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Securing #telemedicine gains in the upcoming lame duck session



#TelemedNow Twitter Chat Wednesday, December 2 – 8 PM ET Introduction & Welcome: Ceci Connolly (@CeciConnolly) - Moderator Securing #telemedicine gains in the upcoming lame duck session

Q1: Some say there’s no rush to lock in #telehealth flexibilities if the Public Health Emergency is extended. Why should Congress act now? What is the most valuable #telehealth flexibility provided during the PHE & what would it mean if you lost it after the PHE?

A1 Notable Responses: Andrew Watson (@arwmd) Providers need to be reassured the Telemedicine will be around for a while. If the funding is cut back, or the rules change again, physicians will go back to the old times of face-to-face medicine. That does not help us at all. #TelemedNow Vince Kuraitis (@VinceKuraitis) Most valuable flexibility. I’ve worked 30+ years in healthcare. To me, Econ 101 best explains observed behavior: Follow the money. Jamey Edwards (@jameyedwards) Physician licensing across state lines. Easing licensing restrictions & allowing us to "load balance" #healthcare resources, meeting patients where they are, when they are needed has been critical to #Telemedicine's success. Helen Burstin (@HelenBurstin) With final @CMSGov rule now in hand, we need Congress to support #telehealth and phone parity beyond only rural areas. Patients still need care - even if only phone call. https://cms.gov/newsroom/press-releases/trump-administration-finalizes-permanent-expansion-medicare-telehealth-services-and-improved-payment… Michael Bagel (@MichaelBagel) We shop for our groceries from home. Many are able to work from home. Amazon delivers to our homes (multiple times per day). Why shouldn't we have #telehealth in our homes. We need site of service restrictions waived today! C'mon Congress. Give us certainty! #TelemedNow Ritu Thamman (@iamritu) Best flexibilities of #TelemedNow -relaxed federal privacy regulations (HIPAA) -Defining #TelemedIcine to include phone -relaxing interstate licensing Anthony Montoya (@MontoyaHealthDC) Providers and payers deserve certainty to best serve their patients. Ensuring that telehealth remains part of the future of care delivery NOW helps @_ACHP members plan and innovate. #TelemedNow

Ceci Connolly (@CeciConnolly) Key point below; yes medicine is a calling but you are running a business too. #telehealth is hugely popular w/customers so hope #Congress won't stand in the way of progress #TelemedNow Aditi Joshi (@draditijoshi) Without it being permanent, there is less investment in long term telehealth programs and planning. (Why start if will be over after the pandemic?) However, it will be impossible to go backward so permanence allows all of us to plan for the #futureofhealthcare #telemednow Vince Kuraitis (@VinceKuraitis) IMO (lack of) reimbursement will be the biggest barrier. Data bears this out. From the COVID-19 Coalition physician survey: Q. Barriers to maintaining #telehealth after COVID-19? “Low or no reimbursement” – 73% Anthony Montoya (@MontoyaHealthDC) We must consider the promise of audio-only telehealth encounters lest we perpetuate and widen the technology gulf between those who can afford a video-enabled device and not. Patients deserve access to care that works for them!#TelemedNow Matt Sakumoto (@MattSakumoto) No time like the present! Any many clinics/orgs are hesitant to invest longterm in telehealth workflows and devices. #Commitment from Congress = Commitment from Clinics #TelemedNow Sam Lippolis (@samiamlip) Providers will not keep doing or building up #telehealth capacity if they aren't 100% sure they get paid. Being able to see patients from their home. NO GEOGRAPHIC restrictions for video visits. Patients could ONLY do video visits from a clinical location. #TelemedNow Andrew Watson (@arwmd) It’s hard to imagine that outside of the state compact this will be much different when this is over. If this is over. What do others think? #TelemedNow Dr. Salim MD (@dr_salim_MD) $ payment parity √ origination, license requirements, etc. If some of these are not made permanent, it would be tough to sustain the long term models Dr. Salim MD (@dr_salim_MD) Agree with #reassurance comes long term strategic investments to make this permanent part of #healthcare delivery. current financial landscape for most #healthcare organizations require tough decisions & with uncertainty this becomes a tough sell #TelemedNow Ginny Whitman (@GinWhitman) completely agree! why @JBarnesHealth and I published a value based payment model for #telehealth Check it out! https://achp.org/paying-for-value-in-telehealth/… Stacy Hurt (@stacy_hurt) Physicians want it. #Patients want it. Seems like a no brainer to me. It stays. Tricia Guay (@TBG_ACHP) Great phrase "Commitment from Congress = Commitment from Clinics." Need to use this more often. #TelemedNow Steve Sonnier (@StevlandS) The most critical portion is the ability to pay for #telehealth outside of rural areas and at home. The rug will be swept out from many pts who cannot utilize this benefit and we will experience a tremendous loss in terms of equitable access to healthcare. Connie Hwang (@hwangc01) With the rapid adoption of #telehealth under PHE flexibilities, what a huge step backwards it would be if we returned to limitations on accessing telehealth from your home and from non-rural settings. Juan Jose Andino (@JJAndinoMD) 100 - even if there is a documentation requirement that patient does not have broadband or tech access, focusing on video visits only risks leaving patients behind #TelemedNow Stacy Hurt (@stacy_hurt) It’s been my experience that legislative precedents on new ideas are set at the beginning- let’s get #telehealth locked in early as a healthcare norm moving forward. I need it. My son needs it. Period. Q2 What regulatory or legal barriers are hampering #telehealth? How would you address these? A2 Notable Responses: Jamey Edwards (@Jameyedwards) AX: Lack of clarity on reimbursement & value based care models future is a major issue. Ensuring that #Telemedicine visits are properly reimbursed can help ensure we are making proper decisions for patients on correct modality & increasing access to #healthcare. Matt Sakumoto (@MattSakumoto) CrossState Licensure Alternative Payment Models (not just parity, but move toward ValueBasedCare) Patient Support (Broadband, devices, pt navigators) Ritu Thamman (@iamritu) -Data Privacy -Data Security/cybersecurity -Licensure -Reimbursement: Rates & Conditions https://mtelehealth.com/10-post-pandemic-regulatory-considerations-for-telehealth-providers-2/ Dr. Salim MD (@dr_salim_MD) Licensure again is the biggest regulatory barrier Beyond the geographic restrictions in place for #TelemedNow Helen Burstin (@HelenBurstin) So many key issues already mentioned: licensing across state lines, HIPAA relaxation, phone reimbursement, etc. Great @BrookingsInst summary from May 2020: https://brookings.edu/research/removing-regulatory-barriers-to-telehealth-before-and-after-covid-19/… Michael Bagel (@MichaelBagel) Amend Social Security Act Section 1834(m). Let's start by removing the statutory barriers to #virtualcare. Easy fix! #TelemedNow Andrew Watson (@arwmd) I feel the biggest one is using platforms. When the PHE expires, then we will have to go back to less phone calls and lose the ability to use a number of common platforms. The technology has to be easy to use. Sam Lippolis (@samiamlip) It's a very good point. Platforms that are easy and ubiquitous make a big difference for patients and providers. #TelemedNow Aditi Joshi (@draditijoshi) licensure, patient/provider (engagement) because of reimbursement. how much we can use in ED - the EMTALA definitions has helped; much needed for remote triaging covid patient. Still, most of us are unsure how to use it. #TelemedNow Steve Sonnier (@StevlandS) A major reg issue is the affordability of broadband for rural/urban pts. W/o access to TH (assuming only video-visits are offered), disparities will increase. Health systems should ask pts if they have access to affordable broadband and if not, help enroll them to Lifeline Tricia Guay (@TBG_ACHP) Amen! Broadband is a huge issue in which Congress needs to make a substantial commitment and investment. #TelemedNow Juan Jose Andino (@JJAndinoMD) If returning to pre-PHE world, the originating site requirement for Medicare patients Payment parity - Health systems (not doctors) will push for in-person visits if they can make more $ than #telehealth visits (for the same medical decision making) Matt Sakumoto (@MattSakumoto) What do you mean by Platforms (like FaceTime and other non-HIPAA compliant means?) In my experience, most health orgs are investing in modalities that can work post-pandemic (and many free/approved options DoxyMe, Doximity, etc) #TelemedNow Jim St. Clair (@jstclair1) Congress did, the whole program is set up wrong. Hopefully Pres-elect Biden will appoint someone who appreciates the public service of broadband #telemednow Ami Bhatt (@AmiBhattMD) The public service of broadband expands beyond medicine and even education. Wholeheartedly agree. #TelemedNow

Q3 Some in Washington fear fraud, waste and abuse if #telehealth continues on a large scale. What strategies can help rein in bad actors and ensure #healthcare dollars are well spent? A3 Notable Responses: Jamey Edwards (@jameyedwards) #Telemedicine is digital & therefore easier to track & manage in many instances than in-person care. There are bad actors in every system (for #DigitalHealth think #hackers, threat actors, etc...), but it should be easier to ensure safety of #Telehealth at scale. Anthony Montoya (@MontoyaHealthDC) I know many @_ACHP members keep a running, open audit of utilization for key services and compare telehealth and in person care. If usage spikes, they intervene immediately. In other words, our members are careful stewards of precious public dollars. #TelemedNow Michael Bagel (@MichaelBagel) Medicare Advantage and other value-based contracts are responsible for fraud, waste and abuse - not government. Give them secure #virtualcare flexibilities NOW and learn from their successes! Need examples - look at @_ACHP members! #TelemedNow Ritu Thamman (@iamritu) Stop pay kickbacks for “leads,” or patient identifications/ insurance information, of persons who may need durable medical equipment -insurance plan representative may suggest that the practice “must use” Vendor X if they want those claims paid ie “steering” stop this Ami Bhatt (@AmiBhattMD) We must establish how to bring video, patient related outcomes, vital signs to areas where access is limited. Telephone alone carries the highest risk of misuse, and underperformance of quality care. Helen Burstin (@HelenBurstin) Digital “fingerprints” may actually make it easier to detect fraud. Build safeguards into high risk areas (e.g., DME and opioids) Use emerging tech #AI/#ML to detect fraud @NCQA TF: https://tinyurl.com/y4u6z7bc Andrew Watson (@arwmd) One key challenge here will be getting the data out of a lot of the platforms that are not necessarily HIPAA compliant. #TelemedNow OCR under HHS relaxed enforcement. Doesn’t this expose the Industry? Steve Sonnier (@StevlandS) The @NCQA's Taskforce on Telehealth Policy report has some excellent strategies for policymakers to consider in this area. FWA will exist and it may just be telehealth's turn in the limelight. But more attention means we can do better! Bobby Clark (@bobbyjclark) public programs have lots of ways to weed out fraud, waste and abuse. We should be looking at how to use those existing authorities in new ways to protect against any emerging fraud, while not holding hostage innovation. #TelemedNow Dr. Salim MD (@dr_salim_MD) Most of this #insurance fraud , not specific to just #telemednow only. First step is to recognize it. And build tools, use data to detect abnormal claims, payments, usage, volume, etc. to actively remove the abusers of the system Connie Hwang (@hwangc01) Moving toward value-based payment where #telemednow activity is reimbursed globally & adjusted based on quality outcomes would help us avoid both hair-splitting on telehealth service payments and the rare instances of high-volume FFS fraud. @_ACHP Sam Lippolis (@samiamlip) This is 100% true. Phone only can be higher risk for fraud. That is what recent #DOJ takedowns were phone center fraud. If the vital data is needed for patient care, clinicians should have access to info. Stacy Hurt (@stacy_hurt) Fraud? Like all the “not documented not done” that I witnessed in my PPM days? Pleeeeeease...improvement in patient outcomes & decreased expense is all the evidence they will need on those dollars well spent #TelemedNow Sam Lippolis (@samiamlip) At @CTeLTweets #CTeLSummit2020 today discussion from #CMS that fraud is always going to happen and recent #DOJ takedowns are call center fraud not #telehealth fraud. Glad to hear they distinguished between the 2 Ritu Thamman (@iamritu) AI is key to help fight fraud by monitoring utilization patterns, unusual patterns of billing activity,unbundling of services #TelemedNow Matt Sakumoto (@MattSakumoto) I'm generally anti-AI, but great potential for Fraud hot-spotting and auto-pattern detection. #TelemedNow See: CMS Medicare Integrity https://cms.gov/blog/future-medicare-program-integrity

Q4 Policymakers seek data to advance #telehealth policies and the industry needs to keep assessing what works best in a virtual setting. So what is the best way to review industry wide #telehealth data and trends? Do we choose an independent entity to do so? A4 Notable Responses: Jamey Edwards (@jameyedwards) Create a government led repository of redacted information submitted directly after each #telemedicine encounter. Works for hospital reporting data to @CMSGov & would work for #telehealth as well. Andrew Watson (@arwmd) Maybe @AmericanTelemed @AnnMondJohnson? The @AmCollSurgeons has done an amazing and transformative job with NSQIP. @pturnermd @SWexner@PittSurgery A model for us to emulate in #TelemedNow #telemedicine. Steve Sonnier (@StevlandS) In the review of industry wide #telehealth data, we need to ensure that race/ethnicity/language data are properly accounted for. This will help w/ equitable deployment, provides feedback for patient-centered designs, and lets us know what gaps we need to address. Bobby Clark (@bobbyjclark) Most important data point IMO: the voice of the patient. Nothing can be more compelling for policy makers then to hear from those who have been able to access quality health care thanks to #Telemedicine. #TelemedNow Helen Burstin (@HelenBurstin) BIG opportunity for #TelemedNow community to advise @CMSgov on newly announced commissioned study of telehealth flexibilities in #COVID19 PHE. - What should be measured? - Who should do the study? Dr. Salim MD (@dr_salim_MD) I feel we need to encourage use of existing entities, @NCQATelehealth @AmericanTelemed to harvest the data from the PHE time this year & glean outcome data on what works best for #TelemedNow Jim St. Clair (@jstclair1) My take: the Direct Contract Entity (DCE) program will move Billions$ to capitated payments by 2025. Smart providers will recognize virtual care as the underpinning to operationally and financially succeeding #telemednow

Andrew Watson (@arwmd) Yes Vince and we crossed tweets. @AmCollSurgeons did a similar effort with NSQIP Ritu Thamman (@iamritu) we are in data silos- need to legislate interoperability if patient is in charge of their data, & healthcare systems must compete for that patient’s business, interoperability becomes a much more attractive business proposition https://bit.ly/3iGUtKY @rashmeeshah Ami Bhatt (@AmiBhattMD) Large medical societies should capture data in existing registries and publish it, while payors must collect and share data publicly @ACCinTouch #TelemedNow while we await a central governmental effort. Connie Hwang (@hwangc01) Agree that rigorous comparative effectiveness research on #telemednow vs usual care can sway policymakers. Let's keep an eye on @PCORI, who has invested $400m in #telehealth research, including a current study on 2 types of remote CBT for depression Tx. Stacy Hurt (@stacy_hurt) Attention fellow #patients & #caregivers: if you have benefited from #telehealth, please send me or someone in the #TelemedNow group your stories so we can ensure that this option remains in tact past the #COVIDー19 pandemic Jessica Spencer Castner (@DrCastner) Interesting question - many states, like NY, have excellent reporting systems with infrastructure & processes in place that can expand to a telehealth component—drawbacks include state-to-state inconsistencies: https://health.ny.gov/statistics/sparcs/ Jessica Spencer Castner (@DrCastner) Meanwhile, NEDS & other national level systems that could expand to telehealth database already have limitations in the transparency about expertise of data abstracters/chart reviewers—leading to uncertanties about validity & misclassifications: https://hcup-us.ahrq.gov/nedsoverview.jsp Ritu Thamman (@iamritu) This is (key) issue We Don’t Need More Data, We Need the Right Data | Circulation http://ahajournals.org/doi/10.1161/CI… “Cleaning & verifying data is painstaking, time-consuming work that clinicians must lead, despite the current urge to churn out algorithms quickly.” #TelemedNow

Q5 What innovative strategies have you implemented to bridge digital divide? How can policymakers turbocharge #telehealth as a tool for closing gaps, addressing inequities and disparities? A5 Notable Responses: Jessica Spencer Castner (@DrCastner) public libraries have served as our great equalizers in access to knowledge, internet, & support. Post-pandemic planning for library telehealth kiosks & stations, considering patron privacy & environmental services for equipment (like blood pressure cuffs) can be considered. Ritu Thamman (@iamritu) Through access for all: Internet access, device access, tech literacy access , health literacy access, language access #TelemedNow Ameya Kulkarni (@ameykulkarnimd) Simplifying the tech is critical. Interestingly, @BestBuy has done really neat work in this space using their jitterbug phones and tech "ambassadors" and relatively low cost. Also @SpatzErica has done amazing work in tech disparities in health care. Joe Angelelli (@GeroAmericano) Digital divide for older adults is truly intersectional issue, about digital health equity cc: @lauraposkin #agefriendly Aditi Joshi (@draditijoshi) improving connectivity/wifi. never realized what a divide there was until #telehealth recognizing that digital is necessary for education/work and giving discounts or part of work/school. The divide and disparity starts early and needs to be evaluated and fixed. #TelemedNow Steve Sonnier (@StevlandS) Policymakers should connect with community-based orgs already engaged in this area. Don't re-invent the wheel but be realistic and strategic about broadband deployment. Also should consider Sen. @PattyMurray's Digital Equity Act! Sam Lippolis (@samiamlip) connectivity - wifi and/or great cell coverage for everyone and affordable Anthony Montoya (@MontoyaHealthDC) Important to help patients adapt to telehealth, especially elderly patients. And to provide guidance in a culturally appropriate and sensitive manner. Proud of @ucaremn who is a leader in this type of community outreach in telehealth and other modes of care. #TelemedNow Stacy Hurt (@stacy_hurt) Glad to hear this is happening! I was just on a panel last week preaching about the education that needs to accompany #telehealth for elderly and sensory impaired populations (ears) (eyes) Helen Burstin (@HelenBurstin) Bottom line - Congress and state govts need to push #universalbroadband. #SDOH ˅ access to #telehealth and disparities will ˄ without action New blog by @bfrist on access to #TelemedNow https://americantelemed.org/blog/how-telehealth-can-address-inequities-in-us-healthcare/…

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