The Status Of Telemedicine In Missouri - Mhanet

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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

Outpatient telemedicine with the MO HealthNetprogram as the primary payer included 1,700 patientvisits between Oct. 1, 2014, and Sept. 30, 2016. Theyear-to-year increase between the periods was morethan 17 percent among the participating hospitals.12All of these Medicaid patient encounters occurred inHPSA areas or facilities. Moreover, most of the activitywas within hospitals that are part of a larger hospitalsystem. Among these system-affiliated hospitals, morethan half were affiliated with a system that has made asignificant investment in virtual care.The American Telemedicine Association publishes anannual scorecard rating the 50 states on the adoptionand utilization of telemedicine and telehealth, andlisting the gaps that may prevent full implementationof these services.13 Missouri has earned a grade of “B”for 2017. This better than average grade is a reflectionof Missouri’s policies towards telemedicine andtelehealth. Items included in the scoring process werethe presence of parity laws, inclusion of telemedicine inthe state employee health plan, and allowable coveredproviders, services and settings in the state’s Medicaidprogram.REACHHealth, a telemedicine software company,conducted a nationwide survey of health careexecutives, physicians, nurses and other professionals,TELEHEALTH in Missouri 50%of rural hospitalsuse telemedicine 80%state it helps themretain patients 100% 33%Source: MHA survey of Missouri rural hospitals6Missouri Hospital Associationreport reimbursementas an obstaclereport access tobroadband asan obstacle

to benchmark the telemedicine industry.14 Participantsrated their successes as providing rural patients’ accessto specialists, improving patient convenience, andincreasing patient engagement and satisfaction. Majorchallenges reported were Medicare and Medicaidreimbursement, inadequate parity laws, and lack ofcommon electronic health record platforms betweenhub and spoke hospitals.It appears that in Missouri, those that are embracingtelemedicine are looking beyond the service linereturn on investment. Current reimbursement ratesat the originating site cannot justify the investmentof financial and human capital required to implementtelemedicine services. The success of telemedicinemust be measured outside a line item on a financialstatement. Missouri’s rural hospitals are investingin telemedicine to increase patient access toprofessional and clinical services not available in localcommunities. They are taking advantage of clinicalexpertise available remotely to supplement the carebeing delivered locally. Hospitals and health systemsare looking at telemedicine as an opportunity to buildrelationships between patients, providers, employersand payers. Increased technological capabilities areallowing for smart systems that can help doctors,nurses and other caregivers to monitor and respondmore quickly to changing patient situations.Policy ConsiderationsReimbursementMO HealthNet has taken a proactive approach toreimbursement for telemedicine, and Missouri statutesrequire payment parity for telemedicine services.Medicare has participated in demonstration activitiesto assess the value of telemedicine and telehealth, butcontinues to have strict limits on services by providerand beneficiary class.Both the “originating” location and the “distantsite” of telehealth have fixed costs of investment inequipment, yet reimbursement for the distant site issmall. There is no requirement for a facility fee amongcommercial providers for delivery of telemedicineservices to a distant site.Telemedicine should be considered and reimbursed thesame as in-person care. The technology is not a low-costsubstitute for in-person care, but an opportunity to extendaccess.Workforce and StaffingRural providers indicate that telemedicine has allowed themto keep patients within the community. However, provideravailability at the originating and distant sites are requiredfor an effective system. Rural providers must have access tobroadband, in addition to the technical and clinical staff tomake telemedicine operational. Originating sites must haveappropriate clinical staff to deliver the service.Physicians’ buy-in is essential. Physicians and physicianextenders — including APRNs and PAs — must betrained on the technology and embrace its use. Obstaclesto reciprocity should be addressed to increase the poolof available providers. This will expand the capacity oforiginating sites to additional venues, and allow distantsites wider opportunity to accept telemedicine servicesin Missouri and elsewhere. Interstate licensure compactscould open opportunity for telemedicine delivery acrossstate lines and nationally.Behavioral health services are a significant portion oftelemedicine delivery. Expanded access to telemedicinefor behavioral health services could help mitigate thesignificant shortage of providers in behavioral healthHPSA counties.BroadbandAccess to broadband has the potential to expand theavailability of numerous technologies to rural and frontierhospitals and the communities they serve. MO BroadbandNow is a public-private initiative to expand broadbandto all of Missouri’s communities. Through the initiative,all Missouri hospitals now have access to broadband. Tofully realize the value of telehealth, broadband must beexpanded throughout rural Missouri. The state and federalgovernments should continue to partner with hospitals,other providers and the private sector to ensure ruralcommunities have the bandwidth to capitalize on advancesin health care technologies. Rural communities have ahigher percentage of Medicare beneficiaries and Medicaidenrollees than suburban and urban areas. Improvementsin delivery of care and value are linked to broadbandtechnology access.The Status of Telemedicine in Missouri7

References1.Health Resources and Services Administration Federal Office of Rural Health Policy. Retrieved from ead, M. (2014, November). The Health of Missouri’s Rural Residents and Hospitals. HIDI HealthStats. MissouriHospital Association. Hospital Industry Data Institute. Retrieved from 1114.pdf3.Data Portal Results. (2017). Retrieved from ults.aspx?paramServiceId HPSA¶mFilterId 1¶mHPSAStatus D¶mHPSADetail Y4.Kenyon, M. & Williams, J. (2017, May). 2017 annual workforce report. Missouri Hospital Association. Retrieved from Hawkins. (2016). Rural physician recruiting challenges and solutions. Retrieved from ttHawkins/Pdf/mha whitepaper rural PDF.pdf6.Health Professional Shortage Areas. (2016, October). Retrieved from eidhead, M. & Willson, S. (2016, June). Mental Health in Missouri: Limited Access, Increasing Demand and TragicConsequences. HIDI HealthStats. Missouri Hospital Association. Hospital Industry Data Institute. Retrieved from, K. & Petito, J. engagedIN. (2015). Designing the consumer-centered telehealth & eVisit experience: Considerationsfor the future of consumer healthcare. Retrieved from R-2015V2edits.pdf9.National Rural Health Association. (2017, July 20). (testimony of David Schmitz). Retrieved from -17 schmitz testimony.pdf10. Telehealth Services. U.S. Department of Health & Human Services. Centers for Medicare & Medicaid Services. MedicareLearning Network. (2016, November). Retrieved from althSrvcsfctsht.pdf11. Heartland Telehealth Resource Center. (n.d.). Retrieved from ouri/12. Hospital Industry Data Institute. (2017, August). Outpatient visit two-year trend report.13. Thomas, L. & Capistrant, G. (2017, February). State telemedicine gaps analysis: Coverage & reimbursement. Retrievedfrom nter/2017%20NEW verage%20and%20Reimbursement FINAL.pdf14. Telemedicine Survey. (n.d.). Retrieved from ustry-survey/Suggested CitationDillon, D. & Mikes, J. (2017, August). The status of telemedicine in Missouri. Missouri Hospital Association.Available at HOSPITAL ASSOCIATION 2017 Missouri Hospital AssociationP.O. Box 60 Jefferson City, MO 65102-0060 www.mhanet.com08/17

Missouri is comprised of 114 counties and the independent City of St. Louis. Except for two counties in the Kansas City metropolitan area and Cole County in central Missouri, all Missouri counties qualify directly, or have institutions that qualify, as a primary care HPSA.3 According to the Health Resources and Services Administration, Missouri

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