Telemedicine is quickly proving itself to be a driving force in the quest to provide broader access to quality healthcare for more Americans. Expansive mobile technology advances, faster connection speeds, and President Obama’s ConnectALL initiative have consequently expanded telemedicine programs through the country and brought this version of digital medicine to the forefront of many healthcare organizations. One government entity in particular, The Centers for Medicare and Medicaid Services or CMS, is recognizing the importance of testing and proving the advantages of telehealth services for Medicare and Medicaid patients.
CMS’s Innovation Center is working on developing and implementing new models for Accountable Care Organizations. One of those new models, based on experiences with Pioneer ACOs and the Medicare Shared Savings Program, the Next Generation ACO model, “sets predictable financial targets, enables providers and beneficiaries greater opportunities to coordinate care, and aims to attain the highest quality standards of care.” However, for MyOnCallDoc, the most innovative part of the Next Generation ACO model is the Telemedicine Waiver for participating Next Generation ACOs.
Previous Telemedicine Restrictions
Telemedicine used to be heavily restricted in many CMS ACOs and payment models. Two regulations initially put in place by CMS made telehealth unavailable to a wide segment of individuals enrolled in various ACOs. First, the Rural Health Professional Shortage Areas (HPSA) stipulation geographically limited which patients could benefit from telemedicine. The HPSAs included “HPSAs located outside of a county, outside of an MSA [metropolitan statistical area], as well as those located in rural census tracts, as determined by the Office of Rural Health Policy.” Individuals residing in these areas experienced shortages of primary care, dental care, or medical healthcare providers. This regulation seriously limited the number of patients able to utilize telemedicine approaches to ongoing healthcare services.
Second, an originating site requirement meant that patients had to travel to an authorized healthcare facility to initiate a virtual visit with a medical provider. The originating site designations where Medicare beneficiaries could receive medical services via telecommunications were:
- The office of a physician or practitioner
- Critical access hospitals (CAH)
- Rural health clinics (RHC)
- Federally qualified health centers (FQHC)
- Hospital-based or critical access hospital-based renal dialysis centers
- Skilled nursing facilities (SNF)
- Community mental health centers (CMHC).
Additionally, and even more restricting, most of those originating sites had to be located in a HSPA or non-MSA location.
MyOnCallDoc has collaborated with the CMS Seamless Care Models Group at The Center for Medicare and Medicaid Innovation Centers to increase telemedicine awareness and access. Through this collaboration, MyOnCallDoc hopes to fully illustrate and maximize the benefits of telemedicine within the Next Generation ACOs and all future ACO models. The Innovation Center at CMS is interested in testing initiatives and models that incorporate innovative approaches to healthcare without disrupting entire systems. Thus, the Telemedicine Waiver has been developed to allow for quality testing of telemedicine procedures without changing the Next Generation ACO model completely.
The Telemedicine Waiver
The Telemedicine Wavier speaks to the potential future of telemedicine as a part of a comprehensive, affordable, and effective healthcare system available to millions of Americans. The Rural Health Professional Shortage Areas regulation and the originating site requirement for the qualified use of telemedicine have been expanded within the Telemedicine Waiver. Qualified beneficiaries can now utilize telecommunications for medical services, which is a testament to the greater understanding of telehealth benefits. However, as with any new endeavor, there still exist certain limitations within the Telemedicine Waiver.
The first limitation outlines allowable originating sites for patients; however, this regulation has been expanded upon from the list of previously allowed originating sites. Now, patients can access telemedicine opportunities from their home or other designated originating sites whether or not they are located in a rural area. The second limitation within the waiver, excludes certain types of care. Patients cannot use telehealth services for:
- Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or skilled nursing facilities (SNF)
- Subsequent hospital care services
- Subsequent nursing facility care services.
While the Telehealth Waiver does not eliminate every barrier to telemedicine services within Next Generation ACOs, it places telemedicine services at the forefront of new development models and allows for the growth of telemedicine opportunities in a variety of healthcare management systems.
MyOnCallDoc and Telehealth Compliant Programs
MyOnCallDoc has spent significant time with CMS Innovation Centers discussing in detail telemedicine services, clarifying telehealth protocols, uncovering areas for improvement within particular ACO models, and developing Telehealth Compliant programs that highlight the potential benefits of incorporating strong telemedicine initiatives. We have compiled a basic overview of the programs we will have implemented, they are as follows:
- Chronic Care Management Services: Telemedicine can be used to effectively manage chronic conditions among an aging population. Medicare created the 99490 code to define how non-face-to-face patient provider interactions can facilitate the proper management of chronic conditions. As 2/3 of patients within the Medicare population experience 2 or more chronic conditions, this program can have far ranging benefits.
- Episodic or Minor Acute Care: Next Generation ACOs have the freedom to offer telemedicine to their members for the resolution of minor care needs. CMS statistics cite nearly 60% of urgent care visits could have been managed via compliant telemedicine services.
- Accurate and Complete Data Collection: Through the use of telemedicine and specially trained medical staff, a Next Generation ACO can improve the accuracy and completeness of HCCs and Risk Adjustment Factor data. This improves an ACOs ability to accurately predict expenditures and receive proper reimbursement per member.