This article appears in the July 2012 issue of HealthLeaders magazine.
While telehealth launched more than 40 years ago to address care for geographically isolated patients, its growth has been slow but steady. However, in the past 10 years, the growth of high-speed communication networks and the push to lower healthcare costs have made telehealth an idea that's time has finally come, and in many instances is now getting reimbursed.
Telemedicine, or telehealth, is the practice of patient caregiving through virtual office visits and virtual rounding. It encompasses the use of various information technologies and clinical applications that capture medically significant data, diagnoses, and consults. Numerous technologies are used in telehealth ranging from standard telephone connections, video conferencing, robotics, healthcare kiosks, PC webcams, iPads, and smartphones.
The passing of the years has softened resistance by patients to using this approach. Patients are now willing to forego an in-person visit with the doctor in order to get the care they need swiftly, without having to travel, and in some instances at a lower cost. Moreover, the reimbursement environment is changing. Whereas at one time payers rejected the notion of reimbursing e-health, now more are willing to pay for it. Plus, legislators nationwide are creating state laws requiring payers to reimburse for these services, though in many instances payers are doing so irrespective of mandate.
"Telemedicine can lower healthcare costs by reducing avoidable hospital visits and providing regular access to care in remote parts of the state, and it's more convenient for patients," says Georgia Partnership for TeleHealth CEO Paula Guy. The nonprofit telehealth provider works with more than 350 partners and 175 specialists and other healthcare providers and has handled some 40,000 patient encounters as of 2011.
Before GPT was started in 2005, the Georgia southeastern public health district realized it had a problem: Children with special needs in rural areas were having difficulty getting access to specialty care. It was decided that telehealth could address the care deficit but the state didn't want to wait for providers to establish telehealth programs. At the time, Georgia payers weren't reimbursing for telehealth so providers lacked the incentive to shell out the capital for the technology-driven systems needed. Instead, the public health district secured two federal grants.
"Being a not-for-profit helped us to build the kinds of relationships that got this program off the ground. Before GPT got involved some of the larger hospitals were doing some telemedicine but they saw it as a competitive advantage, so none of the hospitals wanted to play together. We were able to bring all the players together into one coordinated telehealth network," says Guy.
GPT, which began as part of the Georgia State Insurance Office and in 2008 became a private nonprofit foundation, operates a Web-based system that allows doctors and nurses to schedule visits, and it provides marketing, education, and training on telehealth; plus the system permits providers to electronically share medical records and other data. The undertaking has been so successful that GPT is working to duplicate the program in Alabama, Florida, and other states, she says.
Once it was established, Guy explains, the statewide telehealth network helped young and old alike. In 2010, for instance, in rural Nashville, Ga., 44 children arrived at the emergency department with asthma-related illnesses. So, as of 2011, school-based telemedicine clinics were added to area schools and last year only one child landed in the hospital ED, she explains. Guy adds that 118 ED visits were avoided through the school-based clinics, saving an estimated $354,000. Children with chronic conditions may not get the specialty care needed, but through these clinics they can be routinely checked by specialists—ensuring better continuity of care while also helping parents avoid work absences.
GPT has also placed telehealth into nursing homes. In 2011, using telehealth resulted in 160 ED visits being avoided, saving approximately $480,000 in ED cost, Guy says, "In the past, these older patients may have just called for an ambulance when they had a problem. But now patients can be seen by a doctor without an expensive ambulance trip to the ED. Plus they can use it for routine access to care, and by getting that they're less likely to end up in the hospital as frequently," Guy says.
Telehealth visits saved 310 miles and nearly six hours of traveling on average, according to a study by Children's Healthcare of Atlanta, a three-hospital system for children and teens. CHA reviewed 609 appointments over a nine-month period and noted that approximately 86% of patients would have missed school and more than 80% of parents would have missed a full day of work to go to the city for an in-office visit, according to data published in the Atlanta Journal-Constitution. Additionally, Guy explains that out of the 40,009 telehealth visits GPT tracked, a random sample showed an average savings of patient travel time of 124 miles per encounter and nearly $762,027 in fuel alone.
Although Georgia has mandated that the telemedicine services be reimbursed by payers, not all states have enacted telehealth legislation. Still, some payers are moving forward on their own. Insurers such as Aetna, Cigna, UnitedHealthcare, and BlueCross and BlueShield, along with some large employers like General Electric and Delta Air Lines, are advocating the use of telemedicine as a way to make doctor visits less expensive and more easily available.
Approximately 130 private payers currently reimburse for telehealth services, according to a 2007 Michigan State University study. However, without state regulation each payer can determine which services are billable. Strides are being made though: 12 states have legislation requiring commercial payers to reimburse providers for telehealth services. However, while the legislation may require telehealth to be covered, it may not always stipulate that it be reimbursed at rates equal to an in-person visit. Regardless of the payment legislation, the Michigan State University study also noted the average estimate of the amount of telemedicine activity submitted to a private payer was moderate (40%), indicating a lot of telemedine transactions go unbilled.
Moreover, telehealth can be taken a step further to create another potential revenue stream for hospitals or health systems. For instance, Bloomington, Minn.–based HealthPartners, a four-hospital system with 1.4 million health plan members began an online service called Virtuwell in fall 2010 allowing anyone (with or without insurance) in Minnesota or Wisconsin to consult with a nurse practitioner for $40. Since then, some 23,000 patients have received treatment plans.
More important, says Guy, what makes telemedicine worth investing in for the hospitals "is so patients can remain in their local communities, and revenue from x-rays and other tests can remain in the community hospitals, and they are now accountable for readmissions and they need to manage patients with chronic disease or they're not going to get paid."
While in Georgia the state helped guide the development of telehealth, in Pennsylvania, Pittsburgh-based UPMC opted to expand telemedicine throughout its 20-hospital network and is now working to centralize the infrastructure to keep it cost effective.
"Our strategy is to encourage the development of telemedicine from all points of view, but centralize infrastructure to allow telemedicine to flourish. We're defining the common elements, such as IT expertise and support and legal contracting. We're developing a central platform so we can all work from a common set of technology rather than each developing separate systems and creating silos," says Lawrence Wechsler, MD, chairman of the department of neurology and vice president for telemedicine services for UPMC's physician services division.
Thirteen years ago UPMC tiptoed into telehealth using videoconferencing to offer psychiatry services to prisons. The program has grown and now has telemedicine services in 16 specialties including neurology, cardiology, pathology, dermatology, and ophthalmology and uses a variety of digital peripheries and other communications tools, such as teleconferencing and in-home monitoring. The annual volume for UPMC's telehealth consults is 13,500 visits, and it tracks another 106,000 teleradiology reads annually.
"Patients and doctors don't have to drive as far and some monitoring can be done in the patient's home without even needing a nurse visit. And it provides patients with access to specialists they may not get otherwise," Wechsler. adds.
Telehealth providers at UPMC extend beyond physicians and to nurses and midlevels, such as the telehealth remote monitoring program. In this area, Wechsler explains, UPMC uses in-home telehealth equipment to monitor congestive heart failure patients' key measures, provide reminders, and communicate with patients.
The benefit of this approach is the nurses can monitor the patients proactively, identify potential health risks, and encourage the patient to comply with physician's orders. UPMC also has plans to expand this to other conditions such as COPD, diabetes, and hypertension.
"By using telemedicine and leveraging nurses we can also serve multiple practices at one time and support our medical home model," Wechsler adds.
Though the effort to reduce readmissions will eventually pay dividends, hospitals and health systems in states without telehealth mandates must decide how to bill for services.
"We use midlevel providers but consider the visits telemedicine consultations. Reimbursement for telemedicine consults is limited and thus not all visits are covered by insurers," Wechsler says. "However, the financial viability of telemedicine consults must be considered in the overall scheme of costs and savings. The time and costs associated with travel for patients, time efficiency for physicians, and lower costs associated with testing at community hospitals should be included in any cost-benefit analysis."
Though telehealth has been in practice for years, training for mid-levels, nurses, and physicians is still evolving as new tools are developed. Wechsler says staff telehealth training is an area in need of more attention nationwide. UPMC offers some training to medical staff to help them work with the digital peripherals, but much of the education centers on questions to ask to guide diagnoses.
Telehealth training is a unique area of interest for Central Ohio Primary Care, a 225-physician primary care corporation in Columbus. The group practice is piloting the use of HealthSpot, Inc.'s Care4 Station, a community-based remote care kiosk that enables a physician and another provider at the location with the patient to work seamlessly as one with the patient, explain Robert Stone, MD, a member of the executive committee at Central Ohio Primary Care, and William Wulf, MD, corporate medical director for Central Ohio Primary Care.
COPC comprises 45 separate physician practices and an urgent care facility that's centrally located. Stone was one of the first five physicians trained to use the Care4 Station, which is essentially a booth in which a patient can utilize up to six digital peripheries (in some instances requiring the help of a midlevel) while conversing with a physician via secure video conferencing. In instances where using the periphery tool is challenging for the patient, such as the otoscope, or if the physician needs more information that requires a physical presence, a medical assist is just a button-push away.
During the pilot phase, the kiosk is situated in Central Ohio Primary Care's urgent care facility, and an on-site provider accesses it from an office within the building. Stone explains that as the state hasn't passed a telehealth reimbursement mandate a physician still meets with each telehealth patient in-person following the electronic consult. Thus, the practice bills payers for an office visit.
The in-person follow-up is needed for another reason, Wulf explains, because Ohio prohibits prescribing to a patient the physician hasn't personally, physically examined. "Right now we're waiting for the Ohio state medical board to define what personally, physically examined means in the context of telehealth," he says.
Wulf and Stone agree that while the kiosk has been useful, it isn't going to help physicians see patients faster.
"I don't think a physician is going to get six-to-seven visits an hour by using it. We see the value in this tool as helping divert people from the ED," says Stone."And as we move from fee-for-service work into quality-based work, it's inevitable that one of the biggest metrics that will decide how much we get reimbursed will be the overall care of patients and cost of care."
Another use that Wulf and Stone see for these kiosks is putting booths in employer sites or areas with convenient public access that are connected to local primary care physicians' offices.
That's a future that may not be far off if the reimbursement climate continues to warm, agree Guy, Wechsler, Stone, and Wulf.
"Eventually all payers will reimburse for telemedicine. It only makes perfect sense for them to do so. Right now they have concerns that reimbursing for this opens up a Pandora's box, and it will lead to all kinds of new payment structures, but I believe that concern is overblown and it will happen," says Wechsler.
This article appears in the July 2012 issue of HealthLeaders magazine.
Reprint HLR0712-7
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Karen Minich-Pourshadi is a Senior Editor with HealthLeaders Media.
