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Connected Health - The small matter of price - Nick van Terheyden, MD

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The Centers of Medicare & Medicaid Services decision to include some reimbursement in 2015 for remote monitoring is hailed as a revolutionary step for mHealth. Here are some insights from the different ecosystem players.
- With more insurance plans being open to telemedicine coverage and remote patient monitoring, see how you can take advantage of these new payments and partner with the right groups
- With Medicare fining a record number of hospitals - 2,610 - for having too many patients returning within a month. See how hospitals are adapting to the charges and changes
- Explore the advantages of preventative care at a population management and enterprise level, creating healthier workforces with less strain on the medical system and lowering insurance pay outs

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Connected Health - The small matter of price - Nick van Terheyden, MD

  1. 1. © 2002-2014 Nuance Communications, Inc. All rights reserved mHealth Reimbursement – Who Will Pay Nick van Terheyden, MD (aka @drnic1) HIMSS mHealth Committee CMIO, Nuance Communications, Inc. http://DrNick.vanTerheyden.com
  2. 2. © 2002-2014 Nuance Communications, Inc. All rights reserved Agenda – mHealth Reimbursement – Telehealth Technology Players – Use Cases for mHealth – Preventing Readmissions – The Healthier Workforce
  3. 3. © 2002-2014 Nuance Communications, Inc. All rights reserved “The good physician treats the disease; the great physician treats the patient who has the disease.” Sir William Osler
  4. 4. © 2002-2014 Nuance Communications, Inc. All rights reserved Chronic Disease – Today, 133 million Americans – 1/3 of the total population suffer from at least one chronic disease. – 70% of all deaths result from chronic diseases. – 85% of all healthcare dollars go to treatment of chronic diseases. – More than 2/3 of Medicare dollars are spent on patients with 5 or more chronic diseases.
  5. 5. © 2002-2014 Nuance Communications, Inc. All rights reserved mHealth Reimbursement – 1 January 2015 – Final 2015 Physician Fee Schedule – Physicians can bill Medicare for “non-face-to-face” chronic care management (CCM) – Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensating, or functional decline; comprehensive care plan established, implemented, revised, or monitored.
  6. 6. © 2002-2014 Nuance Communications, Inc. All rights reserved mHealth Reimbursement 3 Core Requirements – Secure the eligible beneficiary’s written consent – Have five specified capabilities needed to perform CCM – Provide 20+ minutes of non-face-to-face care management services per calendar month
  7. 7. © 2002-2014 Nuance Communications, Inc. All rights reserved mHealth Reimbursement – Third party payers are now starting to reimburse for telehealth (video conferencing) but only for certain specialties: – dermatology, mental health, etc – Reimbursement chronic disease – Multiple Doctors, only one can bill for fee per month – Problems with reimbursement – licensing issues for providers – limitations for populations covered (for example Medicaid approves telehealth only for certain jurisdictions mostly rural)
  8. 8. © 2002-2014 Nuance Communications, Inc. All rights reserved 5 Fallacies of Remote Patient Monitoring – All remote monitoring is the same – All remote monitoring is reimbursed – Patients and physicians will welcome and embrace remote monitoring – Remote monitoring should be totally automated – Remote monitoring is only for recently discharged patients
  9. 9. © 2002-2014 Nuance Communications, Inc. All rights reserved Secretary Burwell Establishes Clear Goals for Value-Based Payment Medicare Reforms and the Transition to Risk Source: Burwell, S, “Setting Value-Based Payment Goals — HHS Efforts to Improve U.S. Health Care,” New England Journal of Medicine, March 5, 2015; Health Care Advisory Board interviews and analysis. 1) Alternative Payment models include ACOs, bundled payments, patient-centered medical homes, demonstration projects for those dually eligible for Medicare and Medicaid. HHS Commits to Payment Transformation 80% 85% 90% 2014 2016 2018 "This is the first time in the history of the program that explicit goals for alternative payment models and value-based payments have been set for Medicare." Sylvia M. Burwell, Secretary of Health and Human Services Medicare Payments Through Alternative Payment Models1 Medicare FFS Payments Tied to Quality or Value 0% 20% 30% 50% 2011 2014 2016 2018 ~ Slide courtesy: Dr Kavita Patel
  10. 10. © 2002-2014 Nuance Communications, Inc. All rights reserved mHealth Reimbursement Resources – More Info Center for Connected Health Policy – http://cchpca.org/state-laws-and-reimbursement-policies – AAFP Summary of Medicare Fee Schedule – http://www.aafp.org/news/government- medicine/20141105finalfeeschedule.html – CMS 1612 FC – Final Rule plus details – http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeeSched/PFS-Federal-Regulation- Notices-Items/CMS-1612-FC.html
  11. 11. © 2002-2014 Nuance Communications, Inc. All rights reserved Telehealth Technology Players
  12. 12. © 2002-2014 Nuance Communications, Inc. All rights reserved
  13. 13. © 2002-2014 Nuance Communications, Inc. All rights reserved Social Security Act Sec. 1834(m) [42 C.F.R. § 410.78] “(T)he Secretary shall pay for telehealth services that are furnished via a telecommunications system by a physician (as defined in section 1861(r)) or a practitioner (described in section 1842(b)(18)(C)) to an eligible telehealth individual enrolled under this part notwithstanding that the individual physician or practitioner providing the telehealth service is not at the same location as the beneficiary.” • Medicare covered services • Approved telehealth services • Medicare Part B beneficiary • Authorized clinician • Authorized patient site • Separate physical locations • Interactive audio and video system (federal demo sites in AK and HI may use store-and-forward technology) Medicare Telehealth Benefit
  14. 14. © 2002-2014 Nuance Communications, Inc. All rights reserved Source: Medicare Telehealth Services Fact Sheet Service HCPCS/CPT Code Telehealth consultations, emergency department or initial inpatient HCPCS G0425–G0427 Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs HCPCS G0406–G0408 Office or other outpatient visits CPT 99201–99215 Subsequent hospital care services, with the limitation of 1 telehealth visit every 3 days CPT 99231–99233 Subsequent nursing facility care services, with the limitation of 1 telehealth visit every 30 days CPT 99307–99310 Individual and group kidney disease education services HCPCS G0420 and G0421 Individual and group diabetes self-management training services, with a minimum of 1 hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training HCPCS G0108 and G0109 Individual and group health and behavior assessment and intervention CPT 96150–96154 Individual psychotherapy CPT 90832–90834 and 90836–90838 Telehealth Pharmacologic Management HCPCS G0459 Psychiatric diagnostic interview examination CPT 90791 and 90792 End-Stage Renal Disease (ESRD)-related services included in the monthly capitation payment CPT 90951, 90952, 90954, 90955, 90957, 90958, 90960, and 90961 Individual and group medical nutrition therapy HCPCS G0270 and CPT 97802–97804 Neurobehavioral status examination CPT 96116 Smoking cessation services HCPCS G0436 and G0437 and CPT 99406 and 99407 Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services HCPCS G0396 and G0397 Annual alcohol misuse screening, 15 minutes HCPCS G0442 Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes HCPCS G0443 Annual depression screening, 15 minutes HCPCS G0444 High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes HCPCS G0445 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes HCPCS G0446 Face-to-face behavioral counseling for obesity, 15 minutes HCPCS G0447 Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge) CPT 99495 Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge) CPT 99496 Psychoanalysis* CPT 90845 Family psychotherapy (without the patient present)* CPT 90846 Family psychotherapy (conjoint psychotherapy) (with patient present)* CPT 90847 Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour* CPT 99354 Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes* CPT 99355 Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) first visit* HCPCS G0438 Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) subsequent visit HCPCS G0439 *Effective for services furnished on and after January 1, 2015
  15. 15. © 2002-2014 Nuance Communications, Inc. All rights reserved Source: CMS, as reported to the Center for Telehealth and eHealth Law Medicare Telehealth Claims 15
  16. 16. © 2002-2014 Nuance Communications, Inc. All rights reserved 16 Potential Barriers • Largely limited to fee-for-service (Note: CAH service subscriptions) • Patients must travel to an eligible originating site • Originating site eligibility can change year-to-year (HPSA or MSA updates) • Originating site fee copay makes telehealth more expensive (~$5) • Approved services list isn’t exhaustive; extensive and lengthy process to add services • Limited clinical outcomes data for some services • Clinician state licensure limitations (Note: FSMB interstate compact) • Specialist credentialing/privileging required at each hospital originating site • Most of U.S. can’t use store-and-forward to better utilize specialists’ time • Clinician-to-clinician consultations aren’t billable • RHC and FQHC distant site prohibition • Different coverage policies than other payers (e.g., Medicaid, insurers) • Some equipment is still expensive • Transmission speeds, reliability, and costs
  17. 17. © 2002-2014 Nuance Communications, Inc. All rights reserved Medicare Telehealth Services Fact Sheet  http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf Medicare telehealth regulations  http://www.ecfr.gov/cgi-bin/text-idx?SID=89f51d919ffc5b375f126c606b5b5cd3&node=se42.2.410_178&rgn=div8 Medicare Telehealth Payment Eligibility Analyzer  http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx Medicare telehealth webpage  http://www.cms.gov/Medicare/Medicare-General-information/telehealth/index.html Medicare Benefits Policy Manual Chapter 15 (Sec. 270)  http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf Medicare Claims Policy Manual Chapter 12 (Sec. 190)  http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf Medicaid telemedicine webpage  http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html Resources 17
  18. 18. © 2002-2014 Nuance Communications, Inc. All rights reserved mHealth Use Cases Preventing Readmissions
  19. 19. © 2002-2014 Nuance Communications, Inc. All rights reserved mHealth Value Proposition – Early intervention for people at risk of congestive heart failure (CHF) - the leading cause of hospitalization in the U.S. - could save from $5 to $7 billion per year by expanding telehealth services. – Telehealth documented itself to be efficacious as a tool for early intervention – Miley, Madeline L., et al. "The state of emergency stroke resources and care in rural Arizona: a platform for telemedicine." Telemedicine and e-Health 15.7 (2009): 691-699 – Deployment of an mHealth Patient Monitoring Solution for Diabetes: “Improved Glucose Monitoring Leads to Reduction in Medical Expenditure” – http://www.touchendocrinology.com/articles/deployment-mhealth-patient- monitoring-solution-diabetes-improved-glucose-monitoring-leads-r
  20. 20. © 2002-2014 Nuance Communications, Inc. All rights reserved Healthier Workforce
  21. 21. © 2002-2014 Nuance Communications, Inc. All rights reserved 2009 Continua Health Alliance Brigitte Piniewski, MD2008 21 0 25 65 Age IllnessPre-Illness Wellness Unpredictable Health Predictable (Rules-based) Health Death 60-80% Lifestyle Modifiable Health
  22. 22. © 2002-2014 Nuance Communications, Inc. All rights reserved 2008 22 0 25 65 Age IllnessPre-Illness Wellness Death To put it another way…. Fun No Fun 2009 Continua Health Alliance Brigitte Piniewski, MD
  23. 23. Annual medical costs for people who are obese were $1,429 higher than those of normal weight. Centers for Disease Control and Prevention (2009)
  24. 24. © 2002-2014 Nuance Communications, Inc. All rights reserved Fort Healthcare has run with it! Fall 2011 Six weeks 605 players (four employers) > 222 million steps 1,368 players 365 million steps (so far) 64 teams (341 players) 3,781 pounds lost Spring 2012 Four months Fall 2012 Six weeks
  25. 25. © 2002-2014 Nuance Communications, Inc. All rights reserved Columbia was up for the challenge Columbia Slimdown Challenge 3,586 Participants (75+ local employers) 11,505 pounds lost (winner lost 23% of body weight) 36 sponsors (starting at $2,500) 13 week long weight loss challenge “Thank you so much for the opportunity to lose weight in such a fun way….. Several of us are hoping the contest can continue (lose more weight!) or restart (add new people).” —Slimdown participant
  26. 26. © 2002-2014 Nuance Communications, Inc. All rights reserved Making a difference, changing lives ~ 5.2 BILLION steps taken ~ 76,770 pounds lost (equivalent to the weight of an 18 wheeler) (equivalent to walking around Earth ~40 times) 26,518 lives changed 23 competitions completed
  27. 27. © 2002-2014 Nuance Communications, Inc. All rights reserved Nuance Just Completed their First Challenge Since March over 800 employees have been tracking their steps, food and sleep to manage their health and earned over 337,710 points redeemed for 10,359 entries into the May 31st sweepstakes. We are pleased to announce that we have our first set of winners.
  28. 28. © 2002-2014 Nuance Communications, Inc. All rights reserved Single Individual – 149,000 steps which is equivalent to 70 miles Firstly I would like to thank your team for the Jiff Challenge. Being motivated to compete for the Apple Watch resulted in me losing 21 pounds in 28 days! I’d say the program is a huge success. He sacrifice sleep, changed vacation plans to go to hike mountains instead of visiting family, walked every chance he got morning afternoon and late into the night. He would watch shows on his treadmill and go to the gym and just walk. He didn’t even sleep the last day of the challenge he walked every chance he got.
  29. 29. © 2002-2014 Nuance Communications, Inc. All rights reserved Recognizing New Channels for Growth Established Provider Care Delivery Network Relationship-Based Referring Physician Cost-Conscious Referring Physician Price-Sensitive Consumer Entrenched Payer Vulnerable Payer Activated Employer Exchange Operator Custom Network Builder Secure Enrolled Lives Win Share of Volumes Traditional Growth Channels Key Decision-Makers in Traditional and New Growth Channels Individual Insurance Shopper Accountable Physician Entity New Growth Channels Slide courtesy: Dr Kavita Patel
  30. 30. © 2002-2014 Nuance Communications, Inc. All rights reserved Nick van Terheyden, MD CMIO, Nuance Communications Twitter http://twitter.com/drnic1 LinkedIn http://www.linkedin.com/in/nickvt Voice of the Doctor http://drvoice.blogspot.com/ My Activity http://DrNick.vanterheyden.com AboutMe http://about.me/obiwan FaceBook http://profile.to/drnick E-Mail drnick@nuance.com, drnic1@gmail.com GoogleVoice (301) 355-0877 Questions Where You Can Find Me
  31. 31. © 2002-2014 Nuance Communications, Inc. All rights reserved mHealth Reimbursement – Who Will Pay Nick van Terheyden, MD (aka @drnic1) HIMSS mHealth Committee CMIO, Nuance Communications, Inc. http://DrNick.vanTerheyden.com

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