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Please stand by for realtime captions >> Karen Rheuban Thank you for being here. I am, the
professor of the address at the University of Virginia and the director for the Center
of Telehealth. Telehealth programs have served as a innovative tool for the delivery of care
linking patients and providers separated by geographic and/or socioeconomic barriers.
All the while navigating specialty workforce shortages.
Through an explosion of advanced technologies and the significant federal investment in
Telehealth programs and Rod brand infrastructure, many lives of Americans and likewise patients
around the world now benefit from care provided through Telehealth.
Telehealth programs are entirely aligned with a -- the aims of CMS -- better care, better
health, and lower-cost.
With the passage of recent affirmation of the affordable care act, we are now at a strategic
inflection point in our efforts to further integrate Telehealth into mainstream everyday
healthcare. We must ensure that contemporary public policy alliance with these goals.
Over the next two days, we hope to further delineated evidence base for Telehealth and
highlight special applications for rural and underserved populations, but also for all
patients regardless of location.
We will discussion actions to be undertaken by HHS, the state, and the payers and also
hear from consumers.
This is our opportunity to identify issues that warrant further study by the Institute
of medicine.
I would like to thank the colleagues here -- Dr. Wakefield, Dr. Morris, and [indiscernible]
for their leadership role in advancing this program nationwide. And for funding this workshop.
A special thanks goes to the planning committee -- Dr. Tom Nesbit,, the doctor at partners
healthcare, Dr. Spero Manson, and Dr. Pruitt, the office of Telehealth.
In addition, I want to thank Dr. Tracy lusted who coordinated this and for colleague, Samantha
[last name indiscernible] . >> Our schedule is tight this morning and we encourage people
to move about if they need to. When the time comes for questions and answers, flip the
switch on the microphone and we encourage audience participation.
No food or drinks are allowed in the auditorium since it is brand-new and renovated. These
turn off your cell phones and pagers. Now, it gives me great leisure to introduced Cheryl
Lynn Pruitt -- she will introduce her colleague, Dr. Mary Wakefield Dr. >> Thank you, Karen.
I am honored to introduced the next speaker, Dr. Mary Wakefield. When I saw her this morning,
I asked how she went to be introduced. She said keep it short and leave more time for
content. I will honor her request. Before I do, I want to tell a story. I joined the
office in 2006 and I intended a meeting of the rural health information network. This
meeting was led by Dr. Wakefield. I saw her and I thought who is that lady? She hasn't
so much energy and enthusiasm. She is bright and she can control the room. I was very impressed
by her. When I heard she was going to be the administrator here, we were all excited. She
knows Telehealth and rural health and anybody who is interested in rural communities and
the medically underserved populations, we are blessed to have her as the administrator.
I would like to introduce our administrator and IOM member, Dr. Mary Wakefield Dr.
Thank you very much. As you can tell, Cheryl Lynn is associated with the office and they
are a bit of a [indiscernible] group. They pretend that they take direction from me,
but they go and do what she does. They not and say yes and they go off and do what they
should be doing which is great -- paid no attention to the administrator. I am just
joking, of course. The health resources and services administration has a set of programs.
It is a delight for me because of where I come from to deal with the Terrell office
of rural health policy. I have a long standing history with Tom Moore 17 there. We have fabulous
employees across the entire agency. These are certainly some of the best. And to all
of you with [indiscernible] -- Steve Hirsch is also here and will speak later.. Thank
you Karen for your willingness to serve in helping to coordinate and lead this particular
meeting. We go way back -- she is from the University of Virginia and I have spent some
time myself in some of the university infrastructure of the state of her gender. I appreciate the
opportunity to talk with all of you today about what I think is an incredibly important
topic for the meeting -- focusing on how we can for the meeting -- focusing on how We
Can Dr., Telehealth technology in an even more robust fashion to improve patient outcomes,
especially for people in isolated geographic areas across the United States. And how we
can harness telehealth technology to expand the reach of what our scarce health resources
in rural America are. At HR as they and across HHS, we have been looking forward to this
meeting for quite some time with the hope of a report that will provide us with your
great thinking about how we can really catalyze this agenda going forward.
The six members of the planning committee -- a special shout out to each of you who
are willing to dissipate in the meeting. Also you will be participating in terms of helping
to Perl the content together on the back and with the IOM. It is nice to see familiar faces
in the audience. I know we are broadcasting this as well and that it will be available
archived. For those of you here and why no, we have worked collectively a number of bus
in this rural landscape for now decade. The issues that we are talking about today we'll
he -- really resonate with me today. I am a resident of the state of North Dakota. I
commute for my job. It is still home for me. Obviously, you don't have to look to too many
states that are more rural than the state of North Dakota. These issues we are talking
about -- ensuring access to healthcare resources -- play a way for me and family members who
reside in rural parts of that state. And, Frank, for as long as I have been in healthcare
for decades -- rural issues have been a part of what I have focused on. In that context,
I see a promise and potential impact and also some of the challenges that we have had in
deploying Telehealth -- not just in North Dakota, but in other parts of the United States.
In my home state, though, Telehealth technology and its hardest thing has been a key player
in helping to make available access to healthcare services.
I think that is the ability to capitalize on technology, especially from and through
a rural lands, probably gets its start in a rural communities that are often shy of
a full array of resources. In places like North Dakota, I like to think about those
communities -- rural healthcare leaders -- that really do necessity is the mother of innovation.
When I think of innovation and our ability to better meet these needs in our rural and
frontier parts of the country, I certainly buy into that thinking more effective deployment
of Telehealth technology.
Prior to my current position, I served on the Commonwealth commissions find. This was
on a high performing healthcare system. I brought the commission people from across
the United States -- I brought them to North Dakota to look at innovation in healthcare.
Central to the conversation was the deployment of Telehealth technology. That state, in particular,
we were talking about tele-pharmacy were you do not have a arm assist in every single rural
community and yet you have a lot of people who are relying on the knowledge and availability
-- of pharmacy. I am well aware of the important where role that technology can play in rural
frontier states and even through that tele-pharmacy project is well underway there.
When I came to HRSA, I became more aware of the importance of oral health. As Karen indicated,
any isolated communities. The point would be that some of our most isolated communities
in some respects are actually in some of our urban inner-city areas. I know that because
I've seen it in my current capacity as recently as a week and a half ago. I visited an incredibly
medically underserved part of this District of Columbia -- a stone's throw from -- a stone's
throw from the nation's capital.
So, that is the orientation that we bring to this set of issues around really alighting
on the promise and opportunity of Telehealth technology with an obvious recognition of
some the challenges we have yet to overcome, but frankly I cannot think of a better time
than right now for us to be focusing in on this conversation. It's about the role that
Telehealth can play in what is really a rapidly evolving healthcare environment. The importance
of Telehealth and its potential will, I believe, and many of you believe it too, the importance
of this will continue to grow, especially as more and more people in rural and isolated
areas across the United States are able to seek a full complement of healthcare services.
In no small part part this will be a part of the affordable care act including provisions
lies like health insurance exchangeable reach out the availability of access to health insurance
coverage. Also, the availability without co-pay of preventive healthcare services. Without
out-of-pocket costs. Another set of services that individuals will not have caused barriers
to in terms of accessing as well as some of the new Medicare and Medicaid payment models.
We have a lot of new opportunity that we can take advantage of and I think Telehealth technology
is a key player when we think about these isolated populations.
We all know that when it comes to isolated populations we have real challenges in rural
parts of the nation. The rural population in this country -- nearly 20% of the US population
-- is spread across about 80% of the nations countryside. The landmass. This is a population
that is widely dispersed and calls up the media challenges in terms of connecting healthcare
am a not just emergency care, but preventive health services as I alluded to a minute ago
with populations that reside in very rural parts of the country. We also know that rural
communities and the older. An older population. We know that rural communities tend to have
people with lower incomes and we know that in sharp contrast to some of the myths that
we have higher rates of three -- certain chronic diseases in rural areas. Because of this,
chronic disease, low in, -- low income, and this creates additional barriers to our helping
individuals to obtain healthcare services in real-time.
We also know that in rural areas we have challenges with attracting and retaining healthcare providers.
Physicians, pharmacists, physical therapists, nurses, and others. That can be for many of
the rural communities a difficult challenge. We know that a lot of the for a lot of the
health-care industry, particularly some of the smallest hospitals, today they are operating
on the thinnest of margins. We have a lot of challenges, but I would say also opportunities
of which Telehealth technology applications can be a part, not entirely, but part of the
solution.
So, at HHS we are addressing these issues as we think about the future of health care
across the United States and we are paying attention -- paying attention to healthcare
challenges -- some that I mentioned and others too numerous to mention. Rural communities
and populations will face these. As a result, we are looking forward to the ideas that come
from this meeting. Ideas that will take us to concrete steps to think about how we can
leverage what our limited resources are in many circumstances and how we can advance
this area rural focused agenda.
As many of you know, this administration has made rural America a high priority. This has
been made clear by the president via a number of initiatives that he has advanced and I
would say while it is not an initiative, from my perspective, one of the most important
and periodically I am summoned to talk about this -- one of the most important steps that
I think the president has taken that helps advance for rural America's agenda is by naming
the secretary that he named to head the US Department of health and human services -- Secretary.
Sibilius -- from Kansas -- she can match just about anyone in conversing about the special
needs in the rural communities that she was responsible for helping to govern across the
state. Through that appointment, we have an incredibly tireless advocate and a very knowledgeable
individual who cares about and manages across scores of issues, but who never in any conversation
I've ever been a part of with her has lost sight of some of the unique challenges and
opportunities for rural communities in rural healthcare infrastructure. In addition, the
president created the White House rural Council -- the first Council of its type -- focusing
on rural with an eye toward the economic health of rural communities. And eating that in mind.
This is a Council that HHS interfaces with in no small part to the federal offices in
a council that is been very active in dancing issues in agriculture and other areas and
very much a dancing health care issues, too. Then, coming on the heels of that we have
the affordable care act. I mentioned this earlier. It brings a special tool and opportunity
and benefits from our vantage point to rural populations, too. Starting to help the rural
communities face long-standing challenges. Just a few of these benefits the point -- they
play specific to the rural communities in a positive way. So, for example, expanding
insurance coverage and increasing access to care -- in places where frequently you do
not find it -- individuals that go without insurance or are underinsured is not uncommon
in rural areas. Once insurance is expanded, that benefits those individuals and clearly
benefit the providers who are providing the services as well.
The affordable care act also focuses on improving healthcare quality through team-based patient
centered care. Telehealth has a role in leaking members of teams. You can see the alignment,
if you will, of this focus on Telehealth and how we engage more fiber link the full skill
set that teams bring to care of individuals and communities. In addition, the affordable
care act is focused on addressing health disparities and improving public health. These are important
but praise to benefit rural areas. It focuses on -- sharply -- and we own a lot of work
in this area -- focuses on increasing the numbers and deployment of healthcare providers.
Much of this occurs in rural communities going forward. As a result of the Affordable Care
Act, we have 16 million Americans living in rural areas that a longer days like time limits
on -- in terms of dollar amounts -- on their health benefits. About half of all of the
workers that live in our remote communities across the United States are employed by small
firms that followed by four tax credits that can help them provide coverage and make it
more affordable for their employees. As this is more fully implemented, we will see a dramatic
increase in the numbers of Americans with health care coverage. This reaches right into
and across rural America.
We will also be at a critical juncture in terms of the implementation of electronic
health records is a part of the push toward meaningful use. By 2014, we will also be starting
to finish off the work that we have been engaged in fully in the expansion of our community
health centers, infrastructure, and the investments in the growth and number of primary care providers
that I was talking about earlier. Also, we will be winding down by 2014. We have been
building a platform already and we have got elected he still underway. All of which should
accrue in a favorable way as I mentioned to rural communities.
We will also continue to focus on improving care quality through a range of initiatives
supported through the affordable care act -- partnership for patients that we have an
especially working hard with CMS to working out and into an engaging world hospitals and
other rural healthcare infrastructures all the way to some of the new initiatives that
CMS is supporting through CMM I -- the center on Medicare and Medicaid innovation. Some
of their new initiatives have been supported through the innovation center and focus sharply
on quality, access, and reducing cost. As an aside, two mornings ago in my spare time
-- I took the time to go through about 100+ abstracts of all of the CMM I innovation initiatives
that were just relatively recently funded. It was exciting for me to see -- I mentioned
frequently -- and rural. Also exciting for me to see -- Telehealth technology. You see
this picking up from local levels that were competing for the funds and harnessing of
the technology -- not just for rural areas, but certainly in many instances for rural
areas. All by way of saying that I think Telehealth, given this backdrop, can in some ways has
already started to play an even more important role in what for us is clearly evolving landscape
in healthcare. Especially as we move away from the traditional fee for service system
to work new models of care and putting accountable care organizations and patient centered strategies
and re-engineered designs focusing on outcomes much more sharply than focusing on quantity
of care for example. >> At the same time, the cost of technology associated with Telehealth
like the cost of a lot of these types of technologies, is also dropping. And products in the Telehealth
-- technology world -- are becoming easier to use, either even for someone like me who
did not grow up with this and at least when I was in graduate school thought that computers
were a passing fad and did need to learn a whole lot about the use.
More widely prevalent in the marketplace and accessible. Consequently, a set of tools,
then, that we can bring into play in an even easier fashion than perhaps even five or 10
years ago. Just last week -- for example, Secretary. Sibilius announced the launch of
a new initiative called to care for life. Big is an evidence-based program that will
deploy mobile technology and mobile texting, specifically, to improve retention and care
and to improve medication adherence for ***-positive individuals. In *** world -- retention in
care and adherence to medication usage as prescribed I clinicians are tough challenges.
Right here at a center of part of the response route to that topic set of challenges, technology
applications. This initiative will focus on Southern states, for example. It is a two-year
project and they were developed a message library for delivering phone text notifications
of both Bush and Spanish for appointment reminders and medication reminders and so on. It is
a great harnessing of technology and we look forward to this.
Some of the rest -- the other activities -- not necessarily from the federal government but
other places -- some of you may have heard a few days ago about the exam red will fight
but for each 140 pound telemedicine robot. This robot is being tested and piloted in
emergency rooms to help patients get more rapid treatment from specialists. Especially
at night when hospital staff tends to be lower. That robot allows physicians and others to
visit patients in distant locations and also allows them to carry on conversations and
take information in real time.
So, the pace of innovation is less expensive and it has been it is also accelerating. We
think this will have important implications for the workforce, two, and the quality of
services and efficiency of delivery. Certainly it can have applications for the cost of healthcare
services and the availability of healthcare providers in remote areas. Also, it has implications
for the type of and training of the healthcare providers as well. The types of training that
they will need in order to acquire proficiency in deploying and using the technology in their
space. >> In this rapidly changing environment, then, your ideas and recommendations for leveraging
these technologies to improve health outcomes have isolated and underserved populations
will be extremely important. Especially if we are to successfully reduce health disparities
between rural and urban populations and between people with higher incomes and lower income
and reduce disparities among people that seem to be tenaciously clinging to ethnicity and
age and gender and race and so on. These are the disparities that we far find far too frequently.
While this is not a panacea, we can think about how this can help us reach farther to
minimize and ultimately eliminate those kinds of disparities.
In the next couple of days you will discuss and hopefully have ideas emerging from the
meeting that will populate from our vantage point a roadmap for us that will help us better
meet some of the challenges ahead and take a vantage of the opportunities that we know
exist right now. In that context, some of the opportunities have already become fairly
clear. For example, there is a growing body of evidence that shows the potential for health
information technology to improve care quality if it is used properly to maximize the databases
and so on. It is possible to generate quality measures with the use of technology that improves
clinical outcomes that can contribute to timely and understandable feedback for safety net
providers and other members of clinical teams. HIG derived information is critical for performing
a quality improvement strategy. Everyone in this room knows that and it is especially
important when individuals are participating in patients under medical homes and accountable
care of innovations that don't just reach across writer types, but also sectors of the
healthcare delivery systems. Harnessing the technology is critically important. It is
our hope that you will bite us with your best insight on how to move forward across a range
of issues and topics from Telehealth technology and link to payment and Telehealth technology
a link to care ordination and links to health professions training and so on. Within HHS
and across the government we have been making fairly significant investments in Telehealth
technology. We are moving on his agenda, or have not fast enough, but we do have a few
initiatives that I think I'd a bit of a platform even going forward. This might inform your
thinking.
We have a new cross federal workgroup on Telehealth called bad tell. -- Fed tell. They share knowledge
and identify a collaborative opportunities. There are now 26 federal agencies and offices
across the government with an interest in or an investment in Telehealth technologies.
They are partners within this new entity -- fed tell. For example, we have signed a memorandum
of understanding with the Indian health service to develop a joint quality strategy. This
strategy has enabled and has been designed to improve the quality of care. Along with
aligning the goals of that initiative with the national quality strategy. The -- it has
been an innovator in the field giving the geographic challenges that they face in getting
healthcare services out to some of our most rural and remote populations. We have also
been working closely with CMS to include measures of a proposed rule for stage II of meaningful
use that reflect underserved and vulnerable populations served by the grantees. These
include measures on oral health, behavioral health, rural populations, material and prenatal
care, for example.
Shifting to another read of activity -- the national Library of medicine funds projects
to leverage this technology to improve healthcare outcomes. We are now seeing innovative projects
in Telehealth through the work of the beacon programs nested in the office of the national
coordinator for HIT.
And of course some of the unique projects that I mentioned, an out of the centers for
Medicare and Medicaid innovation. Telehealth is an area of focus from the White House world
health Council not just through the work of HHS, but also the Veterans Administration
and the FCC to identify ways to work together to design and prove access to care for the
veterans residing in rural and remote parts of the country. The Department of Defense,
too, invest heavily in this technology and the department of agriculture and commerce
have also focused heavily on expanding broadband capacity which is integral to pushing out
the utilization of this technology. >> Later in the workshop you will hear from the Department
of Veterans Affairs and the Indian health services about their experience in this area.
Our work in picking about veterans and harnessing technology can also be seen in the federal
office of rural health policy initiative -- the veterans health-care access program. This
program is using Telehealth technology to increase access to mental health care services
for veterans that are returning from Iraq and Afghanistan and living in rural areas.
Currently we have 3 grantees being funded. -- They are Alaska, Montana, and Virginia.
They all provide mental health services including crisis intervention and detection of posttraumatic
stress disorder. They care for patients with dramatic rain a jury and other injuries that
veterans have suffered. Within this we have established a series of programs to promote
the expansion. This includes a focus of the license for portability issues that support
state professional licensing boards to develop and element policies that are designed to
reduce the statutory very jurors -- areas -- I remember a couple of years ago Thompson
to me that from his vantage point something like it was easier for us to extend the reach
of medical services across the Pacific and across California state lines with neighboring
states. That has always stayed with me. So, this focus on license for portability is important.
We also have a Telehealth network grant program and a resource center that we support through
the federal office of rural health policy.
What is the point of sharing this information with you? The point is to let you see a net
of what we have available right now and a bit of what we can build off of great it doesn't
all come from the federal government, for sure, but a lot of activity is unfolding there
right now. That provides a context, hopefully, for some of your thinking over today and tomorrow.
This meeting is really about something different. It is really a heating that focuses on more
about what is happening next. I have given you a lot of the context, but what we would
like to engage the rest of this meeting is where we need to go next. Not we have been
and where we are right now, but I am asking you and I know I am challenging you to figure
out where we need to go next. Any meaningful way. We are well past the point that we need
to prove the applications of some of this technology and prove they technology and that
works. The focus now needs to be again from where I sit on how we can do a better job
of harnessing the technology to improve care and to do that as effectively and as efficiently
as possible to make sure that this is a -- Telehealth technology is embedded in the fabric of healthcare
for rural populations. That focus raises some questions for you to think about. Questions
might include, for example, what is or what can be the role of Telehealth in a healthcare
system that is predicated on value? That is where we are moving. Predicated on improving
patient outcomes. Another question -- how could we or how should we use this technology
in efforts that are designed to improve care coordination? Think about what I said a few
minutes ago -- the focus of the affordable health care act -- teammates care. What is
the role of this technology in that context and how it can it decrease healthcare fragmentation?
What can Telehealth do to help clinicians work more effectively together and harness
data and use it in real time in the care of patients and, rightly, in the care of communities,
not just in terms of what goes on in an exam room and the pages that come through them,
but how can Telehealth technology be harvested more robustly to influence the care and health
status of communities -- people outside of the exam rooms? We hope that today's meeting
will help chart some of these answers to questions like these and other questions that some of
you have and that the reports will inform our future actions going forward. We have
a lot of challenges, that is certain, but the good news is that we have a lot of opportunities.
We are in a new light in terms of this technology and the types of technology available to us.
I think we need it renewed thinking about what we need to get to barriers out of the
way and opportunities put directly in front of us that we can capitalize on.
I would also ask you to keep a night on not just the vertical applications of Telehealth,
but also Telehealth technologies utilization in terms of training. And pushing out even
more robustly the availability of continuing education, new training opportunities, distance-based
health professions training, oversight in the use of these technologies. It is important
for us on the training side, two, two maximize the availability of resources. Really, this
can play a role in supporting the healthcare workforce just as they can help us to be more
efficient, particularly in underserved areas.
Mike thanks to each of you. And your willingness to help us with this agenda. We are hoping
that this summary will set the stage for some steps we could take immediately. I am not
looking for something we can do six months from now or five years from now although that
is important -- we may well come away with a study and look at this. I am also a asking
you to think about what we can move forward on and capturing ideas immediately on what
we can do not today but six months or a year from now or three years from now and so on
if we start to put the right pieces in place. A lot of the building, I think, is not just
from the federal government, but what we can be doing in tandem with state governments
and private sector partners and so on. For all of those reasons, I think the timing for
this discussion could not be better. I want to thank each of you -- those in the room
anticipating virtually -- thank you for your willingness to engage with us on this topic.
It is quite near and dear to my heart and it's value and opportunity to be used that
I have seen as recently as my last trip act to go to go to when I saw a family member
who with her right technology in place would not have had to think about traveling 110
miles to have something checked, but this could have been done if we had the infrastructure
in place. This is very real for me in terms of the opportunities to I miss the technology
-- harness the technology. It is also a good reminder to get back to see these front-line
challenges and to see the opportunities that we have to make a print in terms of access
and care quality and efficiency and cost, too. This is one vehicle for doing that. Thanks
a lot for your time and the opportunity to spend a few minutes with you this morning.
[applause] >> Thank you, Dr. Wakefield. She is energetic, passionate, and the right person
to be leading this agency. We are truly grateful for your participation and the work you do
every day.
It is starting to know that we have Dr. Wakefield and Maryland Chapter -- into the jewels committee
to advance in the feel and that they communicate. The bad tell message is an important one that
we are working together to advance our mission.
It also gives me great pleasure to introduce the next speaker, Dr. Thomas Nesbitt, the
professor of medicine at the University of California at Davis. He is the associate vice
chancellor for the strategic technologies and he has been the lead in the Telehealth
program at UC Davis. I'm a temp years ago -- I met him many years ago and he has ruled
as a mentor for me in many ways. He has an amazing program and I am here -- I am excited
that he is here to talk to us about where we have been and where we are going. Where
we are going is our focus.
Please welcome him.
[applause]
Good morning. I am going to cover a lot of material in a short period of time first,
I want to say I have no conflicts. I am not on any boards. I don't own stock. I am going
to try and get through a lot of material very quickly. I can only touch on some of these
things very briefly. If you have a particular paper or project that doesn't get covered,
I apologize. I want to cover definitions. I want to talk about the rationale. I want
to talk about Telehealth in the setting of the home, clinics, and hospital. I'd put in
radiology, pathology, and pharmacy between the clinic in the hospital because they relate
to go. Then, a quick summary.
In terms of definitions -- into it is medicine defined telemedicine is the use of electronic
information and communication technology to provide and support health care when distant
separations -- as does the provides participants. There has been some interchanging of the terms
of Telehealth and telemedicine. Both of these describe the use of these technologies to
improve patients help status. Telemedicine has typically been used more to describe direct
clinical services where Telehealth has been used to define a broader scope of services
including things like patient education and other related services that improve health.
What is the rationale for this? Probably one of the landmark publications in the last double
of decades has been crossing the quality chasm. In that, the committee said that permission
technology must play a central role in the redesign of the healthcare system if we want
to substantially improve quality. I think it could be argued that nowhere is this more
true than in rural areas and in rural communities.
Keep in mind that at the same time we are talking about this, there continues to be
an increase in medical knowledge. The NIH and national Academy -- there is new knowledge
being developed all the time in science. Some people have access to the new knowledge and
expertise and other people do not. Then, the disparity grows in a relative way. The theme
here is that advances in telecommunication and information technology can help overcome
some of these disparities by redistributing the knowledge and expertise to where and when
it is needed.
Let's jump right into talking about Care at Home and in the Community.
There has been a long history of talking about providing care into the home. There is an
article in the Lancet in 1879 that talked about the telephone to reduce unnecessarily
-- unnecessary physician visits. Monitoring -- home monitoring -- this has a longer history
-- it certainly was developed in the merger we program when they began doing physiologic
monitoring over a distance. They expanded that with this they technology applied to
rural healthcare. -- The project where they further develop this technology in a pilot
with the Indians.
Back in 1925, this was an article published in science innovation magazine where they
envisioned video to the home and they even envisioned a device that would allow you to
examine a patient over distance. They were thinking that this would occur in the next
50 years. We are not that far off.
We certainly have a need. The biggest need, in the home and community relates to chronic
disease which, as Mary said, affects rural areas possibly more than anywhere else. There
are 100 million Americans with chronic diseases account for about 75% of our health care expenditures.
Traditionally, we have used an episodic office-based model for managing chronic disease whether
than a care management model that uses frequent patient contact and regular physiologic measurement.
The BA -- VA -- over a decade ago, they realized this was not the best way to manage chronic
disease so they developed a program with education monitoring and feedback and personalized remote
care management from a disease management support team.
The data goes back even further than the as, but in the study published in 2005 they showed
reductions in hospitalizations and reduction in bed days. They also showed some improvement
in physiologic measures and they also showed that are inherent for medication. >> In a
later report of 17,000 people, they confirmed these reductions in bed days and reductions
in emissions and they had very high satisfaction as well as relatively low per annum cost.
This report came out in May of this year from NEHI. They confirmed reductions in emergency
department visits and hospitalizations and hospital we emissions and hospital length
of stay and overall cost.
I will talk on -- touch on a couple of areas. I have thousands of articles I can share with
you, but I will touch on a couple of specific areas. In the area of hypertension, this is
a study of listing 2010 that showed the addition of monitoring at home that improved the management
of hypertension. This is an analysis done on chronic congestive heart failure of 21
studies negating that home monitoring reduced mortality compared to usual care.
In diabetes, another meta-analysis showed that home telemedicine had a positive effect
on hemoglobin A-1 C. and they also showed that home telehealth helps to reduce the number
of patients hospitalized. In both of these meta- analyses, they'd knowledge the fact
that we do need more high-quality studies in these areas.
Where are we going in this area? I think that the devices that were being used in the VA
study -- we will see more of these. They are being produced by a number of different companies.
Some are going to tablet-based and some are going to wrap top-based systems. They have
peripherals connected. The other thing -- I am trying to avoid brand names -- I am using
this from the Berkeley school of engineering. We are going to see smaller devices for physiological
Margery -- monitoring. This combines a stethoscope and my other be in other functions. It has
Bluetooth to a cell phone or PC and it has a fair amount of storage with it. Because
we are able to use these and make these devices smaller, we can put them into different form
factors. Different factors like a watch or a ring that measures blood pressure and heart
rate or an earring that does pulse oximetry. That kind of thing. I think we are going to
see these kinds of devices put out.
What are our challenges and opportunities for the future in the area of home health?
I think that one of the issues is patient preferences and acceptability of Telehealth.
A lot of studies -- many of them have been done. A lot of pilots show attrition of the
chill -- people using these technologies. There is a lot of attrition from these and
why is that? Have we figured out the kinds of devices that people want to use? How much
intrusion in people's lives are they willing to accept? There is a device that goes on
your chest and will measure whether you swallow your pill or not. Do people really want that?
How do we better involve patients and their families safely in care and what is their
role?
How do we use off the shelf devices like mobile phones and gaming systems and other things
that we need to figure out how to use? What is the quality that we have to use of a mobile
phone if we are going to do this? Probably the last two may be the most important. How
do we manage and transform all the data that is flowing in from these devices and turn
that data into information that is actionable by a clinician? A lot of positions out there
don't have disease management teams that they can use to manage the data. So, how does the
small doctor's office in Nebraska or article to use the data? This flow of data is somewhat
threatening. What policy changes and supports are needed to allow world populations to be
able to use these models of care? Again, although big systems can have disease management, how
does the average clinician use that?
Let's switch to office-based care. The inventor of the ECG published a paper in 2006 talking
about the Tele cardiac Graham. From clinics on ships two sure, they have been using the
radio. This has been used in other places for many decades. Probably one of the most
famous uses of television is the 1968 use of it between Massachusetts general hospital
and Logan Airport.
Going further in time, there is the use of other kinds of telemedicine. In Alaska they
have been a model for the development of telemedicine. I show this picture for a couple of reasons.
This is a community health aide that is doing a test and they added audiometry. In this
population, they have a high rate of middle your disease. The information can be sent
to Anchorage or Fairbanks were specialists can make a determination whether a patient
needs to travel down there for more definitive treatment. Again, this has been done for decades
in Alaska.
Today, we think of telemedicine as these flat screen high-definition units. There are a
lot of them out there. All of these do not talk to each other. Some use proprietary communication
standards. If we want this to be as it ubiquitous as the telephone, we need to think about things
like communication standards.
They have peripheral devices that can aid in the physical examination of the patient.
Something that is been a great advance is the use of more store and forward or asynchronous
technologies. Term ecology has been a successful use of this. In terms of ophthalmology and
optometry, the use of these cameras to screen diabetics -- this has increased the screening
rates of diabetics who need to have retinal screening and these are non--- cameras that
do not have to dilate the eye.
Teledata Street -- -- Tele dentistry. This has been used where you can use this in combination
with x-rays and these examination tools where you can examine patients and to a good agile
exam -- a good dental exam and this can really improve access to dental services.
I want to touch on a couple of office paste areas. -- Office-based areas. I am going to
focus on dermatology and psychiatry, two of the biggest. There have been studies going
back to the 90s showing very good agreement between in person care and Tele dermatology.
Justin June of this year there was a study published on patient satisfaction. There have
been a lot of these studies, but this is a new one showing that patients have a high
satisfaction rate. The third study is important because some people worry that if you see
a patient via Tele term ecology and you diagnose a condition that needs surgery or something,
the patient will get delayed. In this population, this did not have it.
The last one is from April Armstrong. Look at why some dermatologist don't do this. If
it is so wonderful, why is everyone doing this? There were a number of reasons. Issues
about malpractice and training. A lot had to do with reimbursement. Not knowing about
this or the level of reimbursement. You will hear about some of this in the reimbursement
panel about some of the barriers. I will give you a tease with that.
In mental health, there have been studies done -- in 2000 and in 2019 98 and again in
2007. This shows good agreement between in person diagnosis and treatment plans. When
they are done in person versus telemedicine. Again, there are high satisfaction rates.
Even among parents of kids with psychiatric illness.
I wanted to show this study to give you some idea of the peripheral benefits. This is a
study we did in separate rural communities. We looked at the opinion of healthcare in
that community prior to telemedicine being introduced and 19 months later looking at
it after telemedicine was introduced in the community. It showed that rural communities
had -- a higher opinion of healthcare once a new about telemedicine in the community.
People with a higher opinion were less likely to leave the community.
Where we going? I think the equipment will change. This is an otoscope connected to an
iPhone. You can get a good picture. You can show the patient and send it to do otolaryngologists.
You can ask if the tube is in the right place. I think we are going to see more integration
of telemedicine with electronic health records. A lot of the big companies are already doing
this. You will see integration of telemedicine and decision support and the EHR.
In office-based care, what are the challenges and opportunities? How do we use nontraditional
providers such as in Alaska or a dental hygienist? Rather than the traditional providers? This
gets into scope of practice issues and that is a touchy subject. Again, we need to think
about this.
How do we use new models that build community clinical expertise using these technologies?
You will hear about some of these when we talk about the project? Oh.
-- E.
Can we improve the interface? How about less costly equipment like handheld devices as
I showed you with the otoscope? We need to continue to develop evidence a standards for
care, but how can these reimbursement models support telemedicine to rural and remote communities?
Again, in the dermatology study there was a lot of challenges for specialist even getting
the patients in to see them in person. Why should they then add providing care over distance?
We need to think about how the reimbursement models work.
I am good to talk about radiology and pathology and pharmacology quickly. Radiology has been
around for a long time. I found an article from 1948 from Philadelphia to Chester County
Hospital. Teleradiology is the most common form of telemedicine. We used to do it with
camera on a stick or digitized films. Now we use Iraq digital capture in most of radiology
systems. This has allowed for the development of Nighthawk services. If you get an image
tonight in a hospital in this area, the person reading that image might be in Australia.
Again, it is used quite commonly in a way that radiology is done.
One thing really all it is have done is promoted a standard that they use for transmitting
and storing data. They have promoted the DICOM standard. They have been good about this.
These are some images using this standard.
Going back to the late 90s, there were studies that showed that using teleradiology reduces
transports for head injuries at a rural areas. Also, a study done in 1998 show that went
radiology was available to rural emergency room, it changed the diagnosis 30% of the
time and the treatment plant about one quarter of the time.
Pathology -- a report from 1989 showing it used it Northern Norway. It is less common
than radiology, but digitized in pathology slides has become much more common. These
are very large files because you have to have color and you must have to be able to do it
right of occasions. People were concerned about moving these fires across -- these files
across firewalls. There are models developed for the image sits in the cloud and you only
have to do it. It is sitting on a server somewhere else and you can view it over a distance without
having to move the files across firewalls.
These are examples of some digitizers for slides. Certainly, these are used for a second
opinion on critical lesions which is what this study was about. This is a study that
demonstrated that a specialist pathologist doing it via telemedicine is better than a
staff pathologist there on site. In 74% of the cases, the diagnosis was more precise
and in 18% it had a major positive impact. These were just in time pathology cases.
These were two studies -- one in breast cancer and one in neuropathology. This shows that
the histopathology can be done accurately using Tele pathology.
Pharmacy -- this has been done over distance for a long time it. Any healthcare professionals
and the audience will know how often you call the pharmacist -- the first day of your internship
-- you call and say -- I'm supposed to give this guy a medication -- he has real failure
-- how much should I reduce the dose? There are some well-known the projects in North
Dakota as well as in Eastern Washington. Now, Tele pharmacy is facilitated by CPOE and remote
review. Even remote dispensing. You can dispense medication using machines and other things
from a distance. If you combine this with video and being able to review medications
and having a video consultation with the patient, this will allow the whole thing -- the whole
pharmacy visit to be done over distance.
This is a paper published this year demonstrating that on 47 cancer patients, they were able
to save 27,000 miles of travel because of Tele pharmacy. As many of you know, pharmacy
is a critical part of the care of cancer patients for fixing and administering chemotherapy.
This is an interesting study from North Dakota. This showed that -- it was interesting because
they showed the error rate in Tele pharmacy and in person pharmacy. Both of these rates
were far below the national rate. Tele pharmacy was slightly higher. Again, it may be the
difference between no pharmacist and a Tele pharmacist.
I had to put this in because we just published it. This was hospital-based pharmacy. This
was a study we did with six rural California hospitals. They have difficulty affording
24-hour armistice. When medications are ordered and delivered to patients in the hospital,
at night there may not be a pharmacy review. We used Tele pharmacy and found that about
90% of the patients there was one or more medication error that was picked up by the
remote pharmacist.
I'm in the home stretch. Hospital based telemedicine. One of the most famous uses of hospital-based
telemedicine -- this started developing in the late 50s and early 60s -- a closed circuit
television link 20 the Nebraska psychiatric Institute and Norfolk State Hospital where
they did a psychiatric consultation. I was trying to find something on skilled nursing
facilities and I found this study from Boston city Hospital with a low-tech system that
showed some positive results.
Hospital-based telemedicine in the hospital versus nursing facility -- this is really
growing in two areas. The areas are stroke and ICU care. I've to talk about stroke first.
The first report was a study published in the Lancet by Brent Meyer. The second was
the one that significantly change things. That was the American stroke Association publication
that said that stroke exams can be done over distance and a quality way as long as you
have good imaging, but also, they recommend the use of Tele stroke in hospitals that accepted
these patients that to do not have stroke neurologists available. Again, this is very
important.
In the inpatient setting and the skilled nursing facility setting, there are a number of devices
you can have -- there are robots or you can have a nurse but the unit in the room and
see patients this is low hanging fruit. There are a number of studies that show a number
of avoidable this it's to emergency departments for skilled nursing patients. I think particularly
in rural areas -- some skilled nursing facilities existing communities without positions. Getting
physicians they are urgently can be a challenge. NEHI Did a recent look at this. It published
in May of this year. It showed strong evidence of clinical benefit and staving suite includes
use of Telehealth the nursing homes.
This is a paper published in 2010 again at psychiatric your bird via tele-psychiatry.
This showed that nursing home personnel were positive about the use of this. Again, it
provided care that was very acceptable to patients and families in nursing home personnel.
I want to talk about critical care for a minute. You are going to get a talk on this, so I
will just freeze to a couple of things quickly because we are going to talk about this later.
This is probably bordering on 10% of bats now. They are covered by Tele ICU. The components
differ, but the most robust model of Tele ICU includes intensive this from a command
center with nurses and other personnel monitoring systems that track patient status -- smart
alarms with full audio video and protocols that are wrapped around those that help manage
patients.
The literature in this has been mixed and even since I put this talk together, there
is another article that is come out showing that it is mixed. This is an article by Thomas.
You will hear about this in a minute. This did not show overall improvement, but it did
show some benefit for the sickest patients in terms of survival.
This is a study that was done and published last year in JAMA where they showed improvement
in mortality and produced hospital length of stay as well as change and best practices.
This is a study -- meta-analysis that concluded that there probably is lower mortality and
reduction in ICU hospital length of stay, but they did it knowledge that they are not
really sure what configuration and what elements make up the difference. >> This is a paper
that Jim Marson did. It is a consultation only model for pediatric vertical care. What
Jim showed in this paper was that it significantly reduced transport costs from rural areas,
but there were cost savings because of that and there were also financial benefit as any
of the adult ICU studies have shown. There is financial benefit because they keep the
patient and the revenue in these hospitals rather than sending it to a larger tertiary
center.
Where are we going? I try to come up with something space-age for the end of this. Tell
us surgery. -- Tele surgery. The Lindbergh operation that was done in 2001 -- September
7, 2001, from New York to France. They did this surgery and it was a holy suspect to
me. They did it over distance -- it was holy suspect to me. --
cholecystectomy.
There are pilots being done -- operating from one room to another -- you can do this over
hundreds of miles. Certainly, you can get great display and you can operate very well.
I have said to people -- I don't want to be the first one. But, it can work extremely
well and project expertise forward, particularly technical expertise.
Finally, what are the challenges and opportunities for the future? I think in -- one thing we
have to figure out -- what are the elements of Tele ICU they can make a difference and
can be tailored to smaller hospitals? It is difficult for hospitals with two or three
ICU beds to bring this in and I think that people are beginning to work on models that
will incorporate that.
As for the development, a lot of the expansion has been for -- in for-profit companies coming
into stroke care and ICU care, etc. Those models, not unexpectedly, are with hospitals
that can afford it. So, how we can we build incentives into expanding those two rural
communities so that either private or public institutions can't afford to do this in rural
communities? Telemedicine and skilled nursing facilities -- are there enough incentives?
I think they are as we do not pay for re-emissions. I think we will see the increase in telerobotic
surgery as we try to project technical skills.
In summary, I think advanced Tele the communication has a role to play in transforming the health
care system. I think that evidence-based models facilitated by these technologies can improve
access and quality across the geographic and canonic spectrum.
To date, though, we have been attempting to layer these technologies onto a healthcare
system that don't have as a serious sentence. I was going to say a broken healthcare system
-- you can be the judge -- we are attempting to layer the technology onto something that
is not working that well in the first place. I think would be ACA, this can facilitate
the transformation. I think that more research is required to develop appropriate quality
standards and all of the series of care.
Thank you.
[applause] >> We have a minute for a question or two. >>
If not, great. >> While the panelists assembled, good morning. Spero Manson I am and in the
spirit of his remarks, I have no conflict of interest and the only financial disclosure
that I have to make is that I do own stock -- AR of the four-legged type. They are on
my ranch in Colorado.
For those of you who have been with us on the webinar as well as in the audience, since
the beginning this morning, you found that we opened with Dr. Rubin's remarks with respect
to the format and purpose and content for the next today's offerings. We then shifted
to Dr. Wakefield and her enthusiastic overview of how this particular set of issues relates
to her agencies mission and the countries objectives overall with respect to healthcare.
She painted a wonderful view of personally and professionally of the landscape and charged
us with looking ahead. Let's behind and the present and forward into the future of where
we might go.
Dr. Nesbitt's very powerful visitation regarding where we have been and where we are now -- with
respect to a variety of technologies and their applications as well of historical forces
that have been at work. This sets the stage for each of the panelists to come. This first
panel this morning begins to move more narrowly into the issues dissipated by doctors Wakefield
and Nesbitt.
It begins by alerting us to the scope and applications process and structure and capacity
issues that we face. There are four panelists this morning. The first is Mr. Jonathan Linkous,
the CEO of the telemedicine Association. He will focus on the -- using the platform provided
moving us into these issues.
He will be followed by Mr. Kerry -- Gary Capistrant from the Telematic and -- telemedicine Association.
He's the director of public policy.
He will address issues of licensure.
He will be followed by Dr. Dale Alverson from the University of New Mexico where he is a
professor and director of their center on telemedicine and cyber medicine research.
Addressing issues of federal communication and the omission of rule healthcare support
programs.
Followed by Mr. Steve Hirsch from HRSA, specifically their world health policy program. He will
address matters of morality and the misalignment or Mel alignment of the definitions of the
program and how it is organized financially within the healthcare system.
Just a brief comment -- you saw flashing lights. Each presenter with the exception of Mr. Linkous
will have a little bit longer than the other panelists. He will have approximately 20 minutes
and the others 15. They will share their remarks. We ask that you hold your questions until
the conclusion of all four presentations. For those of you who are curious -- I heard
you whispering when you saw the lights flash -- yellow in this case is with a one minute
warning and the red flash means that the time has concluded and we will be asserted about
this. I was teasing about this -- I am American Indian by birth and cultural orientation.
It is a great irony of being the timekeeper.
We will move in that sequence. I encourage you to look at your biographical background
provided at registration to little bit more about each of today's panelists.
Mr. Linkous Mr. >> Thank you. By saying I have a longer time,
I see there is already resentment started.
[laughter] It didn't help when I told them I was good to take 45 minutes.
I want to talk about the challenges of telemedicine. I was going to talk about the world of telemedicine
and I think Todd did a great job of this. He gave us that. Briefly, the world of telemedicine
from our perspective was largely telemedicine that worked was based out of tertiary care
or academic medical centers. Today, it is quite a different picture. I think this leads
to one of the challenges, but we estimate that there are about 10 million patients in
the United States that are getting the services by telemedicine each year. This is broken
down by a number of areas and we will be publishing some data on this shortly. About 5 million
patients get that out of radiology and almost 1,000,000 patients are on a dirt -- cardiac
monitoring. There are devices for a tonight hundred thousand patients that are monitored
by Tele urologic monitoring. They are operated on -- spinal or brain surgery by a neurologist
at it as is. In most cases, they do not know this is done. We think this is a sign of success.
It is also a sign of how telemedicine has been absorb into a lot of the healthcare.
Let me talk about what I call the seven deadly barriers. Money, regulations, hype, adoption,
technology, as it is, and success.
We see all of those right now as really thinks we need to address and overcome. Some of these
are shared with where healthcare is generally and some are traditional barriers that we
talked about. And some are new barriers that we are seeing today that have transformation
in telemedicine.
Which initially, the first is money. -- Traditionally. You will hear a lot about reimbursement. Medicare
does not we ever sent off -- reimbursement of. It is still limited largely to nonpublic
areas, but within non-metropolitan areas, it is limited to the type of institutions
that you can provide and limited by the CPT codes. There are a lot of limitations. This
is largely growing from a fear that the correctional but it did office of the Federal regulators
have that telemedicine will either be -- allow fighters to abuse the healthcare system or
it will be over utilize would drive up costs.
This is a real fear not only by federal but also by private pairs as well.
There is an overwhelming concern of money. But, within the money there is also a whole
area of telemedicine -- healthcare, rather, that we largely ignore in telemedicine. This
is about the payments. The managed care populations. There are about 90 million people who are
receiving services in managed care and that will probably be the fastest growing group
of patients in the next couple of years with the changes in the healthcare system. Except
for the Veterans Administration, there was a lot of -- not a lot of evidence out there
of managed care using telemedicine to control costs. That is a right area. It is low hanging
fruit. It is an area where we have got to start look at an address how within the managed
care system we use telemedicine as an integral part of use of telemedicine. We have yet to
do that.
The other part of the money is the attractiveness of telemedicine. We have little honey in some
areas and get telemedicine -- healthcare is a 20 have billion-dollar market. $2.5 trillion
market. A lot of companies and a lot of people are getting involved in telemedicine and we
have a lot of solutions in telemedicine by people who do not know what is going on in
healthcare. They do not will know what is happening, but they see a huge market and
we are seeing huge groups coming in to work with that. Is a challenge and store us and
healthcare and telemedicine because we see a lot of solutions being used by people who
are attracted to the potential market of telemedicine -- healthcare -- without knowing how to use
these devices and get involved in the actual practice of care.
The next areas regulation. They will talk about licensing. This is a big area. This
is an area of interest when a TA was formed, but it was not a huge area because most of
these systems work listed within a state. Now that we have multistate systems going
on and we have multistate practices, now that most of the major healthcare providers are
moving into a national system, I think that licensure is a big problem. We need to address
that.
Along with that, our practice regulations which I think are more of a problem than licensure.
I would've said that a few weeks ago, but having talked to a lot of medical state regulators
-- talking to them -- they are cranking down on how you can use telemedicine to practice
care through the regulations requiring inpatient and live physician consultation before you
provide any telemedicine services. That -- we are going backwards on that. I think the regulations
are getting worse. Not only have we had several states crack down on this lately, but we have
had national legislation proposed -- they proposed a resolution recently. This is been
reported, but this is a sign that there will be more of this type of approach to looking
at the way that we provide healthcare. It is a big problem.
Then we had the traditional regulatory agencies -- FDA, the mutations commission, all of the
regulatory areas that are moving forward. We're going to talk about that today. I am
sure over the next couple of days we will talk about all of these issues.
Finally, under the regulatory area we have what I call stupid regulations. One of those
is the fact that even though we have accountable care organizations that are supposed to really
move out on telemedicine, even though we have great issues talking about using telemedicine
as we move forward with the healthcare the future, we still have 1830 4 AM which is a
section of the Social Security act which will have its much of the telemedicine work and
this applies to account will care of innovations. If you are and ACO populate a large area,
you cannot use telemedicine even though Congress said when they packed the affordable care
act that this would be a great use of telemedicine. Even though CMS said when they talked about
regulations that this is great for telemedicine on the impact they have not waived that section
of the act. I don't care how much accountable care organizations -- you're not going to
use telemedicine. The stupid laws often waived for that regulation.
Moving on.
That is how it feel about that.
We are victims of our own hype. I am as guilty as anyone, by the way. We tend to talk about
studies and we tend to talk about all the wonderful things that telemedicine can do
-- the studies that we quote are the studies that show the wonderful parts of telemedicine,
but there are a lot of studies that show that some things in telemedicine don't work.
Some studies have shown that telemedicine has caused a lot. There are areas in telemedicine
the cost too much. There are applications that may not work right. If we are going to
get serious -- we will take the telemedicine and move it from Tillman and it 10,000,000
to 100,000,000 -- we have to get serious about this and face these issues. The hype is wonderful
-- we are expected to be hype we also have to be realistic because what happens is you
have an atmosphere that is poisoned. When we come to an organization -- a major payer
or a -- we talk about telemedicine, I can see their eyes glaze. They say here is another
one trying to sell me something. Where is the money they are going to try to make?
[captioners transitioning] If you are looking at the adoption, we need
to look at our own medications. There are some providers. We talk about licensing, and
they are saying I don't want you to fix thealizing problem. I have a telemedicine that works
well. I don't want another telemedicine coming in here and competing with me. It is a real
issue. What is goingoon get worse when we have the large systems moving around to nationwide
networks. We had partners healthcare that just signed with CNH services, which is implant
and in office healthcare assistance. They are providing a national contract to provide
remote medical services to their nursing stations and healthcare offices in plants and offices
all over the country. We see the Mayo Clinic that has three sites now and looking on a
50 state basis as to where they can put their footprint and their referral partners. We
have nation systems moving into this and looking at real, I think, some real resistance to
this innovation, even by some of the traditional telemedicine networks. Because telemedicine
opens up competition. Technology, technology is the focus of telemedicine for a long time.
We have got to get over the point, , it is not the technology. It is not the technology
if we focus on the technology we will not be successful in telemedicine. It is the services.
Technology is ubiquitous in areas. The cost of the technology has to come down, it is
coming down, we have to get onto the point where we are talking about the serviceswork
it can be provided and how the changes people's lives and not the neat new piece of technology
that we have coming up. The other thing that happens with the technology, of course, and
Tom alluded to this, as we implement telemedicine and all of this technology, it will create
huge data flows. If you are look at my vital signs, 24/7, temperature, blood pressure and
on a 24/7 basis. I don't know who wants to look at it, I don't, my interest doesn't,
my doctor doesn't, nobody wants to, it might go into a sims where it triggers an alarm
if invitals go, but we don't have a system of maintaining that and looking at a huge
data flow that we're going to gets a technology coming out there and everybody is hooking
up their cell phones to their bodies. Evidence, we need to look at evidence there. Are areas
that show great progress in telemedicine and areas in telemedicine that needs to be looked
at by large studies that have not been done yet. The large payers in the country are ready
to do telemedicine. United healthcare, the last two days we had a board of directors
meeting. He is a strong advocate, but it is cost, there is cost, there is no more money
in healthcare. Zero. If you're thinking about telemedicine is going to open up new waves
of money. Forget it, it is not going to happen. If you can go to a payer and show if you're
going to use telemedicine in this way, you're going to save money in certain areas you can
get them open. We can talk about quality and access. That is wonderful. It is really important
that people pay attention to that. I'm sorry, if you're not reducing costs you're not going
to have the door open. It is the number one issue. We have to face it. We have the show
evidence of it and be very upfront about that. Finally success. This is an interesting one.
Because as we move forward, the thing that I've seen that's really changed is telemedicine
has moved into the cease week. I had conversations over the last several months preparing this
database and report on where telemedicine is, I'm talking to CEOs of major hospital
change and telemedicine is a fun thing where it is down there. We have funded the grants.
They supported it. It is great and wonderful people. Now, they are saying wait a minute
this is part of our new corporate plan and being a land grab. It is a land grab in healthcare.
Hospitals are making up referring and linking in networks. The CEO is saying this is where
we got to go. CEOs are saying this is a priority for us, because it is in their business plan.
What happens to the rural networks and rural populations. What happens when the priority
for telemedicine, the networks is focused on urban areas and I the population is. It's
like the bank robber because they Rob banks where the money is. The telemedicine is moving
into the urban the urban the urban the urban the urban the urban the urban the urban the
urban the urban the urban the urban the urban the urban the urban the urban the urban the
urban the urban areas, that's where the people are. Understandable and a good things in the
many ways, but the issue is what happens to the rural populations that are being served
under traditional networks. Are they moving forward. We have networks now that are looking
at ICUs and we're looking at neuro networks for stroke care. Many are independent, they
are not tied into the traditional networks. Are they competing or part of it? [ No audio
] So there is a whole bunch of challenges before us, some is the traditional challenge
that we have worked on, but we have no challenges part of our own success moving telemedicine
forward. Thank you. [ Applause ]
Good morning. I want to talk to you about the licenser piece of this as a challenge,
but instead of thinking of it as a challenge, I would like to start what is possible. We
heard a lot about the morning what is possible with the medical science. What is possible
in, in the -- healthcare delivery system. If we were to devise a licenser system for
healthcare professionals and I'm start by saying that is obviously very important. Say,
I do have an occupational license in the District of Columbia. So, I know some of the issues
of that, but if you were to devise a system for healthcare license, it wouldn't look like
what we have today, but let'ses start with some of those issues that we have. We have
an incredibly mobile population. I live in the state of Maryland. I don't have my medical
records in the District of Columbia. I don't deal with the District of Columbia physician.
Yet that would be a barrier if I had emergency medical need right now. We have people that
are always traveling. Think of pilots. Think of -- athletes. They, they -- we, we also
have doctors that are traveling. Number of doctors that are in this room today who are
not licensed in the District of Columbia, but you could not deal with your patients
back home because you're here. The telemedicine has been great for dissolving the barriers
of distance and, and certainly, it can play a role in -- dealing with the, the issues
of distance and geography when it comes to licensing. So, we, we've got a very mobile
population. One of the things is patient choice. I think patients should have the choice of
going to -- whatever practitioner they want to go to. We have -- systems that are multistate
and the, the, in those health care systems you should be able to chose where you want
to go. If you want to use a physician in New York City, you should be able to do that.
If you want to use it wherever, that you should have that choice. Patient safety and quality.
One of the things is to be able to go to a person who you trust, who you think is higher
quality than somebody else. That choice should be yours. One of the things is access to specialist.
We talked a lot about physician -- maldistribution of physicians. Usually that includes an overwhelming
number of physicians who are primary care doctors. That's think about for a minute access
to specialist, not subspecialist, but specialist. These 12 states have less than 2,000 specialists.
If you told somebody in those states they had to be limited to the physician pool in
that state, they wouldn't like that, but that's what we end up doing. So, in, in, you think
of in terms of raw number of specialist, one way to look at it, but also we can think in
terms of perpopulation. What that is. Now, three of the states are on both of these lists.
Montana, Idaho and Wyoming. If you look on a map it is a nice almost square in the northwest.
So, this is a problem for people who have special needs. In particular, let's think
about rare diseases. The national organization of rare diseases looks at those diseases that
have less than 200,000 Americans that have those conditions. What kind of access does
somebody that has one of those rare conditions and there are 6800 of them, have in North
Dakota. In Wyoming, in Montana, in rural areas all over the country, even in the District
of Columbia. With three medical schools right here in 69-square-miles. So, access is a huge
issue. Think in terms of languages. Doctor, pediatric cardiologist, think if you needed
a pediatric cardiologist that spoke Spanish, did sign language, where would you go? We
have a system that doesn't allow you to choose those resources. One of the other issues is
provider productivity. The current system does not encourage provider productivity.
We can't do too much in the short-term about physician supply. Nurse supply. Supply of
physical therapists, but we can do something about the productivity of their precious time
and resources. That there are ways to deal with that. We do have, as I mentioned and
John mentioned, you know, we increasingly have multistate plans for dividing -- for
delivering healthcare. Whether it's managed care plan, an accountable care organization
or our employer is multistate and they want to do a better job of taking care of their
population. We have the issue of border communities. One of, I'm fascinated by what you can find
on the Internet nowadays, do a quick Google search you can find about anything. I was
curious how many miles of borders there are in the United States, not including coastline,
but borders. Where there is a state on one side and a state on the other. There's that
answer on the Internet. There are 22,000 miles of borders. So, we have a lot of people who
live close to that border where they're closest doctor is across the river, is across the
bridge, is, is just down the road, but that's a different state. Now, we do have people
that have multiple state licenses. The other night I was having dinner with an ophthalmologist,
who have 15 state licenses. There is a huge price to that. We conservatively figure, just
physicians, it is about $300 million that is involved. Now, we think that sometimes
that, oh, license is not an issue that affects me. It is kind of like your car insurance.
You have that protection every day. You don't just have that protection when you have a
car accident. In the same way, you, you're -- being harmed by not having that access
to all of what America medicine offers on an on demand basis. That there are also, then
the costs, that gets added to the healthcare system of multistate licenses. Again, just
think 3 ran million$ conservatively for multiple physician licenses. We have one company as
a mer. Radiology company, 380 radiologists. They have 8500 state licenses. They have learned
to be very smart about how to go about dealing with each of the state jurisdictions, but
that is something that may have been acceptable in the past, but is no longer acceptable.
We don't, we don't, are not willing to have those kind of restrictions of being limited
to the supply of physicians in a state for delivery, for delivering health care systems.
There are other issues that go with licenser. John mentioned a couple. Some of the practice
acts, that what is a sufficient doctor' patient relationship. Which is a medical exam involved.
What can you do with prescribing that are becoming greater barriers then they were 10
to 20 years ago. We're going backward, we're not going forward, but there is a lot of potential
to go forward. We have a system of licenser that is unhealthy and doing more harm to patients
than good. There are some solutions. Certainly there are lots of things that people have
looked at. Reciprocity. Great, do it. We, we can't even get some states to allow for
a physician to talk to another physician without being licensed in that other state. That,
that is just bizarre. Not even involving the patient, but a doctor talking to a doctor
that you have to be licensed in that state. We are some states that have gone to a telehealth
license. Which seems like a nice short-term solution. It is a little bit cheaper and faster
to get, but I would suggest that's not a very good long-term solution. Telemedicine should
not be separate it is not a specialty of medicine. It should just be healthcare. So, that's useful
in some cases, but not completely. I do a lot of reading about history and American
presidents, I was recently reading the autobiography of teddy Roosevelt and he had a quote or a
statement in there that surprised me as a particularly a good republican that he was,
he says, the Constitution was formed very largely because it became imperative to give
some central authority to the power to regulate and control interstate commerce. This was
republican saying that the Constitution and, and, you know, you think back to some of those
issues that interstate commerce was a big reason for the Constitution coming into being.
States couldn't agree on weights and measures. States couldn't agree on a whole lot of other
measures. So, the Constitution was formed. We're in the District of Columbia. We're no
longer in what was the state of Maryland. Because the Federal Government did not want
to be hindered by state law. They ran into some problems when they were up in Philadelphia
with the Pennsylvania militia. They decided then that they were not going to be hindered
by state law. They wanted to create a place, a district, that they would would would would
would would would would would would would would would would would would would would
would would be in ultimate control of. Federal Government healthcare programs at not be hindered
by state law. The same way, the Federal Government has, has incredible authority to deal with
interstate commerce. We hear a lot about the Constitution. Well, the first article of the
Constitution that the states had agreed to in developing it, gave to the Congress the
power to regulate interstate commerce. Then later on, in the Constitution, in an amendment,
gave the states the authority to essentially deal with intrastate commerce. I think that
is a pretty good arrangement. Some people have used this to deal with -- exceptions
for federal agencies to multiple state licenser. DOD, VA had some exceptions. In December,
Congress on a bipartisan basis, in fact, unanimously approved an expansion for the defense department.
If you have a license in one state, just as your driver's license in one state, that's
good in all of the other states. You only need one license. You only need one license
to drive. That, that legislation is -- HR1832, that was essentially in acted in a bigger
package. That has, that model is being used in another proposal for the veteran's administration.
The vets act that congressman Rangel recently introduced HR1067, that molecule be used for
other federal agencies, federal health programs like midcare and Medicaid, the Federal Government
is a major payer in and federal funded sites, like community health centers and community
health centers. So, I could suggest that the have lots of ways that we can go at licenser,
it would be useful for the committee and the institute of medicine to think what is possible.
Not starting with where we are, but somewhat possible to have a healthy, good regulatory
system for professional licenser. What is a good way to -- to be patient centered in
our licenser and -- to, to move forward and to deal with some of these other issues, not
just the mere license, but some of the discrepancies and practice issue that vary from state to
state. [ Applause ]
Well, good morning, everyone. What an honor to be here at the national academies of science
and the institute of medicine. We know how important and powerful the reports that come
from the institute of medicine can be. So, we're all very, very fortunate to be here.
I wanted to thank first of all, our moderator, doctor mason, thank you for bringing us today
and -- thank the workshop planning committee and the doctor for organizing twist inviting
many of us in the telemedicine commune to come together to talk about where we go from
here and where we are at now. My talk really, I want to point out we're addressing challenges.
I'll talk about the challenges of broadband and getting connected. But it reminds me of
what many of you may know of the serenity prayer. Would often get discouraged it says
give me the serenity to know those things I cannot change, but also give me the power
to change those things that I can and the wisdom to know the difference. Ladies and
gentlemen, I believe that all of these challenges we're talking about we can change. We can
change in a very positive meaningful way. So we'll talk about the Federal Communications
Commission, rural healthcare support programs. But I'd like to talk about the lenses learned
and opportunities for improvement. First I all I have no financial or afiggationwise
the presentation and I do not represent the Federal Communications Commission. I may be
in a better position to speak to this experience. In doing so in the presentation, I would like
to briefly describe the need for broadband connect tev tafor healthcare. In the end,
we should improve our healthcare system and serve every citizen of the country. Always
describe the FCC healthcare program and the rural healthcare program and rule making.
Describe the challenges and finish with possible solutions and next steps. So, what's the need?
Well there is no question if we're going to do any of these things with healthcare and
telemedicine, this country needs you bickiaitous, adequate, affordable broadband to support
telemedicine and exchange so we can achieve increased access to appropriate care for all
individuals at the right place is the right step when it is needed. This can improv access
to care, better health and cost reduction, but yet there are significant gaps in access
to affordable broadband in this country. Particularly among the rural countries. For the underserved.
Inadequate affordable broadband can be blended with other community needs in education, training,
economic development and government. We, we clearly have gaps in broadband connectivity.
You can look at New Mexico and we have gaps in access to healthcare services in rural
New Mexico. You hear about some of those with some of the other speakers that effect not
just our state, but our entire country. Hepatitis C. Behavior health, a huge issue in our country.
Diabetes, asthma, cancer, oral health, which often we don't talk about, but so critical.
Cardiac and stroke care, hirisk pregnancy, Pediatric care. Walsh, we have to look at
now we saw with Dr. Nesbitt's presentation, even back here in 1924, many of you may have
seen this from radio news about the radio doctor. How do we get into the home environment.
When we talk about connectivity as you and I as providers how do we bring this care to
the patient wherever they are, that includes the home environment. We know that handheld
devices M health, part of the broader umbrella of telemedicine and tell health, I would venture
to say that probably everyone out there in the audience and every one out there in cyberspace,
has a smart phone. Now we're seeing the tablets playing a huge role. This is from the "Chicago
Sun Times" showing an ER physician, pulling up an ankle E x-ray to this young man, showing
him the fracture and to follow-through with his care. There are mote monitoring. The so-called
the smart bandaids. In the U.K. the plasters. We can monitor vitals that can be sent your
cell phone and the clouds to help you as the patient and the healthcare provider management
your care better. That's about about the federal communication issues. Touch on the FCC rural
healthcare programs. And then the fact that the United States general accounting office,
the GAO came out with a tough report about what is happening with the FCC programs and
the fact that we really don't have good data on the impact and we're interesting millions
or billions of dollars in broadband, we need to demonstrate the value it brought to our
country. I see people out in the audience that worked on the FCC's national broadband
plan that was issued in 2010. I -- reference you to chapter 10 that talks about recommendations.
Then finally the implications of the notice of proposed rule making of 2010. Yes. It is
has been over two years and now, a recent request again from the FCC with the release
date of July and for more comments about how we might reform the broadband programs. Many
of you probably already know this, as a quick review. The FCC using the universal services
administration. Company, called USAC for the primary urban rate discount program. In a
urban area you only pay as much as the largest city in your area. So, if it is a thousand
dollars for you to have broadband connectty, but it is only $100 in a larger city. You
only pay $100 and the FCC pays the difference. There is the Internet subsidy that precedes
25% of the cost of Internet. Then, the rural healthcare pilot program. In which we were
provided coaches in addition, to USAC support in managing these programs. I just want to
mention briefly again to look at the national broadband plan, and particularly chapter 10.
There were five sections and you can see here from the slide, I won't go through it, that
reviews the potential value that we're talking about right now and an overview of the current
health I.T. and provides recommendations, which includes a lot of things that have already
been mentioned. The need for better reimbursement. Modern regulation that was brought up. Increased
data capture utilization with sufficient connectivity. I'll bring you back to the notice of proposed
rule making. How many of you out there provided comments. Many of you probably did. It was
released July 15th, 2010 and suggested changes in the rural healthcare programs and asked
for comments by August 14th, 2010, and then reply to the comments as a standard procedure.
Some of the main points, it would allow the apply to the primary program and the primary
urban rate rural discount, each individual site had to apply. That was a big burden if
not a barrier. So, allows clinics to apply would be a positive thing. And increase Internet
subsidy from 25% to 50% and many of said more. Let's continue the construction program at
85% subsidy. Doing so allow administrative costs. Now as of July of 2012. We are all
actiously awaiting the FCC to come out with its new order. As of July 19th. They asked
for more comments on the comments by August 23rd. If you're not already aware, look at
this and make some more comments. Most of that announcements are questions, which we
should be answering as part of the telemedicine community. Those comments are due this month,
August 23rd. I encourage you to look at that announcement and respond. What about the rural
healthcare pilot program, which many of have been involved. I can certainly been in the
trenches in this project and made comments to FCC in that regard. The goal is to facilitate
the creation of a nationwide broadband network dedicated to healthcare. Provide funding for
85% of an applicants direct cost. That means each applicant would have to provide 15% in
cash. It was established by the FCC to heb public and nonprofit healthcare provider degrees
ploy a state or regional dedicated broadband network, that was the purpose. The paperwork
had to be completed by June 30th, 2012 this year for any funds. There were initially 69
funded projects announced in November of 2007. Almost five years ago at a total of 7 $17
million to be distributed over three years. It was a two year program, and then at the
announcements a three year program. To make this program work it is required two one year
extensions. Why I point that out is that if you have to take a program that has so much
potential value and keep extending it to allow people to take advantage of it, there is probably
an issue with the process. Out of the 69, 50 remain. We had an attrition. They were
able the smit $369 million, 88%, that left about $50 million. Out of that $50 million,
they provided another temporary program, we call bridging funs for those programs that
others with had completed what they needed to do for construction. But needed to wait
for the new programs to come in place, for come we are angivistly awaiting the announcement.
This is our program in New Mexico. One of the larger ones really connecting networks
of networks and even trying to determine where does Internet 2 and national rail fit into
that. I will briefly mention those. We were awarded 15-point $5 million, to cover 85%
of our build out and operations for our network of networks. In doing so, as we went through
the process, I have presented this before to the FCC, we did a S.W.A.T. analysis, the
strength, weakness, opportunities and threats. Well, the strength is obvious, what a great
idea for the FCC to build up broadband across this country. It was a great idea to design,
construction and operate broadband to support healthcare and metcon exchange. Provide more
access to healthcare for all Americans. The weakness then, the process did not just work
well. It is cumbersome, I mentioned it requires two one year extensions and several projects
dropped out. That tells you something and hopefully, a lesson learned. There has been
these programs in place using universal services funds, but we have little data to dempen straight
the benefit had it has bought to this country and we have poor coordination with other federal
programs. I will mention those briefly. The opportunity that we have now is to improve
and streamline the process. Make it more user friendly. More timely achievement of the goal
provide adequate and affordable broadband. The threats are we will have incomplete product
implantation because of the difficulties in the process and gaps will remain across this
country, unless we change the way that we approach it. We must then, if we don't demonstrate
the benefits, that's a threat and funds may have been wasted if we are not using them
appropriately and the threat is a lack of sustainability, if we put the programs in
place. I will close with the challenges. There is a need for coordination, cooperation and
collaboration across programs and initiatives. We have the FCC programs that I've mentioned.
The department of commerce and B top,USDA, RUS, the BIP program. We have Internet 2,
we have the process that combines it. We have national land rail. We have gig U, university
communication next generation project. Now, U.S. ignite out of the White House with NSF.
Then nationalism if that is not confusing enough for you, there are proponents are saying
it creates more reliable and high quality services compared to the commodity Internet.
Now you look at I-2, that's its own system and national lambda rail, and they superimpose,
why are they not coordinated. With Internet 2, they are reaching out internationally,
that ads value and someone said to combine the two, you have the U.S. you fined community
anchor network. It is a project of $62.5 million to bring the two organizations together. Then
you have there national coalition of health integration, which is going use national lambda
rail. So, you should be part of that one. That's what this looks like. Don't the networks
start to look familiar, right? Then we have gig U, to accelerate the deployment of my
networks. Should you be part of gig U, if you are a university based program and now
we have U.S. ignite. I'm not saying the programs are not well meaning. It is hard for those
of us in the trenches to look at how these things are coordinated. So, what are the solutions?
I'll close with this, my red light is blinking. Did you Did you say I would drop through the
floor? Or just *** up. One is I would recommend that we form an advisory board. This should
not be the only time we talk about this. It is great we have the federal agencies finally
talking to each other. Those of down in the trenches ought to be part of that. We need
to streamline the processes and develop a network and design for modeling of the state,
regional and national initiatives. We need to look at the gaps and fill them with affordable
appropriate broadband. Develop and implement evaluation metrics. Because in the end, this
is the last slide, this is what it is really all about. How do we serve this mother and
that child and that family anywhere in this country, anywhere in the world and to do that
appropriately, you must have affordable, appropriate, adequate broadband. Thank you, very, very
much. [ Applause ]
Hello. I'm Steve hearse, I'm from the office of rural health policy. I'm here to talk about
what is rural. This is not my fairly well-known presentation, which is anything that you want
to know about rural. This is a much shorter presentation. I'll try to get through it in
15 minutes. Excuse me. Who defines rural? I'm going to talk about some of the major
federal players, in defining what rural is. The census bureau, of course, as you would
expect talks about rural. The office of management and budget. The USDA economic and research
service. The office of rural health policy, has a definition of what rural means. But
to start, I have to really talk about urbanized areas. The census bureau has two different
types of urbanized areas. Urban areas that has a core population of at least 50,000 people.
Then you have urban clusters which have a core population of 2500 to 50,000 people.
Before 1950, the census actually defined urban as any population in a, in, in a core, incorporated
place that had at least 2500 people. That doesn't sound like many people anymore. An
incorporated place with only 2500 people, most of us would consider fairly small, but
back about a century ago the census bureau took that as the minimum amount of people
they would start calling something urban. Around 1950, they realized we were beginning
to see suburbs growing up around cities. They decided to expand their definition of what
urban meant and include suburbs by ignoring the borders of the incorporated places and
start look at what was spreading out. So, they went away from simply defining, using
the incorporated placed borders and began to look beyond that. You'll notice they are
not defining what rural is. In fact, they never define what rural is. They define what
is urban and anything that is not urban is rural. Generally the urbanized places they
have to have a population density of at least 500 people were-square-mile. So, as they start
going out, they look at areas and stop defining the urbanized area when they reach that edge.
500 people per square mile might sound like a lot of people, but one-square-mile has over
600 acres in it. So, you're looking at fewer than one person per-square-mile if you're
looking at 500 people per-square-mile. Now, the census recently back at the end of march
released their latest figures on what the urbgen rural population is. I put it up here
to compare between the 2000 census and the 2010 census and see how things have changed.
Obviously, the population of the whole U.S. went up quite a bit. The population of the
urban United States went up quite a bit. That's where most of the population growth was. You
can see that over all, urban went up over 25, 27 million, actually, right around 27
million. It went up over to be 80% of the population of the United States. Urban clusters
actually lost a little bit of population. The rural areas actually grew a little bit
in population to 59 1/2 million, but for the first time fell under 20% of the population
of the U.S., down to 19.3%. This, to me, this was really interesting. I had to include it.
The population of the U.S. is really concentrated now. It's not spread out all over the U.S.
It is not at all uniform. The U.S. population has a whole, the density of the entire U.S.
is about 87 people perp square mile. New Jersey is the most densely populated state, 1100
people per-square-mile. Alaska is the least densely populated state. One person per-square-mile,
but the population as a whole. The density is 87 people perp-square-mile. The urban population
of the U.S. is very concentrated. 250million people living in 1 mile of square land. Most
people think of the neverlands of being a small country, they have a population density
that is 1/2 that. It is, the U.S. is becoming the majority of the population is living in
a very small amount of the total land area of the United States. Here's what I mean by
that. This is the census bureau's map of urbanized areas. All of the little pink spots you see
are the urbanized areas. Everything else is rural in the United States. Most of the population,
obviously, just over 80% of the population lives in those little pink splotches on the
map. The ads up, I usually round it up and stay it is 5% of the land area of the United
States. It is actually under 5% of the land area of the United States. So, like I said,
250 million people are living in about 3%, 100,000 square miles of the United States.
What has this men over the years? Going back to the 1900 census when they started using
2500 people at the minimum amount for an urban ized population. The majority of the people
of the United States were rural. Before that far more of the population was rural. Obviously
the drops throughout the century, by 1920, it falls under 50% of the population is rural.
We end up now just under 20% of the population, in the 2010 census now considered rural. Somewhat
surprisingly you can see that actually the population is higher, the rural population
is higher than was back in 1900, when it was about 45 million people and over the last
four censuses from 1980 on, it settled in around 60 million people in the United States
are considered rural. So it has been really stable. 60million people is larger than any
state in the United States. It is far bigger than the population of California, which is
the most populated state. So, a good deal of the population is still rural, even though
the portion of the population keeps falling. I don't know how many people here are from
the Washington area, but if you are leaving Washington and you want to get to Baltimore,
you pass through Montgomery county and come to Howard County, the yellow highlighted county
here and reach Baltimore. If you look at the map you notice that Howard county, the pink
area again is the urbanized area. Everything else, at least half of Howard County is considered
rural by the census bureau definition. When the office of rural health policy and look
at maps like this, we go, this is not really very rural land. This is what we're, what
we mean here when -- the title of this talk has to do with malalignment. The census bureau,
by -- using this 500 people per-square-mile cutoff, is -- including in rural areas lots
of land that is really suburban. So, you're getting out into suburban Washington and Baltimore
here. These people in suburban -- in rural Howard county, have easy access to all of
the healthcare resources that exist In Baltimore and Washington, D.C. So, they can get in their
car and within less than an hour or less than 40 minutes or so, get to GW or Georgetown
medicine center or Johns hotchsons in Baltimore. So, we think that the census bureau is over
counting rural. Now, the office of management and budget has a different definition. They
start with a core area, a core urban area of 50,000 people. So, they are using the census
bureau's urban areas and then classifying whole counties as being parts of metro areas.
They do this micro Paulten areas, but they start with an urbanized core of 10,000, but
fewer than 50,000 people. 10,000 feels like a better cutoff than 2500 people. But together
these are known as the core based statistical areas, you will see that referenced CBSAs.
Now, the, the one of the advantages to this it does use whole counties. So it is very
easy to tell if you are in a metropolitan or a micro Paulten county. You will noting
again, they are not defining a rural or a non metro county. They just define metro and
micro. Everything else is non-core based. This is what the U.S. looked like after the
last census with the OMB took the census and the metropolitan county and micro Paulten
counties are the lighter shades and finally the non-core based counties are everything
else that are not shaded in. Before the last sentences, we had 870 metro counties, they
had not defined micro at that time. Everything else was nonmetro. After the 2000 census when
they went back and analyzed the data, they defined 1100 counties being metropolitan.
Then the micro and the non-core based counties are now 241. Or 66% of the counties in the
United States. As far as the office of rural health policy is concerned and CMS is concerned,
micro Paulten counties have nonmetro counties. So, we add them altogether and come up with
the nonmetro counties. This sounds like it works pretty well. Metro micro. The population
based on 2010 census, but the 2000 metropolitan definition, we come out with 260,000 people
living in the metro counties. Non metro, 50.4 million people. That will change when OMB
redoes the designations to the counties in the next year or so. This is Baltimore county
now, every county in the area is a metro county. Those are shaded. The unshaded counties, the
non metro counties, you have to cross the bay. You have to go across the bay to get
to a nonmetro county or across the Pennsylvania line. Those are the metro counties or head
out west until you get to West Virginia or to western Maryland to find non metro counties.
That seems to make sense. Howard County is part of the Baltimore Washington, D.C. metro
area. Well, this is audience population part. So, anybody been to this place it system for
healthcare it is a pretty well-known tourist destination. It is the grand canyon in Arizona.
It is in one of the dark shaded counties here. It is a metropolitan area. The grand canyon
is a metropolitan area. The reason is that most of the population living in the southern,
very, very southern part of the county that go to Flagstaff and Phoenix. They are pulling
the whole county into the metropolitan area. That's what OMB is looking at, but because
it is a really huge county and includes the Grand Canyon, it doesn't make sense really.
This is a malalignment we're looking at areas if census is including a lot of suburben area
that should not be considered as rural. OMB is including a lot of area that should be
rural but inside of the boundaries of the metropolitan
county. OMB says it is a metropolitan area. It doesn't look like a metro area, at least
they would fall into this classification of metro code 3 here. Then there are a bunch
of nonmetro codes as well. I'm having to hurry a little bit, I'm running out of time, but
there is another -- also, way of dividing counties up. Metro areas of a million or more
and small metro areas with less than a million and dividing up the surrounding non metro
counties. Depending if they are next to a micro area with less than 50,000 and more
than 10,000 or nonadjacent, they are further away from a metro or micro area. Finally,
ORHP and ERS worked together to make rural urban community area codes. They are based
on subcounty units. We can look at the large canyon, like in Arizona and say, is there
metro, is there rural area inside of metropolitan counties. So there are a bunch of codes get
assigned to every census tract in the United States. 1-3 are the metro cores and then micro
and small towns and finally 10s that are way out in the middle of nowhere. Frequently.
This map of Arizona shows you that the northern rim of the Grand Canyon is a 10. It is an
isolated census track that is out there. It is not easy to get to Flagstaff. So, it's
not considered really part of the Flagstaff metro area anymore. Now there are problems
with, even with the codes. If you notice on the left hand corner there is a big yellow
census tract. It is a 3, considered part of the Yuma metro area. That census tract is
over 2,000 square miles. So the people if there is anybody out on the Eastern edge of
it. They are way far away tromp Yuma. They are not close to a metro area. So, we put
that in rural. We can crosswalk to this, to ZIP codes. Again if you're doing research
and looking at population data and have ZIP codes you can find out what their code is
and consider they are considered rural or micro or metro. Our definition covers all
non metro counties in the United States. They are considered rural. We just take them. Then
we look for RUCA tracks inside of the metro count. With certain, they have problems and
they have very few few people in them. We end up with 60 million people being rural.
Close to the census bureau number. We also end up with 91% of the U.S., less than the
97% really that is rural by the census bureau's definition and more than the nonmetro counties
in the United States. So -- I'm going to skip on. We have a new frontier definition, but
I have run out of time. So, I'll just, this also has several different categories you
can use, if you want to identify really sparsely populated, isolated areas in the United States.
This is a possibility to use it. This is websites you can use to find out more information about
census. OMB or the ORHP's definition and the USDA. That will wrap me up without going too
much over time I hope. So, thank you. [ Applause ]
Thank you to all of our panelist. I'm reminded by your remarks, Steve, there is a career
in demography, for those interested in telemedicine. So, I'm going to alter my career guidance
counseling to a number of my gradiate students to include that, but I will tell you, it's
fascinating to me about, we're clearly interested in it from a policy point of view in many,
many different census. But one can't help but wonder if there is not another dimension
that rurality has been sort of offered sim boughticly to stand for, that is one of isolation.
I work in the area of beBeattys and obesity prevention. Where am struck by food deserts
and seeing them in our centers, not that different from healthcare deserts and seeing many of
our rural areas not equally afflicted by this notion of food deserters. So, I'm wondering
a little bit about the dimensions that we have assumed that rural and urban capture.
That perhaps that indeed in light of your presentation, Steve, argues that we ought
to reexamine that. Dale, another point, thank you for your very thoughtful comments with
the FCC. Two weeks ago my 16-year-old son we were cleaning out a large abandoned storage
in my home. Came across VHS systems. He said, what are these, I said you can play a videotape.
None of them were compatible with any of the others. Dale as you began to talk about the
different kinds of networks that merged national, regionally and international, I was reminded
of the discontinuity and the challenges of bringing them together. Gary when you held
up your driver's license, I wanted to make sure it was not your room key, that only gets
you into your room, 30 a state there. Are interesting precedences for rethinking the
notion of licensure. Both that state level and at the federal level, but as anticipated
by John's initial remarks, those notions about practice standards and scope of practice and
other regulatory issue of the day that are becoming increasingly polarized in today's
climate. They provide yet another layer to this issue of licensure as a subset of, of
matters, of, facing us with respect to regulation. We want to continue this as a conversation.
So, there are microphones that are throughout the audience. We have -- just under a half-hour,
which we went to fully dedicate to this conversation. So, we encourage you to pose your questions
to an individual panel member or to the panel largely. I will intervene if we get a little
bit too announcement oriented from the floor or panelist. So, let's make it interactive.
So, please start here and move back and forth.
Hello. I'm from West Virginia. This is a great panel. [ Low audio ]
Thank you, panelists?
Let me start out, thanks for your comments. Clearly all the things that we do whether
we call it telemedicine, telehealth, E health, getting connected has to be needed driven.
So, for instance, in our state we have an office for community health. That office is,
is there really to really to really to really to really to really to really to really to
really to really to really to really to really to really to really to really to really to
really to really to really to work with with the communities collaboratively, addressing
what the community sees as their health need, which would also involve the provider. It
is not just physicians, it is PA, advance practice nurses. It's -- the community health
workers. So, in our state, we feel that's critical. We can't, from the health science
center say in New Mexico. This is what we think you need and here it is. Addressing
needs and doing it community by community I think becomes very important. In fact there
is a program called heroes in New Mexico, which is health extension rural offices, which
are patterns after the agricultural rural officials that help farmers understand best
practices. That we're realistically deployed in their communities. We're trying to look
at the same thing with healthcare. So, it is critical for a connection collaboratively
with rural healthcare providers. I will comment briefly on special systems. I believe these
will be really important tools for us to do mapping of a variety of public health issues,
both dynamically, a spread of flu or understanding where our patients with diabetes reside and
the population with the greatest need are, are, within a region. So, that we can better
direct our resources in a meaningful way. So yes. We have to involve our rural healthcare
providers and the communitys. Yes. I think there is new technologies emerging like geo
spatial information systems to make a difference. They are all going the needed aicate connectivity.
So, we got to find a way to facilitate that process and getting people affordable broadband.
Thank you, Dale. Any other comments from panelists.
Let me make a comment. I don't know if this is on. I guess it is on. I think the economics
are such that the days of the independent rural healthcare provider are fairly limited.
Not to say there will not be any, but fewer and fewer as we consolidate systems and develop
networks that are broader, the use of technology, telemedicine and otherwise will be critical
to link in health providers in rural areas to other parts of the network that they belong
or are partners with. We see providers linking in technology. We're going to see a lot more
branding into rural areas that you have an independent provide that may say Dr. Jones
and underneath it an affiliated of the Cleveland clinic or whatever is in that state, for example
and telemedicine will play a very important role in providing that empowerment to the
local provider to link back to larger systems and larger resources.
Thank you, John. Our next audience member? [ Low audio ]
I'll jump in and say that, I think whether you're urban, rural, frontier, inner city,
it should be irrelevant when you talk about healthcare. It should just be what everyone
gets and the artificial distinctiontions in Medicare, in many of the state laws on Medicaid,
that limit it to rural need to be -- done away with. Those kind of artificial disstimulations.
California has done a great job on that and be a beacon for the rest of the states. But
one of the -- one of the challenges, sense this is a challenges panel is to get the government
out of the way. With Medicare, Medicaid, state licensure, some of these things that throw-in
artificial geographic distinctions when you have to look on the map to figure out whether
you're in or out, I just, no longer apply in, in a world that is very connected, 4G.
You know, lambda, what ever, you know, that it just should not matter. Every American
should have access to one healthcare system. We should have tell -- coverage across the
country. Not state by state or county by county. Or plan by plan. It's inexecutable that we
don't have a national network. So, I understand that, some of the needs in rural areas are
different than urban areas, but we have transportation difficulties in metro areas. We have people
that can't get out of their house or their apartment. They may be able to see the specialist
office, but they can't get there. So, I, I think -- while we're hearing a lot of rural
and it is important to deal with rural, that it is important that it -- we remove those
distinctions. It is also important to, for telemedicine, you have to have a population
base to work from. If Medicaid doesn't cover in a state, state of Florida, for example,
highly urban. So, when you don't have the Medicare beneficiaries in Florida covered,
it's hard to create a helnetwork that will be sustained. So, it is important for rural
areas to get the urban population covered as well. So that there can be a robust network
that benefits everybody.
Steve, and wondered if you had any additional thoughts since this truly cross cut with your
area and presentation.
Well, to me and I'm -- not part of the office for the advancement of telemedicine. So, they
are located with us, when I bring up how densely populated the urban U.S. is, to me I go, this
should be a no-brainer that we have broadband coverage in this area. Now the problem is
the rest of the 97% of the U.S. and the 60 million people who live there, mow do we get
broadband to them. So, that's, that's -- where I think we need to -- concentrate more. Though,
I understand even in the urban areas we're not getting the kind of broadband coverage
we ideally see, really the problem is out there where there are 60 million people who
deserve had same kind, the same high quality service that anyone else should be able to
get.
Steve, let me put you on the spot.
All right.
How viable do you believe this continued distinction between rural and urban is? In the context
of the issues under discussion here. Is there something that your privy to.
I'm pretty happy with the definition that we use in the office. It is not perfect. There
are no perfect definitions, but I like the fact that we use subcounty units. The census
tracts and the metropolitan areas. The new frontier definition that I mentioned I think
is also going to be useful for really being able to identify areas that are truly isolated
that really need greater help in being able to connect to -- urban cores and to the kind
of health services there. I'm hopeful that we're, we're going in the right direction.
Thank you. The next member from our audience, please? [ Low audio ]
Thank you. it is more than a point of information. One thing in the workshop. We are been asked
to address the current state and the future opportunities in the field in the context
of the ACA. So, John or Gary, I wonder if you can speak to this issue as you understand
it in the context of AC A and licensure.
Sure. We're aware of that provision. It is a good one. There have lots of different ways
this issue can be dealt with. It could be dealt with the existing state boards through
their national federations. There have lots of things that could happen. I would say that
the problem is getting worse not better. We also have, have the issue of declining productivity
of, of physicians and other practitioners that we need to do everything that we can
to have people operating at the high end of their license to, to, to -- you know, come
up with, with ways and, and, I know telemedicine sometimes adds to the burden of physicians,
John was talking about the tsunami of data, but to come up with ways to use technology
to improve provider productivity to deal with some of the shortage issues. So, there's lots
of opportunities. The nurses have, their nurse compact that started off great, but kind of
stalls out in terms of implementation. We're at, in a position where there have a lot of
big alternatives. I appreciate Mike cash being supportive of telemedicine, I would be happy
to talk to him about a long list of things that his department could do to advance healthcare
improvement for all Americans.
Please do. Thank you.
If, if I could just add a couple quick comments. Jonathan will probably -- grimace when I says
this, but I talk about we're in a perfect storm right now. I mean, you have the affordable
care act, but still very controversial and very partisan. We have an economic downtown,
the healthcare is not sustainable. More demand for care. An aging population. Baby boomers
are in the Medicare error and we have a crisis in the number of providers in at all levels.
I believe this is where telemedicine, telehealth, health information technologies will play
an important role of navigating this perfect storm. I think groups, I think ATA is trying
to work with the federation state medical boards. They a process called the uniformed
application, the federal vudenchallying verification services. Trying to steam line the process
of licensure. It takes too long and lastly integrated health, too often we have taken
physical health and carved out behavior health from the. I believe they have to be integrated.
We have to look at health holistically. I'm hopeful however we use telemedicine in the
technologies will allow us to integrate health in a much more meaningful manner.
Thank you, John. You look like you're about to add something.
I was going to jump in, since you did mention perfect storm. I wanted to add a comment not
on the subject. I don't think this meeting would be right without mentioning another
challenge that is unmentioned, the elephant in the room. Some physicians love telemedicine,
they can see 20 patients in an hour, where there used to be 15 or 10 patients, but they
want to be paid the same amount. Silence in the room. I think that a huge issue. We have
to come to terms with it. Because I think if you're more efficient in telemedicine,
we have to come to terms that maybe we don't pay the same amount for that service, if it
is done over telemedicine. That actually is a model that is being used in other places.
It is being used in neuro physiological monitoring and other places. It is a very sensitive third
rail. The third rail of telemedicine is not state licensure, but payment, that has to
be addressed at some point.
Some of you were worried this panel will be boring. I hope that is set aside by the comments
so far, this morning. Back over to the audience, please.
Would you take a moment to remind the audience how they can find that report? [ Low audio
]
Thank you very much.
Thank you.
I want to make a quick comment on that. When I was young, I thought never bite the hand
that feeds you. So, in the S.W.A.T. analysis. I think it is a great idea. What we have to
do is work together with realistic solutions. I've stated that to FCC as well over and over
again. We all want the same thing. I think if we work together collaboratively, you can
play a huge role or FCC play as huge role in getting this country connected. So, I really
do appreciate your efforts. I think part of my other message, we had a lot of other federal
programs that I don't think, from my standpoint were well coordinated. We dealt with that
is in New Mexico, we had a hospital saying that we were approached by a B top project
and there is no cost and no cash match. So, why would we go with you. Everyone is trying
to do the right thing. They are well intended programs. Hopefully, we can continue this
dialogue, because I believe that this country is falling behind the rest of the world in
adequate broadband connectivity for all kind of things, not just healthcare. I appreciate
what you are doing. Hopefully we can continue this.
We have three audience members left. Let's make it through in the next three minutes.
Please. [ Low audio ] In something less than 15 to 17 years, should we continue to require
the level of R CTs or the level of evidence needed for these studies to be published in
reputable peer reviewed journals? If there is a reason why we might go to a different
standard, how should we go about doing that?
We are about 30 seconds left. [ Laughter ] So -- panelists, please.
Yes. Thank you.
Tom? [ Laughter ]
Yeah. [ No audio ]
Let me very quickly. Let's not spend time on patient acceptance, patients love telemedicine.
I have never seen a patient acceptable study where they didn't love telemedicine. Let's
focus on costs, that is the issue. Quality people talk about, but it is cost. There is
a lot of telemedicine that is proven that it is cost-effective and fine. Let's go with
those. There are other areas that need some study. Part of that is because the studies
are not there. Part of that is the congressional budget office and others are looking at a
very narrow definition of cost savings. That's the other definition that we have. The cost
savings for stroke care it is in rebilitation. So, they think it costs money, so they are
not going to approve it. That's the reality of what we're facing it right now. Part of
it is the studies and part is how you treat it.
High apologizes to the other two audience members we ran out of time, but thank you
for thoughtful comments and to the questions of the pannests and the panelists for their
insightful comments on today's remarks. Thank you. [ Applause ] Now, further directions
with logistics over the lunch hour.
I was going to say next slide, please.
Thanks, I get to talk to you about food. So if those of you who are -- there's a lot of
people here. We have a very small cafeteria, for those who are speakers or part of our
planning committee, we ask that you go straight out into the large atrium and Samantha will
point you in the right direction. The other participants take a right. In terms of going
out of the building there is nothing in the immediate area, you will have to walk if you
chose to do that. I want to remind you that the cafeteria actually closes after that lunch
hour. So, any food that you want to get, get it now, but you can't bring it in the room
here. So, we will have coffee available during the afternoon that you can have outside. We're
going to start sharply at 1:00. So, thank you. [ MUSIC ] [ Music ] [ MUSIC ] [Meeting
is on lunch break at this time and will resume at 1:00 p.m. E.T.] [ MUSIC ] [ Background
music] [ MUSIC ] [Switching captioners at this time. Thank you,
>> Start to take your seats. We want to get started. If you can hear this in the hallway,
come on in. We are going to start in 1.5 minutes. >> We are going to get started. I hope everyone
found food. The talk after lunch is going to be exciting and stimulating and everyone
will be awake for it. A couple of housekeeping things -- I violated this -- when you talk,
make sure the you have a microphone. When I answered a question, I was sitting in my
chair. The webcast doesn't pick it up. Even if you have a comment that is just burning,
you have to jump up and go to a microphone.
This is telehealth and payment. We often talk about the elements necessary for a technology
enabled healthcare system. We talk about ubiquitous broadband and equipment and a trained workforce
and we talk about removal of regulatory barriers. We also talk about reimbursement and payment.
Most people think of that as first among equals -- payment. If there is no payment, it is
amazing how people are not as motivated. This is an important subject for us to cover. Something
that Karen gave me this morning is something that came out from Medicare reimbursement.
I would play a game of guessing how much Medicare reimbursed for telehealth services in 2011,
but you would be wrong. According to this chart, it is less than $6 million. That is
barely a decimal. Even when there is payment, people are not taking advantage of this. The
bill are not addressing this. The biographies of the speakers are available to you. We will
go in the order on your program. We will start with Jeff Stensland from that back. -- MedPAC.
Karyn Edison will follow. She is from the University of Missouri.
Then, Manish Oza and Linda Magno. >> I am an analyst with the Medicare advisory
commission. The commission is a congressional agency that works as the research arm for
Congress. The reason I'm here today is because Congress mandated that we do a study of rural
health care. As a part of this study, we looked at some of the data on Medicare and telehealth.
We try to get an idea of how far it is expanding and why it is expanding and what is promising
and what has been disappointing. That is what I will go through today. I think I will try
to frame my points in terms of what I would call the two triple aims. One that you hear
a lot about -- if we have an insurer with us today -- the government perspective -- often
we want better access for patients. We all want better quality of care and we all want
to see cost growth constrained. That is one of the aims. The other aim is for the providers
-- they want to improve access that their patients we see. They really do all want to
improve the quality that their patients receive and they want to make money. You have two
of these things. If you do not meet both of these aims, there are problems. You will not
see the expansion of telemedicine.
This is a basic slide. There has been a long-standing goal to improve access to care for isolated
beneficiaries and about 7% of Medicare beneficiaries travel an hour or more for -- 7% of rural
beneficiaries -- travel one hour or more to receive care. This could improve access to
care. Medicare pays only for interactive videoconferencing between the beneficiary and a certified rural
site. That is what Medicare is supposed to pay for.
Here is a big shift that is happen. Between 1999 and 2001, the initial payment policy
essentially said we are going to give you one payment, but you have to have 2 providers.
One has to be the originated site and wanted the consulting side. That clearly fails the
AAA and for the provider because there is no way a provider can't be losing money on
that prospect relative to what they could make on a face-to-face visit. We saw very
little telemedicine at that time. I worked at the University of Minnesota telemedicine
center. This was grant funded and there were mission driven people not doing this to make
money even though they were losing money. Under that type of scenario, you do not get
a lot of people joining the bandwagon. We did not get a lot.
Starting in 2001, you see the shift of now having 2 patients -- payments and one practitioner.
From the revenue standpoint, they are made whole. It is equal to what they would make
in a face-to-face visit. The cost I be higher, but at least the revenue is equal. I think
that from the taxpayer standpoint it is important to note that down the payments are higher.
I think that any discussion of expanding telemedicine widely will have to take into consideration
how much more those visits will cost the taxpayer not only on an individual basis, but the number
of visits.
Here is what we found when we look at the data. I think you heard the number of $6 million
which is not a lot of money that Medicare reimbursed. I don't know what year that was
-- probably 2011. We looked at the data, we looking at 2009. We were also surprised that
there was not a lot of use. There were 14,000 beneficiaries of one or telehealth this is.
We found 369 practitioners who provided 10 or more he telehealth services to the beneficiaries.
Most of these were mental health services. We try to ask ourselves why there is a low
level of adoption and certainly there is the nurture I am sure you are familiar with and
some people have told us that in some cases there is extra time for the visit. If I am
a direct knowledges, if it takes extra time for the visit, or if I am a direct knowledges
to -- from ecologist -- dermatologist -- there could also be some issues with cardiology.
Maybe they are making more money from the ancillary is that if they see someone face-to-face
-- they get to have the ancillary income on a telemedicine visit. Maybe they don't.
There are also administrative better start -- barriers. This could be another hindrance.
In general, the bill and we got from talking to people in the literature and you all have
your own opinions that are at least equally valid is that this is a fragile process. Often,
telemedicine except for the mental health providers is that may be part of their business.
If you put enough to call in their way, they may just say no, I will not provided. That
may be why we only saw 369 providers providing a significant amount of telehealth care.
For these providers? Who are these providers? The first row is not surprising -- most are
psychologists. Psychiatrist and clinical social workers.
The second one would eat surprising -- 19% of them were BA's and clinical nerve specialist.
These are not the subspecialists positions. They are nonphysicians. It would be interesting
to learn more about what they are doing. This is not the traditional model you here -- we
had to bring expertise into the world areas and highly trained individuals. You also see
a fair amount of family practitioner. An internal medicine. What you get out of the other categories
-- neurology and cardiology and a dermatology -- there were only eight are one of them that
were billing more than 10 business. There are more now, but still it is not a huge number.
I should also say that we looked at the number of a visits in 2009 there were about 40,000
visits. You will see this in any data you look at on telemedicine. There are usually
two different types of data -- how many visits -- how many bills Medicare received from the
provider, and this was more like 40,000 in 2009. It is public closer to 70,000 or 80,000
now. And how many bills from the originating site? The originating site has a substantially
fewer bills, less than 30,000 from the originating site. You think that these would come in pairs.
We looked at the data and said -- who are these people that are not -- where are these
claims that don't have an associated originating site build? We called them to see what they
were doing.
These were 2 individuals that were responsible for 4% of all the claims. They were providing
a telemedicine claims to individuals in their homes in urban areas and rural areas. This
is not allowed under the rules. It is important that when you look at the data to take it
with a grain of salt. When you see the Medicare claims numbers, do not assume that these are
according to the rules, because of probably a large share are not. >> I also want to talk
about some promising new telehealth uses. This is the stuff that is exciting we talked
to people about telemedicine. One is tell a pharmacy -- we heard about that. Mary Wakefield
talked about North Dakota. I was excited about this because it really that a couple of the
aims. Tell a pharmacy, -- tell a pharmacy -- the critical access pharmacy without a
pharmacist on staff could improve quality. Also, telepharmacy is used in towns with less
than 10,000 people. This improves access. Especially with the freestanding pharmacies
in the small towns -- you can meet a triple aims. You might get better quality and you
are getting more access and it doesn't lost the insurer any extra money. When we talked
to the people running those programs, they said that none of the pharmacies are receiving
any other grant ones other than what they initially started with. They are all self
funded in making all of the money from the additional prescriptions that they sell to
cover the cost of the pharmacy tech in a town of 800 people and the additional cost of the
pharmacist looking at everything over telemedicine. That was promising. It is a triple a winner.
-- Triple aims winter.
Tell emergency care -- this is a broad spectrum. I was struck by the article talking about
Tele ICU care in the New Yorker a couple of days ago. This was about high-tech medicine.
Detailed specialists talking to another physician who is attending to a patient in the room.
Then I think about when I go out on some of these rural site visits to these small hospitals
-- some of you don't know this, but the critical access hospitals often does not have a position
on site. They don't have to have an RN on-site. The highest trained person when you come in
my he and LPN. -- Might be an LPN. This is nerve-racking for the nurse as well as the
patient. It might make a differences the nurse could hit a button it would go to the ICU
somewhere where the physician could help the LPN stabilize that patient.
It is important to think about the spectrum of what is happening, especially those tiny
hospitals.
The nurses that we talked to were fabulous people doing great work with their limited
training, but it is very scary for them when they are the highest trained person in the
hospital in a heart attack comes in the door.
Remaining questions -- these are good for the academics. First, when we went through
this, I think there are a couple of motivators -- back in the 90s when I looked at this,
a lot of people were talking about the motivators -- producing -- producing patient travel time.
-- Reducing it. I am excited about improving quality as a potential motivated. We see this
in pharmacy and telemedicine. I think the troubled times -- another thing I would like
to see more of in the literature that we don't see is looking at the trade-offs between the
physician time and the patient time. One of the difficulties that we may not have seemed
so much expansion of telemedicine is that if you look for some of the providers, if
you talk to a ecologist or cardiologist -- they made be able to bill hundred dollars in 10
minutes -- if you take an extra 10 minutes due to the computer not putting up or them
having to go to another room or administrative hassles with paperwork to deal with, if you
make them take an extra 10 minutes, that is $100 down the tubes. You ask -- how much patient
travel time could we pay for with $100? There are a lot of patients that might be willing
to have a four hour trip from there into the urban area and that for that $100. It is hard
to make the economics work. I would like to see the literature get more sick merger -- serious
about the differential in the race for the positions get aid versus the patient time
and the patience employers.
It is a difficult issue. People may think it is a crash issue -- but you need to think
about this when you ask yourself why telemedicine hasn't taken off.
Back to my top point, we talk about quality, that is not such a big deal because when you
talk about the Tele emergency care, transportation is not an option. This is about the quality
of the patient and improving the care they get. I think it is a more compelling case.
Finally, the research that we looked at -- we did a literature review of telemedicine were
doing our studies -- I think there are two things would like to see -- more studies by
people more involved in actually providing the care. There are a lot of studies by people
saying this is what we did in this all works. More independent studies and I heard about
the difficulty this morning -- more independent studies.
I also think some studies of people who of stopped doing telemedicine. This would be
a fascinating study. One of the things that we mention we talk to these people billing
for care in urban areas or in people's homes -- they said we don't do it anymore because
we found out that it didn't work. We are trying to manage our CHF patients and manage our
diabetes patients better with home on entering and we thought it didn't work, so we stopped.
90% of the time the workcenter presented doesn't. But I would like to see more studies of the
physicians who stopped doing telemedicine. We have 12 years of Medicare claims -- somebody
can take these claims and download all the providers numbers of the physicians were provided
this telemedicine and take the data and look at how many of them are not doing it or how
they stop doing it. My guess is that you will have hundreds of fighters who stopped doing
telemedicine and it would be great to hear their stories. Did they think it didn't work?
Administrative barriers? Cut into the profitability? We have a lot of success stories, but I would
love to hear some failures because it would help us to move to more success stories.
Thank you.
[applause] >> I will tell you a story. My mother is a nurse practitioner. She does diabetes
care. She told me she was not going to do any more telemedicine because she sent a couple
of people for telemedicine in rural areas and they had been told at the door that it
was going to cost the patient if you dollars to come in to get a telemedicine service.
I said that's not right. We are going to fix that. She said I can't do this. Sometimes
it is the little things. Not things you might think.
I am going to talk about challenges to Telehealth with traditional payment. I threw in a little
bit of regulation. When I started to put these comments together, I started to feel guilty.
Many of you know that I was here in the Congress when we were expanding payment for telemedicine.
We put all of these constraints around because we were trying to get the Congressional I
did office to give us a reasonable score. This is so it could get past. That is what
we did things we didn't want to do. That is why we put the codes in the law and why we
made the list of providers and the list of sites -- all of those constraints. That is
why we only sent store and forward in Alaska and Hawaii.
Now, we are fighting against of the constraints. I think it is time to get rid of these. I'm
going to talk about traditional payment and some of the challenges there and a little
bit about new models. Most of you know that reimbursement in that care is for live interactive
Telehealth if the patient is in a nonmetropolitan statistical area. Most of you know that store
and forward is paid for in Alaska and why. You probably know that Medicaid reimburses
in most states 45 states. Store and forward services of one type or another are reimbursed
in 16 states including California with the big Medi-Cal program. This number has gone
up gradually over time.
Private payers in many places. 15 states have mandated that private payers pay for Telehealth.
In my state, there is not such a law. Most of all the private papers paper Telehealth.
Just because 15 states have a lot -- that does not mean these are the only 15 states
in which private payers pay.
Private industry -- this is starting to contract with us directly for services. I didn't know
how much you would get ahead of time of that the payment you have gotten -- you know all
this -- the providers and the site and the services.
You know that the facility fee is over $24. It is low -- the sites where patients are
seen -- they think it is low, but that is what it is.
As a provider, I have to be privileged and credentialed to provide this service and I
have to be licensed in that state. I will talk more about this issue that is been a
barrier for us this year. The licensing issue is a big one. I live in Missouri. I am at
the University of Missouri in the middle of the chat -- the state. Our population centers
on the coasts, if you will. Kansas City and St. Louis is where most of the population
lives. Both of those cities are truly by state cities. This licensure issue is an issue.
Eight different states such our state. We have a lot of cross state issues to think
about.
Dedicated Missouri is every much like the Medicare reimbursement scheme and that is
true for many states. -- Medicaid. The pattern of reimbursement after Medicare. >> In our
state, the facility be in the Medicaid program is only $14.60. It turns out that is not really
enough given the new meaningful use requirements. I don't know how many clinicians are in the
audience, but at how many ears as -- but, that occasion reconciliation where when the
patient comes in you have to go over all their medicines and verify them and put them in
the electronic health record -- that is a time-consuming process. It is a key function
and marker of meaningful use. Meaningful use is providing pressures on Telehealth. Also,
at the end of the visit, the patient has to have a depart summary -- a clinical summary
printed out as a part of meaningful use. Now, we are mailing or faxing our depart summaries
to various sites. Meaningful use is putting pressure on Telehealth. We have a group meeting
to try to solve these problems that come up with some best practices and policy around
meaningful use and Telehealth.
Barriers -- what are they? Some are perceived and some are real. Liability -- the medical
malpractice situation, as you know -- the affordable care act did not do much. We still
have a lot of the fears out there. Particularly in the community health centers and critical
access hospitals. We hear back from them that they are afraid to let us see a patient that
lives in their community in their center if they are not there patient. If you are a community
health center and the patient is not one of your health Center patients, they won't let
the patient come in and be seen via Telehealth because we are -- where the care is delivered
as far as Medicare is concerned is where the patient is. Not where the care providers.
So, they are worried that if something happens, they will be liable. That has turned out to
be quite a barrier. Reimbursement. You have heard from many of the speakers so far in
this covers that have talked about the rural -- mellow politician -- Metropolitan issue.
This is been a big issue for us. About a third of our sites, when a change the designations,
we lost a minute for the Medicare patients we were seeing because of that.
We don't just build -- we actually figure out whether it is appropriate and approved
to build.
Regulation privileging credentialing -- we will talk about that. Here is the map showing
the Metropolitan and nonmetropolitan counties in Missouri. The oranges that enter politics.
I don't know if many of you up into the Donald County in the southwest part of our state,
but I would not call that a enter politics County. I wouldn't call have of these Metropolitan
Counties. They are called this because of where people drive from in the counties to
go to bigger cities to work. Right, Steve? But, it is the able bodied people that do
that. We're talking about Medicare reimbursement. The elderly people are not driving to counties
over there to get their healthcare. We need to get a handle on this urban Metropolitan
restriction on Telehealth reimbursement in the Medicare program.
Credentialing -- I know that CMS tried hard to do this in a way that would not do damage
telehealth. As you know, I was here as a policy fellow in the 106th Congress for two years
on the health education and pensions committee. I learned the lesson well. When it seems like
it makes good sense in Washington, this can play out differently when you get into the
real world.
This one is playing out differently in my state. Basically, the ruling was that hospitals
can't accept the decisions of the distant site hospital; however, the hospital has to
change their bylaws to allow for that. To allow for credentialing by proxy. This has
turned out to be a big area for some of the hospitals. Over the last six months, I have
gotten stacks of papers to fill out and bills for $400 each to join medical staffs. I might
go to 60 different places. We are working on that and trying to work through that, but
that is been quite an issue for us.
This is where we are -- we have 200 210 in points in 67 counties. This is all over Missouri.
We are in the middle -- right there -- that is where the diversity of Missouri is in Colombia.
We are in hospitals and community health centers and state facilities and nursing homes. A
lot of different places. Although use of Telehealth has not gone up dramatically, it is gone up
steadily in our center as well as other peoples. This is just our center. We saw 6000 people
last year in over 20 specialties, but the bulk of it was until health, dermatology,
child health, autism, and a relative. Many different specialties have uses. I do not
give a talk without giving in a patient case. This patient as the two uses case to remind
us all why we are here what we are talking about. This is a father of four -- a 44-year-old
farmer from the story -- three hours away from Columbia in the middle of harvest season.
He would not have given to get his will evaluate it. For the clinicians in the audience, this
was a 1.1 mm superficial spreading melanoma. We got it diagnosed and got a mini got it
off and it saved his life. It saved who knows what for those poor kids for the rest of their
lives not to mention his wife. So, telemedicine matters and access to expertise and care matter.
Back in 2001 we expanded reimbursement, we got this score. The CBO said it was $150 million
over five years. Five years later -- from 2001 to 2006, that Kerry spent $3 million.
I just heard that these tenured numbers have gone up some, but they are very modest.
What we need to do? We set up a system where we are tinkering around the edges. Here are
the codes we want covered. Here are the providers we want covered in the places we can be. Here
are the counties. We need to stop and throw off the bondage and the shackles. Let's stop
and free the Telehealth providers in this cup three -- in this country to do telemedicine.
We need to treat it the same as in person care.
If you drive to see a doctor, no matter where they are, they care is delivered with a doctor
is. Just because technology takes you there should not be any different. If we agree that
the location of the service provided is that the location of the service provider, we will
have a lot of problems.
[applause]
These issues would be helped immensely. These licensure issues would be helped immensely.
The liability of your issue would go away. The patient location issues would evaporate.
What is to fear from doing that?
There is nothing to fear. Early on what we started to talk about expanding reimbursement
for Telehealth, there was a lot of fear. I went to a lot of meetings where I heard a
lot of to change -- fears about fraud and abuse. Well, it hasn't happened and it is
not going to happen. Telehealth is harder to do than in person care. Most of us have
more to do than we can possibly do anyway, so there is nothing to fear. Healthcare for
most Americans to matter what you hear -- the breathless announcements in the media about
all of these different things -- most Americans get their health care in a local regional
fashion.
Referral medicine is based on relationships. People who refer patients to me know me. They
know they can call me and I can call them. That is how medicine works. No, not all of
medicine is going to be bought into the practices. That is something that I here in Washington.
-- I hear this in Washington. We do get out into real America, that is not the case. We
will continue to have independent providers in rural Missouri and we need them.
Having knowledge about health care ever structure about the patient side is critical. You can't
be a good doctor if you don't know what the resources are for the patient where they are.
Do they have access to pharmaceuticals? Is there someone who could do a procedure if
they needed? There are a lot of other constraints that could train -- constrained Telehealth.
The major barrier to the mind -- widespread use -- in the old model -- the major barrier
is a lack of an incentive to do it. Why would you do it? >> Long wait times in most practices
-- I am taking a day to be here and my next available is -- November or December. Long
wait times in most practices and higher reimbursements for procedural codes as referred to is you
earlier. I am a German ecologist and I still make a lot more money with what I do with
my hands and what I do with my brain and my eyes. Hopefully, we will see this change because
we need to. Why now, I lose money every time I do a telemedicine clinic. This is because
I make much more money with what I do with my hands and I don't do those things and telemedicine.
I and the chair of our department so I have to look at the bottom line -- I do to have
taste and -- half days. -- 2 have taste.
I have certain responsibilities. It is patient base and we are a land grant university and
once you start to do this, you realize that power to deliver patients -- the liver care
to patients who were not going to get the care otherwise.
We have a lack of training and mentoring in Telehealth in this company. We are working
with the RRC and we need to get out there and train people and mentor people in its
use.
You heard a lot about the workforce shortages. I will not delay for this, but it is across
the board. Not just primary care, everybody. Not just doctors, but nurses and their business
and everybody. We can't take of the parishes -- we can't take care the patients we have
now and with 30 million new people we will not be able to do this. Let's make the location
of the service where the provider is. What's going to support it? Eliminate the restriction.
Reimburse store and forward services especially dermatology. When it Medicare did away with
the console coats, this resulted in people having no dermatologist that would go to the
major hospitals. We can do that via a store and forward Telehealth and we need to.
Provider supported care will support this. Meaningful use will support this. To Dale's,,
mature electronic health information exchange environment will support this. These are things
that are coming that will support Telehealth. I will stop there.
[applause] My name is Manish Oza, the medical director for Wellpoint. Karen has touched
on a lot of the things that I am going to speak to, also. Conceptually, we know today
that healthcare is complicating and finding a provider is challenging. There is limited
transparency when you go out on the web to find a primary care doctor or an orthopedist
or an and chronologies. We know there is a long wait time in the emergency room trying
to find a primary care doctor, a specialist can be extremely challenging as Karen mentioned.
An accessible -- we have heard a lot about rural areas and the challenges that distance
can be in terms of a barrier to access. Online care -- we know it is a simple. It can be
simple. It potentially can be fast. Video chat is enticing. It is user-friendly. It
is accessible. Being able to log on anytime from anywhere is something that consumers
want and have been asking for. Trusted -- at the Blue Cross Blue Shield, we are handpicking
providers which is been painful -- they are ready to embrace mobile health. This is not
easy. You have heard this over and over again -- there are a lot of obstacles in our way
to try to find providers that are willing to embrace mobile health and get reimbursement
at the right spot so that the carrots are there for them to do this. And that they are
not actually losing money.
From our vantage point, this is what we want. We want car all to have a choice of a trusted
provider with one click that he can choose from and we want to provider to be able to
a prescribed and be able to order lab tests and radiological test is necessary so that
are all does it have to go to the office -- Karl doesn't have to go to the office but all the
testing can be done and then, if necessary, he comes to the provider for a face-to-face
visit.
This slide has the spectrum. It is probably not all the potential things you could do
from a mobile health standpoint. From my manage point, when you start to say -- what could
mobile health impacted -- you start off here -- then, when you say which one of these will
have an R. capital I., you go to hear. Then you say which ones will improve quality or
will be the same quality if you want to the office space to face, you go to hear. Then,
you start to go to now trying to find providers in our environment and the incentives that
are there financially that Karen spoke to -- that is why we are now here. Maybe smaller.
These are the challenges we are facing at and them. I am passionate and I speak to where
I think this will play a big role is in the patient centered vertical homes. I dream of
the day when they could just of our killer patient is discharged from the hospital -- a
congestive heart failure patient -- their physician from their office can talk to the
patient via the web about salt intake and exile their medications and talk about why
it is important for them to weigh themselves on a daily basis. And the science of CHF exacerbation.
We know from managed care our ability to engage members and case management and disease management
-- it is not that great. This is one example of where I feel you could plug in mobile health.
Most of you know that with the patient centered medical home model -- most of the models start
with before service or enhanced fee-for-service in the end with a shared savings. This is
where you would align the incentives. Now this doctor has an incentive to make sure
that congestive heart failure patient is not readmitted or the patience on their panel
are not going to the emergency room for a -- affordable ERP is as in the first reductions
are *** before going to the emergency room.
From the employer perspective, I service national accounts. I am responsible for the East region.
Some of our clients are IBM, Verizon, Goldman Sachs, etc. From their vantage point, they
think this is great. That is music to their ears. They think it is convenient. They think
it is going to be a timesaver. They think it will increase access.
Cost effective -- we have to proceed with caution. Definitely there is an opportunity.
Yes, but there is also potential for abuse and some people don't want to hear that, but
it is a reality. I could give you a separate lecture on abuse of what we face on a regular
basis.
HR directors -- they are excited about increased productivity -- a banker not having to leave
his desk or his phone to go to the ER or to a primary care doctor in Manhattan, that being
able to get on the web and see a doctor for what ever it is that he needs to be.
-- But he needs to do.
You to demand -- who doesn't want this? 74% of our consumers are saying that they would
be likely to use online services. From my vantage point, I worry about whether we are
prepared for the first encounter when you open a program like this up and when the member
goals on the web and the first time we need to make sure that the right doctors are they
are online 30 to receive the members of that they have a good experience. We all know what
happens. We you have a good experience, you're happy. When you have a bad experience, you
will tell seven or 12 other people about why this is bad and how does it work and it was
a waste of time. We are trying to be as diligent in as we can 2.our eyes across our teas and
develop a network and try to find the providers ready to embrace this. The challenge from
our vantage point is -- will we have enough providers available in a 12 hour day time
from 7 to 7 to staff the influx? Especially when you first open this up -- this is a big
concern of ours at anthem.
Bottom line -- these are the have the easy things. Do we think members will be happier?
Yes.
Can they be healthier with greater accessibility or? For sure.
More productive? Yes, if you are getting healthcare to people that potentially would not access
healthcare or the egg example that Karen gave you about the malignant Ellen Oma -- melanoma
-- it probably would not have been treated if they did not access Telehealth.
For medical cost -- I say proceed with caution. There are opportunities. It has to be done
right. It has to be well thought out. The proper incentives have to be in place for
clinicians to embrace this. Today they are not there. I think this is clear. Why wouldn't
someone that can generate $100 or $200 an hour want to be compensated with 20 or $30?
It doesn't make sense. We will spin our wheels unless we align these things properly.
Healthcare in your hand -- we have had a pilot at Anthem which leveraged case management
via the web. The initial feedback was positive. Engagement rates were higher than normal.
The bean counters are still trying to do this -- figure out if there is really an ROI. Some
interesting facts that I learned from this study was that members told us they actually
I to see the nurse, but they don't want the nurse to see them.
This was eye-opening.
The other challenge that we found -- if they want to see the nurse -- a lot of the nurses
work from home. Now you are starting to talk about a nurse -- does she have to wear a uniform?
Does she need to be in a white outfit? Most people think of the white coat and a stethoscope.
They think of the white uniform. Does there need to be a backdrop behind the nurse? Can
you see into her kitchen what she is cooking for lunch or dinner? Barriers -- things we
didn't think about. This is multi-factorial.
The goal, ultimately, we all agree -- we want our members to be healthier when and where
they want and the way they want. From a payers perspective, we have multiple challenges.
We have the integration of the data. You have all these wireless devices that are monitoring
glucose and weight. Where is the data going? Is it being integrated into an electronic
health record? Can we or CMS mine this data we are trying to find out information in terms
of the tricks and quality? Additional costs -- that is a reality. I am a practicing appellee
R. Dr. When they came to me with the ROI -- they listed over 300 diagnoses -- one was ballot
structure. I said are you kidding me? -- Ballot structure -- bowel obstruction. Unless someone
can pop in an IV tube and give them medications, let's be realistic about what you can treat
over the Rebbe -- over the web. Let's be realistic on what it is. I would be lying if I didn't
say that we are concerned about multiple visits. Does the member go to mobile health and get
a Web visit and then say no, I don't think they were right -- I don't know that Dr. I
don't agree. Or as an ER doctor, I have patients coming in that are hell-bent on wanting their
antibiotics. I'd can talk to them until I am blue in the face -- you don't need antibiotics.
This is viral. Antibodies can be bad. There are other side effects. I can tell them they
are not going to get it and then they can talk to my chairman about one of that Dr.
IM, or I can write the prescription. If there is a clinician here that tells you they didn't
write a prescription when they knew they didn't need to, they are lying. We have done it.
I've done it. I worry that it will happen even more or some patients may shop until
they get the antibiotic they want. So, let's be realistic about what we can treat with
this.
Karen did a nice job talking about the laws. We are in shackles right now. We have states
where you can do mobile health, but then you can't prescribe you want to prescribe unless
you physically see the patient. Well, doesn't that defeat the purpose? There are a lot of
barriers there.
I will close with the emphasis on let's look at which ones are going to save money because
I think we are all tasked with trying to find vehicles that will save money? Increase college
-- that is important. Again, the 800th on -- 800 pound grill in the room -- you have
to find the providers willing to embrace this. This number becomes a sickly small, unfortunately,
today.
Thank you.
[applause]
Linda Magno Good afternoon, I am and I appreciate being invited to speak this afternoon. I am
excited to talk about what CMS is doing -- centers for Medicare and Medicaid services -- in the
way of interesting new projects in the area of telemedicine and tele-health. I will talk
about these as I go forward. I will not spend too much time on some of these slides. You
know some of the issues we have with some of the existing delivery system -- it is fragmented,
care is a coordinated and system is not supportive and we have hit you hit the nail on the have
with a lot of this discussion this afternoon. It is not supportive of physicians and patients
and it is not sustainable.
We think we have or we like to think we have the best care in the world does he will come
from around the world to be treated here. In some instances, you can find the best care
in the world, but across the system on a systematic ongoing sustainable basis, that is not what
we have today.
That is what we are try to look for. I am from the Center for Medicaid and Medicare
innovation -- the charges to move the agenda toward a future delivery system that is more
affordable, accessible, it provides seamless and warning data care of high-quality, it
is person and family centered, and it is supportive of clinicians in serving the patient's needs.
We want to transform the delivery system. We think we can innovate this to a reliable
and sustainable and high-quality health care system that produces the goals of better care
the point of delivery through identification and dissemination of best practices. We hear
frequently that it takes 17 years for knowledge for new science to make its way from lab bench
to bedside. That is true with many of the things we are talking about today -- using
our heads instead of our hands delivering care. Things that require using our hands
seem to make their way a lot sooner. We are looking for ways to disseminate best practices
in other areas of care. But, across the spectrum.
Will looking for better outcomes of care through things like measurement and public reporting.
And to changing the incentives and ultimately were looking for lower total per capita cost
of care through restructuring the incentives that all of us face and deal with in order
to be able to reward value over volume. These are easy things to say, but they are challenging
to produce.
We heard about Telehealth. I'm talking about encounter-based telemedicine -- that is much
the focus of this discussion today. We'll time encounters between patients and physicians
in a different location, but there is also a range of Telehealth around remote patient
monitoring. Basically, the transportation -- transmission of information about and from
patients on an ongoing basis to the position to permit ongoing monitoring and adjustment
of care around one or more conditions.
In addition, there is an explosion as we go through -- day-to-day there is an explosion
of new technologies, devices that offer remote monitoring of a lot more things than we used
to be able to do and getting lab values and medication adherence. Sensors will detect
false or movement of elderly patients who live alone in their homes. Keeping track of
whether they are getting in and out of bed frequently during the night with a ball or
flush toilets or return to bat and trip or whether they move from the bedroom to the
kitchen and whether they are eating. There is an explosion of apps for smartphones and
mobile devices. I think increasingly as the devices become more common and the users age,
we will seek much more demand for interest in mobile health outpatient -- reminders and
healthcare management kinds of things.
There are a lot of people out there developing all of these technologies and I have experienced
it in my almost 10 years doing demonstrations in the Medicare program -- they basically
would like to come in as vendors or manufacturers of these technologies and applications and
essentially get ready care coverage and consequently Medicare payment for what they are providing,
but it is important, I think, for that community and for all of us to recognize that we need
to think about who the consumer is of the information that many of these technologies
provide. The consumers are sometimes physicians, sometimes care delivery organizations other
than physicians, sometimes patients, caregivers, remote caregivers -- some of the center devices
are very popular with family members being able to know what is going on with a family
member living alone. Knowing when to call someone your the patient. -- Mute patient.
Sometimes, payers has interest in this information. When we think about reimbursement as we are
today, think about who the consumer of the information is because I think that this helps
frame the discussion around reimbursement. As we look at the Medicare program historically,
we don't generally pay providers for the tools that they use in delivering care. We pay them
for the care that they are delivering. Sometimes, be in equity in the way in which this care
is paid for creates incentives that may discourage the use of better, cheaper, more friendly
and accessible technologies such as Telehealth and telemedicine.
I am reminded of the Clinton campaign slogan from 1992 -- it is the economy, stupid. Don't
forget healthcare. In the era of telemedicine and the information that Telehealth technologies
offer us, I think it is important to remember that it is the delivery system. Much of what
we are looking for as we look at innovations today is to look at where innovations fit
into the delivery system and is the delivery system demanding the information and prepared
to organize itself to use the information and doesn't provide value? In some of the
work we have done in the past, some of the models that we tested and some of the disease
management models, workable, which would've remote monitoring with devices and some just
person-to-person contact by telephone, have not been very well received by position because
it was more information than they wanted or needed about their patients. It was not useful.
There were too many different individuals trying to provide information to a physician
for different patients with different insurers paying different organizations to provide
disease management services. So, it is important to think about the delivery system using the
information. And the challenge for us, then, is to mind some of the delivery and payment
models that work together to create an environment in which Telehealth services are both valued
and can be paid for because of the way in which the entire set of instructions -- incentives
is being structured. This is in order to achieve -- achieve the results we are looking for.
I am happy to report that some of what we are going to do over the next few years is
to support a number of models.
This is my slide that is not going to be readable. We have a number of awards that were recently
made as a part of the healthcare innovation awards. Nearly $1 billion and cooperative
agreements that were made to 100 and 107 different projects around innovation and care delivery.
And payment models.
Seven of them specifically identify and are focused around Telehealth and telemedicine.
To summarize the models, they offer day-to-day monitoring of patients with stroke and heart
disease. They minimize the amount of travel that the patients have from rural or underserved
areas will need to do in order to be treated by specialist for specialty care. I know that
you will hear later in the next session from Dr. [last name indiscernible] -- Project Echo.
We will also look at extend the reach of intense it is to allow them to work as a supervisor's
of -- by remote contact with teams providing ICU care in rural and underserved areas. We
are excited to be beginning to work on these projects and these awards were just an outstanding
in July. Just announced in the month of May in July. The challenge, again, for us is to
be able to work with these organizations to figure out what it takes to make these projects
work and make these technologies work operationally and what the kinks are. This is so we can
learn from them and scale them up and begin to use these and other types of models to
shape national policy as we move forward. With the authorities -- the centers for Medicare
and Medicaid -- through the innovations we have the authority to be able to take models
that work and to produce better care and better outcomes and higher-quality and lower-cost
and expand those in scope and over time to it or national policy without getting specific
legislation. So, we are looking forward to working with these and another of -- a number
of other projects, many of which will also include some of the kinds of things we are
talking about today and encouraging these times of technologies -- these and others
as we move forward. >> I think one of the things that struck me as I was looking at
the descriptions of the projects we have just awarded these organizations is that they have
opportunity to help us achieve what the IOM identified to make care safe, timely, effective,
efficient, equitable, and patient centered. I think the things we will see what these
organizations and these models and others of the types we talked about today really
have a promise to allow us to do this.
I will stop there so we can allow the rest of the time for discussion. Thank you.
[applause]
While you make your way to the microphones, what we have heard is -- Jeff talked about
the realities of where we are today and the kinds of studies that are probably needed.
One of the points that Karen made, I think, is good. It is not only about creating reimbursement,
but also about removing barriers for doctors and other clinicians to take manage of the
reimbursement. You can reimburse, but if you have their ears, it is not going to work -- barriers
-- it will not work. From a private payers point of view, sometimes the payers are getting
ahead because they know what their members want. But, I think you raised some interesting
questions -- if you just open up everything, there are still challenges. Even when you
are paying your providers to do it. You still need to find doctors are willing to do this.
These new models are really very interesting and I think this gives us hope at the end
of this conversation that there really are some great opportunities here.
We will start over there.
Jeff, in the MedPAC report of June 2012 -- in chapter 2 -- you talk about the fragmentation
of care that exists for Medicare beneficiaries, particularly those with chronic conditions,
which is the will to pull majority. -- The majority. We have not heard a lot about care
coordination -- whether it is in the be for servers portion or as we move toward the client
centered patient centered approach to care with a team approach. I think it would be
important to hear more about how Telehealth as a tool, not just for diagnoses, but for
getting at the issue of quality and improving the care coordination for the care patients
in this case because it is recommended in the MedPAC report and as we move forward with
implementation of the ACA -- how it increases if efficiency and will improve the quality
of care. >> I don't have the scope of expertise to talk about all of this, but I will say
that any different to liberate system should be patient centered, whether it is before
service medicine or a managed care plan. I think that I would be somewhat agnostic in
terms of what we know works. A fully, we all want to do what is best for the patient there
are two different avenues going on. One is the more ornate it systems -- the MA plants,
and the ACO, and the fee for service system -- a lot of the demonstrations that you talked
about and in my mind, whichever ones of these are successful, they are the ones that should
win out at the end. In terms of the payment recommendations we have made in the past,
to be a -- neutral with respect to the plan. If the MA blank into a better than Medicare,
go for it. If before service without, then they should be the winners. The patient should
be able to pick whichever one they think delivers better care.
I am from [indiscernible] clinic. Thank you to the panelists for your talks to be a. It
is nice to see people from CMS engaging with us. I want to share -- our program -- we have
45 different clinical services. We have about 25% of our total clinicians around 1000 who
use Telehealth in their practice on a regular basis. We do about 5000 interactive consoles
a year -- about 40,000 telephone the see. -- telepharmacy. We analyze our reimbursement
and we do not build Medicare or Medicaid if it is not allowable. I want to share numbers
with you -- in 2011, we build -- we sent a bill -- we build everybody. In 2011, we sent
a bill for a total of 160,000 $7000. That is about $100 per console. This is what we
sent the bill for. Now we got paid.
Medicaid -- $200,000. At is about $50 per console. The total that we build was -- we
discounted 100 and we discounted $168,000 -- about 40% -- most of this is attributed
to Medicare and Medicaid discounts. This ended up with about $206,491 that the patient had
to pay out of pocket -- 11% of that total discounted rate. We lost about $13,000 which
we can't send a bill to anyone for. This is not include all the services we didn't bill
for. This whole Telehealth reimbursement issue is not so much about Telehealth, it is about
reimbursement in general. Even if we did get paid, we still have significant losses just
trying to provide care to piece it -- to people on an everyday basis. It goes back to equity.
There are regulations that they Medicare beneficiaries and Medicaid beneficiaries to have equity,
but as Dr. Edison said, if you are on that side of the road in one facility, you can't
get care so we have to pay $694 for a skilled nursing facility resume to travel to get wound
therapy what if we did it over Telehealth it would cost the system $56. We have done
a lot of this analysis and it goes back to -- treat it as normal healthcare delivery
and we are still struggling with a dollar a location , but it leaves we have made it
equitable for people. I think the remote monitoring peace -- we need payment because we are delivering
care. This will leave the cost to the technology in a care delivery system. We really do need
to that aim for evaluating the data that comes in and then acting on it in a clinical decision-making
process.
My question -- the other issue -- the Allied providers -- they are providing specialty
care. It is not really the positions. We need to look at what they are doing. They are providing
diabetes management -- some are doing sleep disorder assessments and follow-ups. They
are doing endocrinology. They are doing psychiatric care. They are providing specialty care. It
may not be a physician, but they are doing it incident to a supervised by physicians.
My question is -- we save Medicare millions of dollars in five years. We didn't really
see any of that transform into you payment strategies. What is your thought on -- we
could give you a ton of data -- we could fill up the room -- but, what is the likelihood
that this will actually transform into new payment strategies for us?
The act that the physician group demonstration served as the platform, essentially, on which
the entire Medicaid savings program is built. I am hard pressed to say it has not already
begun to change payment policy or create new payment models. I think we continue to be
challenged and I think part of what I am hearing today or what is part of what that what are
my mind as I listened to the other speakers, is that we are all trapped by before service
because part of what we are talking about is paying for individual services delivered
by telemedicine that are not currently paid for today -- paying different providers and
so on. You are talking about whether the payment amounts are adequate. I will not even go near
that. Congress deals with that once or twice a year. I will not touch that. I think the
real issue is the challenge for timing the types of delivery systems are willing to operate
as a system and create the infrastructure to be able to support the most efficient set
of tools for delivering care whether they are telemedicine tools or whether they are
other types of things that are not necessarily covered and paid for explicitly today, but
would be a part of the care that an organization that is focused on providing the outcomes
we are interested in supporting -- higher-quality, better outcomes, and lower provide the -- lower
per capita costs -- if they are producing those by using some of these technologies,
then the shared savings model or other types of models really are supporting those. We
get out of that issue of what is the right amount to pay for a telemedicine visit versus
and e-mail consult versus telephone consult versus in person visit. All the details of
administrative pricing that were under a fee-for-service system -- you the organization are taking
responsibility for the health of this population. We will pay you on the basis of the outcomes
and results you deliver. There are a lot of measurement issues, but that is the goal that
we are moving toward. That is the way in which reimbursement will change more likely than
by trying to identify each of these individual shortcomings in the existing set of arrangements
and what is covered and what is not and what codes are used for Web services.
Your point is validate it -- validated by the VA system -- they have adopted Telehealth.
Their job is to figure out how to deliver the best care with the amount of money they
have. It is interesting that in California and the Kaiser system is rapidly advancing
the amount of Telehealth but they are doing.
Linda, I wanted to thank you -- I agreed with the shared savings. Our challenge now is that
the only option is the physician fee schedule. A lot of people struggle with that. Thank
you. >> I am Larry Conrad -- University of North Carolina at Chapel Hill. I am working
with a set of people trying to find ways to encourage greater adoption and deployment
of Telehealth in a sustainable manner in North Carolina. I am wondering for the panel what
sort of things can be done at the state level -- state policy? What ideas do you have that
we might want to take a look at? This is to help specifically with a workable payment
model.
I would say whatever you do, don't do it on your own. This room is full of experts. Experts
on state policy around reimbursement. Any number of us would the war than happy to help
with that. Is that fair to say?
There are a lot of people in this room that can help with that. It has been done in most
if not any other states.
-- If not many other states.
One issue at the state level is that different parts of the state have different missions.
Just on the licensure issue, one of the issues around licensure is that our licensure people
are -- they are basically and consumer protection. The medical board said -- we don't care who
is delivering the care. If you are delivering it on a California resident when they are
sitting in California, it is our job to protect them. That person will have a California license
they come into our state. That is because their view isn't a global view. Part of it
is getting a number of people at the table which we have been able to do in California
in a number of settings. We did test pass some enabling legislation for Telehealth by
bringing a lot of it together to him up with what would be the best solution and let every
agency have it say in how we can address their concern.
This is fail [last name indiscernible] from the University of New Mexico. Also, IT medical
director for health information exchange. These comments have been great from the panel.
You have done a tremendous job getting a great overview. I want to reinforce one of the things
that someone just said. One of the things is that we have to make a fundamental change
in how we pay for healthcare. Some people say we are a sick system. We pay more for
procedures and for you to be in the hospital and we don't a well for preventive care. Any,
do you have on that would be welcome. How do you think we can move forward? Linda, you
were just beginning to address that. So did Jeff. I think one of the areas late into this
-- going forward -- I feel a retinal scan should be included in that -- defending blind
isn't detecting a problem. I pointed this over and over in New Mexico -- they will not
reimburse for store and forward in New Mexico, but if we miss retinopathy with the site being
threatened, they will pay for that, but they will pay for her rehabilitation. Something
is backward with the system. I would like to hear from Medicare CMS -- what is the issue
here? Why are we paying for that? Lastly, I want to reinforce what Dr. Edison said.
I don't know why this decision was made -- for some reason, we look at care being provided
only where the patient is at the originating site and we get rid of a host of problems
with us and sure, credentialing, maybe even reimbursement issues. Just say -- just like
when I drive to see Karen in Missouri for a problem, I relied on her credentialing privileges
and her qualifications in Missouri and not in New Mexico. If she did it to Helen House
-- why does she have to the credentialed and privilege where I am living. This doesn't
make sense to me. I would like to see some fundamental change made in that we look at
where the care is provided just as we would with in person face-to-face. Your comments
on that -- I know Karen made them, but I would like to hear from others on the panel how
they look at that. To me, that would take care of a host of problems that we face. One
-- store-and-forward. The other is -- where is the carefully being provided?
-- Where is the care really being provided?
I will not say too much about existing policy -- most of it is governed by statute and has
the constraints basically that are in the statute. Beyond that, I am on the things outside
of the organization. We are looking at alternatives. As I described and put their -- we will continue
to work on innovations that we hope will shape changes in policy. As to the historical practice
of not paying for store and forward technology, I cannot speak to that. >> I am not familiar
with the store and for debate. It sounds like it was a budgetary issue.
It was a budgetary issue 12 years ago. We were worried about what would happen if we
said Mary Kate -- Medicaid would pay for store-and-forward. Alaska and Hawaii have experience with this.
We have 10 states with varying years of experience. In general, we haven't seen that explosion
and fraud and abuse that people were worried about. There has been a variety of other things
that happen. I mentioned -- doing away with the consult close means that people lose money
when they see a hospital console. It is hard to get people to do that. I am not proud of
that. I am the chair of the workforce task force and it is a concern of mine because
we need to be serving those patients. In my own academic health Center, one of my residents
seize patient and I am in the clinic -- they will send me the photos and we will talk about
it and make a recommendation and then I go by and see the patient within 24 hours if
I am going to build for this. But, I never changed my mind. The technology is so good
-- I can't make a split-second decision and make the estimate recommendations in real-time.
I go by to meet the letter of the law. This is so I can bill for that consultation if
no date they don't pay for consult close. I think store and forward tell us their mythology
-- these no-brainers.
When California expanded their Medi-Cal program -- these are the two things they carved out
-- Tele dermatologist and retinal screening. He did this for good reason.
Also, in the patient centered medical homes we are seeing, we are partnering with our
family and immunity medicine department and our internal medicine department and their
patient centered home environments because in dermatology you can do three, direct care,
and consulted care. If they see a patient in a no-no what it is -- they can send me
a photo -- they do this all the time. We are trying to formalize this. Patience send photos
all the times. The VIPs of your organization send you photos -- we are trying to make it
secure and private and formalize it. If they see a patient in a patient centered healthcare
home, they can take a photo and send it to me and I can say -- we have to see that patient
today. Or, that can wait for a couple of weeks or one that you try this. If this doesn't
work it -- let me know. You can do a lot with the technology that is better quality and
better access and lower-cost. When you access me that way, you are going to send less people
to me. That is going to be fine with me because my waiting room is too full already.
Diversity of Pittsburgh -- thank you for a great session. My question is about financial
incentives for telemedicine with the forest service -- I believe that these models are
a great idea, but there will be a role for the four services in a large health system
across state boundaries. I was struck by what Karen and Jeff indirectly said -- questioning
the role of telemedicine to increase efficiency. There are not enough special is that we are
to have too many patients. If we would just rather see a patient person that through telemedicine.
The obvious fee for services solution would be to reimburse more for a telemedicine consult
and that would provide us with financial incentives to see a patient be a telemedicine. Obviously,
this one out there. We've heard someone from the ATA suggest that we should be happy with
less reimbursement. I want to press you to come up with other innovative payment models
within the forest service that might incentivize a specialist to use telemedicine and I will
throw out to potential ideas that you can shoot down. One will be to potentially build
it into the value-based purchasing system so that maybe we get bonus points. You get
the same reimbursement or maybe even less, but bonus points via value-based purchasing
for participating in a telemedicine couple.
Then, this is more of a question -- are there already financial incentives for a specialist
provider to provide rural healthcare in person? And those incentives be translated like loan
repayment in those kinds of things?
Those are my questions. Thank you.
There are not incentives to go in person to provide rural care. For specialist. There
are four PCPs and general surgeons in some circumstances.
I would say that some of us have proposed the idea. The loan repayment programs that
are now used for physicians to go and locate in a rural community -- in a huge number of
those people leave after they met their commitment. This is to break that up and say to graduating
specialists that it you provide 10% or 20% or some time -- you will get that percent
of your time toward your loan repayment. This is in order to incentivize them to start the
model of practice. What we found is that once people start to telemedicine, as long as they
are department chair will let them, there was one right there -- they like doing it.
They want to continue doing it. One of the things to do is to introduce early on in their
practice. If you get new graduates and say -- I can't do one day per week in telemedicine
in a rural area and I will get a percent of my loan payback. That is a potential proposal.
I know there isn't not enough money in the loan repayment program in general, but that
is an idea.
Any other ideas? [indiscernible] This is not a formal position -- but I would toss this
out -- I am concerned about the cost of telemedicine on the go. If everybody has their personal
device and they call someone up and say -- oh, my prescription has run out and I need a refill
and you call up on your device and it used to be a phone call and now is a consult any
new cost for the insurer. I think it would be to get around that -- this is a hypothesis
-- if the telemedicine consults were a part of a medical home Damon. You are getting it
for member per month payment in over order to Courtney cared have access available. Part
of that could be telemedicine. This gets around the trying to hit more units of service, but
it also requires that you provide this access for the patient. I don't know if you think
that is feasible?
We are definitely looking -- that is why I stress -- we have to understand the stresses
we are putting on these doctors and now we are asking them to do management. Whereas
in them to expand access and they have a panel full patience and they are seeing 20 or 30
or 40 a day. Now we are asking them -- can you hire position extenders and we will have
you with that too over the disease management case management and now telemedicine? We are
already trying to ask them to do more things and they are filled to capacity. There are
many hours in a day -- they tell you that they work 10 or 11 or 12 hours a day.
IPO personally that the PM PM reimbursement is the way to go, but the primary care doctors
-- many of them are worried. By fully so. Will I make more less money? Everybody in
society was to make more money, especially the more that they were. Alternately, if we
have the incentives aligned and it makes financial sense for the primary care doctor to keep
the patient to the emergency room to see them via telemedicine for a UTI or a perception
resell in stead of saying come into the office, we will have a potential for this to work.
We are still skeptical. We want to be reassured that they will not make less or that drastically
less -- that is their worst nightmare. In terms of fee-for-service -- I don't know if
this helps -- I will give you an example and maybe this will answer your question. A long
time ago, when we were trying to decide about reimbursement for end up to be and: after
be -- we said use got a certain amount of money. But, if you do them the same day, one
anesthesia and the 2 procedures together should be less time so you will get less. The majority
of the patients -- it is rare to get to see and end o the end: after be on the same day.
-- endoscopy and col;onoscopy. Were not seeing that -- we are seeing them come back to separate
times for two separate procedures because everyone makes more money on the provider
side.
I would just say -- I mentioned it briefly and -- one of the things we are seeing -- health
systems and industry. Contract on it be of service rate. For the consult. For the employees.
Or the members.
That is a fee-for-service -- not a traditional beef or service. It is a contract for services.
So, we negotiate the contract weight and they pay us per no matter what it is.
[captioners transitioning]
retinal New Th non pat thee retinopathy retinopathy [ indiscernible ]
telemedicine end scope pee end scope endoscope pee
colonoscope pee colon pee
I agree that the site fee at $24 is not equitable. I was sensing a lack ofness Tuesday A for
increasing it. People ask us when we advocate what should it be in a rural facility. If
it is not $24, what would be equitable?
I think that is a tough question exactly what it should be. On the one hand, you want patients
to have access to care. On the other hand, if I was, say, 45 minutes away from Sue falls
and I could drive there in 45 minutes and see my dermatology gist or I could stay in
my local community and see the local dermatology gist, I save 35 minutes each way, over an
hour. You could say what is that worth to you? They might say 20 bucks. Should we set
up a 50-dollar extra payment for the hospital to service the point of care for that person
and basically say, Mr. Rural south Dakota, we will take $50 of your tax dollars to cover
the hospital to what you think is worth $20. That is the downside. We want the access there
and maybe we need more payment to have access there. I want to keep it balanced. We don't
always want to spend more money on a service that is not worth that much money to the patient.
It is not a popular thing to say but I think it is the reality. I may be somewhat biased
because back in the 90s when we worked for the telemedicine center, we asked the patients
what would you do if it wasn't there? How much is it worth to you? Would you drive?
It is a difficult question because we want to have as much equal access as we can but
we also don't want to be spending more on something than it is worth to the patient.
Doctor Edison?
I was hoping to duck that one. We actually picked -- when we did this, we were trying
to keep the cost down and I literally picked up the phone and called around the country,
people I knew and asked people and said how much does it cost to put a patient in a room
and sort of averaged it and it was 20 bucks at the time. That was 20 years ago. As I was
trying to point out with the meaningful use requirements, it ratchets up what it means
to put a patient in a room, a lot, particularly if they have a lot of medications and a lot
of chronic diseases. Will maybe that is not the right price point on that right now. I
think we have to really think about this as healthcare evolves and the mature electronic
health exchange information involves, what impact that should or should not have on our
paint systems.
Thank you.
Stew wart Ferguson of Alaska. I have to apologize -- we have benefitted from Karen's efforts
back in the ' 90s I think it was. I guess this is the issue that I see is ten years
ago, maybe 15 years ago, the issue was for reimbursement in general for telehealth, the
strategy was to work with CMS. So go private pairs and their parties and Medicare, right?
What we have learned over the last few years CMS hasn't moved the dial and forward. Most
of your private payers have fee for services or private contracts. There is millions of
telehealth cases happening with groups who do it with store and forward. Two questions
I guess really. One of them is how relevant is a strategy today to work with CMS? Is that
key to what we are trying to do right now given the changes that have happened. It is
a question. The second question is -- again, with Karen's talk was very focused. She is
looking for one change that will move us forward. What is the strategy to make that happen?
Is it a CMS strategy or is it something else? If you haven't had enough coffee, we can talk
about this off line. To me, these are the questions. Life has changed and we are not
talking about how the strategies have to adjust with time. [ laughter ]
I will not tell you whether CMS is the right strategy for you to pursue. CMS deals with
Medicare and Medicaid can move ahead and in some cases has. We are clearly open to testing
new models of payment and delivery. I would note -- the thing that struck me in the previous
discussion about what this is worth to patients is that while our patients are sicker and
maybe less likely to drive over time, by the time they are likely to drive, they are often
more complex that telemedicine may not be the appropriate model for them. Without getting
into an neck dotes, I think there are a lot of elderly people who value face to face time
they have with physicians and if telemedicine brings the care to them in their homes, that
might be a model that would be attractive and appealing and clearly worth considering
but when we talk about saving time in a population that is largely retired and has lots of time,
saving time by not driving 35 minutes or an hour each way or 45 minutes, whatever, is
not as critical as it is clearly for younger population where I think the convenience of
telemedicine is something that will drive -- is driving private insurers as well as
some of the other issues. As I look at the population, I look at the population needs,
the costs are and the complexity. I see it as a case if there is something that makes
the care easier and more convenient for patients and that's the form they want it in, I think
that may be a strategy. In general, there are a lot of other things besides Medicare
that are playing into telemedicine -- who it is valuable for and how and why.
Stew wart, I agree with your comments about how the landscape has changed but I still
think it is a valuable strategy to partner with CMS in both of the issues you mentioned.
I think it is a valuable strategy and I think we should continue to partner with CMS on
these issues. I think not doing so would be a mistake.
I think it is good to partner with CMS and hope people will work with the private issuers
and people outside the fee for service system like a Kaiser or something. In my mind -- when
we do our research, we are looking for what is the private sector doing. We know what
the financial centers are. If we think they can provide better care for less model, we
get excited. If you can't convince CMS and it works for someone else, that's great. If
Kaiser gets bigger and bigger market share and cap at a timed systems get more and more
market share because they can do more for the patients, great. If it kicks Linda and
I out of a job, that's fine with me. Hopefully it goes in both directions and we can let
all good ideas come to the floor.
I wasn't saying not to partner with CMS. For the kinds of things that Medicare can do to
make telecare valuable to the patient. I don't think CMS should be the cornerstone to make
all the rest of the market to move. Medicare often sets the direction, not exclusively
and I think it is important to look across the board at other payers as well. That is
what I was getting at.
Join me in thanking our panel for a great discussion.
[ applause ]
We will be starting back at 3:00 so we have 20 minutes.
[ break ]
We will start in one minute .
Our next panel is the healthcare continue women. We have three speakers today. The first
speaker is Bill apple gate. Executive Director of the Iowa consortium .
I think you heard earlier, project echo is one of the award winners for the CMMI project.
Who will start first? Bill will start first. Thank you.
Good afternoon. You see the title. I ask for world peace but they give me this one. I guess
it was a negotiation. I think I just click this . I will say some things with health
systems over a period of time. I worked with them and was the CEO of multiple healthcare
systems for years. I may be on the outside now but I do have experience with those systems.
I say what I say with a view of what is going on there and for the last ten years, I worked
in a health sciences university at medical school while finding the consume um. We work
in about 28 states so we have a number of projects going on. I wanted to show you this
slide. It is my favorite slide in the whole wide world. We all play in this in different
areas and the better we can play in it, the better off our health of our nation will be.
I like to talk about individual parts of it. We have quizes among our staff that says pick
out one block of this and tell us something important that you want to share about this
block. We enjoy this a great deal. I want to make some personal disclosures. I have
no money and it hasn't been doing very well so I don't know where it is. I can't tell
you whether I have it in the right or wrong place. I thought there would be other personal
disclosures that would be good for me to share with you. I'm deeply, deeply devoted by making
health happen by making shocking strategies that touch the lives of people. I want you
to know that it is really making better health and lower costs which is better healthcare.
So we are kind of involved with the triple aim but we are really focused on achieving
better health and lower cost. Sol route general particulars. It is the opposite of path general
in this cases. It is the building and establishment of health . Then I had a curious pathogenic
industry that we are all involved in and know of in all different ways and seems to busy
itself with a lot of costly approaches to fixing the health and healing the sick and
diagnosing -- but does little for mitigating the most costly component of healthcare expenditures
and the last thing, you will learn a little bit about this the Iowa consortium. I will
talk about that in a little bit. Here is what I will do today. I will talk about some truth
about managing chronic conditions. The real will he ever has to do with chronic conditions.
I like a lot of things that are going on but a lot -- the Willie Sutton comment, why do
you rob banks? Because that's where the money is. A lot of healthcare can be better off.
I want to share some field proven experiences. Just about everything we do is telehome care
and health based. We don't believe you have to come to the office or hospital to do an
awful lot of things to get really powerful results and then I want to explore clinical
health coaching and how I believe it is related to lightening in the bottle. I did a presentation
a couple weeks ago at a meeting and I asked everybody how many of you in the audience
are now directly or indirectly interested in management of chronic diseases? Do you
identify those with chronic conditions and proactively? Do you identify and manage those
fairly well or do you wait in affect until people present themselves with their chronic
conditions and you deal with them at that point? These are the kind of questions that
are really important. You have to reflect on that with your own organizations. I hope
what I share will help move you to a better place on this screen than where you are at
the present time. Why are we in those conditions? Sometimes we are unclear about what our desired
results are. And how we are going to do it. If that's not a problem enough, reimbursement,
we heard about it in the last segment, it is inhibiting getting us going where we want
to go. Frankly there is not a lot of confidence in what we need to do. I review a lot of propose
Sals and like a lot of you do and for organizations we know of and I'm interested in how we have
set ups, lots of data stuff being developed now. It is really impressive and we have outcomes
over here but I'm lost in space in this magic in between about something that is going to
happen in the lives of people to get the outcomes. In fact, I just don't see them very often.
We will expand access, prompt healthcare reform. Implementing new strategies of payment reform
through CMMI and others and reduce overall costs of healthcare. I think we are doing
some specific things in number 1 and 2 and some in number 3 and the last couple of them
are what I call faith based strategies and promises of healthcare reform. I believe in
them a lot but I think we need to work towards those. I want to talk about the big thing.
Some of you say it is not a secret. This is undeveloped and often unspoken saves costs
for individuals and health plans and hospitals and governments. It saves costs all over the
place and improve healthcare and does a lot of other things and we can do it. It is within
our ability to do it. What it is is keeping individuals with chronic diseases out of the
ER. That is it. Well, I know that is big but what does that mean. I want to draw a little
picture for you. 50% of the people on Medicare right now cost $550 a year or less. This is
a lot of people. What does that mean? That means that a bunch of them are costing more.
We go back to some data. In 2007 the average Medicare beneficiary with -- if you flip back
and say 50% are costing 550 and less. The percentage of cost associated with hospital
aces and ER visits and around chronic disease is 83%. This is where the money is. We can
do intervention that will reduce that substantially. We have a sick care system which a lot of
us have talked about that needs to be more of a well care system. We need to move from
path general cysts to absolute general cysts. We have a difficult time doing it because
of the structures and systems we have . The miss aproposition of education as an end game
is a real problem. Healthcare professionals, I'm the patient and I'm the individual. You
tell me what to do and we have operated for a long time under the assumption that after
you have told me, you have done your job. It hasn't changed my behavior or performance
and lastly, we have an over artificial -- artificial over alliance of coming to the healthcare
provider to get chronic disease managed. I'm so sad. It is too bad. I want to talk to you
about projects. They are about what you can do. These are telehealth projects. The Office
of management of telehealth has funded some of these because they have faith in us. We
like to work with Medicaid populations. By the way, we work with other populations. We
work with heart failure program for their 265 cardiologists. We did that. We are doing
things all over. We like to cut our teeth on Medicaid. If you can do things on Medicaid,
you can do things anyplace. 266 members of Medicaid with heart failure. They cost 24,000
when we did this. We did home monitoring devices. It is heavily technology leveraged and we
avoided hospital visits, the entire get dressed up for a party expenditure of $330,000. We
saved over $3 million. This is no science project, how do I want to say it, bad evaluation.
We did match control groups. These are pretty powerful designs to show this. This gives
you some idea. Here are the expenditures in our match cohort and our project. This is
under way at the present time. This is a 2010 and 2012 project on diabetes. Our inpatient
visits are 54% under for those in the control group. Office visits down 6. A lot of our
projects we have office visits go up. 1 to 100. An office visit costs 1% of what a hospitalization
costs. I don't care if we double, quadruple our office visits, we are well on our way
to prevent a hospitalization. The total cost reduction is about 20%. The return on investment
is pretty shocking on this. I just got off the phone with CDC. We want to do behavior
change in health and wellness, Medicare people 58 to 63 and we took farmers because they
are an easy group to change behaviors in and we gave them health risk assessments and gave
them education and we gave them diet and exercise and prevention incentives and then we gave
them coaching. We got reduced risk, improved health status and improved trending. As we
grow older -- we believe in population stuff -- you are all better than this -- as populations
our health risks go up when we grow older and our health status goes down. What our
job is to hit that group and say how can we zero trend those. That's what we have done
and we will report that out in a couple of months and I will be very, very happy about
what we have done and it is exclusively done over the telephone. Even the HRAs and the
fasting blood sugars are all done by home kits so nobody has to go to any doctor to
do this. Doctors are involved in this if they want to be.
Something else we have done. If I don't go to the hospital or you don't go to the hospital,
who saves money. It isn't just you or me or our health planning. 50% of the hospitals
in this country -- happy to name some names -- are losing money on Medicare heart failure
admissions. They don't know it but they are. Some of them believe it helps build their
baseline costs so it is okay. Now, here we go, maybe, our telehome care learning 89%
of the healthcare takes place in the bedrooms and bathrooms and kitchens of our own homes.
If we can't get to those places with people, we will not get healthcare changed. Their
health is priority number 1. We can get a preponderance of these type of interventions
that can take place telephone ton Cal Lee. How do we get the results we get? We give
$35 per month for PMP coordination. 50 doors for technologies and registries and $5 for
the network. You get pattern groups of people doing this and you can do all kinds of things.
If you believe in medical homes or ACOs, we are working with a lot of people on both of
those and it is scaleable to all payer applications.
Health coaching. We are getting to the 80 to 90% of the healthcare that takes place
in the bedroom, bathrooms and kitchens in homes. We developed health coaching. All of
our projects have pretty active health coaching in it. It is not like a football coach. It
is not like a teacher telling people what to do. Health coaching is its own style and
it is important. Why do we want to get to behaviors. If you take a look at factors contributing
to health and behavior things, what you will see a lot of them are, in fact, malable. If
you can get to those, you can get big differences. Self care, HARQ said 95% of the
dye beat tease care. We weren't getting to people like we want to. What we have done
is create something called evidence based healed had health coach. Transform the information.
That's what takes place between the provider and the individual. We don't call them patients
very often. We call them individuals and the truth of the matter is that's where we are
trying to get . I want to make sure some recommendations here. I call them the loving suggestions for
themselves. We need to support telehealth with robust evaluations and that means research
quality. We can't get to clinical trials. I get that fully. I know we can't get to clinical
trials. The reason we need to have pretty good designs is if there is a lot of bad evaluations.
I think we need to take a look at projects that leverage work at costly -- another thing
we need to do is we need to I think provide some design and evaluation technical assistance
to projects, need to work closely with CMS and have seen good demonstrations of that.
I think lastly we need to take a look and value at some of the clinical health coaching.
Remembering the idea that so much of the care that takes place in the country happens as
a function of self management or self care. If we don't get to that, we have to have better
strategies and that won't revolve around changing the healthcare system as we know it now. Done.
Thank you. [ applause ]?
Good afternoon. I'm Joe, vice president of -- I will go as fast as I can because I don't
want to see the red light. I will take about 15 minutes and tell you about some of the
programs we are doing in acute setting and -- thank you to the planning committee, especially
Karen and Tom for inviting me to speak. Where is Allen town, Pennsylvania, hum the Billy
Joel song. Just to give you an idea of what we are. We are a big place. About 981 beds,
three facilities. We employ about 1200 plus doctors and 300 plus nurses and we have about
11,000 employees. I will jump in and talk about critical care right now and talk about
some of the challenges that we have. I will not paint exactly a nice picture at the moment.
We have an aging population, somewhere between 8000 and 12,000 people are turning 65 each
day. I know I'm getting younger but I have to keep an eye on the rest of you. There is
an increased demand for the service and providers and the lovely increased costs. It is about
90,000ICU beds in the country representing about 15% of all hospital beds and actually
there is a decline in the number of hospitals with ICU beds. However, there has been an
increase in the number of beds total. So we have fewer hospitals with those beds but we
have more beds overall. Approximately 540,000 people die in ICUs each year. And mortality
rates average 10 to 20% in most hospitals. Only 10 to 20% of hospitals have critical
care staffing that is dedicated and only 1% have it at night. The bad news is there will
be a 35% shortage of intensiveses going forward. We need to find a way to spread this expertise
out beyond the large centers that are fortunate enough to have large ICUs and a large number
of intensiveses. We developed the ICU at Lee high valley network. We called it the advanced
ICU because we wanted to improve patient safety. We purchased the hospital and wondered how
will we keep the level of ICU equal to the larger facility and we were already leap frog
compliant but we wanted to go beyond what they require in terms of their model and frankly
it was the right thing to do. Let me introduce you to mat Mick Cambridge. He is chief of
critical care. He is silting in one of four identical pods and I will describe them to
you in detail. Mat has every information tool he would have at the bedside and he has it
in a remote location. I don't think it is all about an audio video system. I think it
is about a combination of all sorts of health technology information and we are referring
to as our HIT bundle. He has access to the pack system. He has real time audio and video
into each room. He can zoom the cameras in and do a pipe pill reaction. We have electronic
administration record. We have physician order entry. All orders are done through that system.
We have an ICU electronic medical record that ties to the master medical record. We have
an event system so if a patient's vital signs head in a very bad way, we know it in one
minute. We have access to labs. We have all these tools all night long. What did it take
to develop it? A lot of money. It took two years to develop just on paper. We had to
involve all the key stakeholders in doing it. Of we did site visits and budgeting and
business planning. So let me tell you a little bit about the critical care during the day.
They are rounding during the day 7:00AM. To 7:00PM. They are closed so the intensiveses
can intervene and consult on every case in the ICUs and just so you know our trauma ICU
and our burn ICU have physicians in-house all night long long. It is in a remote location
separate from all three of our facilities. Just so you know, this is an added layer of
care. This was an expense on the hospital system because we replaced nobody at the bedside.
So this is just an added layer of care, a second set of eyes and ears to watch over
the patients all night long. We have 12 board certified intensiveses that rotate through
and four clerical team members rotate with a take home point nobody works full-time in
the advanced ICU. They all maintain their floor and unit duties so they can keep up
their skills with patients on the floor . I wanted to tell you that to put that in context.
One of the first studies was out of northern Virginia. Big decreased in mortality. Length
of stay decrease which decreased their costs. Allowed them to have more admissions through
the ICU and it contributed to their bottom line and I will tell you ours probably does
too as a result of the length of stay. We are able to have more through put into the
system. We published a study in April of 2010 in the archives of internal medicine. We went
back and looked at 954 patients prior to the ICU and 959 after . We did have a drop in
length of stay of .29 days. While that was not significant from a statistic Cal standpoint,
it is always statistical from our standpoint. The patients that benefit from this. Based
on the reduction in mortality, we are estimate tag over 500 more patients are leaving our
ICUs alive in any given year at this point. We had a positive study. There are also some
studies that basically did not find the same results. This one was by Eric Thomas and con
that remote monitoring of intensive care patients was not -- another study by Janet more son,
they did not find any reduction in mortality, length of stay or hospital costs attributeable
to the introduction of the teleICU. Why did our results differ from theirs? In the more
son study, they were looking at a model where only 73% chose low level teleICU involvement.
So they were not using this to its fullest capability. The Thomas study only 66% of admitting
physicians chose minimal admission to the ICU. Every patient is treated the same way
every time. There is no difference in the level of care they receive during the night.
So I don't think it really has much to do with the study, the methodology, the design.
It has to do with the model of the telehealth program. I will be the first one to tell you
if you want me to develop a really bad telehealth program, I can do that fast. It takes time
to create a good one. If you study a bad one, your study would be inn -- I would be remiss
if I didn't do a shout out for my nurses. We looked at this early on. The effectiveness
every nurse on each 12 hour shift got 90 minutes more of direct patient care than they did
prior to the implementation of the ICU. They are feeding the electronic -- they have reduced
the amount of charting. We have a lot more bedside care time back. I will back up one
slide. I will throw this out there for you to consider. If you put a network in place
and you are not treating each patient the same in an ICU environment, have you created
two levels of care? I will let you think about that. I'm not the one to say whether that
is true or false. In some cases if you are just not treating the patients the same, maybe
you have. Back to the nursing thing, not only do they have more time back in patient care,
we don't have to wake up a sleepy intensivist at night and report on something that they
may or may not need to talk about the intensivist about. That has been a real positive for us
as well?
Another project we are looking on is teleinfectious disease. There are provider shortages here
as well. You have to deal with the burn out issue. It becomes how do we use this resource
the best way. What we did was available program remote consultations during daytime hours.
Exam cameras, document cameras and the doctors have access to labs. We are in three hospitals.
One is a rehab facility. Two hospitals seeking an agreement. We do not assume care of the
patient. That stays with the hospital group. We do a true consultation and provide documentation
back. These hospitals have daytime hospital lists and they pay us for the service. Why
would they pay us for the service? This is beyond my wildest dreams. 85% of the patients
we are with now are staying in the remote hospital. You are reducing all the transport
costs associated with an inpatient transfer, an inner facility transfer and we have to
charge them because there are things called the antikickback statutes where you can't
give things away. That is one thing I would like to see stopped. Is there anything else
I wanted to say on that? We are using the services at the smaller hospital, their labs
and X-ray and we are leaving beds open in the bigger centers for people who need them.
I have two minutes before the red light comes on. I'm going -- this is the part where if
you go seconds, someone has already said what you wanted to say. My goal, keep patients
close to home in a safe, lower cost environment. The two themes we have heard today has been
reimbursement and license sure. Your address should not dictate where you receive care
in this day and age. If I lived in New Jersey, I could cross the Delaware river on the Ben
Franklin bridge going to Philadelphia, no questions asked . This is good for the rural
hospitals. Keep them lives. How many of you know that the Office of inspector general
issued an opinion from a requester last September and the requester asked "I have a telestroke
program and this telestroke program is intended to keep patients in their remote hospital
and I would like to give them the equipment. I don't want to charge them for the service.
I will give them the protocols and I will give them the education and for all of this
I would like to do this in an exclusive format where that hospital can only use my services
for two years. This would be a clear violation of the antikickback statutes and it would
but based on your argument that you hope and will keep telestroke patients in the local
communities, we will probably not prosecutor this. You can make that argument for every
single telehealth service you do to a rural area or any under served area. If they have
gone that far to basically kind of push aside the antikickback statutes that we should try
to go for a wider coverage of that so that they gave the antikickback statutes for many
more telehealth programs. I think that is something we need to do. There is my contact
information. That's my story and I'm sticking to it and thank you for listening. [ applause
]?
Echo stance for extension for community outcomes and the mission of project echo is to expand
for common and complex diseases in under served areas and monitor outcomes. It is funded by
the state, legislature, Department of health and Medicaid department, HARQ and Robert Johnson
foundation and most recently by central Medicaid and Medicare innovation. The story of he can
so with hepatitis C. It is expected about 20 million will die from this disease if the
current rates of this continue. In New Mexico where we live 28,000 patients had this disease
and less than 5% have you been evaluated -- have been evaluated for it and 2300 prisoners that
have been diagnosed haven't been treated. This was occurring despite the fact that this
is a curable disease, there are Gene know type can be cured -- 75% of the time. Despite
the fact it was curable, the bad news is it involves weekly injections chemotherapy like
injections. Not a single primary care doctor in New Mexico were treating hepatitis C. There
was an 8 month wait to see me. Sometimes people would need to drive 200 miles each way to
see me . Only 20% of our doctors practice in rural areas. We developed a new model to
take care of this problem with the goal of expanding the capacity to safely and effectively
and monitor outcomes and mon we wanted to develop a model -- we knew if hepatitis C
would work -- Dave Albert son is the head of telemedicina I'm just a clinician in the
Department of medicine there. I said look, I have no money and no grants but I want to
do this and you know who your friends are because they are your friends when you are
poor. He gave me his facility to use without any cost to me and help us set up the echo
model in his facilities and thank you very much for that. We have -- the first step was
we developed a partnership with the University of New Mexico, Department of Corrections,
health department and Indian health service and community clinicians who had an interest
in hepatitis C. These are the four main pillars. First we use technology, multi point video
conferencing and the internet. Second, we use a disease management model. Third, we
set up 21 centers for excellence for treating hepatitis C all over New Mexico. We asked
ourselves how will we make them experts. We will make them experts by case based managing
and by learning by doing. Lastly we do use the internet to track outcomes. This was published
in 2007. We train them to use our web based software to track patients and conduct medicine
clinics which we call knowledge networks. They join us simultaneously. One by one these
primary care clinicians present patients with hepatitis C. I have a standardized format.
I need all 20 pieces of information in a maximum of 3 to 4 minutes. Our team gives them advice
and we co- manage the patients and go to the next place. In two hours we give them a didactic
presentation which lasts 10 or 15 minutes or so. This is what you just saw was a knowledge
network. No patient ever comes onto this network. The way these doctors learn and become experts.
They learn through our presentations. They learn from each other and mostly they learn
from doing. They collect data and no -- we want to reduce professional isolation by improving
professional interaction for rural doctors. We want to bring a mix of learning -- why
is there such high turn over. They tell us there is no blooming deals and here and no
alibi questioner key academy here. When they went to medical school and residency, it was
ague had mix of learning. By giving them access to multiple specialists and learning. We use
very simple technologies which I will not go over. The lectures can be seen. Web cam
interfacing. They can use a web cam we have done 500 such telehealth clinics. We have
expanded to multiple diseases and overall provided 27,000 hours of CME credits to rural
physicians in New Mexico and 19 different conditions. We know a doctor is not going
to be willing to treat hepatitis C. Because there are lawyers out there. We asked our
doctors what is your ability to identify suitable candidates for hepatitis C. Question 3 what
is your ability to treat hepatitis C and treat side effects. Can you now serve as a local
consultant in my clinic question number 5, goes from 2.4 to 5.6. 2.6 to 5.1. Overall
competence goes from 2.8 to 5.5. This is published in hepatology in 2010. We asked them, primary
care clinicians are not just free all the time waiting for television shows to start.
They have very limited time. They are not going to come on a network unless they find
it beneficial. We ask them is this kind of network beneficial to you. 97% said it was
major to moderate. 94% feeling -- 98%. This was published in health affairs in June of
2011. We measured the professional isolation in 2005. Project echo 4.3 out of 5 and 4.8
out of 5. Benefit to my clinic 4.9. Expanded access to my patients, 4.9. The purpose of
the trial was to train primary care clinicians and prisons to deliver care and to show that
that care is as safe as university clinic. Intervention sites were 16 community based
clinics. The control was the university of Mexico, liver clinic. There was auto prospective
-- participation was -- clinician was not feasible. If you were living in silver city,
it would be difficult because you were 250 miles away. The bigger problem is if you live
in Al but questioner key, it is harder to randomize you to the prison . Once you are
cured of hepatitis C even after we go 15 years later, there is no virus. If you have sir
row cyst and you are young, it reverses. These are the treatment outcomes that we published
in the New England journal of medicine on June 9 of 2011. 68% of the patients were minorities,
49% university, highly significant. Cure rate for general know type 150% in echo, 70 for
Gene know type 2 and 3. He as safe and effective -- we can improve careful minorities but a
very, very interesting new finding unexpected occurred. The cure rates were much higher
than any other community to put a trial in the United States. Gene know type cure rates
of 20%. There were community gastroenterology gists in very large trials. We asked ourselves
why are the outcomes so much better, by team based care -- where patients don't have to
travel long distances where you use best practices and where the patient has a relationship with
the team that is actually providing the care, you can get better outcomes than even a specialist
can do. After hepatitis C was successful we were asked by primary care doctor toss start
other disease categories. If you have effective treatments, you can use this model. Here there
are two principles. The 80/20 rule. You don't need echos for 500 diseases. There are about
20 diseases that account for most of the morbidity and mortality. If you do echos on that, you
can have a high impact on healthcare. Everybody provides different care in private practice,
universities. We want to cut horizontally to provide the same care everywhere especially
in rural areas. The key goal of project echo, is the force mute applier. Redefined it in
healthcare, ten times or greater improvement in the capacity to provide care for complex
problems. How does this happen. Like nurse practitioner they ares to provide the same
level of care as specialists, you get forced mute complication. We improved the capacity
more than ten fold and my waits in the clinics have gone to 3 weeks from 8 months. We have
400 sites all over New Mexico for 19 different healthcare problems. In every area, let's
take the bottom right, we have one doctor with a special interest with rheumatology,
one with *** and one with asthma. People don't have to travel 250 miles to see a specialist.
Medical knowledge is increasing expo then shallly. Mine is going down steeply with time.
There is an increasing gap with what a doctor needs to know and what he can possibly learn
with more care. We would like to transform primary care with network. They choose -- I'm
a general list with a special interest in hepatitis C and so on and so forth. Echo doesn't
train primary care doctors and nurse practitioners. We train medical assistants because chronic
disease management is a team support. The potential benefits to our health system are
improved quality and safety. Reducing radiation of care -- work force training by de mon non
pleasing knowledge. Supporting the medical home model. Preventing costs of untreated
disease had disease and integrated -- the VA is having a national replication -- just
the Albuquerque -- our current represent indication sites are university of Washington for those
four diseases, university of Chicago, Utah, Nevada, Department of defense, we have a worldwide
partnership for chronic pain and the other countries shown here also replicating project
echo. This is our team doing this work. I want to share some of the awards they got
in 2001. This team won the award for the most disruptive innovation in healthcare worldwide.
They received the other grants in this slide. -- using multi practice -- could K managing
patients with case based learning is a robust way to effectively -- and under served areas
and outcomes and thank you for your attention.
[ captioners transitioning. Please stand by. ]]
ou this integrated will enter the p aradigm. To get it example the Virginia VA all-caps
putting patients effectively -- University of Washington for those for diseases University
of Chicago Harvard that Israel Utah Nevada South Florida Virginia Virginia for 11 411
regions Department of Defense we have faith partnership for chronic pain and in other
countries shown here also replicating project ECHO. This is a team that has done this work,
I don't want any of you to think I had that much to do with the. I went to share some
of the awards they got into thousand one, this team one the award for the most disruptive
innovation in healthcare worldwide. Subsequently they received the other grants as stated on
the s lide. In conclusion, using multipoint videoconferencing best practice protocols
comanaging patients with case best learning which is the ECHO model is a robust way to
treat common complex diseases in underserved areas and monitor outcomes. Thank you for
your attention.
Everything that you were talking about you did emphasize the technology but what people
can do together with the technology. That was one of the things that came to mind. I
really liked your saluted jet assisted set of basic care system. It was interesting about
the idea of pushing the envelope on the antikickback issue. I'm not recommending it, but something
that you mentioned and the whole project ECHO, but this is the first time that I have seen
it in this type of demonstration. It is obviously very powerful. I want to thank you for that.
I went to turn it over because I know you had something that your presentation.
Yes, I had taken so many notes this morning I fail to mention a couple of things of the
presentation on reimbursement. First, building on what Nina had talked about for reimbursement
in general, this will sound a little sick, but my institution is now looking at things
going, how can we use technology to lose less money on the patients were already losing
money on. Those congestive heart failure patients that will be readmissions. How many readmissions
does it take to do a whole lot of tele- health? This is a different concept than asking how
we get reimbursed and how we was less. Several people asked about the side site of service
never being d efined, especially as it relates to reimbursement. How many people remember
the healthcare finance administration? Is now known as CMS. Back in the day when they
came out with a balanced-budget act in 1997, they've had a proposed rule. In that ruled
they basically said the side of the service will be defined where the provider is located.
That is what we talked about today. All of the other problems tend to go away at that
point. In the final rule, and their final comments, they said, nevermind.
From that point forward the side of service has really never been defined. While the healthcare
financing administrative service years ago try to do that, it did not make it through.
I thought you would like a little bit of history. I don't think the side of service is cacciatore
lead to find and can be changed.
Thank you. I would now like to open it up for questions. Please come to the Mike --mic.
Thank you. Amazing information. Bill, could you give us your thoughts on, you have been
doing this long time, so have we and some other people also. What do you think the reasons
are that we have not been able to transform payment policy around some of the data that
we've gotten out of population health management Rex is it really about shared savings these
days? Doctor Aurora, I was contacted by one of those programs on your list to work through
reimbursement issues and they were convinced that they could get paid for what they were
doing under the ECHO model. I convinced them that they could not built for what they were
doing. What are your thoughts on actually moving to a model where your consultants who
are helping our very care would actually be paid under a consultation model? Thank you.
That may make a quick couple of comments. One, is the question you ask is about how
we are not getting a Cajun reimbursements? A couple of things, one is that we have a
reimbursement system and there are a lot of things to keep in place. It doesn't take too
innovation really well. I don't think you you're going to get reimbursement for the
things we are doing with population groups. We have to move everything t ogether. I think
it becomes very difficult. Plus some of the results we're getting are pretty good. I want
you to know that some of the results on similar things are not so good and they haven't been
so great. Let me give you an example and I want to be clear about this. A big Medicaid
project in this country hires a disease management company and they promised to pay them $20
million if they would sort out the people with chronic diseases in their group and then
save them $15 million. That was the first run. After 1 year, they showed how they saved
$15 million. I want you to know that we were called in to do an analysis of that and it
was of course quite hocus-pocus. This is a big well-known company and they had done anything
but picked people at the point of exacerbation and no one in Medicaid understood the regression
to the mean that occurs with people with chronic disease. They prove that they had $50 million
in savings. I could've done that same thing with no intervention whatsoever. That is what
we call a placebo intervention, I could've gotten the same results just about the cause
of the regression to the mean.
What happens is we have not had an across the board compelling evidence that is needed
to confirm the payment systems. The second thing is, not all of this is really worked
in population especially in big groups. A lot of disease management companies have known
the secret of how you show results without having any very long time and they've been
doing it. That is getting blown a little bit now and that has not helped the reimbursement.
Thanks for the question. I think that there are two fundamental kinds of health care system
in the United States. One is the Kaiser Permanente's, the VA, and accounts for a very substantial
part part of healthcare in the United States. These are fully accountable organizations
where billing and collection is not an important part of their business at all. They adopt
ECHO like a fish adopts water. It is not a problem for them. Nobody has to be paid for
anything for anything, they can see the immediate travel benefits, they can see the benefit
of less hospitalization and other costs. They can push any of their priorities through the
knowledge networks. I know you're talking about the other part. In the other part, in
the and the healthcare system, also there are portions such as the Medicaid, manage
Medicaid programs. These programs are paying for total cost including transportation c
osts. In New Mexico, all of the manage Medicaid plans currently have agreed to pay us for
ECHO. Every aspect of ECHO. The primary care side, to present the patients, the specialty
site, to provide the consultation, the infrastructure side, that is one particular the state Medicaid
also gives us direct grants for ECHO because they see the benefit of that.
We would consider this one off, but Nevada has most recently gotten the grant from Medicaid
for the same purpose. I am currently in meetings in Seattle just yesterday where all of the
managed care health plans and every single one of them is agreeing to pay for it it.
When every health plan comes responsible for the total cost of the patient, you are going
to find them as extraordinarily good partners to pay you, because it will help their pocketbooks
in a very immediate way. I think that is where I would say, yes, in commercial plans to talk
to them about spending $100 for a consultation, I never tried that, I am not interested in
that. We are talking about partnerships to improve healthcare on a statewide basis with
these health plans. One of our health plans gave gave me eight check for $300,000 when
they first set I will give you $200 per console I said I did not want to. You can keep it.
It is paid for the entire infrastructure so we can create a support system for all of
their patients, less transportation, less hospitalization and better access to care.
There is clearly a lot of interest in this and our CMM I grant innovation Grant that
we just received. Every health plan in two states signed it as a partner to pay for it.
My name is Dave Clifford I work with patients like me we are eight technology platform company
for monitoring chronic health disease outcomes. My concern continues to be translation of
knowledge and practice and the route to sustainability. I think Doctor Aurora you just highlighted
one way of when people take on more responsibility there is some inevitability in doing things
like the common sense way, coming from a feel that is not medicine, coming from a generic
background. Secondarily, there are the struggles that Doctor Applegate you are having with
taking this very good 200 or 300% cohort and translating the technology packages that were
pay for under a grant or a pilot study and evangelizing t his. You can point to number
number of graphs and say this is the right thing to do, it will save you m oney, you
should do it, but for totally there is a challenge in many institutions to take up those lessons
of innovation. I am looking to hear some comments on the paddle -- panel around the sustainability
of what we have learned. Health systems tend to be% it percentage with facts and quickly
forget.
I will make a quick comment. We do some work that have been funded by grants and others
funded by healthcare organizations and also by health plans. We have done some for different
kinds of groups. We've also done for Medicaid as well. I would say that we have a thing
that we do in all of our projects, we have a lot going on that we don't run anymore,
because we are a capacity building organization. One thing I would say is that we have a sustainability
claws and our contract. If we get money from grants, we go to whoever the benefactor of
that is a we are training and building capacity to this. If we get results out of that deal
then they have responsibility to continue that with their own funding however they do
that. That varies, but if we do a for your project they typically have a responsibility
that shows value of that period of time that they running for another five years or three
years after 1 year. We are getting everyone signing those agreements. A lot of these are
going on and being paid for by regular funds. What I would say is that, and I feel good
about the sustainability feature, and that is one of the things we have done with these.
If we get these kinds of result, when the funding goes away, you will continue them.
We have had both health systems, health plans, and several Medicaid programs that have done
that. That is one thing that goes on. Some of our projects are 300 and summer 700 and
sometimes they are limited by the fact of the amount of money we have from external
resources to do it. We did one with the Medicaid program that was with 400 people, now that
program is being run under sustainability with about 1600 people.
I would like to echo what you said. We have very low grant funding at Lehigh Valley health
network. We do have a trust which funds and programs, but that tell health function has
been placed under the chief strategy officer. Going forward it is part of the strategic
plan of the network. I think.
I think from our perspective the issue we are trying to solve his is cap we what you're
trying to talk about. 17 years to take best practice to the less mileage healthcare and
less than 50% of people are getting best practice care. The question is, is easy to say the
primary care doctor is not really doing as good job as he could. The point is he can't.
If if I can to you today and said ready hundred meter dash and 9.5 nine seconds like we just
saw, it will be hard for you to do it. The same is true with the knowledge explosion.
The primary care doctor cannot do it. It is impossible. We try to solve the problem where
we have them narrow the scope of the practice and give them the mentorship they need to
provide the best practice in a particular area of their choice. We have found with payment
that we are actually, I am not approaching health plans for funding at this point. They
are coming to me to fund us. I would submit that one possible way, the reason that tell
health is having some difficulty is that we haven't shown adequate value. I think the
important thing here is that the healthcare leadership plan are extraordinarily sensitive
to value. They can smell it out from a nywhere. They are in business to make money and to
provide better care. If we were to provide compelling evidence for value, I think these
reimbursement problems will solve themselves automatically. I think the challenge for us
is the evidence for value has not been compelling enough from their perspective. It has been
compelling enough from hours perspective, but we are preaching to the choir. It has
not been compelling from their perspective. We need to do whatever we need to do to make
that happen.
We will take two more questions in the next three minutes.
[ Indiscernible - Low Volume ] to the speakers gave examples of tell health programs that
have not achieve the same results because the protocols and designs with different.
If we start to go mainstream and this grows, there is a way to do have tell health and
achieve results and one that does not achieve results. I posted to you with 30 seconds left,
where do you see the role of best practices and practice guidelines Intel a health and
what would the role of that be in growing this field into a larger scale?
It is key. I think that is part of the reason that the value proposition to the peers is
not clear because they see this contradicting articles and they say I don't know what to
do. I think that we have to define the value proposition in the trials plus exact methodologies
of how to do it correctly. Otherwise, there is going to be a constant challenge for us.
Yes.
I don't know any other way of doing it then writing a book of why programs work and others
don't. It is all over the country, you can see various programs that have great results
and then you see the articles that come out and sometimes, unfortunately, the payers like
to hang everything on the ones that don't work. This is a way of them saying I do I'm
not sure I want to pay for t his. Other programs have great result. Honestly, I don't know
how we roll that out, but we need to.
One of my comments and recommendations was that some of our projects that are funded
by different agencies need some good technical assistance. I don't know exactly how to make
that work, but I think that there are errors that are evident in really good proposals.
There needs to be some good crap detection or technical assistance. I don't know what
the real word is.
One more thing, there is a group that is called -- that funds regional tele-health health
c enters. Perhaps they can assemble information on programs that work and others that don't.
They are the ones that have access to this information.
There our a lot of different programs and ours doesn't look like anybody else's. It
just doesn't and I'm happy with that, but it is not the same as everybody else's.
Dale Alverson, University of New Mexico. This is great presentations and I have great respect
for after Sanjjeev Arora and ECHO. One of the speakers and writers about this whole
issue of healthcare reform and cost is -- a lot of you'd touched on parts of that what
I would like your comments about that. He is talked about the cost conundrum and looked
at -- in Texas and compared it to El Paso with no better outcomes. He is talked about
the hotspots and give some compelling arguments about changes that have to occur in the system.
Ewald touched on that about unnecessary evaluations in care and best practices. Could you are
have comment on his comments?
I will start with the second spot first, the hot spotters. Our CMMI is tickly focused on
developing outpatient teams to develop a new specialty in medicine for the care of the
5% of Medicaid patients that consume 57% of the resources supported by ECHO like knowledge
networks. We are on that trail right now. The second part about reducing variation,
that really wasn't ever the goal of ECHO. What we find is the second pillar on which
ECHO stands the first technology in the second is best practices. When we disseminate this
practices, variation automatically reduces. For example, if I am a gastroenterology Doctor
and I like to do colonoscopy on a patient frequently, when I am on the knowledge network
I have to follow best practice. We are a community of practice. A community of practice in which
best practices are being discussed. Automatically this reduces variation, despite your contact
just like we all behave better when we are a part of our peers, the same way professionals
gravitate toward the mean. There is much less variation when you have to discuss your decisions
in a peer forum. It is an automatic system property of the ECHO model to reduce variation.
Dale, my bad. I guess I missed the article. In terms of variation, since I have been in
two different institution with tele-health programs, a lot comes down to politics. In
the ICU environment, sometimes they are open environments with multiple different providers
covering the units. Sometimes they don't want others consulting other cases. It is a culture
and in our case, we decided to close the ICUs long ago, before the advanced ICU was even
created so that the intensivists managed care in those units and if need be brought in a
specialist who may have put them in there to begin with.
I am really a student of the -- conundrum article. I would say one thing about that
article and he has other lots of great ones, I am eight student of him. In terms of what
we deliver and what we do with our population health management and also with our tele-health
home care. We have to make it worth where ever and the costs are an additional value.
Even though there are great regional variations, and he illuminated the two that he talked
about, we have to make our things work wherever they are. I don't think the margins are good
enough to say CMS has said, will work in Miami? That is the favor question. It works here,
will work in Miami? I want you to know, I know I have heard that three times. That is
a find question and it is so because whatever it is we are doing it should be the kind of
project that will work in Miami and it will work in North folk and a lot of other places.
I think we need to develop strategies that bridge that cost conundrum issues.
Please join me in thanking the panel. [ Applause ]
[ Silence ]
I would like to invite our planning committee members to the podium, please for a wrapup
of the day. I want to thank everyone for their endurance. This has been a talk full day of
fabulous content and great presentations.
[ Silence ]
Age of us will be constrained to five minutes and then we will take some questions from
the audience. I will start with a summary any recap. This was a fabulous day and I want
to thank everyone for their participation. It is clear and we learned that tele-health
absolutely and key coordination improves access, improves quality. In most cases it lowers
costs when integrated in chronic and acute disease management. Tele-health reduces the
burden and cost of travel with benefits accruing to patients for sure and also to many of the
payers, including Medicare for seniors who are transported in skilled nursing facilities
to emergency d epartments, two Medicaid programs and two patients. In our VA program we have
documented documented travel avoided of 7.2 million miles in our program. That is a lot
of gas and a lot of time. It's also a lot of money. Tele-health is a force multiplier,
I love that. Thank you. It can mitigate workforce shortages and even creating new work force
as we look at new models of care delivery. Tele-health is perfect for integration into
new payment delivery mechanisms such as patient centered medical homes, accountable care organizations,
bundle p ayments, as long as weight affect the regulations to be facility where he. We
still remain constrained by outdated payment delivery mechanisms, federal and state statutes
and regulations that limit the expansion of services and interstate commerce in healthcare.
The way forward, greater engagement of our providers, shared best practices, work with
the specialty societies, advance innovative care coordination m odels, evaluate our programs.
The outcomes we saw demonstrated today our fabulous. Innovative payment models come a
fresh look at point of care and side of service definitions to mitigate the barriers and maybe
that is a simple solution that can be promoted by the Institute of medicine's. Share best
practices regularly and I we need to move for pathogenesis to saluted Genesis. Thank
you.
I have been in this business 15 years time it seems like not that long, but it has been
a long time and I am always struck when I come to meetings like this and listen to other
speakers or I speak and get the questions after the audience how the industry and how
healthcare changes. We think we know how it changes, but I'm always surprised. From today,
I don't have a lot of advice, but I will tell you what I am thinking as a result of today.
Certainly, we need to stop treating tele-health is something different than in person care.
It is in person care it is just that the two people are not in physically the same place.
If we adopted that philosophy and culture whether it is public p olicy, whether it is
working with our attorneys, whether it is whatever we are doing, it would really eliminate
a lot of the discussion, the arguments, the positioning, the barriers, whatever we are
dealing with. I think the issue, and I've talked about this a lot myself over the last
two years, the payment be can I get paid for 15 minutes of care is going to go away and
maybe our energy isn't really worth putting in that area anymore in the shared savings
models are probably the way to go. I love saluted Genesis that is one of my new words.
I think Doctor Sanjjeev Arora comments and this also struck me is maybe we need to stop
asking people to pay for consults underage fee-for-service model or shared savings. Maybe
we just need to say how about paying for the infrastructure and in the infrastructure is
included payment for the physicians and the allied providers to actually provide the consultations.
I am going to be working myself on compelling evidence for value. I have been a value kind
of gal for about 12 years here in tele-health. I think that, again, that is what I've heard
today is we need a more compelling value argument for are business people. What irked me and
and I could've strangled somebody was the comments on what the assumptions were made
that I heard today on what patients want. If anybody asks any of my retiree patients
how much time they had, they would say I am more busy than I will was when I was working.
They don't have time to travel two hours on busy roads in Wisconsin where there is dear,
eyes, crazy teenagers, for a 15 minute ordeal it you consult. I think problems Intel health
our problems in healthcare and we should stop digging about them as separate. Tele-health
is one of the strategies, but it is also subject to everything else that is going on in healthcare.
The other thing that I was struck by is as the day moved on we went from the whining
about everything that is not right to amazing, innovative, and champions who are doing things
out there. They don't don't care if they're getting pay. They know they are making a difference.
The world is a better place. People are healthier, payers are happier, and the government is
actually participating as a p artner. Looking at some of those models is a strategy we need
to do more of as tele-health leaders.
Do we actually know who the providers of care are Rex I heard to date people surprised in
our government that nurse practitioners were providing tele-health but didn't consider
them to be specialists. I find that interesting that maybe we don't even know who the providers
of care are in our country and who is actually out there doing the work.
I learned a lot today and it will keep it brief. I think the perspectives that were
share today we were well articulated. I was telling someone that is been one of the more
useful conversations I've heard him the last year. What struck me hard and we have been
working with for a long time now is what is happening now is that technology is allowing
us to create a new model of delivery. We have been delivering healthcare a certain way and
we are now onto place where we can change how are delivering care and technology will
allow that. It is going to help us keep care simple and keep it patient c entered. This
has been difficult to do so far, but technology can provide us the opportunity. It can help
us focus on -- and we are all going to repeat that word but it spoke to us on overall health
and not just illness is very important. I think it is going to help us with that. It
will help us make care more collaborative instead of prescriptive. I don't need to tell
you any longer to lose weight in come back and six-month but I can give you tools that
will monitor you daily to help you lose weight and I can monitor you more frequently to make
sure that you are losing weight. R-value demonstration needs to be more creative. We need to stop
talking about only cost or only outcomes and be more creative around how we demonstrate
value of the and Desmet -- investment. Our evidence creation needs more creativity we
need to think of newer models of research. We need to fake of newer models of analyzing
the data and collecting the data and proving value and proving our outcomes anyway that
will move this forward without having to wait 15 years again to create something like this
evidence -based system.
Nina, I want to underscore the importance of not isolating a discourse among those in
this particular section of the industry from the broader narrative around health care.
I come to this discussion perhaps less centrally embedded within the tele-health industry than
most, but I am absolutely convinced that the issues that I for today are matters of degree
and emphasis not substantially different than what all others in healthcare interest street
are facing. So, I think your point is extremely important. In my walks of life we talk about
the notions of eight pseudo- species like argument is that we are so different from
everybody else that we've removed ourselves from the discourse and the table and I would
encourage those most centrally involved in the industry to be -- to ensure that this
narrative takes place within the broader landscape. Your point about the science, I'm sorry, RCTs
are possible. The comments I heard earlier today about the challenges of our doing RCTs
set of methods and procedures are the ones that we face in all other aspects with respect
to recruit and retention and minimizing a variety of the threats and the division -- diffusion
of affects. We need to be as you pointed out more creative. I think it is possible, I think
there are great examples out there. I would strongly encourage us to raise the bar in
terms of alternating the level of the science. I am not persuaded that the quality of the
science has been especially great in this particular area.
I dig it has been in normal sleep important. It has been consistent with the evolution
of the methodologies to date, but it can improve and improve more market oblate. It has to
go hand-in-hand with where things are headed today and I would encourage us to not shy
away from seeking to meet those highest expectations around scientific merit.
Speaking of science, it is not just the science of cost as it relates to value or science
with respect to outcomes as it relates to prevention or treatment, but it is also I
think here is a wonderful opportunity to pursue the science of dissemination. Had a we think
about in rigorous ways the diffusion and adoption and operationalization of these effective
models? For example, Dell in your last comments you talked about taking a particular model
and applying it to a variety of you for geographic settings. I am not sure that it is necessarily
feasible or desirable. I think that many of the programs that we've heard of today have
critical essential components to them. It is structure, content, format, and delivery
that we have to carefully describe and understand. How those critical components become assembled
or reassembled among the relationships that obtained with in particular settings are geographies,
which is an enormous source of variation, that is going to be quite resistant to uniformity.
That is the critical piece and that is how we think about it in terms of intervention
resource. What are the critical components and how can they be assembled in the way that
remain true or infidelity to the original models that gave rise to them?
Those are my brief comments, thank you.
Well, I agree with most of what has been said already. One think that is very good and refreshing,
even though sometimes it is not easy, is to be in a setting where it is not tele-health
in Louisiana's talking to other tele-health enthusiast and same we have solved every problem.
It is good for us to have this discourse with some people not being necessarily tele-health
enthusiast and challenging us. That is where we need to get. I think, also, some of us
have complained about the fact that tele-health get help to a higher standard. We don't know
-- in some cases where we are trying to how well tele-health works we don't know how well
in person care works, but if it is tele-health you have a higher standard to prove. We need
to move past that. I think there is good news and there is good news and the bad news about
her health care system.
The good news is we spend a lot of money on every person in this country on average and
we should be able to figure it out with that amount of money, how to fix some things. One
of the problems that I heard little hints of is that people react when it becomes about
the technology as an and in itself. We may have done, and I'm also guilty, two go out
and give talks about tele-medicine rather than evidence -based models of care that are
better facilitated with the use of technology as part of that model of care. I think we
need to begin to approach things in that way. I think that is what we are looking for. Again,
I heard throughout, people are looking for value. That means we just don't have -- people
want to bend that cost curves and so we have been -- if we were doing this 20 years ago,
there would be tons of money flowing to try every thing we can try. There isn't today,
so we fortunately or unfortunately need to really focus on value.
The last thing I will say and it's one thing that we heard from Mary this morning to think
about. As we think about these models like ECHO which is a very impressive system, what
are the implications for medical student in resident training. We need to start thinking
about, because I know you RSA is involved in some primary care funding, what do we do
differently in our medical student and our resident training to prepare the rural practitioner
for the next century rather than train the for the last century. We do need to think
about this and some of us in academic institutions are beginning to plan that.
I think these are exciting t imes. It is a time of tremendous change and somewhat chaos.
Whenever there is a lot of change, there is a lot of opportunity. I really like the different
models that we have seen and I know there aren't lots of other different models that
utilize tele-health that are going on. People should try things like we've seen today, there
have been tremendous possesses and I also expect that there will be failures. That is
expected. Someone this morning said, it would be interesting to find out people that started
to use tele-medicine and then they stopped? Why? What they do? How come it didn't work?
That is something that we need to continue to embrace. What worked, what didn't work,
and then move forward. I am very happy with the way today has turned out. It has been
a very exciting day for me. I could not sleep last night. I'm going to get a good night
sleep tonight in a better night sleep tomorrow. I appreciate you all being here.
I mostly have a lot of q uestions, so I will let you know what is going on in my mind as
I ponder what we've talked about today and more about what we're going to talk about
tomorrow. Are the days of the rule independent provider over? Will all providers become part
of the larger system? Not everybody wants to work for somebody. Will the rush to increase
market share lead out small rural providers or people in urban areas that are underserved,
poverty-stricken, already don't have providers? How will the move toward clinicians reaching
their patient directly in their home impact Comprehensive Care? Will this information
get into their electronic medical records? Who will be their primary care provider? What
about the continuity of care? How will the rapidly evolving technology continue to change
how health care is delivered and how can we keep up with the changes? I think of a hologram
next, not just tele- dermatology, but three D telegraphic image. It could happen it could
be.
This is mundane, but is really important. What is the best way for my office to share
best practices? Posting on a website is not really effective. Face-to-face meetings, webinars,
I don't know. I am really open to ideas. Those are my thoughts for today.
Thanks to everyone. Are there any questions?
[ Silence ]
I am talk door and from NASA and [ Indiscernible - Low Volume ] I would advocate that there
are 18 plus years of experience written in at least two journals and there are five specialty
journals now in tele-medicine worldwide which is amazing. Plus there is also the specialty
journals that you have quoted this morning. I remember, Ron Merrill, when we worked in
Richmond, we talked about medical doctors in 1980 about a shortage in the future. There
was a lot of push to build new medical schools. A lot of people asked who would pay for that.
We did not build them and now we're paying we are paying for it. The point is that, when
we look at this from an economic perspective and there have been a number of articles written
in the journal about business models and so forth, very effective worldwide not just in
the United States, is the concept of opportunity cost.
One of the editorials we wrote in the last couple of months address some of this. It
is like having the opportunity to spend money on this or spend money on that. I spend it
on this, there is an effect on the other side. If we don't do tele-medicine or utilize these
kinds of tools, you can be assured we are going to be spending a lot more money in healthcare
the future. We see that today. It is not a matter of whether we're going to do it or
not going to do it, it is when. It is like if I look at the federal government inability
or it doesn't seem to me that it is going fast enough with keeping up with technology.
If I look at being able to go to Best Buy and buy technology that can monitor my health
and the federal government saying is that a medical device or not, and then there is
five more versions. I bought an android phone and I went to get it fixed the other day and
said we stopped making that 18 months ago we are on the first edition, now. Government
cannot keep -- you can't develop policy today and think it's going to last for 20 years.
It is going to change in the matter of time. There has to be a faster turnaround in that
regard.
The other concept is c onsumerism. We as consumers are going to start demanding these things.
I will close with a quote from Ron. As a asserted he would come out and say, Mrs. Smith we did
everything for your spouse. Today, that spouses going to say did you get a tele-medicine consult
Lex because you can then you can get expertise. We did a lot of telerobotic surgery work several
years ago and if the answer is well no, we did not, what is the answer going to be to
the patient's family that you didn't do the best you could because the technology is there,
the ability is there, it is just a matter of doing it and getting off of this, well
we don't know if there's enough data to show for can be paid for. The Europeans have done
it. The Australians have done done it. They're even doing in China. And we are still trying
to figure out how are going to pay for. We have to look at what the rest of the world
is doing. I will close with that.
Thank you, there is no question, even in terms of case law, tele-medicine has change the
standard of care in rural and remote communities as well. In New Mexico there were some cases
and in Virginia there were cases brought to court over not using tele-health or using
its enough. It is an expectation that this is standard of care in our healthcare delivery
system.
I wanted to make a, regarding Doctor Nesbitt talking about training residents and medical
students. In ECHO we have some medical students rotating through the Public health rotation
than sometime we have residents coming in. We find when early medical student comes into
ECHO and says, why would everybody not be doing this. This make sense for people to
be sharing information with each o ther. As they go through the indoctrination of medicine
and they get into their residencies, they immediately say, this is not the way it is.
They have been slowly indoctrinated into our fee-for-service ways that basically we won't
talk to anybody unless they pay SAV. Essentially, at the end of the day, we have a huge system
problem in terms of how we pay and how we think about healthcare. When an early medical
student comes he is using technology and shares with other people. He is telling people where
years when he when he is entering everything about his life even when he goes to my restaurant.
This transition occurs because we, the elders and healthcare, indoctrinate different ways
of doing business into them and how the fee for service the system works and how we build
level fives when we write a three-page note and Web web rewrite a one-page know we can
only Bill 11.2 and get paid $70. The resident is talking to us and the attending his thing
you need to dictate more and this takes us away from what Doctor Nesbitt was talking
about.
I will tell you a story and thank you, Doctor. Talking about diffusion, we have more and
more examples of diffusion that we think. As I said, I have a doing this 15 years. About
12 or 13 years ago a group of us that, if we want to be here in 10 years, we better
part tainting the world around us. At that time, people could get physicians to use tele-health
and we thought would be really wonderful someday when we didn't have to convince people come
us sell sell our forsworn force point funds for somebody to try tele-health. About eight
years ago we saw schools starting to pick up and teach tele-health. Family started to
get residents who had come out of a residency program that use tele-health. In my business
at Marshfield c linic, I haven't had any trouble getting physicians to use tele-health or allied
p ractitioners. I had the same thing, wouldn't it be nice if we just had this is a normal
practice. Five years ago we started hiring residents that had tele-health and were trained
and they were wondering why they didn't have tele-health. Two months ago, a new physician
was hired, a plastic surgeon at Marshfield clinic and she had six years of private practice
experience with tele-health and she was indignant that she didn't have tele-health in her office
when she arrived. I believe we're seeing it at the practice level, were just not so much
seeing it at the policy level.
I am Karen McNeely from South Florida. I wear two hats, I make goes provider that you talked
that I may psychiatric nurse practitioners and have seen a lot of mental health patients
over the last 25 years. I'm the Executive Director of my program but I am it doctoral
student at the University of Miami. Tele-health seem like the perfect project to merge the
two I am in the process and that is why am here to get this information. You have shared
great information and I appreciate that. My challenges to implement this program in Florida.
The majority of our recipients our Medicaid recipients and floored it doesn't pay for
Medicaid reimbursement. That is my talents to sell that to my executive Board. I know
will work and save money and reduce recidivism. Is getting them to jump on board with the.
I have gotten great feedback and I look forward to tomorrow that may be able to help me get
this program off the ground.
I'm sorry, what was her name?
My name is Karen, McNeely.
Contact one of us because we would like to work with you and I think you can do that
very easily.
It was actually the House last year in Florida just ran out of time. Maybe if it comes up
this year will have some muscle behind it.
Also the national -- [ Indiscernible - Static ] to advance at the state level and will have
someone representing them tomorrow to speak at the state panel.
This is really and formative, thank you.
Dale Alverson, one more comment and get your response. Someone mentioned consumerism, and
I can tell you it is already happening. In the matter what we think is providers or as
federal agencies and so on, the consumer, particularly the younger generation is going
to demand it and is already using it. For example, my daughter who is a young adult
had a rash and I get to calls from my children, one is I need money or dad I got this health
issue what you think? Should I go to the emergency room? She told me that she had a rash and
she had been on a course of antibiotic and the rash suddenly appeared and scared her.
Should she go to the emergency r oom, see a dermatologist, urging care? I asked her
a few questions as most of us would about the rash and any of the problems. It is really
hard for me to say we should do without seeing it. Within 30 seconds I had a whole series
of pictures of her rash on my smart phone. The point is, the younger generation consumer
will use this technology. Whatever we want to collect, tele-medicine, E-letter health,
connected care, virtual care. And we as a system need to keep up because basically value
and in the end we will make a reasonable decision about whether she needed to go to the emergency
room and so on. I just wanted to make that point that hopefully what comes out of this
as well is we are going to have to keep up with the consumers of care and our patients
who are really when they see the advantages of this they will demand.
Yes, and that is a great story. I will tell you to others that are similar. One is relatively
well-known story that happened with one of our infectious disease doctors, Doctor Siddiqui
who was driving to home one night and his phone rang and it was somebody at a smallbore
hospital bed has a guy with the rash and it is cellulitis but he's allergic to these medications
and he's diabetic. What drug would use? He looked at it through an iPhone and he said
get me another picture of that with a blue background behind it, because it is not very
clear. Since the time you took the first picture in the second picture this has advanced significantly.
He's got necrotizing fasciitis and you need to get a surgeon in right away. It to come
along time to get the surgeon in and in and convincing. A brand around the Internet, iPhone
saves patients limb and pace of life. It was interesting just to see the response to that.
There were a number of very negative, people should be using iPhones for this. This is
malpractice etc. It's amazing to think about that particular case.
People are going to use it. They weren't trying to do a tele-medicine consult. The other thing
is that when I flew here I flew with RT period must surgery and she was talking to us about
tele-medicine and other s tuff. It's a good idea, tele- mentoring. My ex- residents use
their iPhones all the time and take pictures during cases and send them to me and say,
do you think this is something I should approach anteriorly or do I need to go post? I never
even thought of that. I think even in -- even if we didn't say we were doing tele-medicine,
doctors are going to start using this to take pictures of things and send to consultants
rather than just talking on phone. You're absolutely right. This is going to happen
whether we try and push it or not and we just have to figure out how to channel it and move
it in the right directions and best practices. Is a good.
Any other comments or questions? I want to thank our planning committee and Cheryl Lynne
in particular and your support of this program I wish you all he good evening. Tomorrow morning
we started a 30:00 a.m. If you don't mind, be here earlier and hopefully we will still
have coffee in the morning. Thank you, Tracy. And thank you for everything you have done
to bring this program forward. [ Applause ]
[ Event Concluded ]