December 14, 2015

Virtual Care: CT preps for telehealth rollout

PHOTOs | Pablo Robles
PHOTOs | Pablo Robles
Dr. Laine Taylor, a Yale psychiatrist
Dr. Laine Taylor, a Yale psychiatrist, demonstrates the IT platform that some of her colleagues use to conduct virtual visits with patients. Pictured on the screen is Yale IT Support Specialist Mark Lazarus.
Pictured on the screen is Yale IT Support Specialist Mark Lazarus.
PHOTO | Pablo Robles
Yale providers and faculty in New Haven use a video-conferencing facility to interact with medical teams from around the world.

Telehealth, or telemedicine, has received a lot of attention since its advent in the 1990s, but odds are you've not yet talked to your doctor through a computer monitor.

Connecticut has been particularly slow in rolling out such technology. It remains one of the only states in which Medicaid does not reimburse telehealth services.

A number of providers, however, from hospitals to doctor groups, have dipped their toes into telehealth waters, and insurers have started to align with various technology companies that facilitate virtual face-to-face meetings between patient and doctor.

The modest level of activity thus far could begin to ramp up in 2016, after state lawmakers passed a law earlier this year requiring commercial insurers — but not Medicaid — to pay for telehealth visits.

The law requires most health insurance policies to reimburse the same set of telehealth-facilitated services that are covered for in-person visits.

Telehealth providers are widely defined, and include primary care physicians, advanced practice registered nurses, podiatrists, optometrists, psychologists, alcohol counselors and a range of other specialties.

Will demand be there?

One early Connecticut adopter of virtual primary care reports a tepid response since rolling out the service over the summer.

In July, Farmington's ProHealth Physicians, which has 239 doctors and 380,000 patients under its umbrella, became the first Connecticut provider group to offer LiveHealth Online to patients.

LiveHealth, which is a preferred service for Anthem, is one of a number of insurer-linked telehealth programs.

As of late November, less than 24 patients have utilized the weeknight service, said Bethany Kieley, vice president of practice programs and services at ProHealth. It's unknown how many patients may have seen a different doctor through LiveHealth outside of those weeknight hours.

"We really want to roll this out faster," Kieley said. "We're not happy with the small slice of it."

Besides the limited hours, why the slow start?

For one, Kieley thinks many health consumers remain unaware of telehealth's availability.

ProHealth has attempted to inform patients using email and other marketing, but those efforts can get costly, and Kieley said the group wants the program to be sustainable.

Another factor is that, at least for now, only 13 percent of ProHealth's patients – Anthem members and legal adults – are eligible to use LiveHealth.

Kieley said ProHealth doctors decided they wanted to provide telehealth services only to their own patients because they have those patients' full medical histories and other relevant information they felt was necessary to make the best healthcare decisions.

Kieley hopes the new law requiring insurers to reimburse for telehealth services, which starts Jan. 1, could spur telehealth awareness and demand.

Since insurers have latched onto specific telehealth programs, Kieley is also concerned that her doctors may have to train on or use separate systems for different insurers.

"For us, the notion of having to use different platforms for different patients is just untenable," she said. "We wouldn't be able to do it."

ProHealth isn't giving up. Besides its LiveHealth offering, the doctor group is also negotiating with UConn Health to launch a telehealth program that will provide physician consults with dermatology specialists, Kieley said.

And there's evidence employers are interested in insurance policies that include telehealth.

A survey released in August by the nonprofit National Business Group on Health, which represents large employers, found that 74 percent plan to offer telehealth to employees in states where it is legal in 2016. That was up from 48 percent in a 2014 survey.

Some other telehealth programs include Teladoc, which is used by Aetna, MDLIVE, used by Cigna, and Doctor on Demand and American Well, used by United Healthcare.

Overcoming cultural reluctance

There's been a reluctance about telehealth among some doctors, said Dr. Laine Taylor, associate medical director of the Yale-New Haven Children's Psychiatric Inpatient Service and an instructor at its Child Study Center.

"There has been interest in Connecticut for a while for telehealth services, but there's been a bit of cultural pushback," Taylor said. "We are a small state so why do we need this?"

Taylor, who pushed for the recent state telehealth bill, said she believes in the technology and its usefulness in Connecticut.

Yale's Child Study Center has made use of grants and other funds to pilot some telehealth programs and studies, including an ongoing autism program and plans for a program targeted at psychiatry services for Native Americans in the Midwest.

Yale providers also make use of large videoconferencing screens in Yale's Cohen Auditorium for educational purposes and presentations.

The biggest current example of telepsychiatry at Yale is one-on-one patient virtual visits that as many as 10 Yale providers have been conducting for the past two years, using a health-IT program called Vidyo, Taylor said. She couldn't say exactly how many visits Yale psychiatry providers have conducted, but described it as a modest number.

Patients have sought reimbursement from their insurers for the fee-for-service visits, but Taylor said they don't always agree to reimburse the visits, and the financial amounts can vary when they do.

She hopes that reimbursement structures will be solidified in the health system's negotiations with insurers in the year ahead.

Yale-New Haven Hospital is also a member of the state-funded Access Mental Health Program, which provides consults to primary care doctors treating youths with behavioral needs.

Taylor hopes to incorporate telehealth into that program after the new law takes effect.

"I do think the bill will open this area up," Taylor said. "This is the next step in providing care."

Competitive concerns

Some doctors have also worried about how telehealth will impact the competitive landscape. Mark Masselli, CEO of Middletown's Community Health Center (CHC), said he thinks telehealth will shake up retail medicine.

"My sense is it's only a matter of time before they put out a Walgreens app that says 'Hey, come see our doctor,' " Masselli said.

Reluctance aside, keeping costs down has become more of an imperative as health care slowly shifts away from a fee-for-service model to a population-outcomes model.

If done correctly, telehealth could be one of the few innovations that offers near-term cost reductions, said Dr. Daren Anderson, director of the Weitzman Institute at CHC, who described the state's telehealth adoption as "glacially slow."

"This is kind of a gimme," Anderson said. "There aren't many things out there that deliver immediate cost savings."

CHC mainly serves Medicare and Medicaid clients, so the state's new law won't have a major impact.

But the network of a dozen health centers has forged its own telehealth path over the past several years, using grant money to launch a pain management telehealth program called ECHO and a program called eConsults, which connects physicians with dermatologists and other specialists. Those consults can otherwise take months to schedule, Anderson said.

The program has now performed around 800 virtual consults, Anderson said. A CHC research study on the program's results will be published soon in the Annals of Family Medicine.

CHC is pushing Medicaid and several commercial insurers, including Anthem, to reimburse for the program, which won't be covered by the new state law because the service is considered a "store and forward" service, meaning it doesn't provide real-time consultations. Specialists review data after it's sent by primary care providers.

If Medicaid started reimbursing telehealth services, Anderson said it would allow CHC to scale up the eConsults program, which has its own software built by Safety Net Connect, and offer it as a service to outside providers.

Several providers, including Middlesex Hospital's family practice, have shown interest in adopting eConsults, Anderson said.

Masselli said telehealth reimbursement by Medicaid would also allow CHC to offer a service that's tough to come by: child psychiatry in schools.

"It would be a big, immediate thing if Medicaid reimbursed this," Masselli said.

Another area ripe for telehealth use is home care, said Beka Apostolidis, a registered nurse and owner of BA Healthcare Consulting in Cromwell.

Apostolidis helps providers, mainly homecare agencies, evaluate telehealth technology options.

"A lot of agencies I've encountered have held off on using it because there's that lack of reimbursement," she said. "I think we're making better strides now."

Correction: The original version of this story omitted that United Healthcare has also partnered with American Well to conduct telehealth patient visits.

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