Connected Health - The small matter of price - Nick van Terheyden, MD

© 2002-2014 Nuance Communications, Inc. All rights reserved
mHealth Reimbursement
– Who Will Pay
Nick van Terheyden, MD (aka @drnic1)
HIMSS mHealth Committee
CMIO, Nuance Communications, Inc.
http://DrNick.vanTerheyden.com

Agenda
– mHealth Reimbursement
– Telehealth Technology Players
– Use Cases for mHealth – Preventing Readmissions
– The Healthier Workforce

“The good physician treats the disease;
the great physician treats the patient who
has the disease.”
Sir William Osler

Chronic Disease
– Today, 133 million Americans – 1/3 of the total population
suffer from at least one chronic disease.
– 70% of all deaths result from chronic diseases.
– 85% of all healthcare dollars go to treatment of chronic
diseases.
– More than 2/3 of Medicare dollars are spent on patients
with 5 or more chronic diseases.

– 1 January 2015
– Final 2015 Physician Fee Schedule
– Physicians can bill Medicare for “non-face-to-face” chronic care
management (CCM)
– Chronic care management services, at least 20 minutes of clinical
staff time directed by a physician or other qualified health care
professional, per calendar month, with the following required
elements: multiple (two or more) chronic conditions expected to
last at least 12 months, or until the death of the patient; chronic
conditions place the patient at significant risk of death, acute
exacerbation/decompensating, or functional decline;
comprehensive care plan established, implemented, revised, or
monitored.

3 Core Requirements
– Secure the eligible beneficiary’s written
consent
– Have five specified capabilities needed to
perform CCM
– Provide 20+ minutes of non-face-to-face care
management services per calendar month

– Third party payers are now starting to reimburse for telehealth
(video conferencing) but only for certain specialties:
– dermatology, mental health, etc
– Reimbursement chronic disease
– Multiple Doctors, only one can bill for fee per month
– Problems with reimbursement
– licensing issues for providers
– limitations for populations covered (for example Medicaid
approves telehealth only for certain jurisdictions mostly rural)

5 Fallacies of Remote Patient
Monitoring
– All remote monitoring is the same
– All remote monitoring is reimbursed
– Patients and physicians will welcome and embrace
remote monitoring
– Remote monitoring should be totally automated
– Remote monitoring is only for recently discharged patients

Secretary Burwell Establishes Clear Goals for Value-Based Payment
Medicare Reforms and the Transition to Risk
Source: Burwell, S, “Setting Value-Based Payment Goals — HHS Efforts to
Improve U.S. Health Care,” New England Journal of Medicine, March 5, 2015;
Health Care Advisory Board interviews and analysis.
1) Alternative Payment models include ACOs, bundled payments, patient-centered medical
homes, demonstration projects for those dually eligible for Medicare and Medicaid.
HHS Commits to Payment Transformation
80%
85%
90%
2014 2016 2018
"This is the first time in the history of the program that explicit goals for alternative
payment models and value-based payments have been set for Medicare."
Sylvia M. Burwell, Secretary of Health and Human Services
Medicare Payments Through
Alternative Payment Models1
Medicare FFS Payments
Tied to Quality or Value
0%
20%
30%
50%
2011 2014 2016 2018
~
Slide courtesy:
Dr Kavita Patel

mHealth Reimbursement Resources
– More Info Center for Connected Health Policy
– http://cchpca.org/state-laws-and-reimbursement-policies
– AAFP Summary of Medicare Fee Schedule
– http://www.aafp.org/news/government-
medicine/20141105finalfeeschedule.html
– CMS 1612 FC – Final Rule plus details
– http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/PhysicianFeeSched/PFS-Federal-Regulation-
Notices-Items/CMS-1612-FC.html

Telehealth Technology Players

Social Security Act Sec. 1834(m) [42 C.F.R. § 410.78]
“(T)he Secretary shall pay for telehealth services that are furnished via a telecommunications system by
a physician (as defined in section 1861(r)) or a practitioner (described in section 1842(b)(18)(C)) to an
eligible telehealth individual enrolled under this part notwithstanding that the individual physician or
practitioner providing the telehealth service is not at the same location as the beneficiary.”
• Medicare covered services
• Approved telehealth services
• Medicare Part B beneficiary
• Authorized clinician
• Authorized patient site
• Separate physical locations
• Interactive audio and video system (federal demo sites in AK and HI may use store-and-forward
technology)
Medicare Telehealth Benefit

Source: Medicare Telehealth Services Fact Sheet
Service HCPCS/CPT Code
Telehealth consultations, emergency department or initial inpatient HCPCS G0425–G0427
Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs HCPCS G0406–G0408
Office or other outpatient visits CPT 99201–99215
Subsequent hospital care services, with the limitation of 1 telehealth visit every 3 days CPT 99231–99233
Subsequent nursing facility care services, with the limitation of 1 telehealth visit every 30 days CPT 99307–99310
Individual and group kidney disease education services HCPCS G0420 and G0421
Individual and group diabetes self-management training services, with a minimum of 1 hour of in-person instruction to be furnished in the initial year training period to ensure effective
injection training
HCPCS G0108 and G0109
Individual and group health and behavior assessment and intervention CPT 96150–96154
Individual psychotherapy CPT 90832–90834 and 90836–90838
Telehealth Pharmacologic Management HCPCS G0459
Psychiatric diagnostic interview examination CPT 90791 and 90792
End-Stage Renal Disease (ESRD)-related services included in the monthly capitation payment
CPT 90951, 90952, 90954, 90955, 90957, 90958,
90960, and 90961
Individual and group medical nutrition therapy HCPCS G0270 and CPT 97802–97804
Neurobehavioral status examination CPT 96116
Smoking cessation services
HCPCS G0436 and G0437 and CPT 99406 and
99407
Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services HCPCS G0396 and G0397
Annual alcohol misuse screening, 15 minutes HCPCS G0442
Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes HCPCS G0443
Annual depression screening, 15 minutes HCPCS G0444
High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual
behavior; performed semi-annually, 30 minutes
HCPCS G0445
Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes HCPCS G0446
Face-to-face behavioral counseling for obesity, 15 minutes HCPCS G0447
Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge) CPT 99495
Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge) CPT 99496
Psychoanalysis* CPT 90845
Family psychotherapy (without the patient present)* CPT 90846
Family psychotherapy (conjoint psychotherapy) (with patient present)* CPT 90847
Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour* CPT 99354
Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes* CPT 99355
Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) first visit* HCPCS G0438
Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) subsequent visit HCPCS G0439
*Effective for services furnished on and after January 1, 2015

Source: CMS, as reported to the Center for Telehealth and eHealth Law
Medicare Telehealth Claims
15

16
Potential Barriers
• Largely limited to fee-for-service (Note: CAH service subscriptions)
• Patients must travel to an eligible originating site
• Originating site eligibility can change year-to-year (HPSA or MSA updates)
• Originating site fee copay makes telehealth more expensive (~$5)
• Approved services list isn’t exhaustive; extensive and lengthy process to add services
• Limited clinical outcomes data for some services
• Clinician state licensure limitations (Note: FSMB interstate compact)
• Specialist credentialing/privileging required at each hospital originating site
• Most of U.S. can’t use store-and-forward to better utilize specialists’ time
• Clinician-to-clinician consultations aren’t billable
• RHC and FQHC distant site prohibition
• Different coverage policies than other payers (e.g., Medicaid, insurers)
• Some equipment is still expensive
• Transmission speeds, reliability, and costs

Medicare Telehealth Services Fact Sheet
 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf
Medicare telehealth regulations
 http://www.ecfr.gov/cgi-bin/text-idx?SID=89f51d919ffc5b375f126c606b5b5cd3&node=se42.2.410_178&rgn=div8
Medicare Telehealth Payment Eligibility Analyzer
 http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx
Medicare telehealth webpage
 http://www.cms.gov/Medicare/Medicare-General-information/telehealth/index.html
Medicare Benefits Policy Manual Chapter 15 (Sec. 270)
 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf
Medicare Claims Policy Manual Chapter 12 (Sec. 190)
 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
Medicaid telemedicine webpage
 http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html
Resources
17

mHealth Use Cases
Preventing Readmissions

mHealth Value Proposition
– Early intervention for people at risk of congestive heart failure
(CHF) - the leading cause of hospitalization in the U.S. - could save
from $5 to $7 billion per year by expanding telehealth services.
– Telehealth documented itself to be efficacious as a tool for early
intervention
– Miley, Madeline L., et al. "The state of emergency stroke resources
and care in rural Arizona: a platform for telemedicine." Telemedicine
and e-Health 15.7 (2009): 691-699
– Deployment of an mHealth Patient Monitoring Solution for
Diabetes: “Improved Glucose Monitoring Leads to Reduction in
Medical Expenditure”
– http://www.touchendocrinology.com/articles/deployment-mhealth-patient-
monitoring-solution-diabetes-improved-glucose-monitoring-leads-r

Healthier Workforce

2009 Continua Health Alliance Brigitte Piniewski, MD2008 21
0 25 65
Age
IllnessPre-Illness
Wellness
Unpredictable Health
Predictable (Rules-based) Health
Death
60-80% Lifestyle
Modifiable Health

2008 22
0 25 65
Age
IllnessPre-Illness
Wellness
Death
To put it another way….
Fun
No Fun
2009 Continua Health Alliance Brigitte Piniewski, MD

Annual medical costs for people who are
obese were $1,429 higher than those of
normal weight.
Centers for Disease Control and Prevention
(2009)

Fort Healthcare has run with it!
Fall 2011
Six weeks
605 players
(four employers)
> 222 million steps
1,368 players
365 million steps
(so far)
64 teams
(341 players)
3,781 pounds lost
Spring 2012
Four months
Fall 2012
Six weeks

Columbia was up for the challenge
Columbia Slimdown Challenge
3,586 Participants
(75+ local employers)
11,505 pounds lost
(winner lost 23% of body
weight)
36 sponsors
(starting at $2,500)
13 week long weight loss challenge
“Thank you so much for the opportunity to lose weight in
such a fun way….. Several of us are hoping the contest can
continue (lose more weight!) or restart (add new people).”
—Slimdown participant

Making a difference, changing lives
~ 5.2 BILLION steps taken ~ 76,770
pounds lost
(equivalent to the weight of an
18 wheeler)
(equivalent to walking around
Earth ~40 times)
26,518 lives changed
23 competitions completed

Nuance Just Completed their First
Challenge
Since March over 800 employees
have been tracking their steps, food
and sleep to manage their health
and earned over 337,710 points
redeemed for 10,359 entries into
the May 31st sweepstakes. We are
pleased to announce that we have
our first set of winners.

Single Individual
– 149,000 steps which is
equivalent to 70 miles
Firstly I would like to thank your
team for the Jiff Challenge. Being
motivated to compete for the
Apple Watch resulted in me
losing 21 pounds in 28 days! I’d
say the program is a huge
success.
He sacrifice sleep,
changed vacation
plans to go to hike
mountains instead of
visiting family, walked
every chance he got
morning afternoon and
late into the night. He
would watch shows on
his treadmill and go to
the gym and just walk.
He didn’t even sleep
the last day of the
challenge he walked
every chance he got.

Recognizing New Channels for Growth
Established Provider
Care Delivery
Network
Relationship-Based
Referring Physician
Cost-Conscious
Referring Physician
Price-Sensitive
Consumer
Entrenched
Payer
Vulnerable
Payer
Activated
Employer
Exchange
Operator
Custom Network
Builder
Secure Enrolled Lives Win Share of Volumes
Traditional Growth Channels
Key Decision-Makers in Traditional and New Growth Channels
Individual
Insurance Shopper
Accountable
Physician Entity
New Growth Channels
Slide courtesy:
Dr Kavita Patel

Nick van Terheyden, MD CMIO, Nuance Communications
Twitter http://twitter.com/drnic1
LinkedIn http://www.linkedin.com/in/nickvt
Voice of the Doctor http://drvoice.blogspot.com/
My Activity http://DrNick.vanterheyden.com
AboutMe http://about.me/obiwan
FaceBook http://profile.to/drnick
E-Mail drnick@nuance.com, drnic1@gmail.com
GoogleVoice (301) 355-0877
Questions
Where You Can Find Me

Connected Health - The small matter of price - Nick van Terheyden, MD

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