1. U.S. Telemedicine Public Policy Gary Capistrant September 25, 2014 Columbia, SC

2. Some Problems Addressed Barriers of time and distance Professional shortages Disparities in access to care Quality of care Hospital readmits, ER overuse Costs of delivery Convenience and patient choice

3. Public Policy Goals Knock down government barriers Promote “value” innovative payment and service models Address care delivery problems Cost, access, outcome, productivity

4. Major Government Roles Rendering Reimbursement Regulation Research Resources Readiness and recovery

5. Innovative Pay Models Tweaks Value-based purchasing Pay for performance Reforms Bundling (services, time) Case-mix Sharing (risk, savings, gains) Salary-based Reference pricing, indemnity

6. Medicare Today 36.6M in fee-for-service 15.7M in Medicare Advantage 1.9M in Special Needs Plans (SNPs)

7. Medicare FFS Barriers Limited live video Only rural counties (20% of beneficiaries) Limited originating sites Limited providers Only specific procedures No store & forward No remote patient monitoring

8. Medicare Bills S. 2662 (Thad Cochran) / H.R. 3306 (Gregg Harper) Telehealth Enhancement Act H.R. 5380 (Mike Thompson) Medicare Telehealth Parity Act

9. Rural Telehealth Enhancement Act, Cochran (S. 2662) / Harper (H.R. 3306) Medicare Telehealth Parity Act, Mike Thompson (H.R. 5380), Phase 1 of 3 Store-and-forward for— Critical access hospitals ♦ Sole community hospitals ♦ Federally-qualified health centers ♦ Rural clinics ♦ Into homes for-- Kidney dialysis (video and RPM) ♦ Hospice patients ♦ “Homebound” patients ♦ Physician recertifications for home health care ♦

10. Metro Fringes Telehealth Enhancement Act, Cochran (S. 2662) / Harper (H.R. 3306) Medicare Telehealth Parity Act, Mike Thompson (H.R. 5380), Phase 1 of 3 All critical access hospitals ♦ All sole community hospitals ♦ Restore coverage for 104 counties that lost it in 2013 ♦ Video for metro counties with < 25,000 population ♦ Video and store-and-forward for metro counties with < 50,000 population ♦

11. All Beneficiaries Telehealth Enhancement Act, Cochran (S. 2662) / Harper (H.R. 3306) Medicare Telehealth Parity Act, Mike Thompson (H.R. 5380), Phase 1 of 3 Hospital readmissions: shared savings for a hospital beating its reduction benchmark ♦ For accountable care organizations ♦ For bundled payments ♦ For medical homes Medicare counterpart for Medicaid “health homes” for chronic care ♦ Authorize specialty care oriented ♦ Stroke diagnosis ♦ Federally-qualified health centers – video and store- and-forward ♦ Remote patient monitoring for-- Congestive heart failure ♦ Chronic obstructive pulmonary disease ♦ Diabetes by federally-qualified health centers ♦ More covered providers Diabetes educators ♦ Therapies – PT, OT, RT, speech & hearing ♦

12. 50 State Medicaids Today All cover imaging 45 states cover something 41 telemental health 18 home telehealth 14 remote patient monitoring 11 store-and-forward Comprehensive risk-based managed 29.1M (51%) 26 states with >50% of recipients

13. State Ratings – Coverage and Reimbursement

14. SC Progress PARITY MedicaidC MEDICAID COVERAGE & CONDITIONS OF PAYMENT Distance or Geography RestrictionsA Informed ConsentA Physician-provided ServicesB Mental/behavioral Health ServicesB Patient SettingC Eligible TechnologiesC TelepresenterC INNOVATIVE PAYMENT OR SERVICE MODELS State-wide Network ✔ HCBS Waiver ✔

15. SC Opportunities PARITY Private InsuranceU State Employee-based PlanU MEDICAID COVERAGE & PAYMENT Eligible ProvidersU Home HealthU RehabilitationN/A INNOVATIVE PAYMENT OR SERVICE MODELS Medicaid Managed Care Medicare-Medicaid Dual Eligibles Health Home Corrections

16. Medicaid Best Practices for Telehealth Uses Telemental and Behavioral Health Stroke Managed Care High-Risk Pregnancy Rehabilitation Patient Monitoring & Home Video School-based Store-and-forward

17. Medicaid Prospects Parity – urban, store-and-forward Managed care flexibility Focused initiatives Specialty – at-risk pregnancies, autism Chronic - health homes Sites – home, school-based

18. Private Insurance Obamacare HIE parity Today 21 states + DC w/parity 7 w/10+ years experience Many insurers choose to cover Prospects 29 w/o parity 14 with 2014 proposals

19. State Ratings – Physician Practice Standards

20. SC Telemed Practice Rules PHYSICIAN STANDARDS & LICENSURE Physician-patient encounterA TelepresenterA Informed ConsentA Licensure & Out-of-State PracticeC INTERNET PRESCRIBING POLICY OR STATEMENT ✔

21. Federal Interstate “One State License” Model Defense -- STEP Act (H.R. 1832) enacted December 2011 Pending VA: VETS Act, H.R. 2001 Medicare: TELE-MED Act, H.R. 3077

22. Other Major Regulatory Federal FDA on medical devices and software FCC on universal services and net neutrality HIPAA privacy and security DEA for controlled substances prescribing ONC/CMS electronic health records and health information exchange State Prof licensure & practice rules at both ends

23. Market Opportunities Mobile and home Specialty care Urban Provider productivity

24. AmericanTelemed.org ATAwiki.org Gary Capistrant Senior Director, Public Policy GCapistrant@AmericanTelemed.org 202-233-3333