1. Federal Telehealth Policy
David Lee
National Rural Health Association

2. What is “Telehealth” or
“Telemedicine”
• The Federal Government defines telemedicine and
telehealth generally as “interactivecommunication
systems for real-time examinations, diagnosis and
treatment .”
• Key Terms:
– Originating Site: Where the patient is located
– Distant Site: Where the medical specialist or practitioner is
located.

3. NRHA and Telemedicine Policy
• CMS should modify the clinical and payment
regulation of Telehealth and Telemedicine
delivery methods.
• Congress should liberalize rules governing
originating sites and distant sites to extend
benefits to a wider range of interactions and
populations.
• Licensure and Credentialing requirements should
be modified to allow for interstate care.

4. Health Care Shortages
• One of the primary challenges for rural
populations is an inability to recruit physicians
and other health providers. Specialty care is
specifically challenging for rural communities.
• The Health Resources and Services
Administration has established qualifications for
designation as a Health Professional Shortage
Area (HPSA). Usually, “HPSAsare designated
using…population-to-clinician ratios. This ratio
is…3,500 to 1 for primary care HPSAs.”

5. Rural America
• 62 million Americans live in rural areas
following the most commonly used Federal
definition.
• These 62 million people are scattered over
90% of the landmass.
• Extreme distances, challenging geography and
weather complicate health care delivery.
• 77% of rural counties are HPSAs and 8% of
counties have no physician at all.

6. Physician Shortages Getting Worse
• Through the Affordable Care Act (ACA),
approximately 30 Million more people will
gain health insurance or coverage by the end
of 2014.
• While the ACA included a number of health
care training provisions, many have not been
funded.

7. Telehealth Offers a Solution
• The Federal Government, State governments, and
private payers have funded numerous pilot
projects that have evidenced the benefits of
telehealth.
• These projects range from public health activities
such as obesity counseling programs to significant
medical procedures such as tele-stroke
consultation.
• The VA and TriCARE have made great strides in
national Telehealth networks.

8. Telehealth in Action
• In February, 2013 Clarence Renno, 66,
experienced a massive stroke at his home in
The City of the Dales in rural Oregon. The City
of the Dales is the county seat of Wasco
County in North-Central Oregon, and has
approximately 25,000 people in the entire
county

9. • Clarence was taken to Mid-Columbia Regional
Hospital. This rural hospital, a CAH,
participates in telehealth activities, specifically
stroke care, with the Oregon Health and
Science University Hospital in Portland,
Oregon. Within minutes, neurologists in
Portland, were analyzing CT Scans taken at
Mid-Columbia and examining Clarence
through a robot-controlled telehealth device,
called a “Remote Presence System”.

10. • Through the examination the treatment team
at the University decided to aggressively treat
the stroke withTPAdrugs, which research has
found to be effective for patients primarily
during the first three-four hours of stroke.
Because of the availability of a health-caredelivering-robot, Clarence was given timesensitive care by some of the foremost
specialists in his state, notwithstanding his
geographic isolation.

11. • Though Clarence was enrolled in Medicare,
this Telehealth interaction was not reimbursed
to either hospital participating in his care.
This is because Tele-stroke care has not been
approved for reimbursement by CMS

12. Licensure and Credentialing
• Because there is no national license for the
practice of medicine, the promise of
telemedicine has been confined, specifically in
specialties
• Due to tedious regulations on credentialing,
many providers are unwilling to participate in
telemedicine

13. Licensure solutions
• NRHA’s Policy Congress has adopted a new
official policy paper that would advocate for a
volunteer national license that would allow for
telehealth consultations and treatments
without modifying any state licensure or
scope-of-practice laws
• Recommendation was based on ICLAST Act,
proposed legislation from the 111th Congress

14. Credentialing
• NRHA also support credentialing by proxy for
the purpose of telehealth consultations. This
would allow the credentialing board of one
facility to carry out the same process for
another facility by proxy, through agreements.

15. Medicare Barriers to Telehealth
• In spite of the benefits that have been shown
by numerous programs, Medicare still fails to
pay for a number of procedures and
interactions. Additionally, payment for these
services is significantly limited by geography
and local HPSA status.
• This refusal to pay discourages originating
sites from acquiring telehealth technology and
distant sites from offering consulting services.

16. Medicare Obstacles
• What Telecommunications System can be
used? The system must:
– Be interactive audio andvideo
– Use real-time communication
– Not be “Store and Forward”

17. Provider Limitations
• Physician
– Medical Doctor
– Doctor of Osteopathy
• Practitioner
–
–
–
–
–
–
–
Physician Assistant
Nurse Practitioner
Certified Nurse Specialist
Certified Registered Nurse Anesthetist
Clinical Social Worker
Clinical Psychologist
Registered Dietician

18. Medicare Telehealth Benefit
• Originating Site Geography
Located in a Rural Health
Professional Shortage Area
Located in a county that is not
designated as part of a
Metropolitan Statistical Area
• Originating Site Description
•Physician office
•Critical Access Hospital
•Rural Health Clinic
•Federally Qualified Health
Center
•Hospital
•Hospital Based ESRD clinic
•Skilled Nursing Facility
•Community Mental Health Center

19. What does Medicare pay for?
• Required by Statute (42 USC 1935m(m))
– Some Office or other Outpatient Consultations
– Some Office or other Outpatient Visits
– Individual Psychotherapy
– Pharmacologic Management
• Secretary may add additional services at her
discretion.

20. The process for “exercising discretion”
• CMS reviews telehealth approved services
during their annual rulemaking process, in the
Physician Fee Schedule annual update.
• The current review process was established
following the passage of the Medicare,
Medicaid, and SCHIP Benefits Improvement
and Protection Act of 2000 (BIPA).

21. How does the Secretary
exercise her discretion?
•
Category I:
•
•
The new service must be “similar to existing services.” CMS’s
review of requests for coverage includes an assessment of
whether the roles and interaction among the patient at the
originating site and physician or practitioner at the distant site
are similar to existing telehealth services.
Category 2:
•
Roles of and interaction among doctor and patient in the
proposed service are not similar to existing telehealth services.
Review of these requests includes an assessment of whether the
service is accurately described by the corresponding code when
delivered via telehealth and whether the use of a
telecommunications system to deliver the service produces
demonstrated clinical benefit to the patient.

22. What has been added?
• A limited number of services have been added
over several years, including:
– Smoking cessation counseling;
– Nutritional counseling;
– Individual health and behavior assessment and
intervention; and
– End Stage Renal Disease services.

23. What’s wrong with this process?
• The process is tedious and time-consuming for
providers with limited administrative
resources.
• There has been little movement. According
the American Hospital Association, CMS has
never approved a new service under category
two.
• Most importantly, Medicare beneficiaries are
being denied services.

24. Counties to Lose Telehealth Status
• Medicare beneficiaries in 104 counties—across 36
states and territories—are slated to lose telehealth
benefits because of updated federal delineations of
Standards Metropolitan Statistical Areas (SMSAs).
• The new federal urban/rural categorization effectively
revokes the option for Medicare recipients to receive
healthcare services via videoconferencing—one of the
most common and cost-effective forms of telehealth.
Hundreds of thousands of beneficiaries are negatively
impacted by this statistical realignment.

25. Box Elder County, UT
• 6,729 square miles of desert, mountains, and
lakes.
• The county is larger than the state of
Connecticut but home to only about 50,000
residents.
• Even though this averages out to about 8.7
persons per square mile, OMB no longer
classifies the county as “rural” because of the
proximity of the County Seat to metropolitan
areas and the passing of 50,000 residents.

27. • Legislation likely needed to address issue.
• Working with American Telemedicine
Association.
• Goal: grandfather in recently-expired
classifications.
• Note: IPPS regulation included some
modification to how CMS defines rural HPSA
for purposes of Telehealth reimbursement.
Will help some, not all counties.

28. Solutions
• CMS needs to adopt a policy to allow
telemedicine providers to receive deemed status
and to allow for health care facilities receiving
telehealth services to perform credentialing by
proxy (delegated credentialing). If a provider is
already credentialed at a Medicare-participating
facility (usually his or her home site), that
credential would be sufficient for providing
telemedicine services at another facility. The
privileging process would still be conducted by
the originating health care facility.

29. Solutions
• Recommendation: Telehealth eliminates barriers to accessing
quality care by using audio-video technology to connect
• patient with providers hundreds of miles away.
• 1) Lift the geographical patient requirements of receiving care in
Health Professional Shortage Areas (HPSAs) and
• non-Metropolitan Statistical Areas (MSAs).
• 2) Eliminate separate billing procedures for telemedicine.
• 3) Reimburse care provided by physical therapists, respiratory
therapists, occupational therapists, speech therapists, licensed
professional counselors and therapists, and social workers.
• 4) Increase reimbursement for the originating telemedicine sites.
• 5) Provide reimbursement for store-and-forward applications.

30. Solutions
• Facilitate a provider’s ability to appropriately
practice across state lines through passage of
the Increasing Credentialing and Licensing
Access to Streamline Telehealth Act .
• Support existing state scope of practice and
licensure laws while encouraging portability
and practice across state lines.

31. Resources:
• http://www.ruralhealthweb.org/go/left/policy
-and-advocacy/policy-documents-andstatements/official-nrha-policy-positions
• http://www.americantelemed.org
• http://www.raconline.org

32. Thank you
David Lee
dlee@nrharural.org
(202) 639-0550