The Status Of Telemedicine In Missouri - Mhanet

The Status ofTelemedicine in MissouriAUGUST 2017MISSOURI HOSPITAL ASSOCIATION

IntroductionTechnology has the power to transform health care.Big data, smart medical devices and electronicmedical records technologies, along with otheradvances, have created a new model of health care.However, the state and federal policies governingthe use of cutting-edge advances — and wide-Telehealth — the use ofelectronic informationand telecommunicationstechnologies to support andpromote long-distance clinicalhealth care, patient andspread technology adoption — often lag behindtechnology’s potential.One area of promise in advanced health caredelivery is telehealth. The continued expansion ofbroadband into rural and frontier communities hasallowed the delivery of health services to expandbeyond the in-person clinical visit into the virtualrealm. Significant investments are being madeprofessional health-relatedto capture the value of the technology. However,education, public health, andmyriad issues remain. Addressing the policy andhealth administration.regulatory challenges will be essential to harnessingthe power of virtual care.The federal government defines1 telehealth as“the use of electronic information and telecommunications technologies to support and promotelong-distance clinical health care, patient andprofessional health-related education, publichealth, and health administration.” The focus ofthis research will be the influence of telemedicine— a subset of telehealth — on patient access, thepotential regulatory challenges to the adoption oftelehealth, provider payment and licensure issues.2Missouri Hospital Association

BackgroundDemographically and geographically, Missouriis similar to other largely rural states. Missouricurrently has 42 rural counties without a hospital.Approximately 30 percent of Missouri’s populationresides in rural areas, but only 9 percent of Missouri’slicensed physicians practice in rural areas. RuralMissourians travel twice as far for inpatient andemergency department care than their urban andsuburban counterparts.2 The workload of a primarycare physician in a Missouri county without a hospitalis almost three times higher than in counties witha hospital.3 According to the Missouri Departmentof Health and Senior Services, 13 Missouri countieshave only one primary care physician — none of thesecounties have a hospital.The workload of a primary care physicianin a Missouri county without a hospital isalmost three times higher than in countieswith a hospital.33xdemographic and institutional considerations.6 HPSAdesignation is important to affected communitiesas HPSA communities can access federal funds tomitigate workforce shortages.Missouri is comprised of 114 counties and theindependent City of St. Louis. Except for two countiesin the Kansas City metropolitan area and ColeCounty in central Missouri, all Missouri countiesqualify directly, or have institutions that qualify,as a primary care HPSA.3 According to the HealthResources and Services Administration, Missourineeds an additional 394 full-time equivalent primaryShortages in the hospital workforce are adding to thechallenge.4 MHA’s 2017 Workforce Report found staffnurse vacancy rates at 15.9 percent statewide — thehighest level in the 16-year history of the survey. Nursepractitioner vacancy was 11.4 percent and physicianassistant vacancy was 14.7 percent.Identifying trained health careprofessionals to serve in ruralcommunities can be difficult,especially for physician specialists,but also for a variety of nonphysician practitioners. Accordingto research from Merritt Hawkins,fewer than 20 percent of final yearmedical residents want to locate incommunities with less than 100,000residents. Only 1 percent indicateda desire to work in communitiesof 10,000 or fewer.5 This creates aproblem for rural hospitals and thepatients they serve.WorthAtchisonSchuyler xDaviess1Clark1AdairGrundyAndrewWarrenPettisSt. LouisColeMorganHenryOsage GasconadeFranklinBentonJeffersonMillerSt. ClairMariesCamden1HickoryVernonPhelpsCrawford WashingtonSte. rightChristianHowellStoneTaneyOzarkRural Counties With a HospitalStoddard1Oregon1ScottCarterRipleyNot a primary care healthprofessional shortage areaRural Counties Without a HospitalUrban nePerrySt. FrancoisDadeJasperMcDonaldSt. CharlesMoniteauBatesBartonHealth professional shortageareas are designated by the federalgovernment. An HPSA designationindicates an inadequacy in theprimary care, dental or mentalhealth workforce relative to thepopulation. Moreover, HPSAsare designated by scotDunklinOnly one primary care physicianThe Status of Telemedicine in Missouri3

care health professionals to meet the needs of thepopulation. However, communities struggle torecruit and retain new physicians — primary careand specialists — when there isn’t enough support toprovide professional interaction, collaboration andcoverage for time off. Moreover, specialists may findthat demand is insufficient within their specialty.A shortage of primary care providers can create accessproblems for rural communities, leading to increasedwait times for appointments, increased travel to care,and difficulty in follow-up care and assessments.Missouri’s behavioral health needs are especiallypronounced. One in 10 Missouri adults have a seriousmental illness, and 40 percent of those adults gowithout treatment. Nearly 1 in 10 children betweenthe ages of 12 and 17 in Missouri experienced adepressive episode during the previous year. Atthe same time, access to mental health services areparticularly limited — 90 percent of counties arefederally designated mental health shortage areasand 61 percent have no licensed psychiatrists.7This shortage results in average wait times to see apsychiatrist of 10 to 30 days for adults in Missouri, andup to six months for children and teens.Telehealthhas the potentialto deliver unavailablemedical servicesto remote locations.adults have a seriousmental illness90%40%BEHAVIORALHEALTHin Missouriof counties aremental healthHPSAsof these adultsgo withouttreatmentSource: HIDI HealthStats4Missouri Hospital Association1 IN 10children had adepressiveepisode duringthe previousyear6 MONTHS 10–30 DAYSaverage wait time forchildren and teens tosee a psychiatristaverage wait time foradults to see apsychiatristTelehealth is an expanding segment of the health caremarketplace, with an estimated compound annualgrowth rate of approximately 32 percent between2013 and 2018.8 Telehealth has the potential to deliverotherwise unavailable medical services to remotelocations, improving the penetration of specialtycare and supporting existing health infrastructure inHPSAs.Telehealth creates a two-fold opportunity for ruralproviders — provider education and patient access tocare.9 According to David F. Schmitz, M.D., Presidentof the National Rural Health Association, throughtelehealth, “virtual communities” like the Universityof Missouri’s Project ECHO, can expand access to bestpractices and bring more support to rural hospitalsand clinics.Discussing the value of telehealth for rural access,Schmitz continued, “Telehealth is an example of one ofthe most important technologies for rural providers.In 2013, over 40,000 rural beneficiaries received at leastone telemedicine visit, and this number is expectedto continue to grow. If rural providers are to movetoward an online future, they must invest in necessarytechnological infrastructure and systems.”Telemedicine and telehealth offer new opportunitiesfor rural patient access and increased interactionbetween practitioners. However, the challenges toimplementation are manifold.1 IN 1061%of counties haveno licensedpsychiatristsOpportunities for TelehealthEligibility and PaymentRequirements for telemedicine services vary byprogram and payer.MedicareMedicare restricts telehealth services to beneficiariesthat live in counties outside of a metropolitanstatistical area and within an HPSA. Although thiswould include most rural Medicare beneficiaries, thelist of eligible services and authorized practitionersfurther restricts the scope of telemedicine delivery.10

“Telehealth is an example of one of the most important technologies for rural providers. In2013, over 40,000 rural beneficiaries received at least one telemedicine visit, and this number isexpected to continue to grow. If rural providers are to move toward an online future, they mustinvest in necessary technological infrastructure and systems.”While current Medicare restrictions may be preventinga broader adoption of telemedicine, there are signsthat policymakers are considering changing rules andregulations to allow greater utilization. The Centers forMedicare & Medicaid Services, through the InnovationCenter, has allowed certain models and demonstrationsto broaden access to telehealth services. In fact, theInnovation Center already has identified that waivingrequirements regarding the originating site would bethe best way to provide greater access to telehealth.Congress also is realizing the benefits of telehealth,and several bills have been introduced to reduce therestrictions imposed by federal law and regulation.Medicaid/MO HealthNetTo participate in telehealth through Missouri’sMedicaid program — MO HealthNet — providersmust be enrolled in MO HealthNet and approved bythe Missouri Telehealth Network.11 Certain providercategories and patient locations are defined. However,the MO HealthNet program has proposed newrules that will expand the number of providers thatcan use telehealth and increase the variety of siteswhere telehealth services may originate. These rulesimplement state legislation enacted in 2016.Under the proposed rules, MO HealthNet wouldexpand eligible originating sites beyond traditionalfacilities like physicians’ offices, hospitals and clinics,to residential treatment facilities, schools, homes anddesignated areas in pharmacies. The rule also wouldexpand the types of providers that can participatein telemedicine services from physicians, advancedpractice registered nurses and psychologists, to includephysician assistants, assistant physicians, dentistsand oral surgeons, psychologists, social workers andcounselors, pharmacists, podiatrists, optometrists,and speech, occupational and physical therapists. Theproposed rules also would allow for asynchronousstore-and-forward technology and remote homemonitoring. Store-and-forward technology allows thetransfer of pictures, videos, and audio and text filesthrough telecommunication for consultation withoutrequiring the simultaneous presence of the patientand their provider. Remote home monitoring allowsthose patients with chronic conditions at high risk ofhospitalization to be safely monitored without beinginstitutionalized. In addition, the state requirement toobtain the Missouri Telehealth Network’s technologyand security approval of the telehealth service hasbeen replaced with acceptance of the security andencryption standards of the National Institute ofStandards and Technology.Commercial InsuranceIn 2013, Missouri law was updated to requireprivate insurers to cover services provided throughtelemedicine if they cover the same servicesin-person.11 This is not the case in all states. However,there is no specific requirement that commercialproviders pay a facility fee, which is allowed under thestate’s Medicaid program.Telehealth in MissouriAn MHA survey of rural hospitals found that morethan half of participating hospitals used telemedicine.Among this same sample, more than 80 percentindicated that telemedicine helped them retainpatients within their community. Nearly all indicatedthat reimbursement was an obstacle in telemedicineuse, while one-third indicated access to broadband wasan issue.11The Status of Telemedicine in Missouri5