1. Telehealth in Indiana: Recent Developments and Current Opportunities Jonathan Neufeld, PhD, HSPP Becky Sanders Upper Midwest Telehealth Resource Center IRHA Annual Conference June 11, 2014 1

2. Outline UMTRC and National TRC Program Federal Developments Indiana Developments Best Practices and Developing Opportunities Questions 2

4. telehealthresourcecenters.org Links to all TRCs National Webinar Series Reimbursement, Marketing, and Training Tools

5. UMTRC Services Presentations & Trainings Individual and Group Consultation Training and Technical Assistance Connections with other programs Program Design and Evaluation Information on current legislative and policy developments

6. Federal Developments - Medicare New Definition of “Rural” New Originating Sites New Transition Codes Legislative Action and Political Pressure 6

7. Update to HPSA Rural Designation Effective January 1, 2014: Otherwise eligible sites in health professional shortage areas (HPSAs) located in rural census tracts of MSA counties will be eligible originating sites. (RUCA codes 4-10, also 2-3 in counties over 400 sq. mi., <35/sq. mi. density) Eligibility Lookup Tool http://datawarehouse.hrsa.gov/telehealthAdvisor /telehealthEligibility.aspx http://datawarehouse.hrsa.gov/telehealthAdvisor /telehealthEligibility.aspx

8. Coverage for Transitional Services Effective January 1, 2014: CPT codes 99495 and 99496 added: Communication (direct, telephone, or electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate (or high) complexity during the service Face-to-face visit within 14 (or 7) calendar days of discharge

9. Indiana Developments - Medicaid SB 554 (EA 554) – Status: Awaiting SPA approval – OMPP to publish rule once SPA is approved 9

10. Waiting on OMPP Eliminate 20-mile rule (for FQHCs, RHCs, CAHs, and CMHCs) FQHCs and RHCs can be reimbursed for telemedicine “Telehealth Services” provided by licensed Home Health Agencies will be reimbursed 10

11. RHCs and FQHCs – “Telecommuting” Is not new and has always been available Is NOT Telemedicine Does not require HUB nor SPOKE as it is a agreement between an employer and employee/contractor There is only one billing entity – The provider does not bill as they are an employee/contractor of the FQHC/RHC – The FQHC/RHC bills as they would for any other valid encounter No Bulletin or Banner will be issued, nor will the Provider Manual be updated as there is no change from current policy 11

12. Telecommuting Considerations The physician is contracted by the FQHC and compensated for the services under a contractual arrangement ("under agreement"). 42 CFR 491.9 The services are "physician" services. 42 CFR 405.2412 The services are covered by the Medicaid program and the HCPCS code is a recognized encounter code The FQHC bills the Medicaid program for the service (and the physician does not bill for the service) 12

13. Home Health – “Telehealth” “The office shall reimburse…a home health agency…for telehealth services.” “the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across a distance.” 13

14. “Telehealth” Remote monitoring of health information EKG, weight, BP, BG, etc. Will require prescription Maximum 60 days without renewal Reimbursement: est. $8-10/day (rumor) 14

15. What Can Telemedicine Do? Managing Population Health – Utilizing Telehealth to Increase Your Business Implementation and Compliance Issues Concerning Telemedicine Video Therapy and the Next Generation of Service Fostering Organizational Commitment Using Telehealth Technology 15

16. The Promise of Telehealth Professional Fee (Part B) Facility Fee (Part B) Rural “originating site” Specialist at “distant site”

17. Three Domains of Telehealth Hospital & Specialties Specialists see and manage patients remotely Integrated Care Mental health and other specialists work in primary care settings (e.g., PCMH’s, ACO’s) Transitions & Monitoring Patients access care (or care accesses patients) where and when needed to avoid complications and higher levels of care **Value proposition differs among these types** 17

18. Hospital and Specialty Care 18

19. Three Domains of Telehealth Hospital & Specialties Specialists see and manage patients remotely Integrated Primary Care Mental health and other specialists work in primary care settings (e.g., PCMH’s, ACO’s) Transitions & Monitoring Patients access care (or care accesses patients) where and when needed to avoid complications and higher levels of care **Value proposition differs among these types** 19

20. Integrated Primary Care 20

21. Three Domains of Telehealth Hospital & Specialties Specialists see and manage patients remotely Integrated Care Mental health and other specialists work in primary care settings (e.g., PCMH’s, ACO’s) Transitions & Monitoring Patients access care (or care accesses patients) where and when needed to avoid complications and higher levels of care **Value proposition differs among these types** 21

22. Transitions and Monitoring 22

23. Hub & Spoke vs. Peer-to-Peer Background – Early years of telemedicine focused on connecting urban resources to rural areas – Most programs that explored/developed telemedicine services were urban/academic – Most research was/is done from the perspective of the academic “hub” site 23

24. Hub & Spoke Telemedicine – Providers at the hub – Patients at the spoke – Spoke receives services – Hub receives payment – Examples: Specialty Consults, MH in ED

25. 25

26. The Peer-to-Peer Model In P2P, “spoke” sites develop their own telehealth capacity with available resources Equipment – Inexpensive; capital or grant funds Support – National Telehealth Resource Centers These “peer” sites develop the network to meet the mental health needs of their rural clients Sustainability through clinical billing alone Growth through P2P collaboration, innovation

27. Hub and Spoke Telemedicine HUB Spoke pt Spoke pt Spoke pt Spoke pt MD PhD DO NP Spoke pt Spoke pt

28. Peer-to-Peer Telemedicine CAH pt MD CSW NP DO PhD NP pt MD

29. Peer-to-Peer Telemedicine – Peer-to-Peer Model Clinicians anywhere Patients anywhere Patient site bills, receives payment Clinician gets paid by patient site (as an employee or contractor) Clinicians anywhere Patients anywhere Patient site bills, receives payment Clinician gets paid by patient site (as an employee/contractor) “Telecommuting” (Indiana & Illinois)

30. P2P – Putting Rural in Charge Rather than connecting with a large health system, rurals can hire/contract directly with the clinicians/services they need – Rural drives the project – Rural chooses clinicians/services/format – Rural bills for services – Rural pays clinicians Rural maintains ownership/control 30

31. Peer-to-Peer Telemedicine CAH pt MD CSW NP DO PhD NP pt MD “tele-commuters”

32. Integrated Primary Care 32

33. On Site MH (or other) Services 33

34. Equipment Standard Video End Point ($5,000) LifeSize Passport 32” HDTV (monitor + speakers) Desktop stand or rolling cart Web-based System ($1,500) Software (Zoom, Vidyo, etc.) Mini computer + HD webcam 26-32” HDTV monitor + speakers Desktop stand or rolling cart

35. Equipment Web-based System ($500) All-in-one desktop computer HD webcam Software package

36. Sweet Spots Remote Staffing Home Monitoring Population Health Management 36

37. Remote Staffing ● Recruit from anywhere to anywhere ● Retain staff when they move ● Requires new admin skills, flexibility ● Key considerations: ● Licensure ● Reimbursement ● No Shows

38. Two Types of Direct Hiring Wholesale: Direct recruitment and hiring Two-party agreement (employ/contract) Retail: Third party recruiting/staffing company Key to Success: Continuity of relationship with the tele- provider (for both staff and patients) Make them part of your staff!

39. Example – Oaklawn (CMHC) ● Service locations in Goshen, Elkhart, and South Bend (2 counties) ● 2+ hours from Chicago; 3+ from Indy ● Established 3 telemedicine clinic sites and 3 provider home offices ● Home offices designed for best effect ● 2 in Chicago, 1 in Indianapolis ● Chicago providers do on-site clinics also

40. Example – Valley Professionals (FQHC) ● Service locations in Vermillion and Parke Counties ● Mental health (psychiatry) ● Could be used for any provider ● Clinicians can see patients at multiple sites ● Requires change of scope (but not PPS)

41. Example – Capabilities Clinic (RHC) ● Service locations in Marion ● Wanted specific mental health services for its target/core population of developmentally disabled adults ● Also opened clinic to the public ● Psychiatrist and Nurse Practitioner contracted to “telecommute” ● ~4 hours/wk, scheduled onsite

42. Home Monitoring Many successful examples exist Target high utilizers and high risk of readmit “Touch” more important then “tech” – Focus on building relationships – Spend less on technology; keep it simple Successes “graduate” into population health management program 42

43. Population Health Management Aggressively seek patients who need care Drive utilization toward primary care Engage patients as active participants Treat illness before it becomes costly 43

44. HMO (1990’s) vs. Today HMO/Managed Care Reduce Utilization Avoid High Utilizers Reduce All Costs Focus on Profits Population Health Management Steer Utilization Engage High Utilizers Reduce Bad Costs Focus on Health 44

45. Key Factors That Drive Success Clear Vision (with a sustainable model) Technological Openness – “Can we meet by video?” Good Information Solid Partners Testing and Rehearsal (per Schedule) 45

46. Summation Federal and State environments for telemedicine are improving rapidly Market growth (nationally) is explosive Rural providers are taking more control over their options Several “sweet spots” exist for sustainable programs that attain the “Triple Aim” 46

47. QUESTIONS Becky Sanders Program Director Upper Midwest Telehealth Resource Center bsanders@indianarha.org (812) 478-3919 x232 Jonathan Neufeld, PhD, HSPP Clinical Director Upper Midwest Telehealth Resource Center jneufeld@indianarha.org (574) 606-5038 47