1. Telehealth: A Conceptual Overview
10/5/2018
Telehealth: A Conceptual Overview
Jonathan Neufeld, PhD, HSPP November 1, 2018
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number G22RH This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. 1
gpTRAC and the National Consortium of TRCs 2 3

2. 10/5/2018 gpTRAC Provides (like all TRCs) TELEHEALTH Resources4
gpTRAC Provides (like all TRCs)
Resources
(toolkits, assessments, sample forms)
Contacts
A national network of telehealth programs, and close relationships with many programs in the Great Plains region.
Training (virtual and on-site)
Clinician effectiveness with video and other technologies
Site evaluation and readiness
Resource for discussions/decision making 5
TELEHEALTH 6

3. 10/5/2018 Conceptual Framework Four Domains of Telehealth
TELEHEALTH IS A DELIVERY MECHANISM, NOT A SERVICE
Providers may need skills or training, but no new certification or credentials (usually)
All regulations regarding traditional healthcare services apply equally to telehealth
ANALOGY
Urban University Hospital vs CAH vs MASH Unit
Skills are the same, but some adjustment needed for context 7
Four Domains of Telehealth
Remote Specialty & Hospital Care
Specialists see and manage patients remotely
Integrated Primary Care
Specialists (often MH) integrate services into primary care environment
Remote Monitoring and Management
Physiological monitoring and care coordination to maintain best function in least restrictive, least expensive, or most preferred environment
Direct to Consumer Services (Primary/Urgent Care)
Convenient access to needed/desired services; younger, busier, and generally healthier patients; not recommended for chronic disease care 8
Four Technologies of Telehealth
Live Video
Secure; real-time (“synchronous”)
Store & Forward
Image (or video clip) recording and transfer for later evaluation (“asynchronous”)
Remote Monitoring
Physiological and behavioral monitoring to maintain best function in least restrictive, least expensive, or most preferred environment
mHealth (mobile apps)
Why not just use a cell phone for everything? 9

4. 10/5/2018 Three Hard Lines of Telehealth
Live video vs Other (Store & Forward, Remote Monitoring)
Clinic-based vs Direct-to-Consumer (home)
Encounter-based vs Management (Monthly) Payment 10
Five Perspectives on Telehealth
Patient/Family
Provider
Clinic/Hospital/Health System
Payer
Community/Society
A telehealth program may “work” (or not) from any, many, all, or none of these perspectives. And they may not all agree. 11
Telemedicine is Growing - Medicare
40%-plus growth for 10 years
Mental
health is largest patient
group 12

5. 10/5/2018 Telehealth is Covered - Medicaid13
Commercial Payers are On Board - Example
“Typical” large commercial payer ● Significant 2016 expansion
Separate MH and DTC products ● Most DTC not in rural areas 14
Regulatory Environment
FEDERAL REGULATIONS
Prescribing Controlled Substances (Ryan Haight Act)
In person visit required before prescribing controlled substances (or consultation model)
Telemedicine exemption (undefined)
HIPAA/HITECH (General Healthcare Regulations)
Medicare (reimbursement, “conditions of payment”) 15

6. originating sites, and billing codes
10/5/2018
Regulatory Environment
STATE REGULATIONS
Licensing Boards (many are silent regarding telehealth)
State-level definitions
Medicaid (definitions & reimbursement)
Commercial payer regulations (parity or other regulations) 16
Medicare Billing - MLN Fact Sheet
Updated annually as needed
12 pages
Provides all eligible provider types,
originating sites, and billing codes
Eligibility Lookup Tool ealthAdvisor/telehealthEligibility.aspx 17 18

7. $ 10/5/2018 Billing Procedures (Standard)19
Billing Procedures (Standard)
Provider/Medical Group (Medicare “Distant Site”):
Bill covered CPT code with modifier ‘GT’ (via live video)
Use POS code ‘02’ (Place of Service = Telemedicine)
Clinic/Patient Site (Medicare “Originating Site”):
Bills CPT code ‘Q3014’ (telemedicine facility fee, $24)
NO Modifier; all Telehealth is Part B
Use regular POS code
*CMS assumes telemedicine occurs between 2 separate entities! 20
Standard Billing/Reimbursement
Widespread availability (Medicare, almost all Medicaid, many commercial payers); Separate payment for each side of the call:
Professional Fee: CPT Code + Modifier
Originating Site Fee: about $25 21 $
Originating Site

8. $ 10/5/2018 Most Telehealth is NOT STANDARD
REASONS:
Hard to sustain on the spoke/rural end (poor reimbursement)
Hard to interest hub/urban providers (busy enough already)
Organizations already have providers, just poorly distributed
INSTEAD:
Internal resources are re-deployed (majority of programs)
Internal value generation is targeted (good, but difficult)
External resources are engaged via contracts 22
Telehealth Changes and Variations
Telestroke services will be available anywhere in 2019
FAST Act is part of 2018 Budget, allows any originating site (maybe even home)
RHCs may bill telehealth services out of a CAH rather than RHC
Standard or Method II billing OK
Method II has benefits of assignment, assumes distant site is the CAH (no address on the claim)
Next Gen ACOs have many more options
a. Any originating site can be used, including urban areas and patient homes
4. Quality-based contracts - any contractual goal 23
Alternative Arrangement (TH + Assignment)
Many commercial payers allow, some Medicaid (not Medicare):
Provider Site: Paid via hourly contract; billing assigned to site
Patient Site: Bills according to standard procedures
Sometimes called “telecommuting” $
Contract
Originating Site 24

9. 10/5/2018 Virtually “Entering the Four Walls”
Originating Site $ 25
A Successful Telehealth Service
FOUR NECESSARY COMPONENTS
Services (Assessing Need, Defining the Service, Finding Providers, Developing and Structuring the Program)
Reimbursement & Sustainability
Policies & Procedures
Technology 26
Common Challenges (in order)
Value generation & monetization
Doesn’t serve any monetizable need, or value isn’t realized
Generating internal interest, utilization
Lack of champions among thought leaders and executives
Technical (or policy) decisions made too early, inflexibly
Inadequate information
No unified vision OR inability to develop/support local vision(s)
** These are management issues, not telehealth issues ** 27

10. 10/5/2018 Model - Chronic Care Mgmt Specialty Care “Service Gap”
Registry-enabled team-based care for multi-morbid chronic disease patients.
CPT: 99490, 99487, 99489, G0506, G0511
Transitional Care Management
Coordination with Home- and Community-Based Clinical Service Providers
24/7 Access for Urgent Needs
Enhanced Communication (for example, )
Advance Consent
Services include:
Use of a Certified Electronic Health Record (EHR)
Continuity of Care with Designated Care Team Member
Comprehensive Care
Management and Care Planning 28
Specialty Care “Service Gap”
Community Health Center
Specialty Care Center
Primary Care Providers
Spec Care Providers
{Service Gap}
Minimal MH Mild/Mod
Need Intermittent
Mild/Mod Mod/Severe Management Management
Severe/ Inpatient
<<< - - LOW NEED Patient MH Care Needs HIGH NEED - - >>> 29
Collaborative Care Fills the Service Gap
Community Health Center
Specialty Care Center
Collaborative Care
Primary Care Providers
Care Manager
Specialty Consultant
Spec Care Providers
Minimal MH Mild/Mod Mild/Mod Mod/Severe Need Intermittent Management Management
Severe/ Inpatient
<<< - - LOW NEED Patient MH Care Needs HIGH NEED - - >>> 30

11. 10/5/2018 Collaborative Care Mgmt Process (MH)
Initiating visits and assessments,
Assessment of treatment adherence, tolerability, and clinical response using validated rating scales; brief psychosocial interventions such as behavioral
administration of rating scale(s) by a psychiatric care manager (PCM).
Care planning by the primary care
team, jointly with the beneficiary, with care plan revision for patients whose condition is not improving adequately (treatment to target).
activation or motivational interviewing.
70 minutes of behavioral health care manager time the first month (60 minutes subsequent months; add-on code for 30 additional minutes)
Proactive follow-up by PCM using
validated rating scales and a registry ● Regular case review with psychiatric
consultant 31
Collaborative Care Model
PSY
Chart review Discussion with PCM
Recommendations to PCP
PCP
Behavioral Activation Motivational Interviewing Feedback to PCP
Reporting and Monitoring to PSY Additional Therapy Services
PCM Pt 32
Collaborative Care Model
PCC & Primary Care Check-in (1-4x/mo)
Review Cases
Report Response
Coordinate
Psychiatric Consultant
Psych Care Coordinator
PCC & Psychiatrist Check-in (1-2x/mo)
Review Cases
Assess Response
Modify Treatments
A subset of cases reviewed each week; all cases reviewed each month
Primary Care Provider
Weekly Contact
Patient 33

12. 10/5/2018
Contact Information
Jonathan Neufeld, PhD
(574) 34