Telemedicine: Expanding Access to Medicaid Services

1
Telemedicine Expanding Access to Medicaid
Services

• Presentation to
• National Association of State Medicaid Directors

Patrick W. Finnerty, Director Va. Department of
Medical Assistance Services
November 13, 2008 Washington, D.C.
2
Federal Guidance on Medicaid and Telemedicine

• CMS (Health Care Financing Administration) issued
  guidance in 2001 on Medicaid and telemedicine.
  Among the items discussed
• No formal definition exists for telemedicine
  under the Medicaid program
• Federal Medicaid law does not recognize
  telemedicine as a distinct service
• Medicaid reimbursement for services furnished
  through telemedicine is available at the states
  option as a cost-effective alternative to the
  more traditional ways of providing care

3
Federal Guidance on Medicaid and Telemedicine
(Cont)

• Advises that states should consider factors such
  as the quality of the equipment, type of services
  to be provided and location of providers (such as
  remote rural sites) when deciding on the scope of
  telemedicine coverage
• Medicaid reimbursement must satisfy Federal
  requirements of efficiency, economy, and quality
  of care

4
Virginia Medicaids Interests in Telemedicine
Coverage

• Improved patient access to medical services
• Improved patient compliance with treatment
• Medical services rendered at an earlier stage of
  disease, improving long-term patient outcomes
• Reduction in service expenditures such as
  hospitalizations and transportation
• Allows for an opportunity to work proactively
  with physicians and other providers has
  potential to be a win-win situation

5
Virginia Medicaid at a Glance
Total Enrollment 873,978

• Approximately 60 of enrollees are in Managed
  Care Organizations (MCOs)
• Total FY 2008 budget 5.8 billion

123,620
489,893
260,465
6
Virginia Medicaid Telemedicine Coverage

• Virginia Medicaid started with a telemedicine
  pilot project in 1995. Services covered were
• Some consultations
• One psychotherapy service
• Select clinical services in cardiology and
  colposcopy
• Used Virginia defined billing codes
• Only physicians recognized as providers
• Reimbursed providers at hub and spoke site, using
  the existing fee schedule

7
Virginia Medicaid Telemedicine Coverage (Cont)

• Pilot project was limited to three Virginia
  localities one was for psychiatric care and the
  other two were for medical consultations
• Virginia Medicaid was one of the first states
  with telemedicine coverage

8
Virginia Medicaid Telemedicine Coverage (cont)

• Virginia Medicaid expanded telemedicine coverage
  July 1, 2003 to be statewide.
• Governor Warner announced the coverage in July
  2003 at a community health event in southwest
  Virginia
• Additional services covered
• Evaluation and management, office visits
• Individual psychotherapy
• Full range of consultations
• Select clinical services such as in cardiology
  and obstetrics

9
Virginia Medicaid Telemedicine Coverage (Cont)

• Providers now recognized for telemedicine
• Physicians
• Nurse practitioners
• Nurse midwives
• Clinical nurse specialists
• Clinical psychologists
• Clinical social workers
• Licensed professional counselors

10
Virginia Medicaid Telemedicine Coverage (Cont)

• Reimbursement process uses the Health Insurance
  Claim form (CMS-1500)
• Spoke practitioner, where patient is located,
  bills a telemedicine code for presenting patient
• Hub practitioner bills for services such as
  consultation
• Reimbursement is according to Virginia Medicaid
  fee schedule
• A procedure modifier for telemedicine is entered
  on the claim form
• No telemedicine equipment costs recognized in
  reimbursement

11
Virginia Medicaid Telemedicine Coverage (Cont)

• Provider of telemedicine services is expected to
  fully comply with service documentation and other
  coverage and billing requirements described in
  the Virginia Medicaid provider manuals
• Virginia Medicaid telemedicine coverage is
  similar to Medicare coverage but is not tied to
  rural area definitions for the originating site

12
Telemedicine Billing In Virginia Medicaid

• Telemedicine billing has been low for Virginia
  Medicaid predominant service is psychiatric
  consults, especially pharmacologic management.
• Other Medicaid programs have reported low billing
  as well.
• Possible explanations as to why telemedicine is
  not appearing in claims data include
• Providers not using telemedicine billing modifier
  on claims form
• Telemedicine as part of the larger bundle of
  services rendered to patients with particular
  diagnoses
• Contracts for services with hospitals/clinics do
  not break out telemedicine

13
Telemedicine, Virginia Medicaid Managed Care
Organizations

• Currently, 60 percent of the Virginia Medicaid
  population is in enrolled in a Managed Care
  Organization (MCO)
• MCOs are to cover telemedicine at least to the
  extent the select services are covered for the
  fee-for-service population
• Limited data on Virginia Medicaid MCOs
  reimbursement for telemedicine psychiatric
  consults appear to be most frequent use

14
Future Possibilities for Virginia Medicaid
Telemedicine Coverage

• Coverage of telemedicine for home health
  services.
• A telemedicine station is in the Medicaid
  recipients home connected to a station at the
  home health agency office
• Telemedicine applications for Medicaid recipients
  at home include
• Post-operative care
• High risk pregnancies
• Asthma
• Diabetes
• Congestive Heart Failure

15
Future Possibilities for Virginia Medicaid
Telemedicine Coverage (Cont)

• Use of telemedicine for home health patients
  depends on the diagnosis, medical need,
  permission of the patient, and patients ability
  to use the equipment
• Home health providers are interested in
  telemedicine because care is delivered more
  efficiently. The home health nurse can serve more
  patients in a day than when the care is delivered
  conventionally. The telemedicine visit is not
  intended to substitute for needed physical visits
  to the home by the nurse
• Studies have documented savings particularly due
  to fewer hospitalizations and shorter hospital
  lengths of stay.
• Medicaid transportation is reduced

16
Future Possibilities for Virginia Medicaid
Telemedicine Coverage (Cont)

• Coverage of telemedicine store and forward
• Store and forward involves electronic medical
  information, such as video, still images, and
  MRIs, which is stored and transmitted for review
  by a physician or other practitioner at a later
  time.
• The patient is not present when the physician
  conducts the review but findings are reported
  back to the patients primary care provider

17
Future Possibilities for Virginia Medicaid
Telemedicine Coverage (Cont)

• Store and forward applications include
• Screening of diabetics for retinopathy
• Screening for retinopathy of prematurity
• Dermatology
• Other Pediatric subspecialties
• Store and forward can be inexpensive for the
  spoke and hub sites because the electronic
  medical information, such as a digital picture,
  simply needs to be captured and transmitted to
  the physician or other practitioner
• Virginia Medicaid will continue to explore
  additional areas for use of telemedicine