee schedule. One change: finalizing CPT code 99091 to promote more remote patient monitoring Another change: creating multiple new telehealth codes to address health risk assessments, psychotherapy, chronic care management, and many other services. . This new model of care delivery is successfully operating several states including in North Carolina, Colorado, California, Minnesota, Maine, Nevada, New Mexico, Pennsylvania, and Texas where programs have demonstrated that paramedics can be trained to safely and effectively perform in an expanded role. Under these models emergency medical technicians provide outpatient urgent and extended primary care services for patients who might otherwise visit or be transported to an emergency department (ED). For patients with complex medical or behavioral health needs, ED visits can often lead to hospital admissions that might otherwise be avoided by allowing emergency medical technicians to provide coordinated services in patients’ homes. Reimbursement - Minnesota and Nevada have CMS-approved Medicaid state plan amendments for community paramedicine services. In both states’ Medicaid state plans, the services are covered as physician services. They paramedics aren’t independent service providers there must be physician supervision and oversight Physician Oversight – if in state plan as physician services, it needs to be overseen by a provider Scope of Practice – some states are avoiding the physician oversight by developing new provider types. Examples of States that have taken steps to define this new provider and to address regulatory barriers include the following: Minnesota passed legislation in 2011 that formally recognized community paramedics as a distinct provider, and clarified their educational and training requirements. Maine lawmakers removed regulatory barriers by authorizing up to 12 pilot programs throughout the state (2012). In Colorado, the state EMS office is developing a new regulatory framework that provides oversight through a conditional license for community paramedics. Evaluation and Sustainability go hand in hand and are part of anything we do in Medicaid. Understanding the volume of patients and the potential to improve outcomes, utilization and spend are critical to making these programs sustainable long term. We are hearing from states with rural issues and how they have used these two strategies – Telemedicine and Paramedicine – to improve access and the quality of care in their state.