By Bob Wolverton NRTRC Program Director

MY 2cent WORTH

APRIL l MAY 2015

NEWS ampVIEWS

THANK YOU FOR ANOTHER GREAT CONFERENCEWell the fourth annual NRTRC Regional Telehealth Conference is over From all the comments wersquove heard it was another good oneIrsquod like to take a few lines to offer some thanksbull Thanks to our plenary speakers Your

expertise and encouragement excited everyone who had the opportunity to hear you We learned a lot from your presentations and very much appreciate your taking the time to join us

bull Thanks to the ldquoTelehealth 101rdquo presenters This year again we heard from attendees how helpful and educational the session was A lot of folks joined us and learned about the many aspects of building or expanding a telehealth network

bull Thanks to our educational track presenters The sessions were well-attended and well-received Wersquore still tallying the survey results but all indications are that your presentations offered a lot of valuable useful information to the folks who attended I didnrsquot get to spend much time in the ClinicalAdministrative track because I was hosting the technology track I know

the technology track went very well with the seminar and summit being well attended and driving a lot of active discussions

bull Thanks to our sponsors and exhibitors Without sponsorsrsquo generosity our conference would still be educational and helpful but it wouldnrsquot be as filled with amenities as it is Sponsorships help us provide good meals in an atmosphere that stimulates networking and friendship building Exhibit Hall participation brings information to our attendees that is timely and very much needed

bull Thanks to our attendees of course If you hadnrsquot taken the time and made the effort to join us we wouldnrsquot have much of a conference I spoke with a lot of you and truly appreciate your support and friendship

bull Thanks to our planning committee for your hard work and ideas for speakers presentations and for bringing the event together Your support and tireless work throughout the year made it a lot easier for the staff to put the event into its final form

bull Oh did I mention staff I want to offer a big shout-out to Martha and Patricia who did all the ldquogruntrdquo work who negotiated with the venue and the providers and who pulled their hair out worrying about the event You two made it happen

LOOKING AHEAD TO THE 2016 CONFERENCEThe Conference Committee and NRTRC Board met after the conference and discussed the results and the general response from our attendees to start the process of planning for the 5th annual conference The responses were so positive for this yearrsquos conference that we decided it would be a good idea to hold the meeting in Seattle again next year Wersquoll be back at the Hyatt Olive 8 Hotel on March 21-23 2016 Mark those dates on your calendar and plan to join us next Spring

Irsquoll start calling now too for ideas about what yoursquod like to see for educational presentations what yoursquod like included in Telehealth 101 who yoursquod like to see for plenary speakers and general conference enhancements We do this for you and your input will go a long way toward helping us continue to make a better event each year

Wersquoll be sending out requests for presentation abstracts before long and if yoursquod like to share information about your telehealth project let me know and Irsquoll see to it that you get a copy of the request We always like to get a wide variety of suggestions for the presentations so we encourage you to offer an idea or to suggest a presenterHerersquos to Conference 5

Your source for confidential objective answers and valuable insights into Telehealth issues in the Northwest

CONFERENCE 2015

CONFERENCE 2015

Community Health Centersand Telehealth

By Bob Wolverton NRTRC Program Director

SPOTLIGHT

APRIL l MAY 2015

NEWS ampVIEWS

CHCs and Telehealth l continued

I RECENTLY ATTENDED A

SYMPOSIUM SPONSORED BY

THE MONTANA PRIMARY CARE

ASSOCIATION I WAS ASKED

TO DISCUSS HOW TELEHEALTH

COULD HELP COMMUNITY HEALTH

CENTERS (CHC) MEET THEIR

MISSIONS AND SERVE THEIR

PATIENT BASE BETTER

I was lucky enough to have time to attend a number of presentations and found them all interesting The presenters were great and the audience was really engaged Thatrsquos a fine recipe for a conference Kudos to the MPCA staff for putting together such a fine gathering

When it was my turn I discussed telehealth from the ground up Only about three people in the session said they were using telehealth currently so I thought a basic introduction would be a good idea I then moved on to what I thought would be good telehealth services CHCs could offer

Of course therersquos specialty care CHCs often deal with patients who have chronic illness and need care from a specialist But those patients are frequently frail and canrsquot easily make the trip to the big city for specialty care Or they might not be able to afford to take time off from work to travel for care And of course in the big square states with high altitudes and low populations the weather might cause difficult or dangerous travel (as I write this Wyoming is just cleaning up from three multi-car accidents caused in large part by the weather More than

100 vehicles were involved and there were a few fatalities and a lot of hospitalizations Weather in our region is always a challenge)

I offered a few suggestions for telehealth-based specialty care Kind of a list of the usual suspects I suppose

REMOTE PATIENT MONITORING There are some telehealth options that seem to work very well with small clinics and chronically ill patients Remote Patient Monitoring (RPM) will likely become a huge factor in chronic illness care in the next few years as the health care system evolves We have a few CHCs offering RPM in the region and they are doing some wonderful things for their patients When the clinics offer a means by which the patients can have their conditions monitored daily their health is maintained in a stable manner Potentially dangerous changes can be caught and stopped before they become critical

REDUCED ER VISITS There arenrsquot many academic studies on RPM but individual organizations have reported a lot of good from RPM NRTRC has a partner that has been doing RPM for a little over a year now and they report that they have saved 75 emergency room visits Thatrsquos pretty significant Each ER visit is expensive and avoiding that many can have a significant impact on health care expenses Of course itrsquos good for the patients too and thatrsquos what really counts

REDUCED READMISSIONS Other organizations estimate the number of readmissions theyrsquove

avoided along with the ER avoidance through their RPM programs Reports have ranged from 7 reduction in readmissions to a whopping 70 That wide variance is why an academic study with rigorous controls would offer a clear estimate of readmissions

Another topic that is of interest to CHCs is mental health care Theyrsquore required to provide access to care and there is a great shortage of mental health care providers not only in Montana but in all our states where population density is extremely low We discussed some options for care and Irsquom hopeful that we can expand access to our truly rural residentsWe talked about specialty care in general and covered quite a bit of territory

Then a question came up that I couldnrsquot answer Is anyone doing tele-dentistry in Montana Dentistry

can benefit from telehealth as can many other disciplines Of course I wouldnrsquot want to undergo an extraction by telehealth but oral cancer screens general dental health care or other exams can be carried out by a trained dental assistant with the patient and the dentist in a remote location That would get at least initial care and screenings to remote patients and allow CHCs to offer that important service to their clients Irsquom investigating that and hope to have some information to share in the future

I APPRECIATE THE MONTANA

PRIMARY CARE ASSOCIATIONrsquoS

INVITING ME TO THE CONFERENCE

AND LOOK FORWARD TO A LONG

PARTNERSHIP WITH THEM AND

THEIR MEMBERS

CHCs and Telehealth l continued

How Washington FinallyEnacted a Telemedicine Law

By Chelene Whiteaker MHAPolicy Director Washington State Hospital Association

SPOTLIGHT

APRIL l MAY 2015

NEWS ampVIEWS

Washington l continued

When the idea of working on a telemedicine law was raised back in 2012 no one around the table would have guessed it would take Washington State three years to enact a law The problem was clear Insurers

one learns in civics class These are lessons we could all use a quick reminder on when thinking about proposing or working to enact legislation

For states still debating a law here are the top six things that made the difference in Washington State

1 BUILD A COALITION Identify and create an advisory group that helps think through the tough decisions that will need to be made but can also help provide stories

EDITORrsquoS NOTE Chelene Whitaker is Policy Director for the Washington State Hospital Association In that position she was instrumental in shepherding Washingtonrsquos recently enacted telehealth parity law through the State Legislature This article relates the process of moving a law from concept to enactment

were placing geographic restrictions or refusing to contract for services delivered through telemedicine technology The solution was solid Enact legislation that would require payment for telemedicine and bring needed health care services to rural and underserved patients The benefits were obvious Patients would get necessary services faster and more efficiently which we believe will save lives and money

Yet the Byzantine journey of this law reminded us of many lessons

Washington l continued

about why the legislation is needed The advisory group can be the start of a grassroots coalition that can help advocate for the law We had a broad group of our members along with the Washington State Medical Association to help with this work

2 IDENTIFY IMPACTED ORGANIZATIONS OR PROVIDERS The biggest beneficiaries of telemedicine are the patients ndash children with autism people with Parkinsonrsquos disease people having a stroke Restrictions on telemedicine have real consequences for patients Gather those stories early The hospital association worked to identify those who could convincingly tell the impact of limited telemedicine take-up Work with these individuals before the legislative session starts so they are ready to engage in advocacy

3 IDENTIFY STRONG LEGISLATIVE CHAMPIONS This is as important as building the coalition Having an elected official who is ldquoon-firerdquo for this cause is crucial One of our champions was also the person who told us we had more work to do on the legislation in 2013 after our bill died She told us to negotiate with the insurers and bring her back a piece of legislation that both of us could support Our other champion legislator is married to a child psychiatrist and clearly saw the benefit of the law for the children his wife treats Both these legislators were key to getting the bill to the finish line

4 DONrsquoT GIVE UP Passing this bill took three years of hard work and heartbreak It took significantly longer than we expected and in the second year was derailed at the eleventh hour by a concern that telemedicine would lead to ldquowebcam abortionsrdquo This was a concern that took us completely by surprise It was an ideological issue we could not overcome in a short time frame near the end of the legislative

session But we persevered and found a solution to address the issue ndash tying telemedicine coverage to the federal essential health benefits package The concept of ldquowebcam abortionrdquo is a concern about telemedicine worth knowing about and researching in order to respond to objections The concern issue is a national issue for groups opposing abortion and it has now surfaced in states other than Washington We would recommend that advocates adopt the same solution

5 BE WILLING TO COMPROMISE While our law is not the most progressive law in the country it is a major step forward in health care for patients If we had dug in our in heels and refused to compromise I would be writing a very different article Knowing when to move to a middle ground is key

During our first year of work the telemedicine bill died in the Senate Health Care committee Not making it very far in the legislative process in the Senate told us that we had problems with the proposal that would not solve themselves The commercial insurers strongly

opposed the bill because it required payment rate parity not just parity in coverage of services The definition of telemedicine was also called into question as were the originating sites

Unless there is a change in legislative makeup or the facts have significantly shifted on an issue running the same legislation over and over again is not typically a recipe for success We had neither a shift in legislative power or a major shift in the fact base

After the 2013 legislative session we entered into negotiations with the three major commercial insurers in our state We also added our statersquos Medicaid program to our legislation which we had overlooked the first time around to bring the number of health plans to negotiate with to nine We had to give up ground in the negotiations but what we received in return was all nine health plans being supportive or neutral of the bill The same insurers who had worked hard to kill the bill in 2013 became some of our best allies and testified repeatedly in favor of the bill in 2014 and 2015

Washington l continued

Washington l continued

6 SOMETIMES YOU NEED TO SAY ldquoNOrdquo Throughout the process and especially when the bill was poised to pass we had various groups trying to tack their issue onto our bill ndash asking us to add home visits or specifically identify nurse practitioners or any number of other provisions that would have upset the negotiated agreements we had struck on the bill While we agreed that the bill could go farther and payment for home visits would be great we knew we were politically at the edge for maintaining support for the bill We had several tough conversations where we told advocates no Getting a law passed that requires payment for telemedicine is an enormous victory and we were unwilling to snatch defeat from the jaws of victory

WASHINGTON STATErsquoS TELEMEDICINE LAWBy 2017 Washington Statersquos law requires commercial Medicaid and public employee health plans to reimburse for covered health plan services provided through telemedicine The law defines telemedicine as ldquothe delivery of health care services through the use of interactive audio and video technology permitting real-time communication between the patient at the originating site and the provider for the purpose of diagnosis consultation or treatment Telemedicine does not include the use of audio-only telephone facsimile or emailrdquo

In order to trigger reimbursement for a service delivered through telemedicine a patient must be in one of the seven originating sites The sites include a hospital rural health clinic federally qualified health center physicianrsquos

or other health care providerrsquos office community mental health center skilled nursing facility or renal dialysis center except an independent renal dialysis centerThe law explicitly prohibits geographic restrictions on a patientrsquos location for reimbursement purposes Specific to hospitals it also clarifies that an originating site hospital may rely on a distant site hospitalrsquos decision to grant or renew clinical privileges when the two facilities have a written agreement in place

Lastly the law recognizes use ldquostore and forwardrdquo technology for commercial and public employee plans but does not require reimbursement unless the service is in the negotiated contract For Medicaid plans this recognition may be the avenue for allowing services delivered through store and forward to be included in the actuarial rate setting for the plans something that is not recognized currently Changing the incentive for Medicaid plans to pay for store and forward will be an important shift for our state

MOVING FORWARDOur telemedicine law is a big step forward for the delivery of care for patients with strokes psychiatric illness heart problems and so many others While we did not get everything we wanted in the law we made significant headway In the future if we seek to expand the law it will take many of the steps I described above We are encouraging our providers to get more aggressive about contracting with insurers Return on investment for the coverage of services is key to showing how technology will transform health Use of store and forward as well as remote patient monitoring are two areas we are beginning to see roll out with pilot projects

Legislators remain interested in continuing to discuss other areas important to the use of telemedicine including licensing compacts and state-endorsed advisory committees to help guide the next steps There will also be important work in monitoring how the telemedicine law gets implemented

UPCOMING EVENTSBy Martha Nikides

FOR MORE INFORMATIONFor more informationon upcoming events please go to wwwnrtrcorg

EVENT SUBMISSIONSPlease forward event information to marthanrtrcorg

APRIL l MAY 2015

ABOUT USThe Northwest Regional Telehealth Resource Center leverages the collective expertise of 33 telehealth networks in Alaska Idaho Montana Oregon Utah Washington and Wyoming to share information and resources and develop new telehealth programs

NRTRC SERVICESbull Provide technical assistance for new programs and applicationsbull Increase exposure to telehealth as a health care delivery toolbull Improve access to specialty care through regional collaborationbull Develop information on best practices and telehealth toolkitsbull Provide current information and facilitate discussion of regional regulatory policy and reimbursement issues

NORTHWEST REGIONAL TELEHEALTH RESOURCE CENTER1233 North 30th StreetBillings Montana 59101888-662-5601 or 406-237-8665

NRTRC STAFFBob Wolverton Program DirectorPatricia Inabnit MarketingOutreach SpecialistMartha Nikides Telehealth CoordinatorDoris Barta Principal Investigator

NRTRC BOARD MEMBERSALASKA Cynthia Roleff Christie ArtusoIDAHO Tom Hauer Neill Piland MONTANA Doris Barta Thelma McClosky-Armstrong OREGON Cathy Britain Doug RomerUTAH Patricia Carroll Wesley ValdesWASHINGTON Cara Towle Nancy VorheesWYOMING Jim Bush PJ Treide

NEWS ampVIEWS

May 28 2015 NRTRC Open Mic Webinar

A Payerrsquos Perspective200pm MST

May 21 2015National TRC Monthly Webinar

Things to Consider When Developing a Credentialing and

Privileging Process for Telehealth200pm MST

ARTICLE AND PHOTO SUBMISSIONS If you would like to write an article or provide photographs for this publication please contact Bob Wolverton bobnrtrcorg or 406-237-8660

SAVE THE 2016 DATE

CONFERENCE 2015

CONFERENCE 2015

Community Health Centersand Telehealth

By Bob Wolverton NRTRC Program Director

SPOTLIGHT

APRIL l MAY 2015

NEWS ampVIEWS

CHCs and Telehealth l continued

I RECENTLY ATTENDED A

SYMPOSIUM SPONSORED BY

THE MONTANA PRIMARY CARE

ASSOCIATION I WAS ASKED

TO DISCUSS HOW TELEHEALTH

COULD HELP COMMUNITY HEALTH

CENTERS (CHC) MEET THEIR

MISSIONS AND SERVE THEIR

PATIENT BASE BETTER

I was lucky enough to have time to attend a number of presentations and found them all interesting The presenters were great and the audience was really engaged Thatrsquos a fine recipe for a conference Kudos to the MPCA staff for putting together such a fine gathering

When it was my turn I discussed telehealth from the ground up Only about three people in the session said they were using telehealth currently so I thought a basic introduction would be a good idea I then moved on to what I thought would be good telehealth services CHCs could offer

Of course therersquos specialty care CHCs often deal with patients who have chronic illness and need care from a specialist But those patients are frequently frail and canrsquot easily make the trip to the big city for specialty care Or they might not be able to afford to take time off from work to travel for care And of course in the big square states with high altitudes and low populations the weather might cause difficult or dangerous travel (as I write this Wyoming is just cleaning up from three multi-car accidents caused in large part by the weather More than

100 vehicles were involved and there were a few fatalities and a lot of hospitalizations Weather in our region is always a challenge)

I offered a few suggestions for telehealth-based specialty care Kind of a list of the usual suspects I suppose

REMOTE PATIENT MONITORING There are some telehealth options that seem to work very well with small clinics and chronically ill patients Remote Patient Monitoring (RPM) will likely become a huge factor in chronic illness care in the next few years as the health care system evolves We have a few CHCs offering RPM in the region and they are doing some wonderful things for their patients When the clinics offer a means by which the patients can have their conditions monitored daily their health is maintained in a stable manner Potentially dangerous changes can be caught and stopped before they become critical

REDUCED ER VISITS There arenrsquot many academic studies on RPM but individual organizations have reported a lot of good from RPM NRTRC has a partner that has been doing RPM for a little over a year now and they report that they have saved 75 emergency room visits Thatrsquos pretty significant Each ER visit is expensive and avoiding that many can have a significant impact on health care expenses Of course itrsquos good for the patients too and thatrsquos what really counts

REDUCED READMISSIONS Other organizations estimate the number of readmissions theyrsquove

avoided along with the ER avoidance through their RPM programs Reports have ranged from 7 reduction in readmissions to a whopping 70 That wide variance is why an academic study with rigorous controls would offer a clear estimate of readmissions

Another topic that is of interest to CHCs is mental health care Theyrsquore required to provide access to care and there is a great shortage of mental health care providers not only in Montana but in all our states where population density is extremely low We discussed some options for care and Irsquom hopeful that we can expand access to our truly rural residentsWe talked about specialty care in general and covered quite a bit of territory

Then a question came up that I couldnrsquot answer Is anyone doing tele-dentistry in Montana Dentistry

can benefit from telehealth as can many other disciplines Of course I wouldnrsquot want to undergo an extraction by telehealth but oral cancer screens general dental health care or other exams can be carried out by a trained dental assistant with the patient and the dentist in a remote location That would get at least initial care and screenings to remote patients and allow CHCs to offer that important service to their clients Irsquom investigating that and hope to have some information to share in the future

I APPRECIATE THE MONTANA

PRIMARY CARE ASSOCIATIONrsquoS

INVITING ME TO THE CONFERENCE

AND LOOK FORWARD TO A LONG

PARTNERSHIP WITH THEM AND

THEIR MEMBERS

CHCs and Telehealth l continued

How Washington FinallyEnacted a Telemedicine Law

By Chelene Whiteaker MHAPolicy Director Washington State Hospital Association

SPOTLIGHT

APRIL l MAY 2015

NEWS ampVIEWS

Washington l continued

When the idea of working on a telemedicine law was raised back in 2012 no one around the table would have guessed it would take Washington State three years to enact a law The problem was clear Insurers

one learns in civics class These are lessons we could all use a quick reminder on when thinking about proposing or working to enact legislation

For states still debating a law here are the top six things that made the difference in Washington State

1 BUILD A COALITION Identify and create an advisory group that helps think through the tough decisions that will need to be made but can also help provide stories

EDITORrsquoS NOTE Chelene Whitaker is Policy Director for the Washington State Hospital Association In that position she was instrumental in shepherding Washingtonrsquos recently enacted telehealth parity law through the State Legislature This article relates the process of moving a law from concept to enactment

were placing geographic restrictions or refusing to contract for services delivered through telemedicine technology The solution was solid Enact legislation that would require payment for telemedicine and bring needed health care services to rural and underserved patients The benefits were obvious Patients would get necessary services faster and more efficiently which we believe will save lives and money

Yet the Byzantine journey of this law reminded us of many lessons

Washington l continued

about why the legislation is needed The advisory group can be the start of a grassroots coalition that can help advocate for the law We had a broad group of our members along with the Washington State Medical Association to help with this work

2 IDENTIFY IMPACTED ORGANIZATIONS OR PROVIDERS The biggest beneficiaries of telemedicine are the patients ndash children with autism people with Parkinsonrsquos disease people having a stroke Restrictions on telemedicine have real consequences for patients Gather those stories early The hospital association worked to identify those who could convincingly tell the impact of limited telemedicine take-up Work with these individuals before the legislative session starts so they are ready to engage in advocacy

3 IDENTIFY STRONG LEGISLATIVE CHAMPIONS This is as important as building the coalition Having an elected official who is ldquoon-firerdquo for this cause is crucial One of our champions was also the person who told us we had more work to do on the legislation in 2013 after our bill died She told us to negotiate with the insurers and bring her back a piece of legislation that both of us could support Our other champion legislator is married to a child psychiatrist and clearly saw the benefit of the law for the children his wife treats Both these legislators were key to getting the bill to the finish line

4 DONrsquoT GIVE UP Passing this bill took three years of hard work and heartbreak It took significantly longer than we expected and in the second year was derailed at the eleventh hour by a concern that telemedicine would lead to ldquowebcam abortionsrdquo This was a concern that took us completely by surprise It was an ideological issue we could not overcome in a short time frame near the end of the legislative

session But we persevered and found a solution to address the issue ndash tying telemedicine coverage to the federal essential health benefits package The concept of ldquowebcam abortionrdquo is a concern about telemedicine worth knowing about and researching in order to respond to objections The concern issue is a national issue for groups opposing abortion and it has now surfaced in states other than Washington We would recommend that advocates adopt the same solution

5 BE WILLING TO COMPROMISE While our law is not the most progressive law in the country it is a major step forward in health care for patients If we had dug in our in heels and refused to compromise I would be writing a very different article Knowing when to move to a middle ground is key

During our first year of work the telemedicine bill died in the Senate Health Care committee Not making it very far in the legislative process in the Senate told us that we had problems with the proposal that would not solve themselves The commercial insurers strongly

opposed the bill because it required payment rate parity not just parity in coverage of services The definition of telemedicine was also called into question as were the originating sites

Unless there is a change in legislative makeup or the facts have significantly shifted on an issue running the same legislation over and over again is not typically a recipe for success We had neither a shift in legislative power or a major shift in the fact base

After the 2013 legislative session we entered into negotiations with the three major commercial insurers in our state We also added our statersquos Medicaid program to our legislation which we had overlooked the first time around to bring the number of health plans to negotiate with to nine We had to give up ground in the negotiations but what we received in return was all nine health plans being supportive or neutral of the bill The same insurers who had worked hard to kill the bill in 2013 became some of our best allies and testified repeatedly in favor of the bill in 2014 and 2015

Washington l continued

Washington l continued

6 SOMETIMES YOU NEED TO SAY ldquoNOrdquo Throughout the process and especially when the bill was poised to pass we had various groups trying to tack their issue onto our bill ndash asking us to add home visits or specifically identify nurse practitioners or any number of other provisions that would have upset the negotiated agreements we had struck on the bill While we agreed that the bill could go farther and payment for home visits would be great we knew we were politically at the edge for maintaining support for the bill We had several tough conversations where we told advocates no Getting a law passed that requires payment for telemedicine is an enormous victory and we were unwilling to snatch defeat from the jaws of victory

WASHINGTON STATErsquoS TELEMEDICINE LAWBy 2017 Washington Statersquos law requires commercial Medicaid and public employee health plans to reimburse for covered health plan services provided through telemedicine The law defines telemedicine as ldquothe delivery of health care services through the use of interactive audio and video technology permitting real-time communication between the patient at the originating site and the provider for the purpose of diagnosis consultation or treatment Telemedicine does not include the use of audio-only telephone facsimile or emailrdquo

In order to trigger reimbursement for a service delivered through telemedicine a patient must be in one of the seven originating sites The sites include a hospital rural health clinic federally qualified health center physicianrsquos

or other health care providerrsquos office community mental health center skilled nursing facility or renal dialysis center except an independent renal dialysis centerThe law explicitly prohibits geographic restrictions on a patientrsquos location for reimbursement purposes Specific to hospitals it also clarifies that an originating site hospital may rely on a distant site hospitalrsquos decision to grant or renew clinical privileges when the two facilities have a written agreement in place

Lastly the law recognizes use ldquostore and forwardrdquo technology for commercial and public employee plans but does not require reimbursement unless the service is in the negotiated contract For Medicaid plans this recognition may be the avenue for allowing services delivered through store and forward to be included in the actuarial rate setting for the plans something that is not recognized currently Changing the incentive for Medicaid plans to pay for store and forward will be an important shift for our state

MOVING FORWARDOur telemedicine law is a big step forward for the delivery of care for patients with strokes psychiatric illness heart problems and so many others While we did not get everything we wanted in the law we made significant headway In the future if we seek to expand the law it will take many of the steps I described above We are encouraging our providers to get more aggressive about contracting with insurers Return on investment for the coverage of services is key to showing how technology will transform health Use of store and forward as well as remote patient monitoring are two areas we are beginning to see roll out with pilot projects

Legislators remain interested in continuing to discuss other areas important to the use of telemedicine including licensing compacts and state-endorsed advisory committees to help guide the next steps There will also be important work in monitoring how the telemedicine law gets implemented

UPCOMING EVENTSBy Martha Nikides

FOR MORE INFORMATIONFor more informationon upcoming events please go to wwwnrtrcorg

EVENT SUBMISSIONSPlease forward event information to marthanrtrcorg

APRIL l MAY 2015

ABOUT USThe Northwest Regional Telehealth Resource Center leverages the collective expertise of 33 telehealth networks in Alaska Idaho Montana Oregon Utah Washington and Wyoming to share information and resources and develop new telehealth programs

NRTRC SERVICESbull Provide technical assistance for new programs and applicationsbull Increase exposure to telehealth as a health care delivery toolbull Improve access to specialty care through regional collaborationbull Develop information on best practices and telehealth toolkitsbull Provide current information and facilitate discussion of regional regulatory policy and reimbursement issues

NORTHWEST REGIONAL TELEHEALTH RESOURCE CENTER1233 North 30th StreetBillings Montana 59101888-662-5601 or 406-237-8665

NRTRC STAFFBob Wolverton Program DirectorPatricia Inabnit MarketingOutreach SpecialistMartha Nikides Telehealth CoordinatorDoris Barta Principal Investigator

NRTRC BOARD MEMBERSALASKA Cynthia Roleff Christie ArtusoIDAHO Tom Hauer Neill Piland MONTANA Doris Barta Thelma McClosky-Armstrong OREGON Cathy Britain Doug RomerUTAH Patricia Carroll Wesley ValdesWASHINGTON Cara Towle Nancy VorheesWYOMING Jim Bush PJ Treide

NEWS ampVIEWS

May 28 2015 NRTRC Open Mic Webinar

A Payerrsquos Perspective200pm MST

May 21 2015National TRC Monthly Webinar

Things to Consider When Developing a Credentialing and

Privileging Process for Telehealth200pm MST

ARTICLE AND PHOTO SUBMISSIONS If you would like to write an article or provide photographs for this publication please contact Bob Wolverton bobnrtrcorg or 406-237-8660

SAVE THE 2016 DATE

CONFERENCE 2015

Community Health Centersand Telehealth

By Bob Wolverton NRTRC Program Director

SPOTLIGHT

APRIL l MAY 2015

NEWS ampVIEWS

CHCs and Telehealth l continued

I RECENTLY ATTENDED A

SYMPOSIUM SPONSORED BY

THE MONTANA PRIMARY CARE

ASSOCIATION I WAS ASKED

TO DISCUSS HOW TELEHEALTH

COULD HELP COMMUNITY HEALTH

CENTERS (CHC) MEET THEIR

MISSIONS AND SERVE THEIR

PATIENT BASE BETTER

I was lucky enough to have time to attend a number of presentations and found them all interesting The presenters were great and the audience was really engaged Thatrsquos a fine recipe for a conference Kudos to the MPCA staff for putting together such a fine gathering

When it was my turn I discussed telehealth from the ground up Only about three people in the session said they were using telehealth currently so I thought a basic introduction would be a good idea I then moved on to what I thought would be good telehealth services CHCs could offer

Of course therersquos specialty care CHCs often deal with patients who have chronic illness and need care from a specialist But those patients are frequently frail and canrsquot easily make the trip to the big city for specialty care Or they might not be able to afford to take time off from work to travel for care And of course in the big square states with high altitudes and low populations the weather might cause difficult or dangerous travel (as I write this Wyoming is just cleaning up from three multi-car accidents caused in large part by the weather More than

100 vehicles were involved and there were a few fatalities and a lot of hospitalizations Weather in our region is always a challenge)

I offered a few suggestions for telehealth-based specialty care Kind of a list of the usual suspects I suppose

REMOTE PATIENT MONITORING There are some telehealth options that seem to work very well with small clinics and chronically ill patients Remote Patient Monitoring (RPM) will likely become a huge factor in chronic illness care in the next few years as the health care system evolves We have a few CHCs offering RPM in the region and they are doing some wonderful things for their patients When the clinics offer a means by which the patients can have their conditions monitored daily their health is maintained in a stable manner Potentially dangerous changes can be caught and stopped before they become critical

REDUCED ER VISITS There arenrsquot many academic studies on RPM but individual organizations have reported a lot of good from RPM NRTRC has a partner that has been doing RPM for a little over a year now and they report that they have saved 75 emergency room visits Thatrsquos pretty significant Each ER visit is expensive and avoiding that many can have a significant impact on health care expenses Of course itrsquos good for the patients too and thatrsquos what really counts

REDUCED READMISSIONS Other organizations estimate the number of readmissions theyrsquove

avoided along with the ER avoidance through their RPM programs Reports have ranged from 7 reduction in readmissions to a whopping 70 That wide variance is why an academic study with rigorous controls would offer a clear estimate of readmissions

Another topic that is of interest to CHCs is mental health care Theyrsquore required to provide access to care and there is a great shortage of mental health care providers not only in Montana but in all our states where population density is extremely low We discussed some options for care and Irsquom hopeful that we can expand access to our truly rural residentsWe talked about specialty care in general and covered quite a bit of territory

Then a question came up that I couldnrsquot answer Is anyone doing tele-dentistry in Montana Dentistry

can benefit from telehealth as can many other disciplines Of course I wouldnrsquot want to undergo an extraction by telehealth but oral cancer screens general dental health care or other exams can be carried out by a trained dental assistant with the patient and the dentist in a remote location That would get at least initial care and screenings to remote patients and allow CHCs to offer that important service to their clients Irsquom investigating that and hope to have some information to share in the future

I APPRECIATE THE MONTANA

PRIMARY CARE ASSOCIATIONrsquoS

INVITING ME TO THE CONFERENCE

AND LOOK FORWARD TO A LONG

PARTNERSHIP WITH THEM AND

THEIR MEMBERS

CHCs and Telehealth l continued

How Washington FinallyEnacted a Telemedicine Law

By Chelene Whiteaker MHAPolicy Director Washington State Hospital Association

SPOTLIGHT

APRIL l MAY 2015

NEWS ampVIEWS

Washington l continued

When the idea of working on a telemedicine law was raised back in 2012 no one around the table would have guessed it would take Washington State three years to enact a law The problem was clear Insurers

one learns in civics class These are lessons we could all use a quick reminder on when thinking about proposing or working to enact legislation

For states still debating a law here are the top six things that made the difference in Washington State

1 BUILD A COALITION Identify and create an advisory group that helps think through the tough decisions that will need to be made but can also help provide stories

EDITORrsquoS NOTE Chelene Whitaker is Policy Director for the Washington State Hospital Association In that position she was instrumental in shepherding Washingtonrsquos recently enacted telehealth parity law through the State Legislature This article relates the process of moving a law from concept to enactment

were placing geographic restrictions or refusing to contract for services delivered through telemedicine technology The solution was solid Enact legislation that would require payment for telemedicine and bring needed health care services to rural and underserved patients The benefits were obvious Patients would get necessary services faster and more efficiently which we believe will save lives and money

Yet the Byzantine journey of this law reminded us of many lessons

Washington l continued

about why the legislation is needed The advisory group can be the start of a grassroots coalition that can help advocate for the law We had a broad group of our members along with the Washington State Medical Association to help with this work

2 IDENTIFY IMPACTED ORGANIZATIONS OR PROVIDERS The biggest beneficiaries of telemedicine are the patients ndash children with autism people with Parkinsonrsquos disease people having a stroke Restrictions on telemedicine have real consequences for patients Gather those stories early The hospital association worked to identify those who could convincingly tell the impact of limited telemedicine take-up Work with these individuals before the legislative session starts so they are ready to engage in advocacy

3 IDENTIFY STRONG LEGISLATIVE CHAMPIONS This is as important as building the coalition Having an elected official who is ldquoon-firerdquo for this cause is crucial One of our champions was also the person who told us we had more work to do on the legislation in 2013 after our bill died She told us to negotiate with the insurers and bring her back a piece of legislation that both of us could support Our other champion legislator is married to a child psychiatrist and clearly saw the benefit of the law for the children his wife treats Both these legislators were key to getting the bill to the finish line

4 DONrsquoT GIVE UP Passing this bill took three years of hard work and heartbreak It took significantly longer than we expected and in the second year was derailed at the eleventh hour by a concern that telemedicine would lead to ldquowebcam abortionsrdquo This was a concern that took us completely by surprise It was an ideological issue we could not overcome in a short time frame near the end of the legislative

session But we persevered and found a solution to address the issue ndash tying telemedicine coverage to the federal essential health benefits package The concept of ldquowebcam abortionrdquo is a concern about telemedicine worth knowing about and researching in order to respond to objections The concern issue is a national issue for groups opposing abortion and it has now surfaced in states other than Washington We would recommend that advocates adopt the same solution

5 BE WILLING TO COMPROMISE While our law is not the most progressive law in the country it is a major step forward in health care for patients If we had dug in our in heels and refused to compromise I would be writing a very different article Knowing when to move to a middle ground is key

During our first year of work the telemedicine bill died in the Senate Health Care committee Not making it very far in the legislative process in the Senate told us that we had problems with the proposal that would not solve themselves The commercial insurers strongly

opposed the bill because it required payment rate parity not just parity in coverage of services The definition of telemedicine was also called into question as were the originating sites

Unless there is a change in legislative makeup or the facts have significantly shifted on an issue running the same legislation over and over again is not typically a recipe for success We had neither a shift in legislative power or a major shift in the fact base

After the 2013 legislative session we entered into negotiations with the three major commercial insurers in our state We also added our statersquos Medicaid program to our legislation which we had overlooked the first time around to bring the number of health plans to negotiate with to nine We had to give up ground in the negotiations but what we received in return was all nine health plans being supportive or neutral of the bill The same insurers who had worked hard to kill the bill in 2013 became some of our best allies and testified repeatedly in favor of the bill in 2014 and 2015

Washington l continued

Washington l continued

6 SOMETIMES YOU NEED TO SAY ldquoNOrdquo Throughout the process and especially when the bill was poised to pass we had various groups trying to tack their issue onto our bill ndash asking us to add home visits or specifically identify nurse practitioners or any number of other provisions that would have upset the negotiated agreements we had struck on the bill While we agreed that the bill could go farther and payment for home visits would be great we knew we were politically at the edge for maintaining support for the bill We had several tough conversations where we told advocates no Getting a law passed that requires payment for telemedicine is an enormous victory and we were unwilling to snatch defeat from the jaws of victory

WASHINGTON STATErsquoS TELEMEDICINE LAWBy 2017 Washington Statersquos law requires commercial Medicaid and public employee health plans to reimburse for covered health plan services provided through telemedicine The law defines telemedicine as ldquothe delivery of health care services through the use of interactive audio and video technology permitting real-time communication between the patient at the originating site and the provider for the purpose of diagnosis consultation or treatment Telemedicine does not include the use of audio-only telephone facsimile or emailrdquo

In order to trigger reimbursement for a service delivered through telemedicine a patient must be in one of the seven originating sites The sites include a hospital rural health clinic federally qualified health center physicianrsquos

or other health care providerrsquos office community mental health center skilled nursing facility or renal dialysis center except an independent renal dialysis centerThe law explicitly prohibits geographic restrictions on a patientrsquos location for reimbursement purposes Specific to hospitals it also clarifies that an originating site hospital may rely on a distant site hospitalrsquos decision to grant or renew clinical privileges when the two facilities have a written agreement in place

Lastly the law recognizes use ldquostore and forwardrdquo technology for commercial and public employee plans but does not require reimbursement unless the service is in the negotiated contract For Medicaid plans this recognition may be the avenue for allowing services delivered through store and forward to be included in the actuarial rate setting for the plans something that is not recognized currently Changing the incentive for Medicaid plans to pay for store and forward will be an important shift for our state

MOVING FORWARDOur telemedicine law is a big step forward for the delivery of care for patients with strokes psychiatric illness heart problems and so many others While we did not get everything we wanted in the law we made significant headway In the future if we seek to expand the law it will take many of the steps I described above We are encouraging our providers to get more aggressive about contracting with insurers Return on investment for the coverage of services is key to showing how technology will transform health Use of store and forward as well as remote patient monitoring are two areas we are beginning to see roll out with pilot projects

Legislators remain interested in continuing to discuss other areas important to the use of telemedicine including licensing compacts and state-endorsed advisory committees to help guide the next steps There will also be important work in monitoring how the telemedicine law gets implemented

UPCOMING EVENTSBy Martha Nikides

FOR MORE INFORMATIONFor more informationon upcoming events please go to wwwnrtrcorg

EVENT SUBMISSIONSPlease forward event information to marthanrtrcorg

APRIL l MAY 2015

ABOUT USThe Northwest Regional Telehealth Resource Center leverages the collective expertise of 33 telehealth networks in Alaska Idaho Montana Oregon Utah Washington and Wyoming to share information and resources and develop new telehealth programs

NRTRC SERVICESbull Provide technical assistance for new programs and applicationsbull Increase exposure to telehealth as a health care delivery toolbull Improve access to specialty care through regional collaborationbull Develop information on best practices and telehealth toolkitsbull Provide current information and facilitate discussion of regional regulatory policy and reimbursement issues

NORTHWEST REGIONAL TELEHEALTH RESOURCE CENTER1233 North 30th StreetBillings Montana 59101888-662-5601 or 406-237-8665

NRTRC STAFFBob Wolverton Program DirectorPatricia Inabnit MarketingOutreach SpecialistMartha Nikides Telehealth CoordinatorDoris Barta Principal Investigator

NRTRC BOARD MEMBERSALASKA Cynthia Roleff Christie ArtusoIDAHO Tom Hauer Neill Piland MONTANA Doris Barta Thelma McClosky-Armstrong OREGON Cathy Britain Doug RomerUTAH Patricia Carroll Wesley ValdesWASHINGTON Cara Towle Nancy VorheesWYOMING Jim Bush PJ Treide

NEWS ampVIEWS

May 28 2015 NRTRC Open Mic Webinar

A Payerrsquos Perspective200pm MST

May 21 2015National TRC Monthly Webinar

Things to Consider When Developing a Credentialing and

Privileging Process for Telehealth200pm MST

ARTICLE AND PHOTO SUBMISSIONS If you would like to write an article or provide photographs for this publication please contact Bob Wolverton bobnrtrcorg or 406-237-8660

SAVE THE 2016 DATE

Community Health Centersand Telehealth

By Bob Wolverton NRTRC Program Director

SPOTLIGHT

APRIL l MAY 2015

NEWS ampVIEWS

CHCs and Telehealth l continued

I RECENTLY ATTENDED A

SYMPOSIUM SPONSORED BY

THE MONTANA PRIMARY CARE

ASSOCIATION I WAS ASKED

TO DISCUSS HOW TELEHEALTH

COULD HELP COMMUNITY HEALTH

CENTERS (CHC) MEET THEIR

MISSIONS AND SERVE THEIR

PATIENT BASE BETTER

I was lucky enough to have time to attend a number of presentations and found them all interesting The presenters were great and the audience was really engaged Thatrsquos a fine recipe for a conference Kudos to the MPCA staff for putting together such a fine gathering

When it was my turn I discussed telehealth from the ground up Only about three people in the session said they were using telehealth currently so I thought a basic introduction would be a good idea I then moved on to what I thought would be good telehealth services CHCs could offer

Of course therersquos specialty care CHCs often deal with patients who have chronic illness and need care from a specialist But those patients are frequently frail and canrsquot easily make the trip to the big city for specialty care Or they might not be able to afford to take time off from work to travel for care And of course in the big square states with high altitudes and low populations the weather might cause difficult or dangerous travel (as I write this Wyoming is just cleaning up from three multi-car accidents caused in large part by the weather More than

100 vehicles were involved and there were a few fatalities and a lot of hospitalizations Weather in our region is always a challenge)

I offered a few suggestions for telehealth-based specialty care Kind of a list of the usual suspects I suppose

REMOTE PATIENT MONITORING There are some telehealth options that seem to work very well with small clinics and chronically ill patients Remote Patient Monitoring (RPM) will likely become a huge factor in chronic illness care in the next few years as the health care system evolves We have a few CHCs offering RPM in the region and they are doing some wonderful things for their patients When the clinics offer a means by which the patients can have their conditions monitored daily their health is maintained in a stable manner Potentially dangerous changes can be caught and stopped before they become critical

REDUCED ER VISITS There arenrsquot many academic studies on RPM but individual organizations have reported a lot of good from RPM NRTRC has a partner that has been doing RPM for a little over a year now and they report that they have saved 75 emergency room visits Thatrsquos pretty significant Each ER visit is expensive and avoiding that many can have a significant impact on health care expenses Of course itrsquos good for the patients too and thatrsquos what really counts

REDUCED READMISSIONS Other organizations estimate the number of readmissions theyrsquove

avoided along with the ER avoidance through their RPM programs Reports have ranged from 7 reduction in readmissions to a whopping 70 That wide variance is why an academic study with rigorous controls would offer a clear estimate of readmissions

Another topic that is of interest to CHCs is mental health care Theyrsquore required to provide access to care and there is a great shortage of mental health care providers not only in Montana but in all our states where population density is extremely low We discussed some options for care and Irsquom hopeful that we can expand access to our truly rural residentsWe talked about specialty care in general and covered quite a bit of territory

Then a question came up that I couldnrsquot answer Is anyone doing tele-dentistry in Montana Dentistry

can benefit from telehealth as can many other disciplines Of course I wouldnrsquot want to undergo an extraction by telehealth but oral cancer screens general dental health care or other exams can be carried out by a trained dental assistant with the patient and the dentist in a remote location That would get at least initial care and screenings to remote patients and allow CHCs to offer that important service to their clients Irsquom investigating that and hope to have some information to share in the future

I APPRECIATE THE MONTANA

PRIMARY CARE ASSOCIATIONrsquoS

INVITING ME TO THE CONFERENCE

AND LOOK FORWARD TO A LONG

PARTNERSHIP WITH THEM AND

THEIR MEMBERS

CHCs and Telehealth l continued

How Washington FinallyEnacted a Telemedicine Law

By Chelene Whiteaker MHAPolicy Director Washington State Hospital Association

SPOTLIGHT

APRIL l MAY 2015

NEWS ampVIEWS

Washington l continued

When the idea of working on a telemedicine law was raised back in 2012 no one around the table would have guessed it would take Washington State three years to enact a law The problem was clear Insurers

one learns in civics class These are lessons we could all use a quick reminder on when thinking about proposing or working to enact legislation

For states still debating a law here are the top six things that made the difference in Washington State

1 BUILD A COALITION Identify and create an advisory group that helps think through the tough decisions that will need to be made but can also help provide stories

EDITORrsquoS NOTE Chelene Whitaker is Policy Director for the Washington State Hospital Association In that position she was instrumental in shepherding Washingtonrsquos recently enacted telehealth parity law through the State Legislature This article relates the process of moving a law from concept to enactment

were placing geographic restrictions or refusing to contract for services delivered through telemedicine technology The solution was solid Enact legislation that would require payment for telemedicine and bring needed health care services to rural and underserved patients The benefits were obvious Patients would get necessary services faster and more efficiently which we believe will save lives and money

Yet the Byzantine journey of this law reminded us of many lessons

Washington l continued

about why the legislation is needed The advisory group can be the start of a grassroots coalition that can help advocate for the law We had a broad group of our members along with the Washington State Medical Association to help with this work

2 IDENTIFY IMPACTED ORGANIZATIONS OR PROVIDERS The biggest beneficiaries of telemedicine are the patients ndash children with autism people with Parkinsonrsquos disease people having a stroke Restrictions on telemedicine have real consequences for patients Gather those stories early The hospital association worked to identify those who could convincingly tell the impact of limited telemedicine take-up Work with these individuals before the legislative session starts so they are ready to engage in advocacy

3 IDENTIFY STRONG LEGISLATIVE CHAMPIONS This is as important as building the coalition Having an elected official who is ldquoon-firerdquo for this cause is crucial One of our champions was also the person who told us we had more work to do on the legislation in 2013 after our bill died She told us to negotiate with the insurers and bring her back a piece of legislation that both of us could support Our other champion legislator is married to a child psychiatrist and clearly saw the benefit of the law for the children his wife treats Both these legislators were key to getting the bill to the finish line

4 DONrsquoT GIVE UP Passing this bill took three years of hard work and heartbreak It took significantly longer than we expected and in the second year was derailed at the eleventh hour by a concern that telemedicine would lead to ldquowebcam abortionsrdquo This was a concern that took us completely by surprise It was an ideological issue we could not overcome in a short time frame near the end of the legislative

session But we persevered and found a solution to address the issue ndash tying telemedicine coverage to the federal essential health benefits package The concept of ldquowebcam abortionrdquo is a concern about telemedicine worth knowing about and researching in order to respond to objections The concern issue is a national issue for groups opposing abortion and it has now surfaced in states other than Washington We would recommend that advocates adopt the same solution

5 BE WILLING TO COMPROMISE While our law is not the most progressive law in the country it is a major step forward in health care for patients If we had dug in our in heels and refused to compromise I would be writing a very different article Knowing when to move to a middle ground is key

During our first year of work the telemedicine bill died in the Senate Health Care committee Not making it very far in the legislative process in the Senate told us that we had problems with the proposal that would not solve themselves The commercial insurers strongly

opposed the bill because it required payment rate parity not just parity in coverage of services The definition of telemedicine was also called into question as were the originating sites

Unless there is a change in legislative makeup or the facts have significantly shifted on an issue running the same legislation over and over again is not typically a recipe for success We had neither a shift in legislative power or a major shift in the fact base

After the 2013 legislative session we entered into negotiations with the three major commercial insurers in our state We also added our statersquos Medicaid program to our legislation which we had overlooked the first time around to bring the number of health plans to negotiate with to nine We had to give up ground in the negotiations but what we received in return was all nine health plans being supportive or neutral of the bill The same insurers who had worked hard to kill the bill in 2013 became some of our best allies and testified repeatedly in favor of the bill in 2014 and 2015

Washington l continued

Washington l continued

6 SOMETIMES YOU NEED TO SAY ldquoNOrdquo Throughout the process and especially when the bill was poised to pass we had various groups trying to tack their issue onto our bill ndash asking us to add home visits or specifically identify nurse practitioners or any number of other provisions that would have upset the negotiated agreements we had struck on the bill While we agreed that the bill could go farther and payment for home visits would be great we knew we were politically at the edge for maintaining support for the bill We had several tough conversations where we told advocates no Getting a law passed that requires payment for telemedicine is an enormous victory and we were unwilling to snatch defeat from the jaws of victory

WASHINGTON STATErsquoS TELEMEDICINE LAWBy 2017 Washington Statersquos law requires commercial Medicaid and public employee health plans to reimburse for covered health plan services provided through telemedicine The law defines telemedicine as ldquothe delivery of health care services through the use of interactive audio and video technology permitting real-time communication between the patient at the originating site and the provider for the purpose of diagnosis consultation or treatment Telemedicine does not include the use of audio-only telephone facsimile or emailrdquo

In order to trigger reimbursement for a service delivered through telemedicine a patient must be in one of the seven originating sites The sites include a hospital rural health clinic federally qualified health center physicianrsquos

or other health care providerrsquos office community mental health center skilled nursing facility or renal dialysis center except an independent renal dialysis centerThe law explicitly prohibits geographic restrictions on a patientrsquos location for reimbursement purposes Specific to hospitals it also clarifies that an originating site hospital may rely on a distant site hospitalrsquos decision to grant or renew clinical privileges when the two facilities have a written agreement in place

Lastly the law recognizes use ldquostore and forwardrdquo technology for commercial and public employee plans but does not require reimbursement unless the service is in the negotiated contract For Medicaid plans this recognition may be the avenue for allowing services delivered through store and forward to be included in the actuarial rate setting for the plans something that is not recognized currently Changing the incentive for Medicaid plans to pay for store and forward will be an important shift for our state

MOVING FORWARDOur telemedicine law is a big step forward for the delivery of care for patients with strokes psychiatric illness heart problems and so many others While we did not get everything we wanted in the law we made significant headway In the future if we seek to expand the law it will take many of the steps I described above We are encouraging our providers to get more aggressive about contracting with insurers Return on investment for the coverage of services is key to showing how technology will transform health Use of store and forward as well as remote patient monitoring are two areas we are beginning to see roll out with pilot projects

Legislators remain interested in continuing to discuss other areas important to the use of telemedicine including licensing compacts and state-endorsed advisory committees to help guide the next steps There will also be important work in monitoring how the telemedicine law gets implemented

UPCOMING EVENTSBy Martha Nikides

FOR MORE INFORMATIONFor more informationon upcoming events please go to wwwnrtrcorg

EVENT SUBMISSIONSPlease forward event information to marthanrtrcorg

APRIL l MAY 2015

ABOUT USThe Northwest Regional Telehealth Resource Center leverages the collective expertise of 33 telehealth networks in Alaska Idaho Montana Oregon Utah Washington and Wyoming to share information and resources and develop new telehealth programs

NRTRC SERVICESbull Provide technical assistance for new programs and applicationsbull Increase exposure to telehealth as a health care delivery toolbull Improve access to specialty care through regional collaborationbull Develop information on best practices and telehealth toolkitsbull Provide current information and facilitate discussion of regional regulatory policy and reimbursement issues

NORTHWEST REGIONAL TELEHEALTH RESOURCE CENTER1233 North 30th StreetBillings Montana 59101888-662-5601 or 406-237-8665

NRTRC STAFFBob Wolverton Program DirectorPatricia Inabnit MarketingOutreach SpecialistMartha Nikides Telehealth CoordinatorDoris Barta Principal Investigator

NRTRC BOARD MEMBERSALASKA Cynthia Roleff Christie ArtusoIDAHO Tom Hauer Neill Piland MONTANA Doris Barta Thelma McClosky-Armstrong OREGON Cathy Britain Doug RomerUTAH Patricia Carroll Wesley ValdesWASHINGTON Cara Towle Nancy VorheesWYOMING Jim Bush PJ Treide

NEWS ampVIEWS

May 28 2015 NRTRC Open Mic Webinar

A Payerrsquos Perspective200pm MST

May 21 2015National TRC Monthly Webinar

Things to Consider When Developing a Credentialing and

Privileging Process for Telehealth200pm MST

ARTICLE AND PHOTO SUBMISSIONS If you would like to write an article or provide photographs for this publication please contact Bob Wolverton bobnrtrcorg or 406-237-8660

SAVE THE 2016 DATE

100 vehicles were involved and there were a few fatalities and a lot of hospitalizations Weather in our region is always a challenge)

I offered a few suggestions for telehealth-based specialty care Kind of a list of the usual suspects I suppose

REMOTE PATIENT MONITORING There are some telehealth options that seem to work very well with small clinics and chronically ill patients Remote Patient Monitoring (RPM) will likely become a huge factor in chronic illness care in the next few years as the health care system evolves We have a few CHCs offering RPM in the region and they are doing some wonderful things for their patients When the clinics offer a means by which the patients can have their conditions monitored daily their health is maintained in a stable manner Potentially dangerous changes can be caught and stopped before they become critical

REDUCED ER VISITS There arenrsquot many academic studies on RPM but individual organizations have reported a lot of good from RPM NRTRC has a partner that has been doing RPM for a little over a year now and they report that they have saved 75 emergency room visits Thatrsquos pretty significant Each ER visit is expensive and avoiding that many can have a significant impact on health care expenses Of course itrsquos good for the patients too and thatrsquos what really counts

REDUCED READMISSIONS Other organizations estimate the number of readmissions theyrsquove

avoided along with the ER avoidance through their RPM programs Reports have ranged from 7 reduction in readmissions to a whopping 70 That wide variance is why an academic study with rigorous controls would offer a clear estimate of readmissions

Another topic that is of interest to CHCs is mental health care Theyrsquore required to provide access to care and there is a great shortage of mental health care providers not only in Montana but in all our states where population density is extremely low We discussed some options for care and Irsquom hopeful that we can expand access to our truly rural residentsWe talked about specialty care in general and covered quite a bit of territory

Then a question came up that I couldnrsquot answer Is anyone doing tele-dentistry in Montana Dentistry

can benefit from telehealth as can many other disciplines Of course I wouldnrsquot want to undergo an extraction by telehealth but oral cancer screens general dental health care or other exams can be carried out by a trained dental assistant with the patient and the dentist in a remote location That would get at least initial care and screenings to remote patients and allow CHCs to offer that important service to their clients Irsquom investigating that and hope to have some information to share in the future

I APPRECIATE THE MONTANA

PRIMARY CARE ASSOCIATIONrsquoS

INVITING ME TO THE CONFERENCE

AND LOOK FORWARD TO A LONG

PARTNERSHIP WITH THEM AND

THEIR MEMBERS

CHCs and Telehealth l continued

How Washington FinallyEnacted a Telemedicine Law

By Chelene Whiteaker MHAPolicy Director Washington State Hospital Association

SPOTLIGHT

APRIL l MAY 2015

NEWS ampVIEWS

Washington l continued

When the idea of working on a telemedicine law was raised back in 2012 no one around the table would have guessed it would take Washington State three years to enact a law The problem was clear Insurers

one learns in civics class These are lessons we could all use a quick reminder on when thinking about proposing or working to enact legislation

For states still debating a law here are the top six things that made the difference in Washington State

1 BUILD A COALITION Identify and create an advisory group that helps think through the tough decisions that will need to be made but can also help provide stories

EDITORrsquoS NOTE Chelene Whitaker is Policy Director for the Washington State Hospital Association In that position she was instrumental in shepherding Washingtonrsquos recently enacted telehealth parity law through the State Legislature This article relates the process of moving a law from concept to enactment

were placing geographic restrictions or refusing to contract for services delivered through telemedicine technology The solution was solid Enact legislation that would require payment for telemedicine and bring needed health care services to rural and underserved patients The benefits were obvious Patients would get necessary services faster and more efficiently which we believe will save lives and money

Yet the Byzantine journey of this law reminded us of many lessons

Washington l continued

about why the legislation is needed The advisory group can be the start of a grassroots coalition that can help advocate for the law We had a broad group of our members along with the Washington State Medical Association to help with this work

2 IDENTIFY IMPACTED ORGANIZATIONS OR PROVIDERS The biggest beneficiaries of telemedicine are the patients ndash children with autism people with Parkinsonrsquos disease people having a stroke Restrictions on telemedicine have real consequences for patients Gather those stories early The hospital association worked to identify those who could convincingly tell the impact of limited telemedicine take-up Work with these individuals before the legislative session starts so they are ready to engage in advocacy

3 IDENTIFY STRONG LEGISLATIVE CHAMPIONS This is as important as building the coalition Having an elected official who is ldquoon-firerdquo for this cause is crucial One of our champions was also the person who told us we had more work to do on the legislation in 2013 after our bill died She told us to negotiate with the insurers and bring her back a piece of legislation that both of us could support Our other champion legislator is married to a child psychiatrist and clearly saw the benefit of the law for the children his wife treats Both these legislators were key to getting the bill to the finish line

4 DONrsquoT GIVE UP Passing this bill took three years of hard work and heartbreak It took significantly longer than we expected and in the second year was derailed at the eleventh hour by a concern that telemedicine would lead to ldquowebcam abortionsrdquo This was a concern that took us completely by surprise It was an ideological issue we could not overcome in a short time frame near the end of the legislative

session But we persevered and found a solution to address the issue ndash tying telemedicine coverage to the federal essential health benefits package The concept of ldquowebcam abortionrdquo is a concern about telemedicine worth knowing about and researching in order to respond to objections The concern issue is a national issue for groups opposing abortion and it has now surfaced in states other than Washington We would recommend that advocates adopt the same solution

5 BE WILLING TO COMPROMISE While our law is not the most progressive law in the country it is a major step forward in health care for patients If we had dug in our in heels and refused to compromise I would be writing a very different article Knowing when to move to a middle ground is key

During our first year of work the telemedicine bill died in the Senate Health Care committee Not making it very far in the legislative process in the Senate told us that we had problems with the proposal that would not solve themselves The commercial insurers strongly

opposed the bill because it required payment rate parity not just parity in coverage of services The definition of telemedicine was also called into question as were the originating sites

Unless there is a change in legislative makeup or the facts have significantly shifted on an issue running the same legislation over and over again is not typically a recipe for success We had neither a shift in legislative power or a major shift in the fact base

After the 2013 legislative session we entered into negotiations with the three major commercial insurers in our state We also added our statersquos Medicaid program to our legislation which we had overlooked the first time around to bring the number of health plans to negotiate with to nine We had to give up ground in the negotiations but what we received in return was all nine health plans being supportive or neutral of the bill The same insurers who had worked hard to kill the bill in 2013 became some of our best allies and testified repeatedly in favor of the bill in 2014 and 2015

Washington l continued

Washington l continued

6 SOMETIMES YOU NEED TO SAY ldquoNOrdquo Throughout the process and especially when the bill was poised to pass we had various groups trying to tack their issue onto our bill ndash asking us to add home visits or specifically identify nurse practitioners or any number of other provisions that would have upset the negotiated agreements we had struck on the bill While we agreed that the bill could go farther and payment for home visits would be great we knew we were politically at the edge for maintaining support for the bill We had several tough conversations where we told advocates no Getting a law passed that requires payment for telemedicine is an enormous victory and we were unwilling to snatch defeat from the jaws of victory

WASHINGTON STATErsquoS TELEMEDICINE LAWBy 2017 Washington Statersquos law requires commercial Medicaid and public employee health plans to reimburse for covered health plan services provided through telemedicine The law defines telemedicine as ldquothe delivery of health care services through the use of interactive audio and video technology permitting real-time communication between the patient at the originating site and the provider for the purpose of diagnosis consultation or treatment Telemedicine does not include the use of audio-only telephone facsimile or emailrdquo

In order to trigger reimbursement for a service delivered through telemedicine a patient must be in one of the seven originating sites The sites include a hospital rural health clinic federally qualified health center physicianrsquos

or other health care providerrsquos office community mental health center skilled nursing facility or renal dialysis center except an independent renal dialysis centerThe law explicitly prohibits geographic restrictions on a patientrsquos location for reimbursement purposes Specific to hospitals it also clarifies that an originating site hospital may rely on a distant site hospitalrsquos decision to grant or renew clinical privileges when the two facilities have a written agreement in place

Lastly the law recognizes use ldquostore and forwardrdquo technology for commercial and public employee plans but does not require reimbursement unless the service is in the negotiated contract For Medicaid plans this recognition may be the avenue for allowing services delivered through store and forward to be included in the actuarial rate setting for the plans something that is not recognized currently Changing the incentive for Medicaid plans to pay for store and forward will be an important shift for our state

MOVING FORWARDOur telemedicine law is a big step forward for the delivery of care for patients with strokes psychiatric illness heart problems and so many others While we did not get everything we wanted in the law we made significant headway In the future if we seek to expand the law it will take many of the steps I described above We are encouraging our providers to get more aggressive about contracting with insurers Return on investment for the coverage of services is key to showing how technology will transform health Use of store and forward as well as remote patient monitoring are two areas we are beginning to see roll out with pilot projects

Legislators remain interested in continuing to discuss other areas important to the use of telemedicine including licensing compacts and state-endorsed advisory committees to help guide the next steps There will also be important work in monitoring how the telemedicine law gets implemented

UPCOMING EVENTSBy Martha Nikides

FOR MORE INFORMATIONFor more informationon upcoming events please go to wwwnrtrcorg

EVENT SUBMISSIONSPlease forward event information to marthanrtrcorg

APRIL l MAY 2015

ABOUT USThe Northwest Regional Telehealth Resource Center leverages the collective expertise of 33 telehealth networks in Alaska Idaho Montana Oregon Utah Washington and Wyoming to share information and resources and develop new telehealth programs

NRTRC SERVICESbull Provide technical assistance for new programs and applicationsbull Increase exposure to telehealth as a health care delivery toolbull Improve access to specialty care through regional collaborationbull Develop information on best practices and telehealth toolkitsbull Provide current information and facilitate discussion of regional regulatory policy and reimbursement issues

NORTHWEST REGIONAL TELEHEALTH RESOURCE CENTER1233 North 30th StreetBillings Montana 59101888-662-5601 or 406-237-8665

NRTRC STAFFBob Wolverton Program DirectorPatricia Inabnit MarketingOutreach SpecialistMartha Nikides Telehealth CoordinatorDoris Barta Principal Investigator

NRTRC BOARD MEMBERSALASKA Cynthia Roleff Christie ArtusoIDAHO Tom Hauer Neill Piland MONTANA Doris Barta Thelma McClosky-Armstrong OREGON Cathy Britain Doug RomerUTAH Patricia Carroll Wesley ValdesWASHINGTON Cara Towle Nancy VorheesWYOMING Jim Bush PJ Treide

NEWS ampVIEWS

May 28 2015 NRTRC Open Mic Webinar

A Payerrsquos Perspective200pm MST

May 21 2015National TRC Monthly Webinar

Things to Consider When Developing a Credentialing and

Privileging Process for Telehealth200pm MST

ARTICLE AND PHOTO SUBMISSIONS If you would like to write an article or provide photographs for this publication please contact Bob Wolverton bobnrtrcorg or 406-237-8660

SAVE THE 2016 DATE

How Washington FinallyEnacted a Telemedicine Law

By Chelene Whiteaker MHAPolicy Director Washington State Hospital Association

SPOTLIGHT

APRIL l MAY 2015

NEWS ampVIEWS

Washington l continued

When the idea of working on a telemedicine law was raised back in 2012 no one around the table would have guessed it would take Washington State three years to enact a law The problem was clear Insurers

one learns in civics class These are lessons we could all use a quick reminder on when thinking about proposing or working to enact legislation

For states still debating a law here are the top six things that made the difference in Washington State

1 BUILD A COALITION Identify and create an advisory group that helps think through the tough decisions that will need to be made but can also help provide stories

EDITORrsquoS NOTE Chelene Whitaker is Policy Director for the Washington State Hospital Association In that position she was instrumental in shepherding Washingtonrsquos recently enacted telehealth parity law through the State Legislature This article relates the process of moving a law from concept to enactment

were placing geographic restrictions or refusing to contract for services delivered through telemedicine technology The solution was solid Enact legislation that would require payment for telemedicine and bring needed health care services to rural and underserved patients The benefits were obvious Patients would get necessary services faster and more efficiently which we believe will save lives and money

Yet the Byzantine journey of this law reminded us of many lessons

Washington l continued

about why the legislation is needed The advisory group can be the start of a grassroots coalition that can help advocate for the law We had a broad group of our members along with the Washington State Medical Association to help with this work

2 IDENTIFY IMPACTED ORGANIZATIONS OR PROVIDERS The biggest beneficiaries of telemedicine are the patients ndash children with autism people with Parkinsonrsquos disease people having a stroke Restrictions on telemedicine have real consequences for patients Gather those stories early The hospital association worked to identify those who could convincingly tell the impact of limited telemedicine take-up Work with these individuals before the legislative session starts so they are ready to engage in advocacy

3 IDENTIFY STRONG LEGISLATIVE CHAMPIONS This is as important as building the coalition Having an elected official who is ldquoon-firerdquo for this cause is crucial One of our champions was also the person who told us we had more work to do on the legislation in 2013 after our bill died She told us to negotiate with the insurers and bring her back a piece of legislation that both of us could support Our other champion legislator is married to a child psychiatrist and clearly saw the benefit of the law for the children his wife treats Both these legislators were key to getting the bill to the finish line

4 DONrsquoT GIVE UP Passing this bill took three years of hard work and heartbreak It took significantly longer than we expected and in the second year was derailed at the eleventh hour by a concern that telemedicine would lead to ldquowebcam abortionsrdquo This was a concern that took us completely by surprise It was an ideological issue we could not overcome in a short time frame near the end of the legislative

session But we persevered and found a solution to address the issue ndash tying telemedicine coverage to the federal essential health benefits package The concept of ldquowebcam abortionrdquo is a concern about telemedicine worth knowing about and researching in order to respond to objections The concern issue is a national issue for groups opposing abortion and it has now surfaced in states other than Washington We would recommend that advocates adopt the same solution

5 BE WILLING TO COMPROMISE While our law is not the most progressive law in the country it is a major step forward in health care for patients If we had dug in our in heels and refused to compromise I would be writing a very different article Knowing when to move to a middle ground is key

During our first year of work the telemedicine bill died in the Senate Health Care committee Not making it very far in the legislative process in the Senate told us that we had problems with the proposal that would not solve themselves The commercial insurers strongly

opposed the bill because it required payment rate parity not just parity in coverage of services The definition of telemedicine was also called into question as were the originating sites

Unless there is a change in legislative makeup or the facts have significantly shifted on an issue running the same legislation over and over again is not typically a recipe for success We had neither a shift in legislative power or a major shift in the fact base

After the 2013 legislative session we entered into negotiations with the three major commercial insurers in our state We also added our statersquos Medicaid program to our legislation which we had overlooked the first time around to bring the number of health plans to negotiate with to nine We had to give up ground in the negotiations but what we received in return was all nine health plans being supportive or neutral of the bill The same insurers who had worked hard to kill the bill in 2013 became some of our best allies and testified repeatedly in favor of the bill in 2014 and 2015

Washington l continued

Washington l continued

6 SOMETIMES YOU NEED TO SAY ldquoNOrdquo Throughout the process and especially when the bill was poised to pass we had various groups trying to tack their issue onto our bill ndash asking us to add home visits or specifically identify nurse practitioners or any number of other provisions that would have upset the negotiated agreements we had struck on the bill While we agreed that the bill could go farther and payment for home visits would be great we knew we were politically at the edge for maintaining support for the bill We had several tough conversations where we told advocates no Getting a law passed that requires payment for telemedicine is an enormous victory and we were unwilling to snatch defeat from the jaws of victory

WASHINGTON STATErsquoS TELEMEDICINE LAWBy 2017 Washington Statersquos law requires commercial Medicaid and public employee health plans to reimburse for covered health plan services provided through telemedicine The law defines telemedicine as ldquothe delivery of health care services through the use of interactive audio and video technology permitting real-time communication between the patient at the originating site and the provider for the purpose of diagnosis consultation or treatment Telemedicine does not include the use of audio-only telephone facsimile or emailrdquo

In order to trigger reimbursement for a service delivered through telemedicine a patient must be in one of the seven originating sites The sites include a hospital rural health clinic federally qualified health center physicianrsquos

or other health care providerrsquos office community mental health center skilled nursing facility or renal dialysis center except an independent renal dialysis centerThe law explicitly prohibits geographic restrictions on a patientrsquos location for reimbursement purposes Specific to hospitals it also clarifies that an originating site hospital may rely on a distant site hospitalrsquos decision to grant or renew clinical privileges when the two facilities have a written agreement in place

Lastly the law recognizes use ldquostore and forwardrdquo technology for commercial and public employee plans but does not require reimbursement unless the service is in the negotiated contract For Medicaid plans this recognition may be the avenue for allowing services delivered through store and forward to be included in the actuarial rate setting for the plans something that is not recognized currently Changing the incentive for Medicaid plans to pay for store and forward will be an important shift for our state

MOVING FORWARDOur telemedicine law is a big step forward for the delivery of care for patients with strokes psychiatric illness heart problems and so many others While we did not get everything we wanted in the law we made significant headway In the future if we seek to expand the law it will take many of the steps I described above We are encouraging our providers to get more aggressive about contracting with insurers Return on investment for the coverage of services is key to showing how technology will transform health Use of store and forward as well as remote patient monitoring are two areas we are beginning to see roll out with pilot projects

Legislators remain interested in continuing to discuss other areas important to the use of telemedicine including licensing compacts and state-endorsed advisory committees to help guide the next steps There will also be important work in monitoring how the telemedicine law gets implemented

UPCOMING EVENTSBy Martha Nikides

FOR MORE INFORMATIONFor more informationon upcoming events please go to wwwnrtrcorg

EVENT SUBMISSIONSPlease forward event information to marthanrtrcorg

APRIL l MAY 2015

ABOUT USThe Northwest Regional Telehealth Resource Center leverages the collective expertise of 33 telehealth networks in Alaska Idaho Montana Oregon Utah Washington and Wyoming to share information and resources and develop new telehealth programs

NRTRC SERVICESbull Provide technical assistance for new programs and applicationsbull Increase exposure to telehealth as a health care delivery toolbull Improve access to specialty care through regional collaborationbull Develop information on best practices and telehealth toolkitsbull Provide current information and facilitate discussion of regional regulatory policy and reimbursement issues

NORTHWEST REGIONAL TELEHEALTH RESOURCE CENTER1233 North 30th StreetBillings Montana 59101888-662-5601 or 406-237-8665

NRTRC STAFFBob Wolverton Program DirectorPatricia Inabnit MarketingOutreach SpecialistMartha Nikides Telehealth CoordinatorDoris Barta Principal Investigator

NRTRC BOARD MEMBERSALASKA Cynthia Roleff Christie ArtusoIDAHO Tom Hauer Neill Piland MONTANA Doris Barta Thelma McClosky-Armstrong OREGON Cathy Britain Doug RomerUTAH Patricia Carroll Wesley ValdesWASHINGTON Cara Towle Nancy VorheesWYOMING Jim Bush PJ Treide

NEWS ampVIEWS

May 28 2015 NRTRC Open Mic Webinar

A Payerrsquos Perspective200pm MST

May 21 2015National TRC Monthly Webinar

Things to Consider When Developing a Credentialing and

Privileging Process for Telehealth200pm MST

ARTICLE AND PHOTO SUBMISSIONS If you would like to write an article or provide photographs for this publication please contact Bob Wolverton bobnrtrcorg or 406-237-8660

SAVE THE 2016 DATE

Washington l continued

about why the legislation is needed The advisory group can be the start of a grassroots coalition that can help advocate for the law We had a broad group of our members along with the Washington State Medical Association to help with this work

2 IDENTIFY IMPACTED ORGANIZATIONS OR PROVIDERS The biggest beneficiaries of telemedicine are the patients ndash children with autism people with Parkinsonrsquos disease people having a stroke Restrictions on telemedicine have real consequences for patients Gather those stories early The hospital association worked to identify those who could convincingly tell the impact of limited telemedicine take-up Work with these individuals before the legislative session starts so they are ready to engage in advocacy

3 IDENTIFY STRONG LEGISLATIVE CHAMPIONS This is as important as building the coalition Having an elected official who is ldquoon-firerdquo for this cause is crucial One of our champions was also the person who told us we had more work to do on the legislation in 2013 after our bill died She told us to negotiate with the insurers and bring her back a piece of legislation that both of us could support Our other champion legislator is married to a child psychiatrist and clearly saw the benefit of the law for the children his wife treats Both these legislators were key to getting the bill to the finish line

4 DONrsquoT GIVE UP Passing this bill took three years of hard work and heartbreak It took significantly longer than we expected and in the second year was derailed at the eleventh hour by a concern that telemedicine would lead to ldquowebcam abortionsrdquo This was a concern that took us completely by surprise It was an ideological issue we could not overcome in a short time frame near the end of the legislative

session But we persevered and found a solution to address the issue ndash tying telemedicine coverage to the federal essential health benefits package The concept of ldquowebcam abortionrdquo is a concern about telemedicine worth knowing about and researching in order to respond to objections The concern issue is a national issue for groups opposing abortion and it has now surfaced in states other than Washington We would recommend that advocates adopt the same solution

5 BE WILLING TO COMPROMISE While our law is not the most progressive law in the country it is a major step forward in health care for patients If we had dug in our in heels and refused to compromise I would be writing a very different article Knowing when to move to a middle ground is key

During our first year of work the telemedicine bill died in the Senate Health Care committee Not making it very far in the legislative process in the Senate told us that we had problems with the proposal that would not solve themselves The commercial insurers strongly

opposed the bill because it required payment rate parity not just parity in coverage of services The definition of telemedicine was also called into question as were the originating sites

Unless there is a change in legislative makeup or the facts have significantly shifted on an issue running the same legislation over and over again is not typically a recipe for success We had neither a shift in legislative power or a major shift in the fact base

After the 2013 legislative session we entered into negotiations with the three major commercial insurers in our state We also added our statersquos Medicaid program to our legislation which we had overlooked the first time around to bring the number of health plans to negotiate with to nine We had to give up ground in the negotiations but what we received in return was all nine health plans being supportive or neutral of the bill The same insurers who had worked hard to kill the bill in 2013 became some of our best allies and testified repeatedly in favor of the bill in 2014 and 2015

Washington l continued

Washington l continued

6 SOMETIMES YOU NEED TO SAY ldquoNOrdquo Throughout the process and especially when the bill was poised to pass we had various groups trying to tack their issue onto our bill ndash asking us to add home visits or specifically identify nurse practitioners or any number of other provisions that would have upset the negotiated agreements we had struck on the bill While we agreed that the bill could go farther and payment for home visits would be great we knew we were politically at the edge for maintaining support for the bill We had several tough conversations where we told advocates no Getting a law passed that requires payment for telemedicine is an enormous victory and we were unwilling to snatch defeat from the jaws of victory

WASHINGTON STATErsquoS TELEMEDICINE LAWBy 2017 Washington Statersquos law requires commercial Medicaid and public employee health plans to reimburse for covered health plan services provided through telemedicine The law defines telemedicine as ldquothe delivery of health care services through the use of interactive audio and video technology permitting real-time communication between the patient at the originating site and the provider for the purpose of diagnosis consultation or treatment Telemedicine does not include the use of audio-only telephone facsimile or emailrdquo

In order to trigger reimbursement for a service delivered through telemedicine a patient must be in one of the seven originating sites The sites include a hospital rural health clinic federally qualified health center physicianrsquos

or other health care providerrsquos office community mental health center skilled nursing facility or renal dialysis center except an independent renal dialysis centerThe law explicitly prohibits geographic restrictions on a patientrsquos location for reimbursement purposes Specific to hospitals it also clarifies that an originating site hospital may rely on a distant site hospitalrsquos decision to grant or renew clinical privileges when the two facilities have a written agreement in place

Lastly the law recognizes use ldquostore and forwardrdquo technology for commercial and public employee plans but does not require reimbursement unless the service is in the negotiated contract For Medicaid plans this recognition may be the avenue for allowing services delivered through store and forward to be included in the actuarial rate setting for the plans something that is not recognized currently Changing the incentive for Medicaid plans to pay for store and forward will be an important shift for our state

MOVING FORWARDOur telemedicine law is a big step forward for the delivery of care for patients with strokes psychiatric illness heart problems and so many others While we did not get everything we wanted in the law we made significant headway In the future if we seek to expand the law it will take many of the steps I described above We are encouraging our providers to get more aggressive about contracting with insurers Return on investment for the coverage of services is key to showing how technology will transform health Use of store and forward as well as remote patient monitoring are two areas we are beginning to see roll out with pilot projects

Legislators remain interested in continuing to discuss other areas important to the use of telemedicine including licensing compacts and state-endorsed advisory committees to help guide the next steps There will also be important work in monitoring how the telemedicine law gets implemented

UPCOMING EVENTSBy Martha Nikides

FOR MORE INFORMATIONFor more informationon upcoming events please go to wwwnrtrcorg

EVENT SUBMISSIONSPlease forward event information to marthanrtrcorg

APRIL l MAY 2015

ABOUT USThe Northwest Regional Telehealth Resource Center leverages the collective expertise of 33 telehealth networks in Alaska Idaho Montana Oregon Utah Washington and Wyoming to share information and resources and develop new telehealth programs

NRTRC SERVICESbull Provide technical assistance for new programs and applicationsbull Increase exposure to telehealth as a health care delivery toolbull Improve access to specialty care through regional collaborationbull Develop information on best practices and telehealth toolkitsbull Provide current information and facilitate discussion of regional regulatory policy and reimbursement issues

NORTHWEST REGIONAL TELEHEALTH RESOURCE CENTER1233 North 30th StreetBillings Montana 59101888-662-5601 or 406-237-8665

NRTRC STAFFBob Wolverton Program DirectorPatricia Inabnit MarketingOutreach SpecialistMartha Nikides Telehealth CoordinatorDoris Barta Principal Investigator

NRTRC BOARD MEMBERSALASKA Cynthia Roleff Christie ArtusoIDAHO Tom Hauer Neill Piland MONTANA Doris Barta Thelma McClosky-Armstrong OREGON Cathy Britain Doug RomerUTAH Patricia Carroll Wesley ValdesWASHINGTON Cara Towle Nancy VorheesWYOMING Jim Bush PJ Treide

NEWS ampVIEWS

May 28 2015 NRTRC Open Mic Webinar

A Payerrsquos Perspective200pm MST

May 21 2015National TRC Monthly Webinar

Things to Consider When Developing a Credentialing and

Privileging Process for Telehealth200pm MST

ARTICLE AND PHOTO SUBMISSIONS If you would like to write an article or provide photographs for this publication please contact Bob Wolverton bobnrtrcorg or 406-237-8660

SAVE THE 2016 DATE

Washington l continued

6 SOMETIMES YOU NEED TO SAY ldquoNOrdquo Throughout the process and especially when the bill was poised to pass we had various groups trying to tack their issue onto our bill ndash asking us to add home visits or specifically identify nurse practitioners or any number of other provisions that would have upset the negotiated agreements we had struck on the bill While we agreed that the bill could go farther and payment for home visits would be great we knew we were politically at the edge for maintaining support for the bill We had several tough conversations where we told advocates no Getting a law passed that requires payment for telemedicine is an enormous victory and we were unwilling to snatch defeat from the jaws of victory

WASHINGTON STATErsquoS TELEMEDICINE LAWBy 2017 Washington Statersquos law requires commercial Medicaid and public employee health plans to reimburse for covered health plan services provided through telemedicine The law defines telemedicine as ldquothe delivery of health care services through the use of interactive audio and video technology permitting real-time communication between the patient at the originating site and the provider for the purpose of diagnosis consultation or treatment Telemedicine does not include the use of audio-only telephone facsimile or emailrdquo

In order to trigger reimbursement for a service delivered through telemedicine a patient must be in one of the seven originating sites The sites include a hospital rural health clinic federally qualified health center physicianrsquos

or other health care providerrsquos office community mental health center skilled nursing facility or renal dialysis center except an independent renal dialysis centerThe law explicitly prohibits geographic restrictions on a patientrsquos location for reimbursement purposes Specific to hospitals it also clarifies that an originating site hospital may rely on a distant site hospitalrsquos decision to grant or renew clinical privileges when the two facilities have a written agreement in place

Lastly the law recognizes use ldquostore and forwardrdquo technology for commercial and public employee plans but does not require reimbursement unless the service is in the negotiated contract For Medicaid plans this recognition may be the avenue for allowing services delivered through store and forward to be included in the actuarial rate setting for the plans something that is not recognized currently Changing the incentive for Medicaid plans to pay for store and forward will be an important shift for our state

MOVING FORWARDOur telemedicine law is a big step forward for the delivery of care for patients with strokes psychiatric illness heart problems and so many others While we did not get everything we wanted in the law we made significant headway In the future if we seek to expand the law it will take many of the steps I described above We are encouraging our providers to get more aggressive about contracting with insurers Return on investment for the coverage of services is key to showing how technology will transform health Use of store and forward as well as remote patient monitoring are two areas we are beginning to see roll out with pilot projects

Legislators remain interested in continuing to discuss other areas important to the use of telemedicine including licensing compacts and state-endorsed advisory committees to help guide the next steps There will also be important work in monitoring how the telemedicine law gets implemented

UPCOMING EVENTSBy Martha Nikides

FOR MORE INFORMATIONFor more informationon upcoming events please go to wwwnrtrcorg

EVENT SUBMISSIONSPlease forward event information to marthanrtrcorg

APRIL l MAY 2015

ABOUT USThe Northwest Regional Telehealth Resource Center leverages the collective expertise of 33 telehealth networks in Alaska Idaho Montana Oregon Utah Washington and Wyoming to share information and resources and develop new telehealth programs

NRTRC SERVICESbull Provide technical assistance for new programs and applicationsbull Increase exposure to telehealth as a health care delivery toolbull Improve access to specialty care through regional collaborationbull Develop information on best practices and telehealth toolkitsbull Provide current information and facilitate discussion of regional regulatory policy and reimbursement issues

NORTHWEST REGIONAL TELEHEALTH RESOURCE CENTER1233 North 30th StreetBillings Montana 59101888-662-5601 or 406-237-8665

NRTRC STAFFBob Wolverton Program DirectorPatricia Inabnit MarketingOutreach SpecialistMartha Nikides Telehealth CoordinatorDoris Barta Principal Investigator

NRTRC BOARD MEMBERSALASKA Cynthia Roleff Christie ArtusoIDAHO Tom Hauer Neill Piland MONTANA Doris Barta Thelma McClosky-Armstrong OREGON Cathy Britain Doug RomerUTAH Patricia Carroll Wesley ValdesWASHINGTON Cara Towle Nancy VorheesWYOMING Jim Bush PJ Treide

NEWS ampVIEWS

May 28 2015 NRTRC Open Mic Webinar

A Payerrsquos Perspective200pm MST

May 21 2015National TRC Monthly Webinar

Things to Consider When Developing a Credentialing and

Privileging Process for Telehealth200pm MST

ARTICLE AND PHOTO SUBMISSIONS If you would like to write an article or provide photographs for this publication please contact Bob Wolverton bobnrtrcorg or 406-237-8660

SAVE THE 2016 DATE

UPCOMING EVENTSBy Martha Nikides

FOR MORE INFORMATIONFor more informationon upcoming events please go to wwwnrtrcorg

EVENT SUBMISSIONSPlease forward event information to marthanrtrcorg

APRIL l MAY 2015

ABOUT USThe Northwest Regional Telehealth Resource Center leverages the collective expertise of 33 telehealth networks in Alaska Idaho Montana Oregon Utah Washington and Wyoming to share information and resources and develop new telehealth programs

NRTRC SERVICESbull Provide technical assistance for new programs and applicationsbull Increase exposure to telehealth as a health care delivery toolbull Improve access to specialty care through regional collaborationbull Develop information on best practices and telehealth toolkitsbull Provide current information and facilitate discussion of regional regulatory policy and reimbursement issues

NORTHWEST REGIONAL TELEHEALTH RESOURCE CENTER1233 North 30th StreetBillings Montana 59101888-662-5601 or 406-237-8665

NRTRC STAFFBob Wolverton Program DirectorPatricia Inabnit MarketingOutreach SpecialistMartha Nikides Telehealth CoordinatorDoris Barta Principal Investigator

NRTRC BOARD MEMBERSALASKA Cynthia Roleff Christie ArtusoIDAHO Tom Hauer Neill Piland MONTANA Doris Barta Thelma McClosky-Armstrong OREGON Cathy Britain Doug RomerUTAH Patricia Carroll Wesley ValdesWASHINGTON Cara Towle Nancy VorheesWYOMING Jim Bush PJ Treide

NEWS ampVIEWS

May 28 2015 NRTRC Open Mic Webinar

A Payerrsquos Perspective200pm MST

May 21 2015National TRC Monthly Webinar

Things to Consider When Developing a Credentialing and

Privileging Process for Telehealth200pm MST

ARTICLE AND PHOTO SUBMISSIONS If you would like to write an article or provide photographs for this publication please contact Bob Wolverton bobnrtrcorg or 406-237-8660

SAVE THE 2016 DATE