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

2. 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

3. 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

4. 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.

5. 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 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.