Telemedicine is transforming our healthcare system in three distinct ways, by increasing access to primary care doctors and specialists; reduced costs; and improved health outcomes. To help readers of Nurses Advocate understand how Telehealth will change the delivery of care, I have invited Stewart Levy to be a guest writer for Nurse Advocate

Stewart Levy is the CEO and President of HealthWell Solutions which focuses on evidence-based wellbeing solutions for employers and hospital systems. He has presented at a number of employer and insurance benefit conferences and has served on the board of the National Occupational Health Professional Association, Functional Medicine Coaching Association, Retail Clinic Association, North East Business Group on Health and Medical Fitness Association. He has published studies with the American Heart Association on the impact of remote health screening programs with Large Employers and Consumer Venues. He is a corporate wellness executive with over 20 years of experience along with 15years in The Pharmaceutical Industry.

One of the most critical areas where healthcare is being transformed is through the wide-scale adoption of telemedicine and digital health. This is being accomplished through innovation in mobile technology, by the government and payers reducing regulatory barriers, and encouraging financial incentives to reduce unnecessary costs. Telemedicine has been well established with hospital systems to interpret radiological reports, Telepsych for counseling sessions, and “Teladoc” acute care employer services,

The exciting development for case managers and patient advocates are that studies have shown the effectiveness of using Telemedicine/ Digital Health to support care coordination in the convenience of one’s home or in a community setting by providing efficiencies in patient interaction, provision of specialty care, allow platforms to share data with providers, family members, and caregivers. Moreover, studies show that 87% of seniors over 65 prefer to age at home which is creating an opportunity for home-based technology and now non-skilled caregivers to become a valuable resource for complex care management.

A recent law adopted by CMS now permits unskilled homecare staff to become a supplemental benefit for Medicare Advantage Policies. This is an exciting opportunity for home care agencies, and telemedicine providers since routine care services, remote patient monitoring, and care coordination can be mobilized more efficiently using non-clinical staff and technology.

 Financial benefits:

Financial benefits are now available for these non-clinical community-based providers where previously it required care from clinical providers or hospital systems for patients who may have transportation issues or functional limitations such as the inability to walk, obtaining and preparing meals, adherence to medications.

Since 5% of our elder population is driving 50% of governmental healthcare costs, this new reimbursement strategy is facilitating less expensive healthcare providers that are skilled enough and trained to create a more efficient care delivery model.  Two areas that are driving costs today are:

Functional Limitations: Functional limitations occur when a person does not have the physical, cognitive or psychological ability to perform the routine activities of daily living independently. The Commonwealth Fund on August 29, 2016, said a typical patient with 3 or more chronic care conditions costs the healthcare system $7,526 on average per year and with functional limitations the fee is $21,021 (over 200%). So if this is extrapolated to 11.8 million people with functional limitations add another $159 billion per year in incremental cost source: http://www.commonwealthfund.org/publications/issue-briefs/2016/aug/high-need-high-cost-patients-meps1)

Social Determinants of Health are the economic and social conditions that influence individual and group differences in health status. – One of the social determinants of health that impacts the cost of healthcare is food insecurity. Food insecurity occurs when people do not have reliable access to a sufficient quantity of affordable, nutritious food. This is especially true for patients who have diabetes and cardiovascular disorders. It is estimated Food insecurity incurs a $1,863 additional health care fees which equate to $77.5 billion when look at nationally https://onlinelibrary.wiley.com/doi/abs/10.1111/1475-6773.12730)

Today, care providers and agencies realize that they are well positioned to support functional limitations and social determinants. Technology and other advances are helping to address these barriers that cause challenges to quality of life and increased healthcare costs.

 Technology to support caregivers – Telemedicine

There are five platforms for digital health that are now reimbursable for CMS including:

1. Live Video (Synchronous)
2. Store and Forward (Asynchronous)
3. Remote Patient Monitoring (RPM)
4. Mobile Health (mHealth sensors)
5. Electronic Consultants – (Provider to provider)

In the past, CMS limited telehealth reimbursement to rural sites (40 miles from a geo metro area) and could only utilize live video platforms for reimbursement. There are new rules and regulatory changes to fee schedules for “asynchronous” telemedicine with “virtual care” codes for remote patient monitoring and two new codes for preventive services in the office or other outpatient settings.

 Mobile Health or Remote Patient Monitoring include;

• Personal home assistants – Like Alexa and Google Home are being used by seniors to track data to physicians
• Smart medication containers – Smart pillboxes are being designed to take prescriptions,
• Sensor-embedded clothing – Clothes, belts, socks, and shoes are being embedded with sensors to measure movement
• The smart home can feature a wide variety of mHealth helpers
• Connected care platforms will become more intuitive to relay data back to caregivers and into their medical record.
• Artificial intelligence software -will analyze that data and help predict an emergency or fall. Remote patient monitoring has documented reduced expenses and achieves better outcomes. AARP is working on projects that remind individuals to take medication, connects them with family and caregivers, and enables seniors to engage in their own health care through Artificial intelligence (AI). The primary target is high-risk individuals with wound care, post-surgical incisions, and rehab can be monitored at home and at nursing facilities to reduce re-admissions.

Traditional medical care requires in-person visits and that patients or family members bring in their own health data whereas hospitals and health systems are finding better accuracy and value in health data collected from the home in real time than they are from a traditional office visit. Remote monitoring programs utilized by trained caregivers, family members or patients collect and transmit health data from in-home devices to providers and care teams.

 Let’s look at some specific caregiver situations:

• There are easy approaches which can be implemented with a caregiver, smartphone, Wi-Fi and protocols from clinicians and care managers.
• At a basic level, they can document that prescribed care plan is delivered and adhered to by the patient
• If a consult is needed the caregiver can then facilitate a call or video conference session for a telehealth visit (which is reimbursable)
• The caregiver can also connect remote patient monitoring devices and upload data to the clinician. They can be trained on devices such as scales, BP monitors, EKG, and other sensors

Examples of programs using telemedicine that are changing the delivery of care: Many Insurers have developed specific programs such as

• “Humana at Home” which is currently serving  25% of all of Humana’s Medicare Advantage members and has delivered a 44% reduction in hospitalizations Source: https://www.humanaathometraining.com/About-Humana-At-Home)
• Geisinger has Community Health Assistants who are unskilled caregivers that they have trained where they provide food for diabetes patients reducing $100,000+ by over $60,000, per patient per year. (source: https://hbr.org/2017/10/how-geisinger-treats-diabetes-by-giving-away-free-healthy-food)
• Other programs have utilized and trained unskilled care providers to monitor the patient’s vitals. This can help prevent an urgent crisis through notifying a care manager or clinician for change in conditions. These programs have been undertaken by Harvard Medical School, Right at Home, and ClearCare, (source: https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.14351)

 New laws encouraging changes

Some of the new regulations and reimbursement codes have the potential to allow for tremendous resources to be saved in scheduling, administrative and clinician time.  Reimbursement is now available for:

• Virtual Check-Ins “Brief Communication Technology-Based Service” for established patients only
• Asynchronous Images and Video, “Remote Evaluation of Pre-Recorded Patient Information” would reimburse for a provider’s asynchronous review of “recorded video and/or images captured by a patient to evaluate the patient’s condition” and determine whether or not an office visit is necessary. This type of review is also referred to as “store-and-forward” communication technology.
• Peer-to-Peer Internet Consults, “Interprofessional Internet Consultation.” Patient Centered Medical Home (PCMH) – there are new virtual care reimbursement codes for peer-to-peer internet consultations but require Patient Consent and Utilization Management.
• Besides the new codes, there are data regulations to improve care and reduce the administrative burden for healthcare systems.  CMS’ MyHealthEData Initiative gives patients’ rights to their Personal Health Information to be shared among patients, caregivers, and providers.
• Patients have the right to access their own data including medication history, treatments, and medical procedures. Patients can choose any provider to share the data which can reduce duplicative medical testing, medication, and procedures, (Over 100 healthcare vendors and organizations have signed on to this program)
• Updates to meaningful use guidelines will also reduce the administrative burden put onto providers, so they have more time for patient visits. The program will focus on interoperability, to allow patients to access health data uniformly on any personal device to be able to share with providers. The agency also announced regulations to disallow information blocking, which is where providers withhold patient health data intentionally.

This can prevent informed decisions by other providers and can become a patient safety issue. CMS also has eliminated the administrative burden of requiring that physician’s estimate how long-term skilled services will be needed for patients receiving home healthcare since this is already included in patients’ care plans. The new rule will also build on recent amendments by several states to make Medicaid patients’ homes an originating site for accepted reimbursement instead of traditional clinics or treatment facilities.

Thank you, Stewart, for sharing this information. I am sure readers will have questions as they absorb this information. I am including your email so readers can email you directly. If you have questions for Stewart, feel free to email him at slevy@healthwellcorp.com   You can also visit the Healthwell website by clicking here

If you have experience with using telemedicine as a patient or as a provider, feel free to share your experience in the message box so others can see how this technology affected your care.

Editors Note: 

On November 26, 2018, I wrote about Care on Demand: Are You Ready? In this post, I shared a traditional doctor’s visit, and I envisioned the benefit of Telehealth in changing how we interact with providers in the future. There were many comments from that post which was the impetus for my asking Stewart to share his knowledge on this topic! 

Have a good week!