1. Telemedicine: Helping Meet Health Care Challenges Debbie Voyles, MBA Director of Telemedicine F. Marie Hall Institute for Rural and Community Health October 2011

2. Four Core Programs Telemedicine –community-based telemedicine in Texas; one of 2 correctional programs; one of longest running programs in nation; 45,000+ consultations Rural Research – Project FRONTIER, TARC, Alzheimer’s Disease Health Education – West Texas Area Health Education Center (WTAHEC), Hot Jobs, Double-T Health Service Corps, region-wide community health needs assessment Electronic Health Records – West Texas Health Information Technology Regional Extension Center (WTxHITREC) Texas Tech University Health Sciences Center F. Marie Hall Institute for Rural and Community Health

3. Unique challenges for Rural Health Care What is Telemedicine Benefits to using Telemedicine Challenges/Barriers to Telemedicine Critical Steps to Implement Telemedicine Reimbursement Today’s Discussions :

4. US 2010 Census Population = 308,745,538 9.7% increase from 2000 83.7% live in the nations 366 metro areas (population over 50K) 10.0% live in the nations 576 micro areas (population between 10K and 50K) 6.3% live in rural areas (population less than 10K) US Department of Commerce Population Distribution and Change: 2000 to 2010

5. Current Challenges in Rural Health Care Workforce shortages Geographic isolation – limited transportation Diminishing community economics Low healthcare margins Difficulty recruiting physicians Increasing dependence on specialty and expensive technologies Demand for quality

6. Is this the Future of Healthcare?

7. Health Professional Shortage Areas

8. HPSA – Mental Health Designated Populations

9. HPSA – Dental Health Designated Populations

10. Reported Reduced Access to Care In 2009 11.4% of population reported they did not get or delayed medical care due to cost – up from 8.3% in 1997 In 2009 8.4% of population reported they did not get prescription drugs due to cost – up from 4.8% in 1997 In 2009 13.3% of population reported they did not get dental care to due the cost – up from 8.6% in 1997 US Census Bureau, Current Population Survey, 2009

11. Ratio of Providers per 100,000 Population Primary Care Doctors Physician Assistants Nurse Practitioners RNsLVNs U.S., 20006914.433.7780.2240.8 Texas, 2005 (2000) 68.5 (56) 14.7 (11.9) 17.7 (24.4) 628.6 (603.4) 269 (280.9) West Texas, 2005 41.71613.4364.5424 West Texas/Border, 2005 25.715.218.4230.7183.3

12. Nurse Practitioner Share of Primary Care Workforce by County, 2009 September 2010 Document by K. Strange, PhD and D. Sampson, PhD, FNP-BC, APRN

13. Physician Care Share of Primary Care Workforce by County, 2009 September 2010 Document by K. Strange, PhD and D. Sampson, PhD, FNP-BC, APRN

14. Family Practice Physicians in Rural Counties

15. Texas Counties Without a Pharmacists Source: Texas Department of Rural Affairs, August 2010

16. Dentists in Rural Counties

17. ACCESS Hospital: Clinics: Physicians: Nurses: P.A.s: 0 1.5 2.5 (nearest 85mi.) Presidio, TX Presidio to Lubbock: 398 mi. / 7.5 hrs. Presidio to Lubbock: 398 mi. / 7.5 hrs. El Paso to Lubbock: 343 mi. / 7 hrs. El Paso to Lubbock: 343 mi. / 7 hrs. Population: Medicaid Enrolled: 4167 705

19. We know a need exists

20. What is Telemedicine? Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patient’s health status.

21. Telemedicine began… In 1924, when the concept was introduced of a physician seeing his patient over the radio using a television screen and an RCA Victor style speaker First wave of telemedicine programs started in the 1950’s Now in the third wave

22. The Radio Doctor – Maybe!

23. How it Works Video conference system Various medical peripherals High-speed T-1 phone lines DSL Cable Wireless Satellite

24. Telemedicine Components Equipment standardization

25. Electronic Stethoscope

26. General Exam Camera

27. Otoscope

28. Electrocardiogram (ECG)

29. Emerging Technology Applications

30. Service Lines Burn/Wound Care Dermatology Genetics Infectious Disease Mental Health Neurology Nutritional Orthopedics Primary Care Pulmonology Cardiology Endocrinology Geriatrics Internal Medicine Nephrology Oncology/Hematology Pharmacy Pulmonology Urology

31. Telemedicine Philosophy Telemedicine does not alter the practice of medicine. It is only a tool.

32. Telemedicine Access Response to: Fewer physicians in rural/frontier communities Fewer specialists throughout region Technology advancements Changes to state rules Services w/out taking too much time off from work/school Reduces escalating (spiking) personal travel costs Another way to see a health care professional; comparable to face-to-face care… Meeting increasing need for specialties due to increasing chronic illnesses (diabetes, obesity, psychiatric, geriatric, cognitive…) Expand benefits that health services bring to rural and frontier communities …and patients like telemedicine

33. Benefits to Using Telemedicine Improved access to specialty services and care – “care closest to home” High patient satisfaction – improved access, reduced travel costs (mileage and travel time) reduced time away from home/school/work Improved patient outcomes – earlier interventions, reduced complications, consistent use of evidenced based medicine Healthy People/Healthy Communities - better relationships with rural communities – create, improve and maintain local access to appropriate high quality care

34. Challenges/Barriers to Telemedicine Keeping up with changes in technology Investment in equipment and training Credentialing/licensing (especially across state lines) Limits on reimbursement from insurance companies, Medicare, Medicaid Connectivity issues Regulatory Restrictions Systems implementation and interoperability End user adoption and training

35. Three Links to Effective Telemedicine Referring providers Technology Specialists We have a handle on the technology link – challenge is connecting the other two

36. Critical Steps to Implementation Community Assessment – in person Be clear on goals – what are you trying to achieve? Identify a telemedicine team – find champions Determine how telemedicine will fit into the organizational structure Develop a plan for educating and training Continually educate senior leadership, medical staff, community and state leaders, on performance and advances

37. Community-Based Participatory Assessment Communities What health care services are available What health care services are needed Demographics Sustainability Acceptance and use Will telemedicine make a difference? Will the community embrace telemedicine? Will the current healthcare providers embrace telemedicine? Are there limitations on connectivity?

38. Treat Telemedicine The Same As Any Other Practice of Medicine Apply same protocols, techniques, standards and style Treat patient in the same manner as if they were presented in the same room

39. Licensure State licensing – does not require a different license Physician must be licensed in the same state the patient is located Federal licensing proposal

40. Telemedicine Credentialing and Privileging Requirements If seeing patients in a hospital setting must be credentialed with facility as if seeing the patient in person New CMS rule, which applies to all hospitals that participate in Medicare, and inpatients at critical access hospitals, upholds The Joint Commission's current practice of allowing the hospital or CAH to utilize information from the distant-site hospital or other accredited telemedicine entity when making credentialing or privileging decisions for the distant-site physicians and practitioners. Effective July 5, 2011

41. Confidentiality and Consent Forms Employee confidentiality forms Patient consent to treatment form – same as if being seen face to face Release of medical records forms

42. Telemedicine Reimbursement Medicare Medicaid Third-Party Private Pay

43. Medicare Eligible areas include : Health Professional Shortage Area (HPSA) County that is not included in metropolitan statistical area (MSA) Eligible sites include: Office of physician or practitioner Critical access hospital (CAH) Rural health clinic (RHC) Federally qualified health clinic (FQHC) Hospital Skilled nursing facility (SNF) Hospital-based or CAH-based Renal Dialysis Centers (including satellites) Community mental health center (CMHC)

44. Medicare Practitioner who may bill: Physician Nurse practitioner (NP) Physician assistant (PA) Nurse midwife Clinical nurse specialist (CNS) Clinical psychologist (CP) and clinical social workers (CSW) (CPs and CSWs cannot bill for psychotherapy services that include medical evaluation and management services under Medicare. These practitioners may not bill or receive payment for Current Procedural Terminology (CPT) codes 90805, 90807, and 90809) Registered dietitians or nutrition professionals

45. Medicare Eligible Medical Services Consultations (CPT codes 99241-99255) Office or other outpatient visits (CPT codes 99201-99215) Individual psychotherapy (CPT codes 90804-90809) Pharmacologic management (CPT code 90862) Psychiatric diagnostic interview examination (CPT code 90801) End stage renal disease related services included in the monthly capitation payment (CPT codes 90951, 90952, 90954, 90955, 90957, 90958, 90960 and 90961) Individual Medical Nutritional Therapy (HCPCS codes G0270, and CPT codes 97802, and 97803) Neurobehavioral status examination (CPT code 96116) Follow-up inpatient Telehealth consultations (HCPCS codes G0406, G0407 and G0408)

46. Medicare Distant site physicians and practitioners submit claims for Telehealth services using the appropriate CPT or HCPCS code for the professional service along with the Telehealth modifier GT, “via interactive audio and video telecommunications system.

47. Medicare Originating sites are paid an originating site facility fee HCPCS Code Q3014. The originating site facility fee is a separately billable Part B payment. Current fee is $24.10

48. Telemedicine Reimbursement Medicaid 35 States Reimburse for Telemedicine Alabama, Alaska, Arizona, Arkansas, California, Colorado, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, North Carolina, North Dakota, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, Wyoming

49. Texas Medicaid Reimbursement Texas Medicaid Started reimbursing in 1998 One of the first states in the country Must be “face to face” interactive video, no store and forward, except for Tele-radiology Patient site bills for a facility fee – Code Q3014 Must use GT modifier, indicating it was a telemedicine visit

50. Texas Medicaid Reimbursement Eligible areas include: Rural county – less than 50K Medically Underserved Area (MUA) or Medically Underserved Population (MUP) Patient Site Location State hospital State school Physician office Hospital Rural Health Clinic (RHC) Federally Qualified Health Center (FQHC) Intermediate care facility for persons with mental retardation (ICF/MR) that is not a state school Community Center as defined in Health and Safety Code  534.001 or outreach site associated with a community center Local health department

51. Texas Medicaid Reimbursement Patient site presenter: Licensed or certified in this state to perform health care services Qualified mental health professional (QMHP ) Eligible Medical Services Consultations Office or other outpatient visits Psychiatric diagnostic interview Pharmacologic management Psychotherapy

52. Private Payers States with government mandated legislation California, Colorado, Georgia, Hawaii, Kentucky, Louisiana, Maine, New Hampshire, Oklahoma, Oregon, Texas, Virginia All prohibit payers from excluding services solely because they are delivered via telemedicine

53. Private Payers Providers Texas Insurance Code (Chapter 1455) generally requires health care coverage providers to treat telemedicine consults as if they had occurred in a face-to-face environment. JUST BILL THEM

54. Self Pay Patients are billed at a discounted rate similar to what they would be billed if seen in person

56. Texas Tech Telemedicine Q&A Contact information: Debbie Voyles, MBA TTUHSC Telemedicine debbie.voyles@ttuhsc.edu 806-743-4440