Cover: Telehealth - New legislation to improve access to health care across Colorado

Sunday, March 01, 2015 11:00 AM

by Kate Alfano, CMS communications coordinator

A bipartisan bill likely to be signed into law in Colorado soon would expand access to telehealth – care delivered remotely via computers, cameras, smartphones or other devices – by removing a restriction that limits payment for this technology to rural counties with a population of 150,000 or less and by prohibiting health benefit plans from requiring in-person care delivery if consulting, monitoring and other care can effectively be administered remotely.

House Bill 15-1029 would remove the requirement for a provider to demonstrate a barrier to in-person care; prevent health plans from reimbursing providers for telehealth differently than for in-person care; and prevent health plans from charging different deductibles, co-payments or co-insurance amounts, or setting different annual or lifetime dollar maximums for telehealth services.

It is sponsored by Rep. Perry Buck, R-Windsor, and Rep. Joann Ginal, D-Fort Collins, in the House of Representatives and Sen. John Kefalas, D-Fort Collins, and Sen. Beth Martinez Humenik, R-Thornton, in the Senate.

The Colorado Medical Society House of Delegates passed a resolution in September 2014 that updated CMS policy on telemedicine and telehealth and directed CMS to push for legislation in the 2015 session. CMS Immediate Past President John L. Bender, MD, who uses telehealth in his practice, helped draft the bill and recruit its sponsors, and the CMS Council on Legislation voted to support it.

“I was very honored and very fortunate when Dr. Bender asked me if I would carry this bill,” Buck said. “Through that, the Colorado Medical Society, the Boulder County Medical Society, Children’s Hospital and a lot of different stakeholders all got behind me and helped me to carry probably one of the best pieces of legislation I’ve ever had the pleasure of carrying.”

“I have heard just a lot of wonderful opinions that this is so needed for the state of Colorado, and more than anything in the rural areas,” she continued. “That’s why I felt very strongly about carrying this bill, for the rural areas, the elderly and ones who can’t drive to Denver for specialized care.”

“I signed on to this bill, first, because telehealth as a new way to practice medicine was brought up at the Northern Colorado Medical Society legislative meeting last year as one of their top priorities,” Ginal said. “Second, because of the shortage of doctors I think it’s really important that we provide ways that people can reach physicians and ways that physicians can reach people.”

“The testimony that we heard during a House committee hearing was quite touching because it shows it will help not only the doctor and the patient but the family in general,” Ginal said. One parent told the story of having to take their child from Durango to Denver once a month for a 15-minute checkup.

“What this does is it allows the doctor to see if the child is getting better and it doesn’t take the child out of school or the parent out of work, and it saves the cost of transportation they were using to get to Children’s Hospital and back again. I see it as cost savings not just for our health care community but also patients in general.”

As of press time, the bill passed unanimously out of the House and passed the Senate by a wide margin. It is awaiting signature by Gov. John Hickenlooper, but with broad acceptance on both sides of the aisle, this is an expected outcome.

“This bill is fairly straightforward; the vast majority of people are in favor of it regardless of political affiliation because the meat of the bill is about access to health care and everyone across party lines needs access to health care,” said Ryan Westberry, MS, MBA, project manager and business analyst for the Colorado Telehealth Network.

More options for access
Proponents name better access and convenience as the top benefits for patients. Clay Watson, MD, an infectious disease specialist and director of infection prevention at Saint Joseph Hospital in Denver, said, “especially if I happen to be running late and they’re at home or work, it’s much more convenient for us to connect, have the visit, and they’re on their way. They don’t have to sit here in my office waiting and be exposed to other infections.”

Watson said it also extends his reach around the state, allowing him to see patients who live several hours away and for more frequent check-ins. “If I have to have someone drive three hours to see me, I’ll push [a follow-up appointment] as far as I can safely. But if I can do a weekly follow-up with a post-op patient over video conferencing, then they have more access and more time with their physician.”

Lower costs across the system
Though seemingly counterintuitive, proponents believe wider use of telehealth could drive down costs to the health care system overall. “When care is more accessible, we get people addressing issues far before they need to go to into the hospital or the emergency room,” Watson said. “Our follow-up care from discharge is much, much better with telemedicine. Then broader disease management like group management diabetes, HIV, or hepatitis C, all of those things can be far cheaper than the traditional one-off visit with your doctor every month or every three months.”

Jeff Wagner, MD, a neurologist with HealthOne, agreed. Their telehealth network is centered at Swedish Medical Center in Denver and comprises more than 40 cameras. He receives acute neurology calls from emergency departments and can “beam in” to evaluate the patient and determine whether the patient should be transferred to Denver. The “old-fashioned approach” would be to just transfer everyone – at a great cost.

“When we put a camera in we see transfer rates drop about 60 percent,” Wagner said. “Many of those transfers, because it’s for an acute issue, were happening via air. I can’t quote how much an air transfer costs, but it’s a lot. If we can cut down by 60 percent, you’re going to see a huge benefit across the system.”

Opportunity for coordination
One of the biggest benefits of telemedicine to the system is care coordination, said Debbie Voyles, MBA, director of clinical operations for telehealth for Colorado Access/Access Care. “You can bring mental health services into a primary care setting where it’s not traditionally offered and offer those services to the clients in that setting. You can coordinate who all is touching those clients and the primary care provider can be kept in the loop as to what other people are doing so they know how to better manage their patients.”

“Besides Colorado Access there are other insurance plans looking at how they can better manage clients and provide them the care they need at the right time and at the right place,” she continued. “All of that is huge as far as trying to save costs to the system overall. If we can use technology to be able to do that, we’re all going to win in the long run.”

Impact on quality
While gaining convenience and cost savings, patients and providers don’t have to sacrifice quality. “Telemedicine is just a modality to provide services,” Voyles said. “It doesn’t alter the way a physician and a patient interact with one another. A physician is going to treat a patient through telemedicine the same way they would if a patient walked through the front door. We want them to meet the same quality, the same standards. We follow the same rules, the same regulations. We equate telehealth to be the same equivalent as a face-to-face in-person encounter.”

Some argue that it could actually increase quality. John Bender, mentioned earlier, is the senior partner and CEO of Miramont Family Medicine with six offices throughout northern Colorado. He uses the BeamPro Smart Presence System – an eye-level computer screen mounted on top a mobile two-wheeled platform – for remote patient visits with their diabetic nurse educator and psychologist. Eventually he hopes to expand telehealth so he can open up appointments on the weekend for patients who would prefer to see him – a physician with whom they have an established relationship rather than go to the emergency room. “The initial market niche that I think we’re going to see ramping up is physicians using it with their own patients,” he said.

He further illustrated the potential of telehealth with a hypothetical blood pressure patient. “Right now I see him in the office and tell him to come back in six months, and I make decisions about his blood pressure medication off of two data points every year. Wouldn’t it be smarter if I told him to pick up a Bluetooth-enabled blood pressure cuff out of our dispensary that sends the data into our server? Then I could have care coordinators monitor exception reports and I could adjust his medicine if his blood pressure goes out of bounds for more than a week or two. And that would actually be safer because then I would be making decisions based on 100 data points instead of just two.”

Next steps
Moving forward, the Colorado Telehealth Working Group (CTWG) – of which CMS is a member – will work with DORA and the Department of Professional Occupations to update their regulations, said Samantha Lippolis, telehealth manager of Centura Health. “Right now they have two particular rules that require a face-to-face encounter prior to being able to prescribe. They don’t count live video conferencing as meeting the standard for a face-to-face encounter even though the literature and the Centers for Medicare and Medicaid Services do.”

Physicians testified in front of the medical board in November and, as a result, DORA hosted a telehealth symposium on Feb. 23 that brought together all regulatory bodies so different practitioners and organizations could explain how telehealth might work in Colorado and the regulatory bodies could consider updates to their licensure.

Another barrier Lippolis identified is how to get paid for telehealth in the home setting. “You get paid for home health right now as long as the patient has been referred into home health, but we need to consider whether we want them coming into a facility or whether we can provide interaction, where clinically appropriate, at home.”

“This is an area that is going to require regular re-evaluation,” Bender said. “We want telehealth to be safe. It does have the promise of potentially reducing health care costs and improving outcomes, primarily because of its ability of enhanced remote patient monitoring and enhanced contact. This isn’t going to solve all situations; if a person needs an IV, they’re still going to have to come in. But I’m probably going to be able to take care of a rash, I’ll probably be able to ascertain certain chronic disease conditions like education for a diabetic patient or blood pressure monitoring, psychologist visits, behavioral health; it’s a force multiplier.”