health care reform, telepractice, and a look at the future of reimbursement for audiologists and...
TRANSCRIPT
Health Care Reform, Telepractice,
and A Look at the Future of
Reimbursement for Audiologists and
SLPsJanet Brown, MA CCC-SLP
Director, Health Care Services—ASHAMSHA Oct. 20, 2012
Speaker Disclosure
Financial•ASHA employee since 1997
Non-financial• Ex officio for Business
Practices,Telepractice Committees• Member, American Telemedicine
Association
• “America’s health care is essentially a cottage industry of fragmented, dedicated artisans who eschew standardization. Care is frequently highly variable, and performance is, in large part, unmeasured.”
Swenson, et al., 2012.The Mayo Clinic value creation system. AJMQ 27 (1), 58-65.
What is the Problem?
• Health care spending has doubled as share of GDP in 30 years 9.2 to 17.9
• Medicare population will grow by 1/3 in the next 10 years
• Variation in spending by region without evidence of difference in outcomes
Source: MedPAC report, March 2012: Executive Summary
Problems with Current System
• Fee-for-service creates incentives for unnecessary care
• Variability in payment across settings• Fragmented care (ex:VFSS)• No penalties for bad outcomes (e.g.,
rehospitalization)
Components of the Patient Protection and Affordable Care Act (2010-2014)
Expanded Coverage• Dependents• Medicaid eligibility• Exchanges (Iowa Affordable
Insurance Exchange) • Individual mandate
Payment• Bundled• Incentives for qualityAdapted from Fabius, et al. 2012. Vocabulary of Health Care Reform. Thomson Reuters
Care Coordination• Medical homes• Accountable care
organizations
Delivery Innovations• EHR• Meaningful use• Disease management
Essential Health Benefits—Medicaid and Exchanges
• 10 categories that must be included
Ambulatory patient services Prescription Drugs
Emergency Services Rehabilitative and Habilitative Services and Devices
Hospitalization Laboratory Services
Maternity and Newborn Care Preventive and Wellness Services and Chronic Disease Management
Mental Health and Substance Use Disorder Services
Pediatric Services, Including Oral and Vision Care
SLPs and Pediatric Services
• % of SLPs in health care providing services 17% to infants and toddlers 13% to preschoolers 11% to school-age children
• 27% provide Early Intervention services • 20% of SLP caseload in autism up
considerably from 6% in 2009
Source: 2011 ASHA SLP Health Care Survey
Medicare
• Medicare Part A—hospitals, SNFs May join ACOs Bundled care
• Medicare Part B—outpatient Alternative to therapy caps— Documentation of outcomes Bundled care, ACOs Episodic payment?
The New Order in Health Care—Public and Private Pay
•Value
Transition to Measures
• Accountability through programs involving measures
• Quality reporting systems affect reimbursement Under Medicare
•Hospital value-based purchasing•Physician Quality Reporting System
Outcome Measures
• National Outcomes Measurement System (NOMS) developed by ASHA Data collection system that illustrates the value
of SLP services Uses Functional Communication Measures
(FCMs), a series of disorder-specific, seven-point rating scales to describe the change in an individual's functional communication and/or swallowing ability over time
ASHA NOMS
• SLPs register to become a NOMS user (free)• Submit FCM scores at admission and discharge
(online database)• Submit data on diagnosis, tx frequency, etc.• Receive standard reports and national
benchmarking data• More information at
http://www.asha.org/members/research/noms/
NOMS
• In 2008, eight of the 15 adult FCMs were endorsed by the National Quality Forum (NQF) as quality measures
• NOMS can be used as an objective measurement tool for home health reassessments or Part B documentation
How Will Life Change
• Billing for services Fee for service to episode of care Bundling/ACO
• Documentation systems EMR ICD 10
• Documentation/Justification of services Value/outcomes Medical Necessity
What We May See More Of
• Different levels of care within episode Support personnel Community Family/caregivers
• Use of technology Telepractice/videoconferencing Technology apps/tools for independent practice
What You Can Do
• Look at your practice How can you be more efficient?
•Process, documentation, practice How do you measure your outcomes? Are you diversified? What are your competitors doing? Reach out to potential referral sources, ACOs
What You Can Do
Be informed ASHA Leader ASHA web site: Health care reform page ASHA Healthcare Landscape Summit
recommendations
What You Can Do
• ADVOCATE! Respond to Take Action—ASHA Grassroots
network Contact your representatives at home Capitol Hill visits
Role of Telepractice in Health Care
• Increasing access to providers to specialists to equipment
• Savings costs travel Complications from delayed treatment
Role of Telepractice in Schools
• Respond to shortages
• Efficiencies in reducing driving time
ASHA’s Definition
• Telepractice is the application of telecommunications technology at a distance by linking clinician to client, or clinician to clinician for assessment, intervention, and/or consultation.
ASHA, 2005Speech-Language Pathologists Providing
Clinical Services via Telepractice: Position Statement
Terminology Makes a Difference
• Using telepractice as a means of direct service delivery Telespeech, telehealth, telemedicine, telerehab,
teletherapy Typically via teleconferencing (“face-to-face,”
but not “in person”
• NOT distance education• NOT distance supervision
Why This Can Be Confusing
• Telepractice: students delivering services via teleconferencing with supervisor sitting with them
• Telesupervision: Clinical Fellow delivering services face-to-face with supervisor observing via teleconferencing
And In Education…
• Distance learning may incorporate interactive videoconferencing, virtual classrooms
• May be used to teach SLPs• Not used to describe SLP services
Quality Qualifier 2005 Position Statement
• "The use of telepractice does not remove any existing responsibilities in delivering services, including adherence to the Code of Ethics, Scope of Practice, state and federal laws (e.g., licensure, HIPAA, etc.), and ASHA policy documents on professional practices."
• “Therefore, the quality of services delivered via telepractice must be consistent with the quality of services delivered face-to-face." Position Statement, 2005
Challenges of Developing “Standards”
• Rapid advance of technology• Lack of comparative effectiveness research
on different types of technology• Scope of the professions: broad range in
age disorders assessment and treatment procedures
Quality Components
• Provider competence• Patient selection• Technology selection• Transmission quality• Efficiency, effectiveness of service• Patient, caregiver, provider satisfaction
ASHA’s Telepractice Resources
• www.asha.org/telepractice
Video clip Policy documents Articles Model licensure
regulations Reimbursement
information Bibliography
Types of Telehealth
• Synchronous (real time)• Asynchronous (store and forward)• Self-monitoring (not typically used in SLP)
Technology Is Used To…
• Capture
• Transmit
• Display
• Camera, microphone, peripheral devices
• Bandwidth
• Computer,videoconferencing equipment
Technology
• Equipment Hardware
•Dedicated system, computer•Camera, monitor, microphone, multisite capability
Software Peripheral devices
•Document camera, videoendoscope
Collaboration
• Whiteboards• Chat• Screen sharing
Technology
• Connectivity Connection speed (bandwidth) Minimum cited in research: 384 kps Standard definition vs high definition Influenced by others using same bandwidth Quality consequences
•Delays, jitter, loss of data, turntaking
Licensure
• What is licensure for?• Current status—full licensure in state where
client resides• What are other disciplines doing?• ASHA model regulations: general and
interstate practice
Privacy & Protections
• FERPA School records
• HIPAA Privacy of protected health information for
providers and their business associates
• Notification/Consent• Secure transmission via virtual private
networks, firewalls, encryption
Reimbursement--Medicare
• Physicians, nurses, CSWs, psychologists, dietitians for selected CPT codes
• Designated originating sites Rural health professional shortage area Outside Metropolitan Statistical Area
• ASHA and ATA advocacy• http://www.cms.hhs.gov
Search Telehealth Services Fact Sheet
Reimbursement--Medicaid
• Varies from state to state• Need approved CPT codes to receive payment for
using modifier• Oklahoma has established Medicaid payments
with schools receiving origination fee• Missouri, but not for schools• Kentucky and Virginia are pending
Reimbursement--Private Insurance
• Trend for state legislation to mandate payment for approved services
• CareFirst Blue Cross/Blue Shield (see ASHA Leader story)
Reimbursement--Schools
• Largest area for reimbursed telepractice• Within-district or contractor services• Virtual schools—some providing special ed
and related services e.g., North Carolina, Idaho, Colorado, PA
“It’s Not the Technology”
• Planning, stakeholder support, training Business plan Who are the stakeholders
• Licensure, school boards• Administrators at all levels• Teachers, facilitators• Parents, clients
Training and information: managing expectations
Technology
• Available bandwidth, firewalls • Ongoing tech support• Other means of connection when there is a
problem
Research
• More articles being published on comparability, esp. from Australia
Tests for dysarthria, CELF LSVT, Lidcombe, voice, post-laryngectomy, aphasia,
apraxia, swallowing, fluency, early intervention• Telehealth Journals:
Telemedicine and e-Health Journal of Telemedicine and Telecare
• Bibliography at www.asha.org/telepractice
Other Telehealth Groups
• American Telemedicine Association• Center for Telemedicine and e-Health• Association of Telehealth Service Providers
Telemedicine Information Exchange
• Office for Advancement of Telehealth (HRSA)
