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10 State-Based Perspectives In this session, a panel of experts discussed many of the telehealth issues that can fall under the purview of states, such as statutes, regula- tions, health reform issues, licensure, reimbursement, Medicaid issues, and credentialing. THE VIRGINIA PERSPECTIVE Cindi B. Jones, M.S. Virginia Department of Medical Assistance Services Telehealth should not be an afterthought, but an integrated aspect of health care delivery. The governor of Virginia realized there were many op- portunities for health care reform within and beyond the ACA. Therefore, he created an advisory group of health care leaders and business leaders to talk about what we could do better in Virginia in several strategic areas, including payment and delivery reform, capacity, Medicaid, technology, and how to get employers involved for value-based purchasing. Telehealth is intertwined in all of these areas. For example, we do not have enough health care professionals now, and so we spent a lot of time discussing how telehealth combined with team-based care can increase capacity. Virginia Medicaid serves nearly a million people with a budget of al- most $8 billion. Virginia Medicaid telemedicine coverage started in 1995 as a small pilot with a small number of services. In 2003, coverage was expanded and a variety of providers were recognized for the provision of telemedicine services. Generally, any new services in the Medicaid program 89

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90 THE ROLE OF TELEHEALTH must be priced out for the governor and the general assembly. However, Virginia has embraced telemedicine not as new service, but instead as a method in the delivery of services. Therefore, telemedicine is seen as a new mechanism to provide access for Medicaid clients. In October 2009, the program expanded the list of originating sites. Recently, even more services have been added to the Medicaid telemedicine program based on services available in the commercial market. Over time, as Virginia has moved farther away from fee-for-service payment systems toward managed care (Virginia Medicaid is about 70 percent managed care), the use of telemedicine has evolved from needing a specific modifier on claims to being included as part of the global pay- ment for what is done to serve the individual. Providers of telemedicine are expected to fully comply with service documentation and other coverage and billing requirements, and they may be audited for their compliance. Telemedicine coverage is similar to Medicare coverage, but it is not tied to rural area definitions. Even though telemedicine tends to be used in rural areas, telemedicine is also very useful method in urban areas. Use of telemedicine in fee-for-service Medicaid looks low if you just look at claims. However, this may be because some providers are not using the billing modifiers on claims forms, some providers are using telemedicine as part of a larger bundle of services, and hospitals and clinics often do not break out telemedicine on their claims. Medicaid managed care plans have gone even further in their use of telemedicine. Surveys of these plans show that one plan has focused on adolescents and psychiatric services while another focused on aged, blind, and disabled individuals. One plan covers telemedicine without preauthorization. Virginia Medicaid is discussing the use of telemedicine for home health services, postoperative care, high-risk pregnancies, and infections. They are also considering S&F coverage (e.g., for ophthalmology). In addition, Virginia Medicaid is working on a memo to help inform out-of-state physi- cians about how to receive reimbursement in caring for Virginia residents. THE MARYLAND PERSPECTIVE Laura Herrera, M.D., M.P.H. Maryland Department of Health and Mental Hygiene Maryland is like Virginia in terms of the numbers of individuals it serves in the Medicaid program, but unlike Virginia, it is not as far along in using telehealth. In 2010, the Maryland Health Quality and Cost Council (chaired by the lieutenant governor and the secretary of health) was tasked with identifying challenges and solutions to advancing telehealth. After the council issued a report, a task force (led by the Maryland Health Care

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STATE-BASED PERSPECTIVES 91 Commission and the Maryland Institute for Emergency Medical Services) was established to further pursue these issues. Telemedicine Task Force Three advisory groups were established to develop recommendations: the Finance and Business Model Advisory Group, the Technology Solu- tions and Standards Advisory Group, and the Clinical Advisory Group. The Finance and Business Model Advisory Group recommended that state- regulated payers should be required to reimburse for telemedicine services to the same extent as face-to-face health care services. The Technology So- lutions and Standards Advisory Group wanted a network built on existing standards and integrated into the statewide health information exchange. All 46 Maryland hospitals are reporting regularly into the health informa- tion exchange (e.g., discharge data, lab data, radiology data), and so the group wanted telehealth integrated into this network. Additionally, the group recommended certain minimum requirements related to connectivity. The Clinical Advisory Group focused on changes in licensure, credentialing, and privileging of providers to facilitate the adoption of telehealth. Legislation As a result of the recommendations of the Finance and Business Model Advisory Group, legislation was introduced in 2012 in both the Maryland House and Senate. The bill required state-regulated private payers and Medicaid to cover services delivered through telehealth as they would if delivered in person. Furthermore, private payers would not be permitted to require preauthorization for telehealth services, nor could they limit these services to just rural areas. The Maryland Department of Health and Men- tal Hygiene (DHMH) supported the bill with amendments. One amendment allowed Medicaid to conduct a review. Unlike other states, the Maryland Medicaid program sits within the DHMH, as opposed to the Department of Social Services. So while the DHMH supported the bill, they wanted to fully understand the implications to the entire system. DHMH stated that if services were deemed to be cost neutral, it would cover services in FY2013, but if they were not neutral, they would seek coverage in FY2014 through budget initiatives in the 2013 legislative session. Another amendment al- lowed private payers to require preauthorization for telehealth services. The bill was passed and signed into law with both of these amendments.

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92 THE ROLE OF TELEHEALTH Current DHMH Activities Pursuant to the amendment on cost neutrality, the DHMH started a review of the current literature and evidence on telehealth. They did a com- prehensive analysis of publicly available information as well as the network available to Medicaid directors to understand what was being covered by other states. They found that 37 states covered hub-and-spoke teleconfer- encing, 16 covered S&F technologies, 15 covered home health monitoring, and only 2 covered telephone and e-mail. Furthermore, they looked at what private payers (both commercial and managed care organizations) covered in the state of Maryland. DHMH also started researching different modalities and services, as well as looking for any cost studies, to see if any specific modalities stood out. Assumptions included everything from real- time interface to S&F technologies to home health monitoring, especially in light of long-term care rebalancing efforts currently happening in the state. Prior to all of this, Maryland did cover telemental health services in 12 rural counties, but the originating site could only come from an outpatient mental health service hospital or a federally qualified health center and the distant provider could only be a psychiatrist. So, in addition to what is be- ing done now to expand coverage, Maryland is also reassessing telemental health usage and seeing what can be done to expand it. DHMH undertook all of these efforts while thinking about how to implement the ACA. Maryland has a lot happening at the state level related to PCMHs as well as ACOs. Maryland was just funded for four ACOs, three of which are practicing in rural areas. DHMH has been synthesiz- ing these findings and developing assumptions based on what other states are doing, ACA implementation efforts, and what private payers within Maryland are doing. The DHMH will report back to the general assembly in December 2012. THE DELAWARE PERSPECTIVE Rita M. Landgraf Delaware Department of Health and Social Services The state of Delaware has less than a million residents in just three counties. Sussex County is the largest from a geography standpoint, but is very rural. Also, many retirees are coming to this county. Telehealth pres- ents a marvelous opportunity to advance the medical infrastructure to care for those populations.

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STATE-BASED PERSPECTIVES 93 Successes The Delaware Telehealth Coalition, formed in 2011, has more than 50 members, including all the hospitals. The coalition evaluated the use of tele- health, and coverage was established as a policy of the Medicaid program, and not through the general assembly. Delaware Medicaid, housed within the Delaware Department of Health and Social Services (DHSS), started reimbursing for telehealth services on July 1, 2012 (the start of the fiscal year). Delaware Medicaid is largely supported by managed care organiza- tions that have contracts with numerous providers, all of whom are now able to offer telehealth. In conjunction with that, one hospital in Sussex County and DHSS are specifically using telepsychiatry for crisis evaluation. New Castle county has a more robust medical infrastructure, and so the use of telemedicine has helped to avoid transferring patients from Sussex over to New Castle (e.g., for consulting on trauma cases). La Red Health Center, a federally qualified health center in Sussex County, has received a Rural Health Services Outreach grant to provide telepsychiatry services. They are also interested in moving beyond psychiatry services as well. Part of the success of adopting telehealth in Delaware comes from the personal commitment and advocacy of many individuals. Dr. Karen Rheuban came to Delaware in 2011 to advocate for the adoption of tele- health in Delaware Medicaid, which in many ways was a turning point. Additionally, in 2008, Dennis and Betty Leebel retired to Lewes, Dela- ware, from College Park, Maryland. Betty Leebel had been diagnosed with Parkinson's disease about 10 years earlier. In 2009, Dennis Leebel founded the Sussex County Parkinson's Education & Support Group. They found that many of their members were traveling great distances to visit special- ists, sometimes taking up to 2 days round-trip. As a result, they began working with the La Red Health Center and Dr. Ray Dorsey, a Johns Hopkins neurologist, to use telehealth to bring care to Parkinson's patients in Sussex County. Barriers As mentioned previously, the aging of the population is also a major consideration for Delaware. Telehealth offers an opportunity to provide all individuals in the state with the best care (whether it be from providers within or outside the state) with the most effective and cost-efficient care. However, the Delaware Telehealth Coalition continues to address several barriers. First is that distant-site providers must be licensed in Delaware to practice telehealth. Since that licensure issue falls within the office of the Secretary of State, the Secretary of the DHSS has dedicated one individual to work with them to streamline that licensing process. The second bar-

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94 THE ROLE OF TELEHEALTH rier is that telehealth technologies have not been widely adopted. Some providers are skeptical, so hopefully with the Medicaid coverage, evidence will be generated that demonstrates that the cost is not prohibitive and the care is high quality. Some individuals may not be comfortable seeing a pro- vider in this manner, but when faced with lengthy travel, this concern may disappear, especially when they see the opportunities it provides. Finally, some hospitals and practitioners see telehealth as a threat to their revenue streams. However, with the availability of reimbursement, this threat should become an opportunity for them to serve even more patients. Looking to the future, in addition to the state and the advocates, more hospitals and primary care providers are coming into the coalition. Next, they hope to engage the private sector so that this can be a true collabora- tion to facilitate cooperation. The state is also looking at different applica- tions of telehealth, including at-home uses for the aging population and the state's underserved rural areas. Furthermore, they are looking at telehealth as a way to manage chronic conditions as supported by the ACA. STATE-BASED ADVOCACY: NOBEL WOMEN Maurita K. Coley, J.D. Minority Media and Telecommunications Council The Minority Media and Telecommunications Council (MMTC) is a leader in media and telecommunications policy and advocacy for minority and underserved communities. MMTC started out advocating for minor- ity ownership and diversity of voices in the media, and has expanded into broadband adoption and advocacy and telecommunications policies that are designed to address the individuals who do not have the most advanced technologies available to them. The National Organization of Black Elected Legislative (NOBEL) Women are 235 current and former members of state legislatures in 39 states. They work to communicate the legal, social, politi- cal, economic, education, and health care needs of children, women, and families. MMTC works with NOBEL Women to advocate on telecommunica- tions issues at the local, state, and federal levels: the White House, the FCC, the Federal Trade Commission, the U.S. House of Representatives, and the U.S. Senate. MMTC has worked with the NOBEL Women on a number of proceedings before the FCC, such as the Open Internet, Univer- sal Service Reform, Lifeline Telephone Service for Low-Income Families, and Minority Media Ownership. MMTC and NOBEL Women have part- nered on a number of legislative and regulatory policies. For example, they have worked on the National Broadband Plan with the goal of 98 percent broadband adoption by 2015 and also to create jobs and opportunities

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STATE-BASED PERSPECTIVES 95 for small minority-owned businesses. MMTC has worked with NOBEL Women and on their own on spectrum exhaustion issues and wireless and smartphone adoption. Model Telemedicine Legislation Telehealth technology is a "game changer" for both rural and urban communities. For underserved communities, there is not that big a differ- ence between rural and urban. Disparities often result from a lack of access or a lack of representation. NOBEL Women are especially concerned about the racial and ethnic minority or rural populations who do not have pri- mary care physicians, often because of financial and transportation barriers. In 2011, the NOBEL Women first created model telemedicine legisla- tion. The legislation represents the opportunity for widespread adoption of telemedicine, much as has already been done in broadband adoption. The legislation, similar to that of the American Telemedicine Association, focuses on requiring private pay mandates to be the same for in-person care as it is for telemedicine. However, the NOBEL Women also focus on extending state Medicaid coverage. The NOBEL Women's model telemedicine legislation · requires the coverage of telemedicine; · expands the definition of telemedicine (or in some cases, establishes the definition) as including audio, video, or other telecommunica- tions technology at a site other than where the patient is located; · allows home telehealth (via videoconferencing) and remote patient monitoring; · makes denial of coverage subject to review procedures; · prohibits state Medicaid plans from denying coverage if the service would be covered through in-person consultation; · requires statewide medical assistance benefit of health home for individuals with chronic conditions; and · applies to all insurance policies, plans, etc., but not short-term travel, accident-only, or other limited coverage plans. Most states provide some coverage for telemedicine, but this varies widely. The NOBEL Women have chosen to work on establishing a "level playing field." In July 2012, the NOBEL Women formally launched their goal to expand their telemedicine legislative initiative to every state where a NOBEL Woman serves. The NOBEL Women's 2013 Telemedicine Group Action Plan includes addressing legislation on state-by-state basis. This may include clarifying existing law with state officials, hosting roundtables to increase awareness, and identifying key stakeholder organizations and groups for partnering and collaboration.

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96 THE ROLE OF TELEHEALTH At the state level, the overall strategy is to look at the health home for chronic care, high-risk pregnancies, stroke diagnosis and rehabilita- tion, mental health counseling, school-based health services (e.g., speech and hearing), Medicare-level telehealth coverage for rural and underserved populations, safety net critical access facilities, and telehealth coverage for state employees. At the federal level, the strategy is to advocate for federal legislation to improve Medicare coverage for urban beneficiaries, home- based services, S&F telehealth (for both rural and urban populations), and telehealth payment and service models for dually eligible patients; to work with the FCC on rural health programs to enable wider broadband access; and to support nationwide portability for health care professional licensure. NOBEL Women are especially interested in the licensure of practitioners. NOBEL's telehealth licensure resolution was passed at their legislative sum- mit on June 22, 2012, which would prevent health care professionals from needing to seek a new license in every state in which the patient is located if they are using telemedicine. Overall, this strategy will need federal ad- vocacy, state advocacy, and media advocacy in order to create a successful national campaign REACTION AND DISCUSSION Moderator: Karen S. Rheuban, M.D. University of Virginia Health System An open discussion followed the panelists' presentations. Audience members were able to give comments and ask questions of the panelists. The following sections summarize the discussion session. Cost Neutrality One participant asked if Maryland's cost neutrality study will be pub- licly available. Herrera answered that it would be made available to the public at a very detailed level, including the activity level in all 50 states and within the VA and the IHS, as well as what they find in their literature review. Rheuban noted that Virginia Medicaid found that telehealth would save millions of dollars in transportation costs and wondered if Maryland's analysis would consider that. Herrera said they would be looking at cost savings and noted that the ACA included a lot of initiatives concerning emergency department use, hospital admissions, and 30-day readmissions, which could also be considered among cost savings. She emphasized that in addition to looking at the costs of real-time interface, they are also con- sidering S&F technologies and home health monitoring.

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STATE-BASED PERSPECTIVES 97 Functionality of Technology One participant asked Herrera to clarify the intent or desired function- ality behind the requirement for telehealth to be integrated with their health information exchange. Herrera responded that this had to do with record- keeping of the telehealth encounter to be incorporated into the patient's full record. She added that right now the exchange is getting information from hospitals, but they want to expand that at least to involve their ACOs and PCMHs. One participant was concerned about choosing the right technology, and asked the panelists if they are considering the stepwise integration of telehealth, giving the example that some patients may not even have a telephone. Jones agreed that sometimes we get carried away in jumping to the most sophisticated technologies, and that there are significant areas of Virginia where people still have problems with Internet access. She said the secretary of technology surveyed Virginia health care providers about their capabilities on a variety of issues, including electronic health records, and found many holes. Jones noted that there is a push to try to provide fund- ing to ensure everyone can communicate electronically. Herrera responded that she had previously served in the IHS and used telehealth in areas north of the Arctic Circle more than 14 years ago, and compares that to a state now where it is not used pervasively and is hard to get providers engaged. She asserted that providers want to do all they can to improve access and deliver quality care, but with all the factors competing for their time, it just will not happen without proper reimbursement. Landgraf agreed that reimbursement is necessary for the sustainability of telehealth, and that we should also work with the retail markets. Coley added that MMTC and the NOBEL Women have focused on broadband adoption because they found that many women and minority groups did not have high-speed Internet at home, in part due to the fact that they could not afford computers, because they did not know how to use computers, or because they did not find computers to be relevant to them. Coley asserted that some of this basic infrastructure is necessary to get telehealth at the level we might want. Overcoming Barriers One participant asked Landgraf about the source of the listed bar- riers in her presentation. Landgraf replied that the barriers were identi- fied through grassroots efforts. She noted that licensure surfaced as the predominant issue and is the one they would be focusing on in Delaware. Landgraf also noted that some in the medical community may be threatened by telehealth. In part because of workforce shortages, they have been turn- ing more to nurse practitioners and others to become involved in telehealth

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98 THE ROLE OF TELEHEALTH services. She further noted that there are many myths to dispel regarding the use of telehealth, including those held by the public. Landgraf added that while Delaware Medicaid was able to achieve coverage of telehealth services through policy, she believes coverage needs to be codified as a state law, so that it does not depend on the support of the sitting administration. Another participant asked Herrera if they planned to engage with pro- viders to increase their interest in and use of telehealth. Herrera responded that two large academic centers (Johns Hopkins University and the Univer- sity of Maryland) are already doing a significant amount of telehealth, and have their own telehealth departments. Herrera noted the centers are very involved in the advisory committee in providing subject matter expertise (e.g., equipment, standards of care). Herrera added that once Maryland Medicaid makes a decision, they will go forward with educational efforts for providers. Specific Populations One participant asked if any of the panelists had experience with us- ing telehealth for the Department of Corrections. Rheuban responded that in Virginia, telehealth is a large element of service delivery, but that this population is managed by a different department than the Department of Medical Assistance Services. She added that there are correctional telehealth programs around the country that have been very successful. Another participant asked about expectations for managing chronic disease through telehealth. Landgraf noted that in meeting with Medicaid managed care organizations, they have observed that traditional chronic care disease management is not producing the desired outcomes. She said they are working together to determine the high-cost drivers, choose meth- odologies, and conduct real-time evaluation to determine benefits. Jones added that like many states, the 30 percent who are in fee-for-service Medicaid are often the most costly. She said that when they talk about care coordination for this population, they might suggest the use of telehealth, but they cannot require its use.