CCHP E-Consult Workgroup In-Person Workshop Sierra Health Founda0on - - PowerPoint PPT Presentation

CCHP E-Consult Workgroup In-Person Workshop

Sierra Health Founda0on October 17, 2017

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Welcome and Introduc0ons

§ Mei Kwong, Center for Connected Health Policy § Rachel Wick, Senior Program Officer, Blue Shield of California Founda0on § Carl BouthilleMe, Senior Program Officer, Health Innova0on Fund, California HealthCare Founda0on § Jana Katz-Bell, MPH, Assistant Dean, Interprofessional Programs, BeMy Irene Moore School of Nursing and UC Davis Medical Center

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CCHP E-Consult Workshop Objec0ves

The third CCHP E-Consult Workgroup in-person workshop session, supported by Blue Shield of California Founda0on and California HealthCare Founda0on, brings together e-consult stakeholders to determine next steps to gain state-level support for making e-consult programs sustainable across California. Workshop

• bjec0ves include:

§ Determine next steps for E-Consult following recent telehealth legisla0on (e.g. AB 205) § Present and refine a Fiscal Analysis of E-Consult to share with State leadership § Con0nue coali0on building through the sharing of consistent e-consult messages and posi0ve stories § Define paths forward and near term goals for achieving policy and payment support for e-consult

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Agenda

Session Facilitator/Speaker Time E-Consult and Alterna9ve Access Standards Moderator: Timi Leslie, BluePath Health, and Reactor Panel:

• Caroline Davis, MPH, Senior Policy Director, Local Health Plans of California
• Lisa Matsubara, JD, Legal Counsel, California Medical Associa0on
• Lyle Smith, Director of OpEx/PMO, and Kelli Cousineau, Program Manager-Telehealth,

OpEx/PMO, Partnership Healthplan 9:30-10:30 Break Stories of Pa0ent and Provider Successes with E-Consult 10:30-10:45 E-Consult Fiscal Analysis, Case Studies and Discussion Moderator: MaM Meyanathan, BluePath Health, and Reactor Panel:

• Lisa Murphy, MD, Medical Director, Central California Alliance for Health
• Delphine Tuot, MDCM, MAS, Assistant Professor of Medicine,

Division of Nephrology, University of California San Francisco

• Paul Giboney, MD, Director, Specialty Care,

Los Angeles County Department of Health Services 10:45-12:00 Lunch

• Buffet lunch and networking

12:00-12:45 Paths Forward: Op9ons and Milestones to Advance State Support of E- Consult in the Coming Year Moderator: David Lown, MD, Medical Director, Safety Net Ins0tute/California Associa0on of Public Hospitals, and Panel:

• Seleda Williams, MD, Integrated Systems of Care Division, Department of Health Care

Services

• Mary Watanabe, Deputy Director, Health Policy and Stakeholder Rela0ons, Department of

Managed Health Care

• Julie Bates, MS, Gerontologist, ASD, AARP
• Mike WiMe, MD, Vice President and CMO, and Cindy Keltner, Deputy Director of Health

Center Transforma0on, California Primary Care Associa0on (CPCA) 12:45-1:30 Tabletop Sessions

• Administra0ve Ac0on
• Legisla0on
• Leveraging Exis0ng Programs

1:30-2:15 Group Readout

• Group leaders present draf Paths Forward for discussion

2:15-2:45 Wrap-up

• Mei Kwong, Center for Connected Health Policy, presents next steps for workgroup ac0on

2:45-3:00

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eConsult – store and forward provider to provider communica0on is spreading across the state and increasing access to specialty care

eConsult (Expert Opinion) Pa9ent Involved Store and Forward Live Video Remote Pa9ent Monitoring

Telehealth

Project ECHO

Store and Forward Synchronous

Telehealth is a means for enhancing health care, public health, and health educa0on delivery and support, decreasing the need for physical health care visits using telecommunica0on technologies.

• Videoconferencing to help urban specialists

train primary care doctors in rural sehngs. The training allows these general prac00oners to provide specialty care, especially chronic condi0on services, that would otherwise be unavailable to pa0ents in these areas.

• Data collected from an

individual in one loca0on via electronic communica0on technologies, which is transmiMed to a provider in a different loca0on for use in care and related support.

• Transmission of recorded health history through an

electronic communica0ons system to a prac00oner, usually a specialist, who uses the informa0on to evaluate the case or render a service outside of a real- 0me or live interac0on.

• Live, two-way interac0on between a pa0ent

and a provider using audiovisual telecommunica0ons technology.

Remote Patient Monitoring

• Electronic message exchange (including clinical

ques0on and related diagnos0c data) ini0ated by the primary care physician to a specialist. Specialist can convert an eConsult to a referral if necessary.

Provider to Patient Provider to Provider

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Introduc0on: Electronic Consult Defini0on and Benefits

An electronic consulta.on is an asynchronous dialogue ini.ated by a physician or other qualified health care professional seeking a specialist consultant's expert opinion without a face-to-face pa.ent encounter with the consultant. To capture the service rendered, the specialist will report a code for inter-professional consulta.on (e.g. 99446). Electronic consults provided by consulta.ve physicians include wriGen report to the pa.ent's trea.ng/reques.ng physician/qualified health care professional.

Pa9ents: More 0mely access to specialty care with improved health outcomes as a result; greater sa0sfac0on with care a result of not having to travel and engage in unnecessary in-person visits.

1 2

Literature and pilot programs demonstrate long term benefits and improvements for:

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Primary Care Providers: Higher quality coordinated care and enhanced communica0on with specialists, ul0mately expanding the knowledge and scope of prac0ce of the PCP. Public/Private Health Plans: Increased ability to meet 0mely access requirements, while increasing the efficiency and reducing cost per pa0ent.

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Specialists: More efficient use of 0me as a result of decrease in unnecessary referrals.

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CCHP and BluePath Health work to facilitate the eConsult Workgroup in parallel with suppor0ng complementary efforts across the state

• Facilitate CCHP eConsult Workshops to

further reimbursement discussions among DHCS, MCPs and DPHs

• Discuss rates for eConsult CPT codes based
• n 0me spent
• Work with MCP stakeholders within pilot

regions to discuss poten0al reimbursement of specialist eConsults

• With BSCF pilots and MCPs, develop an

incen0ve plan to engage PCPs at FQHCs

• Consider eConsult to address increased

specialty care 0mely access requirements following Covered California expansion

• Acknowledge e-consult in network

adequacy requirements

eConsult Defini0on and Incen0ves Engagement and Collabora0on DHCS and DMHC DPHs CHCs/FQHCs

• Provide opportuni0es for BSCF pilot DPHs to share

best prac0ces in eConsult to op0mize Waiver programs and repor0ng, aligning measures with BSCF pilot requirements

• Facilitate collabora0on and par0cipa0on in

CAPH educa0onal events (e.g. PRIME webinars)

• Facilitate FQHCs, BH/MH and social services in

pilot regions in pursuing GPP programs, u0lizing eConsult as appropriate to meet program goals

• To op0mize available incen0ves, seek
• pportuni0es to engage FQHCs in waiver

programs which value alterna0ve (specialty care) touches and avoidable u0liza0on of high-cost health care services

• Work with FQHC APM pilots planned to

determine how to incorporate eConsult programs

MCPs

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Key Tenets of Electronic Consult

§ E-consult directly impacts pa9ent and provider sa9sfac9on. E-consult related surveys report overwhelming improved sa0sfac0on from both pa0ents and providers. § E-consult is the standard of care. E-consult in no longer in pilot stage. There is a significant experience base that has demonstrated las0ng results. § E-consult improves access to specialty care and network adequacy. E-consults

• p0mize face-to-face visits and sa0sfy specialty access standards. Improved access is

demonstrated through:

• Decreased wait 0mes for specialty care
• Decreased ”repeat” appointments
• Decreased “no shows”

§ E-consult promotes health homes and builds PCP capacity. Over 0me, E-consult is shown to expand the ability of the PCP to care for the pa0ent, keeping him/her within the health home. § E-consult is not an electronic referral. E-consult is separate and dis0nct from an electronic referral. The two processes should not be subject to the same regulatory requirements.

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California’s reimbursement for store and forward telehealth services

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E-Consult and Alterna0ve Access Standards

• Caroline Davis, MPH, Senior Policy Director, Local Health Plans of California
• Lisa Matsubara, JD, Legal Counsel, California Medical Associa0on
• Lyle Smith, Director of OpEx/PMO, Partnership Healthplan and
• Kelli Cousineau, Program Manager-Telehealth, OpEx/PMO, Partnership

Healthplan

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Break

Our Mission

To advance the health and well-being of American Indians and low income individuals living in our communities by providing convenient access to high quality, compassionate care.

Chapa-De Indian Health

501c3 Non-Profit Organization

Indian Health Service 33% 3rd Party & Pa0ent Fees 60% Grants 3% Other 4%

Revenue Mix

Why eConsults

• paucity of brick and mortar specialists
• long delays
• long distance to travel
• frustrated patients/providers

eConsult Implementation

1) Stakeholder analysis 2) Engaged leadership 3) Physician Champion 4) Transparency with Providers 5) Process Mapping 6) Managing Resistance 7) Monitoring Provider/Patient satisfaction 8) Regular and frequent problem-solving meetings with partners

Stakeholder Strongly against Moderately against Neutral Moderately suppor9ve Strongly suppor9ve Providers C D Nurses C D Medical assistants C D Referral team/ HIM team C D Senior leadership CD Board of directors C D PSR C D

Stakeholder Analysis

Stakeholder Desired behavior Short term concerns Short term wins Influencing strategy: Ac9on, By whom? By when? Providers

• Choose to/

want to use eConsult

• Stay highly

engaged in process

• Previous bad

experience with change ini0a0ve

• Giving up

too soon

• BeMer access to

specialty services

• Improved pa0ent

sa0sfac0on

• Process is

streamline and easy for them

• Improved provider

morale

• Provider powerpoint on July 18th by Dr.

Anderson (lunch)

• Emails to providers about eConsults

and provider training-ongoing

• Clear guidelines as to what to do if

something isn’t working right

• Graphical representa0on of the

eConsult process from the providers’ perspec0ve

• On-site check-ins with providers by Dr.

Mulligan and Wendy afer implementa0on

• Survey to providers regarding

sa0sfac0on with process

Influencing Strategy

Stakeholder Desired behavior Short term concerns Short term wins Influencing strategy: Ac9on, By whom? By when? Referral team/ HIM team

• Successful

execu0on

• f process
• Stay highly

engaged in process

• None
• Successful

movement of referrals

• Reduced backlog of

referrals

• Improved morale

among coordinators

• Training of new eConsult

process on July 12th with breakfast

• Clear guidelines as to what to

do if something isn’t working right

• Graphical representa0on of the

eConsult process from the referral team’s perspec0ve

• On-site check-ins with providers

by Dr. Mulligan and Wendy afer implementa0on

• Survey to referral team

regarding sa0sfac0on with process

Influencing Strategy

Chapa De Provi vider Surve vey

Ho How can the specialist improve the quality of the eConsult responses? An Answer Options

cant think of anything. Spend more time with the patient. not sure at this time since not have sent anything to them yet timely response add other specialties We are make no progress in understanding what they can offer as opposed to what we expect. i think the problem is more on our end with the EHR we use and the fact that the specialist does not have access to navigate the chart. Be sure to read the other specialist's e-consult recommendation. For example, if one e- consult led to an e-consult in a different specialty I think it is helpful for them to read the other specialist's recommendation so they can see why we ordered what we did

not at this time Make sure that the Specialist is not in a hurry during the econsult. none. give us more!

Chapa De Provi vider Surve vey

Do Do you have any additional suggestions for improving eConsults? An Answer Options

THANK YOU!

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LA Care Health Plan E-Consult Story

Topic Narra9ve Detail Contacts

Increased access to specialty care In 2012 L.A. Care Health Plan implemented eConsult in collabora0on with Health Care LA (HCLA), MedPOINT Management, and Los Angeles County Department of Health Services. The system was intended to improve care for Medi-Cal managed care and uninsured pa0ents within L.A. County. eConsult aims to: (1) enhance collabora0on and co- management of pa0ents between PCPs, specialists and other healthcare professionals (2) op0mize ini0al face to face specialty visits (3) reduce unnecessary specialty visits, and (4) decrease no shows and cancella0ons

• Len Rosenthal –

lrosenthal@lacare.org

• Shamika Mane –

smane@lacare.org

Who Benefited from E-Consult? How?

PCPs/clinic staff/pa0ents benefited. PCPs reported a high educa0onal value in electronic consulta0ons in helping them address clinical ques0ons and for their own personal development in trea0ng their pa0ents. More than 75% of par0cipa0ng clinics reported that their clinics are func0oning more efficiently with eConsult and having

• ne electronic, integrated referral platorm

for all pa0ents has been an achievement. Pa0ent’s care improved by the ability of PCPs and clinic staff to interpret specialist recommenda0ons and answer pa0ent ques0ons directly and allowed them to triage pa0ents with urgent needs and shortened wait 0mes. eConsult helped expedite care for individuals who otherwise may have had to wait for six months or more to see a specialist.

Organiza9on(s) Involved

• L.A. Care Health Plan
• Health Care LA IPA
• MedPoint Management

Who Needs to Hear this Story?

• PCPs
• Specialists

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E-Consult Fiscal Analysis and Discussion

• Lisa Murphy, MD, Medical Director, Central California Alliance for Health
• Delphine Tuot, MDCM, MAS, Assistant Professor of Medicine,

Division of Nephrology, University of California San Francisco

• Paul Giboney, MD, Director, Specialty Care,

Los Angeles County Department of Health Services

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Pa0ent Quotes:

“Just a click away: exploring pa.ents’ perspec.ves on receiving care through the Champlain BASETM eConsult service”

Source: “Just a click away: exploring pa0ents’ perspec0ves on receiving care through the Champlain BASETM eConsult service” (Family Prac0ce, 2017)

§ Pa0ents surveyed from June 2015 and January 2016 and completed 15-min semistructured interviews. § Of 30 interviews, 26 stated that eConsult was useful in their case § All agreed that eConsult was an acceptable way to access specialist care § 29 stated that they would ask their primary care provider to use eConsult on their behalf in the future. [E-consult] saves me having to take a day off work to sit around a wai:ng room all day just to find out that there was really no point in coming here. [I]f I wanted to see [the specialist] face-to-face it would have taken possibly months. [I]t…gives me a bit of peace of mind knowing that there’s more than one person involved making the decision. [Your PCP] is familiar with you as a pa:ent and all of your medical records and also the type of individual that you are…If you go and see a specialist, your family doctor may cover more ground and bring some different insights into it. With e-consult, PCPs become a “one stop shop for healthcare.”

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Lunch

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Pa0ent Story: LA County Department of Health Services

A 52 year old man comes into my office with a history of high blood pressure. Over the past two months he has had some mild, atypical chest pain with climbing stairs. I was concerned that this might be heart disease. In our old system, he would have been referred to the Cardiologist (would have waited several months to see him). The Cardiologist would have then ordered a Treadmill test. Afer the Treadmill test, the pa0ent would have had to go back to the Cardiologist to review the results. (3 days off work and many months of 0me) Because of eConsult, this is how the care went. I eConsulted the Cardiologist who responded within 24 hours and reviewed the pa0ent's symptoms and EKG online, asked me a few ques0ons and then recommended the Treadmill test. The pa0ent then went for the Treadmill test -within a month of the visit with me. (One day off work). The results came back to me and I shared them (via eConsult) with the Cardiologist. We discussed the case and determined that the problem was not due to Cardiac disease. I called the pa0ent at home, reviewed the results and recommended that he keep his next rou0ne visit with me.

The benefits are obvious – a faster, more coordinated work up for this pa.ent and fewer days off of work.

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Paths Forward:

Op.ons and Milestones to Advance State Support of E-Consult in the Coming Year

• Moderator: David Lown, MD, Medical Director,

Safety Net Ins0tute/California Associa0on of Public Hospitals

• Seleda Williams, MD, Integrated Systems of Care Division,

Department of Health Care Services

• Mary Watanabe, Deputy Director, Health Policy and Stakeholder Rela0ons,

Department of Managed Health Care

• Julie Bates, MS, Gerontologist, ASD, AARP
• Mike WiMe, MD, Vice President, CMO, California Primary Care Assn, and
• Cindy Keltner, Deputy Director of Health Center Transforma0on, CPCA

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What is the first step? Who will guide us? What audience must we convince? What bumps will we hit? What are the steps along the way - language? tools? 0ming? How do we know we’ve reached our des0na0on?

Which path should we take? _____________

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Breakout Tabletop Discussions:

• Administra0ve Ac0on
• Legisla0on
• Leveraging Exis0ng Programs

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Wrap-Up and Next Steps

§ Synthesize findings for review on November CCHP E-Consult Workgroup call § Meet with DHCS and DMHC to share progress and present proposed path forward § Celebrate e-consult successes at CAPH and upcoming associa0on mee0ngs

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Overview of Fiscal Analysis of costs and poten0al savings resul0ng from e-consult

Predict the budget impact to payers (Fee-for-Service and Managed Care) if e-consult is

• implemented. Fiscal analysis does not represent overall benefits of e-consult, but

focuses solely on the impact to costs and poten0al savings.

Purpose

Central California Alliance for Health Harvard School of Public Health Los Angeles County Department of Health Services San Francisco Health Network San Mateo Medical Center UC Davis Health System UCSF University of Vermont/American Academy of Medical Colleges

Feedback Par9cipants

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Key interview takeaways informed the fiscal analysis

Subject maLer experts agree that e-consult has: § Improved pa0ents’ ability to get the type of care they need at the 0me they need it § Demonstrated both pa0ent and provider sa0sfac0on § Reduced costs to pa0ents, specifically in transporta0on § Resulted in PCP learning and fewer specialty care visits They also agree on findings including: § Addi0onal supply of care (e-consult) does not increase demand for in-person visits § E-consult has already improved access to care, but must be reimbursed to be sustainable § Majority use telephone or secure messaging to communicate completed e-consult recommenda0ons to pa0ents Research is limited in certain areas: § Limited data are available on downstream effects in care sehngs such as Emergency Room and Hospital Inpa0ent, however, posi0ve impact in these areas are an0cipated

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E-consult programs show consistent reduc0ons in unnecessary in-person specialty care visits

23-25% Average Avoided Unnecessary Specialist Office Visit Rate

Programs with 10+ Special9es Programs with Select Special9es

Referral Rates to In-person Specialty Care or E-consult

12.19 per 100 primary care visits 10.68 per 100 primary care visits

30-50%

(e.g. ZSFG, LADHS) (e.g. Central California Alliance for Health)

Pre E-consult Implementa9on With E-consult Op9on

Source: Gleason N, et al. Adop.on and impact of an eConsult system in a fee-for-service seYng. Healthcare (2016)

Programs with published and/or interview data demonstra0ng reduc0on in unnecessary in-person visits as a result of e-consult implementa0on include (not limited to): CCAH, Community Health Centers, Inc, CT, Bruyere Ins0tute, University of OMawa; LADHS, UCSF, ZSFGH, LA Care (Mul.-Specialty Program)

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California E-consult programs have the opportunity to save transporta0on costs

July 2017 All Plan Leaer Update

§ Beginning on July 1, 2017, Managed Care Plans (MCP) must provide NMT for MCP members to obtain medically necessary MCP-covered services § The Department es0mates the annual cost per member to provide nonmedical transporta0on is between $0.50 and $2.00 per year. § “Ongoing costs of $3 million to $6 million per year to provide nonmedical transporta0on to Medi-Cal beneficiaries enrolled in Medi-Cal managed care plans that do not already provide nonmedical transporta0on as a covered benefit and fee-for-service beneficiaries who do not already qualify for nonmedical transporta0on.“

Source: BILL ANALYSIS for AB 2394 (Eduardo Garcia) - Medi-Cal: nonmedical transporta.on, 2016

Costs

Source: ALL PLAN LETTER 17-010 (REVISED) Non-emergency Medical and Non-medical Transporta0on Services , Department of Health Care Services, July 17, 2017

§ Nonmedical transporta0on (NMT) includes, at a minimum, round trip transporta0on for a beneficiary to obtain covered Medi-Cal services…and mileage reimbursement when conveyance is in a private vehicle arranged by the beneficiary

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E-consult PMPM savings example

Assump0ons: Popula0on: 450,000 eConsults: 115,000 Timeframe: 6 months

($0.50) ($0.40) ($0.30) ($0.20) ($0.10) – $0.10 $0.20 $150 $160 $170 $180 $190 $200 $210

Specialist Office Visit Rate Effect on PMPM

Avoided in-person specialty office visit: 25% eConsult cost: $40 Transporta0on: $80 RT/ 1.2% specialty visits use benefit Assumes all recommended referrals are completed

Specialist Office Visit Cost PMPM Savings

Modeled using LADHS popula0on and e-consult volume

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Over 0me, e-consult programs have shown downstream effects

• f reduced ED visits and inpa0ent admissions

Special0es Included: Allergy & Immunology, Cardiology, Endocrinology, Gastroenterology, Hematology, Hepatology, Infec0ous Diseases, Occupa0onal Medicine, Pulmonary, Sleep Medicine, Rheumatology, Nephrology

120 Days Following all Referrals & eConsults (n = 13,738)

• ED visits decreased 12%
• Pro fee costs decreased 17% (p = 0.016)

120 Days Following all Referrals & E-Consults (n = 13,738)

• Admissions decreased 10.8% ( Rate of 6.6% to 5.9%)
• Pro fee costs decreased 9.5% (NS)

Adop9on and impact of an E-Consult system in a fee-for-service sedng

E-consult programs have also shown a reduc.on in referral rates as a result of the PCP learning from consistent and repeated communica.ons with their specialist partners

Source: Gleason N, et al. Adop.on and impact of an eConsult system in a fee-for-service

• seYng. Healthcare (2016)

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LADHS demonstrated 25% reduc0on in unnecessary specialty

• ffice visits through e-consult

Health Affairs – March 2017

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ZSFG referral and e-consult data show eConsult improves access to care

46,765 eConsult submissions 28,170 eConsults for diagnos0cs 50,621 eSchedule submissions 62% 2% 60% 38% 22% 16% Appropriate and complete consults Consult inappropriate

• r incomplete or clinic

visit not needed Itera0ve communica0on as needed

PCP ini9ates eConsult request Specialist reviews Scheduled need to be seen in clinic Not ini9ally scheduled specialist responds to request more informa0on and/or make recommenda0ons PCP provides informa0on, ini0al evalua0on complete, visit needed No appointment 6 months afer last exchange Urgent

• verbook

appointment Non –urgent rou9ne appointment Scheduled Never Scheduled

Adapted from Chen AH, NEJM, 2013.

July 2016-June 2017

125,556 Total

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Central California Alliance for Health has demonstrated e-consult ROI and added value by

• ffering e-consult to network FQHCs
• For every 10 specialty referrals:
• Option 1: 10 in-person specialist referrals @ $X/referral
• Option 2: 5 eConsult referrals @ $Y/referral + 5 eConsults w/ specialty

referral @ $X/referral

• Net savings of $230 or 10.6%* per 10 consults

*Based on assumption of $Y per eConsult, no need for follow up consult for an in-person specialist referral, and $X per in-person specialist referral. Does not include transportation costs. Value Considerations:

• Timeliness of needed referrals - eConsultant response time in hours, in-

person referral can take weeks for appointment and completion of specialist’s report - possible delay of care

• Burden to members for transportation costs, childcare, lost work time
• “No shows” may result in loss of specialist opportunity

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Discussion

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AARP is figh0ng to break down barriers to u0liza0on

§ Federal and state governments should encourage coverage and payment of health services provided by telehealth for eligible pa0ents and family caregivers

— To improve access and quality of care, — Allow patients to remain safely in the community, — Assist with care transitions from institutional to community settings.

§ Federal and state governments should remove unnecessary restric0ons that limit beneficiary access to health services provided by telehealth. § Congress should remove geographic restric0ons on Medicare coverage for telehealth services.

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AARP is figh0ng to break down barriers to u0liza0on

§ CMS should con0nue making public the Medicare Current Beneficiary Survey data on access, health care u0liza0on, and other relevant informa0on § The agency also should pay par0cular aMen0on to access problems of special popula0ons including:

— Rural areas — People with disabili0es — Low-income individuals — Racial and ethnic groups that have experienced discrimina0on — Beneficiaries with end-stage renal disease — People living in ins0tu0ons — People living in communi0es with a shortage of health care personnel

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AARP is figh0ng to break down barriers to u0liza0on

§ Services provided by telehealth should offer quality and ensure that pa0ent-related records and communica0ons are protected from fraud § Policymakers should ensure that individuals have access to the technologies that enable telehealth including Broadband Services § All of this means Administra0ve and Legisla0ve ac0ons need to

• ccur to eliminate barriers to u0liza0on

IMPROVED HEALTH OUTCOMES + COST SAVINGS = WIN-

WIN

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eConsult Program

Kelli Cousineau Program Manager

PHC & Telehealth

45

Sometimes telehealth is the only option

• Contracted with Safety Net

Connect in 2016 to provide the eConsult platform

• 9 Northern region primary

care sites actively utilizing the system

• 6 Specialty Services

available

• Partnered with telemedicine

vendor TeleMed2U to provide specialty eConsults

PHC eConsult System

PHC eConsult Program:

eConsult Specialties

• Endocrinology
• Dermatology
• Rheumatology
• Infectious Disease
• Neurology
• Urology

Current

(TeleMed2U)

• Neurology (Local specialist)

Limited

47

130 27 5 69 47 11 Dermatology Endocrinology Infec9ous Disease Neurology Rheumatology Urology

eConsult by the Numbers

April – September 2017

87% 26% 100% 39% 32% 82% 2% 70% 0% 38% 45% 0% Dermatology Endocrine Infec9ous Disease Neurology Rheumatology Urology Pa0ent Needs Addressed Refer F2F (includes telemedicine referral)

Closed eConsults

49 *data represents Apr-Sep 2017

These referrals can take anywhere from 2-5 months. For the 289 eConsults in the past 6 months, the average time of response (in calendar days) by specialists is

1.1 Days!

eConsults Save Time

Specialty Average distance in miles Average round-trip in hours

Dermatology 378 7 Endocrinology 477 9 Neurology 302 7 Rheumatology 575 9

Patient Travel Per Visit

*data represents April-September 2017

Avoided Travel

Total Miles saved: 26,798 Total Hours saved: 455

Other savings to consider:

• CO2 emissions
• Time off work/school
• Loss of wages
• Wear & tear to car
• Gas
• Hotel

*data represents April-September 2017

Contact: PHC Telehealth Program telemedicine@partnershiphp.org

Questions?

53

California Department of Managed Health Care

October 17, 2017

Mary Watanabe, Deputy Director Health Policy and Stakeholder Rela0ons

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DMHC Mission Statement

The California Department of Managed Health Care protects consumers’ health care rights and ensures a stable health care delivery system.

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What is the DMHC?

Regulator of 124 plans, including 74 full service and 50 specialized health plans

• All HMO and some PPO/EPO products
• Some large group and most small group &

individual products

• Most Medi-Cal Managed Care plans
• Dental, vision, behavioral health, chiroprac0c and

prescrip0on drug

• Medicare Advantage (for financial solvency)

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Health Coverage that is NOT Regulated by the DMHC

• CDI products
• Most Medicare coverage1
• Some Medi-Cal coverage (FFS and COHS)
• ERISA self-insured plans
• Private health benefit exchanges

1 The DMHC issues KKA licenses to Medicare plans and has limited oversight of these types of plans including financial

solvency and administra0ve capacity.

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How Does the DMHC Regulate Plans?

§ License plans and approve products § Analyze provider networks § Ensure basic health care services and mandated benefits are provided § Monitor financial health § Evaluate plan policies and procedures § Resolve grievances and appeals § Track enrollee complaints § Enforce the law 58

Plan Monitoring – Division of Provider Networks

Division of Provider Networks

• Monitors provider networks and accessibility of

services, including Block Transfers

• Reviews annual health plan 0mely access

compliance reports

• Conducts annual compliance review of all full

service and behavioral health networks

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E-consult Proposal

§ Where will services be provided? (e.g. emergency department, inpa0ent sehng, outpa0ent sehng)

• Service areas
• Providers and provider capacity
• Geographic access
• Provider contracts and payment structure
• Cost sharing and other disclosures
• Integra0on into overall plan quality assurance process
• Grievance process

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Ques0ons

Mary Watanabe Deputy Director Health Policy and Stakeholder Rela0ons Mary.Watanabe@dmhc.ca.gov (916) 324-2560

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Payment Reform for FQHCs

October 17th 2017

APM Demonstra9on

§ DHCS sets rates for health plans § Monthly, plan would tell State how many Medi-cal members are assigned to FQHC site in demonstra0on. § State would pay the plan an addi0onal “Wrap Cap” for all pilot sites’ assigned members § Rate Adjustment between FQHC and plan. § Health center receives PMPM amount for all services in their PPS rates for the four aid categories for assigned members This model provides sites with much more flexibility and the opportunity to do prac9ce transforma9on.

DHCS

Tradi0onal Rate Sehng

FQHC

APM = a per-member- per-month (PMPM)

Health Plan

Wrap Cap- Child Adult SPD Expansion

Poten9al Pilot Upsides

§ Increased panel size with flexibility for care team to serve pa0ents = more revenue per member § Increased pa0ent sa0sfac0on/loyalty = increased market share § Improved quality outcomes = improved performance under P4P contracts § Increased staff/provider sa0sfac0on = improved reten0on and recrui0ng

Flexibility for Care Teams with APM

§ Clinics will not be bound by:

— Billable provider restric0ons; clinics can add non-billable providers to their care teams to provide the right care, right place, right 0me — Providing care within the four walls of the clinic; if having Community Health Workers (CHW) on the care teams makes sense clinics can use CHWs to care for pa0ents — In-Person visits: with the new payment methodology clinics can provide services or care for pa0ents using non- tradi0onal types of services

Non-tradi9onal Services

§ Alterna0ve payment model provides clinics with the opportunity to see pa0ents through non- tradi0onal services.

— U0lizing staff at their full scope — Flexibility in how these touches are staffed because of no billable provider restric0ons. — Flexibility in how care is delivered to members

Contact Informa0on

Mike WiMe Chief Medical Officer mwiMe@cpca.org Cindy Keltner Deputy Director of Health Center Transforma0on ckeltner@cpca.org

How medi-cal ccs & ghpp programs work to promote telehealth services in California

CENTER FOR CONNECTED HEALTH POLICY e-consult workshop, October 17, 2017 SELEDA WILLIAMS, M.D., M.P.H. Department of health care services (DHCS) public health medical

• fficer

University of California, Davis Faculty & professor

No commercial interests

• Dr. Seleda williams

Telehealth background

§ 1996: California Legislature passed the Telemedicine Development Act which laid the groundwork for developing medical communica0on technology § 2011: AB 415, Logue: Telehealth Advancement Act: replaced & amended various statutes with the intent to remove barriers & encourage use of telehealth. § AB 415 did not allocate Department of Health Care Services administra0ve funds.

DHCS & California Children’s Services (CCS)/Gene0cally handicapped persons (ghpp) & Telehealth Policy development

§ 2011-2013: DHCS conducted internal analysis of telehealth services and conducted stakeholder mee0ngs on telehealth § December 2012: AB 415 & CCS Telehealth Stakeholder Mee0ng convened, leading to learn more about local CCS & GHPP needs and recommenda0ons about telehealth. § 2013: DHCS conducted webinar on billing for telehealth services

Ccs/ghpp & Telehealth Policy development § June CCS N.L. 14-12-13: Telehealth Services for CCS and 2014: CCS This Computes! #446 on Telehealth Codes & Modifiers § October 2014: CCS/GHPP FAQs on telehealth posted on Medi-Cal & Telehealth webpage § January 2015: Collabora0on between CCS and The Children’s Partnership launched a survey on telehealth and children with special health care needs. § 2015- present: ongoing CCS stakeholder dialogue and telehealth policy development

California Children’s Services & Telehealth Policy

§ CCS/GHPP POLICY LETTER PENDING: CCS telehealth code updates: Addi0onal CCS Specialty Care Center (SCC) procedure code descrip0ons will be added, including relevant care coordina0on, office visit, and support staff X and Z codes. An0cipated implementa0on date Fall/Winter 2017. § CCS is currently working on also upda0ng addi0onal teleaudiology and teleophthalmology codes.

Telehealth modifiers & Transmissions costs

§ Modifier GT: E&M and psychotherapy provided by interac0ve telehealth must be billed with modifier GT (via interac0ve audio telecommunica0ons systems) § Modifier GQ: must be used when telehealth is provide by asynchronous telecommunica0ons systems, such as teleophthalmology services provided by store and forward telecommunica0ons (only the distant site) § The origina0ng site facility fee is reimbursable when billed with code Q3014 (telehealth origina0ng site facility fee). § Transmission costs incurred while providing telehealth services via audio/video communica0on are reimbursable when billed with code T1014 (telehealth transmission, per minute, professional services bill separately).

Medi-cal telehealth policy

§ Medi-Cal currently does not pay for telehealth services done via phone, e- mail ,or fax § Further discussion is needed as to how this impacts e-consult ability § Home health services, E-consults, and chronic/complex care services need further review and evalua0on

CCS/GHPP AND MEDI-CAL TELEHEALTH RESOURCES

California Department of Health Care Services Medi-Cal and Telehealth Web Page: hMp://www.dhcs.ca.gov/provgovpart/Pages/Telehealth.aspx CCS/GHPP NL 14-1213 on telehealth: hMp://www.dhcs.ca.gov/services/ccs/Documents/ccsnl141213.pdf CCS This Computes! 446 Telehealth Modifiers: hMp://www.dhcs.ca.gov/services/ccs/cmsnet/Documents/ thiscomputes446.pdf

Medi-cal Billing ques0ons about telehealth

For ques9ons about submidng a claim for services provided by telehealth, please call the Telephone Service Center (TSC) at 1-800-541-5555 (outside of California, please call 916-636-1980).