HIT $olutions for PPACA or Symbiosis between Telemedicine & PPACA

Notwithstanding the Republican House majority, health care reform is probably here to stay; at least as long as Mr. Obama is President.

By adding approximately 45M health care consumers to the system, while mandating extended coverage, it will exponentially increase costs of health care. The system will be further burdened by the increased consumption of health care by aging baby-boomers and medical complications of a younger obese generation.

The current system is starting to come apart at the seams. Despite attempts to increase the supply of Primary Care Providers (PCP) via the expansion of residency programs, demand for primary care services will exceed the supply of providers, as less than 6% of graduates of U.S. medical schools choose primary care specialties.

Primary Care Physicians account for 35 percent of the U.S. physician workforce, compared to 50 percent in most of the world’s developed health systems. By 2025, the U.S. will face a 27 percent shortage of generalist physicians. ⁽²⁾

The scarcity of resources will be compounded by a shortage of the most experienced physicians that are opting for an early retirement rather than dealing with the upcoming 23% cut in Medicare rates paid to physicians as of December 1, 2010, to be followed by a second reduction, pushing the total loss of income to 25%.

Similarly, the network of hospitals in the country continues to shrink at an alarming rate as hospitals are responding to the financial pressure and constraints of managed care and ever shrinking Medicare reimbursements.
Further, the physician-owned hospital industry is a particular target in PPACA through Section 6001, which contains massive changes to the Stark Law Exception under which physician-owned hospitals have historically operated and been permitted to bill Medicare/Medicaid. ⁽³⁾

Band-Aid solutions such as expanding the scope of practice for advanced practice nurses, mitigating frivolous liability claims, improving respect for the profession among medical peers, group visits and changes in clinical processes alone are not enough to ease the shortage.

Fortunately, there are innovative high quality and cost effective HIT/Telemedicine solutions to provide continuous, high quality, appropriate, affordable, and accessible heath care for all. ^{(4, 5, 6)}

That’s why the cornerstone of the Patient Protection and Affordable Care Act of 2010 is the patient-centered medical home which is a way of organizing primary care so that health care consumer receive care that is coordinated by a primary care physician, supported by information technologies.

The patient-centered medical home model affords health care consumers the benefits of self-care management, delivered by a multi-disciplinary team of allied health professionals and adherent to evidence-based practice guidelines.

Truth be told—most of the former patients have become quite “inpatient” with the current care system, and more specifically with its rising cost and diminishing choices and coverage ⁽⁷⁾.

For the purposes of this article we will refer to recipients of health care services as Health Care Consumer (s) or HCC. This change in terminology reflects the ever rising participation of HCC in directing and administering care they receive, especially in the telemedicine setting ^{(8, 9)}.

Telemedicine and PPACA seem to have an interesting symbiotic relationship between them, as PPACA relies on HIT/Telemedicine for its successful implementation; and HIT/Telemedicine hopes PPACA will promote and advance its industry-wide acceptance and implementation.  ⁽¹⁰⁾

Telemedicine offers value-added solutions by delivering health care value to health care consumers.

Quality Outcomes + QOL + Customer S/R

HCV=   ------------ =     ----------------------------------------------

Cost CPU

Health CarING Value (HCV©) is a mathematically simple equation where the numerator is a sum of evidence- based repeatable, verifiable outcomes, disease management and practice guidelines compliance, quantitative quality of life measurements, customer satisfaction and rate of retention.

The denominator is expressed as cost per unit reflecting continued to cost savings per covered population, employer, disease entity, etc ⁽¹¹⁾.

Obviously if the quality of care goes up, the health care value of the modality/care model/devices/application goes up concurrently. Similarly, if the value of denominator goes down, the health care value increases!

Recent actuarial studies anticipate minimal savings of $3.36 (for commercial) & $6.95 (for Medicare) per member per month ⁽²⁷⁾.

HCV© is a near-quantitative time-tested measure, first introduced to the U.S. FDA in October.  The measure has since been adopted and is widely used by the U.S.FDA, U.S. FTC and many forward-thinking payers, providers, pharmaceutical & medical device manufacturers ⁽¹²⁾.

Telemedicine solutions offer increased quality of care while reducing costs and markedly improving accessibility to appropriate care in the lowest cost setting, as well as health care consumer satisfaction.

A word of caution- telemedicine is not a substitute for care provided by the PCP. Nor is it a panacea to cure all ills of our overburdened and very expensive health care system.  It is, however, a very useful and cost effective adjunct tool to provide appropriate services to health consumers and relief for payers as care is provided in the least expensive and most comfortable setting i.e. HCC ⁽¹⁴⁾

Today, telemedicine seems to be the best viable alternative to provide basic and primary care for the ever growing, soon to be expanding, needs of the HCC.  The only marginal choice is to construct 1,400 hospitals but in these uncertain economic times, that may not be an option. 

Continuity of comprehensive health care consumer-centered care overseen by the Primary Care Physician is assured, and application telemedicine allows the patient to find the “right” physician among qualified credentialed providers. HCC finally gains the ability to broker and to manage a multi disciplinary physician and caretaker teams without the administrative burdens. ^{(15, 16)}

PCP directed practice has an “out of the gate” impact by integrating real-time home informatics directly into the care encounter. It provides the single audit trail & exchange of clinical information with the HCC and members of MDP team further reinforcing treatment plans and increasing compliance.    

Innovative technologies tasked with information gathering, analysis, storage and proper dissemination and reporting offer a unique “whole person” orientation applicable to acute, chronic, and preventative end of life services. To purchasers (employers and/or purchasing groups) of health care and payers it offers valuable data that can be easily transformed into invaluable executive, decision support, operational, and return on investment (ROI) information.

The single point of visibility into the HCC past and present condition and medical history allows all members of the care team to literally come into the home, thus complementing existing health plan programs, systems and processes.⁽¹⁷⁾

Coordination of care afforded by a robust Electronic Medical Record (s) (EMR),the heart and soul of telemedicine, closes gaps among multi-disciplinary providers, decreases the incidence of unplanned hospitalizations, emergency room visits, avoids duplication of services and reduces incidence of medication errors.^{(18, 19)}

It allows the PCP to always remain in the information loop and literally keep his/her finger on the pulse of health care consumer. Similarly, it allows HCC or the care taker/advocate an ability to engage and coordinate care teams as the Telemedicine/EMR draws and incorporates information from patient health records, analytical engines and disease management applications.

Despite the evidence that telemedicine can reduce hospital re-admissions by up to 25 percent and significantly cut costs for health care organizations, changes in reimbursement policy are necessary to enable wider access to telemedicine care.

Such advantages of telemedicine markedly improve the quality & safety while reducing the costs of health care by providing physicians and physician-extenders with tools in real time and at the point of care. The costs are reduced by providing services in the HHC home the safest, most convenient and least expensive level of care.

Further, telemedicine overcomes traditional scheduling challenges by leveraging open schedule, expanded hours & new communication options. Utilizing Web or phone options, video-conferencing, secure text chat and messaging affords near-immediate access to care when it’s wanted and where it’s needed.

These systems finally allow the highest degree of Health Insurance Portability & Accountability Act (HIPAA) compliance. ^(20-22)

Care coordination (as part of a compensated encounter) improves utilization of health care services, maximizes scarce primary care capacity and physician productivity, and balances PCP and specialist capacity within and between states. ⁽²³⁾

Additional cost savings will be realized by significant reduction of waste associated with health care fraud and abuse, especially in the Medicare system.

There is one more, not immediately apparent, stream of cost savings for health consumers and their families—the costs of residential (non-medical) homecare.  The average caretaker spends approximately 37-40% of their paid for time arranging the logistics of and physical travel to and from routine medical visits. Employing telemedicine for the home-bound health consumers with multiple chronic diseases can significantly reduce time dedicated to the logistics of health care, or be used to provide a higher level of personal care, homemaking and companionship improving quality of life for the health consumer.

In addition to reductions in direct cost of health care, employers will be saving costs associated with visits to a medical office, the primary cause of workplace absenteeism. Productivity is increased as employees use the  ease and convinience of telemedicne, saving related costs and time for to-and-from physicial travel.

An overwhelming 89 percent of health care decision makers believe telemedicine will transform health care in the next 10 years, according to Intel-sponsored survey. The study reveals reimbursement and fear of technology as the top perceived barriers to implementation of telemedicine. ⁽²⁴⁾

Of the providers not yet utilizing telemedicine, 50 percent plan on implementing it within the next year as the market for telemedicine and home health monitoring is expected to grow from $3 billion in 2009 to an estimated $7.7 billion by 2012. ⁽²⁵⁾

One more barrier to implementation of HIT/Telemedicine is the forthcoming $20 billion 'medtech' tax. As it stands, the 10-year reform law stipulates that medical technology firms will be assessed a 2.3 percent excise tax on sales of their products, beginning in 2013. New Republican House majority could mean changes to the unpopular law. It will probably be repealed or pared back creating additional incentives for implementation of HIT/Telemedicine. ⁽¹⁾

Other concerns are that clinical staff and patients will be reluctant and/or unable to successfully use some of the new technologies, despite strong evidence to the contrary (Kaiser Healthcare, for example).

Telemedicine is already creating sustainable change in today’s health care industry by moving care from the hospital to the home and achieving true patient-centered care that transcends boundaries of time and location. ⁽²⁶⁾

There is an obvious need for better education of health care consumers, payers and employers to overcome perceived barriers in order to implement proven and cost-effective systems that improve quality of life for patients and clinicians alike.

Only time will tell if Telemedicine delivers health care value, or becomes another case of dispositional optimism. ⁽²⁹⁾

________________________________________

1. Moore, Janet, “Members of Minnesota’s congressional delegation say the tax may get more discussion”, Star Tribune, Minneapolis, MN, November 8, 2010

2. H. Keckley, Paul. “Medical Home 2.0: The Present, the Future” Deloitte Development LLC. 2010

3. Walsh, Amber, “The Health Care Investor”,November 6, 2010. 1996,  http://www.thehealthcareinvestor.com/tags/ppaca/

4. Dorodny, V.S.,”Information Systems & Technology Solutions”, National Managed Healthcare Congress (NMHCC), Palm Springs, CA,October, 1996.

5. Dorodny, V.S. “Is Managed CarINGF in Jeopardy?”, Guest Editorial, Los Angeles Times, February 1995.

6. Dorodny, V.S., “How to Deliver Ethical Medical Care to patients with Chronic Illness Better and Cheaper”, Managed Care Medicine, March 1995.

7. Dorodny, V.S., “Protecting Patients’ Rights in a Merged Health Care System”, Valley Business Journal, July 1997

8. Dorodny, V.S., “Sharing a Vision for Empowered Patients and Healthier Communities”, Medical Interface, October, 1995.

9. Dorodny, V.S., “Breathing LIFE into the legend of the CPR”, Managed Healthcare, June 1997.

10. Dorodny, V.S., “Choosing the ideal CPR to meet your needs”, Managed Healthcare, June 1997.

11. Dorodny, V.S., “The Role of the Chief Medical Information Officer” ISBN 0-8493-1248; 2002, 223-239.

12. Dorodny, V.S, US FDA Public Hearings, October 1995 http://www.fda.gov/AboutFDA/CentersOffices/CDER/ucm179880.htm

13. Dorodny, V.S., “The Art of Complaint in Mis-Managed Care”, Herald Tribune, Los Angeles, January 1997.

14. Dorodny, V.S., “Quality and Caring: A Fad or a Religion”, Hospital Pharmacy, March 1997.

15. Dorodny, V. S., “Why I Left NAMCP--The Risks of Managing Without Caring”, Medical Sentinel, the American Association of Physicians & Surgeons (AAPS) , Volume 2, No. 2, Spring 1997 http://www.haciendapub.com/medsent.html

16. Dorodny, V.S.“ Movement of Medicare and Medicaid Patients Into the Managed Care Setting”, Advances in Integrated  Healthcare, July 1997

17. Dorodny, V.S. “Have Computerized Patient Records Kept Their Promise of Improving Patient Care?”,The Joint Commission (JCAHO) Journal on Quality Improvement, Vol. 23, Number 12,  December 1997.

18. Dorodny, V.S. 1999, “Introducing the definition of ”Clinical Informatician",  transcripts of Association of Medical Directors of Information Systems” (AMDIS) Forum & Board meeting, Feb. 16, 1999, San Diego, CA

19. Dorodny, V.S. “Patient Privacy at Risk”, TIPS, Official Publication of The IPA Association of America, August 1997.

20. Dorodny, V.S., “Encryption Grows in Importance to Physicians”, Health Data Management, September 1997.

21. Dorodny, V.S. “Fate of Federal Privacy Legislation Far From Certain “, Health Data Management, September 1997.

22. Dorodny, V.S., “ Let the Market Do The Managing”, LACMA  Physician, April 7, 1997

23. Combined data for United States and Europe. Data Monitor reports Telehealth spending North America and Telehealth spending 2007 –2012.

24. Seto, Emily. “Cost Comparison Between Telemonitoring and Usual Care of Heart Failure: A Systematic Review.” Telemed J E Health. 2008 Sep; 14(7):679-86.

25. Little, Alan and Meyers, Brett, MD. “SCAN Health Plan and HeathCare Partners Explore the Use of Remote Health Management Technology for Frail Seniors.” 2010.

26. Pyenson, Bruce “Milliman Research Report”, March, 2009, www.Milliman.com

27. Dorodny, V.S., "The Piracy of Privacy," Information Security” # 46 (Aug. 1996), National Computer Security Association (NCSA)

28. Douglas S. Krull (2001). "On Partitioning the Fundamental Attribution Error: Dispositionalism and the Correspondence Bias". Cognitive Social Psychology: the Princeton Symposium on the Legacy and Future of Social Cognition (Lawrence Erlbaum Associates): 211. ISBN 9780805834147.

29. American Telemedicine Association (ATA), “What is Telemedicine & Telehealth?” http://www.americantelemed.org/files/public/abouttelemedicine/What_Is_Telemedicine.pdf

About the Author:

Prof. Victor S. Dorodny M.D., N.D., Ph.D., M.P.H. (www.DrDorodny.com) is the CMO for US Tele-Medicine and the President of TeleMed Partners.  He is s specialist with over 30 years of clinical and executive experience, as well as a Doctorate in Health Information Technologies (HIT) and over 17 years of hands-on HIT/Telemedicine experience Prof. Dorodny enjoys international recognition for advancing electronic health record technologies (EHR, EMR, PHR), and promoting confidentiality and security of health information.

He has served as Advisory Board Member of: The Association of Medical Directors of Information Systems (AMDIS); National Association of Managed Care Physicians (NAMCP) and The IPA Association of America (TIPAA).

He was one of the creators of the current Health Insurance Portability and Accountability Act of 1996 (HIPAA).

He conceived, designed, and led development of Knowledge–based Health Information Systems (KbHIS©) operational databases for healthcare organizations. He served as consultant to the Economic and Social Council of the United Nations; Technical Advisor to the United States Department of Justice and the FBI.

Prof. Dorodny originated the revolutionary concept of health and pharmaceutical care value (HCV©) that continues to shape emerging health systems. He consults for: the Institute for Alternative he , National Association of Consulting Pharmacists, the Joint Commission for Accreditation of Hospital Organizations (JCAHO), the National Pharmaceutical Council, and the FDA.

Prof. Dorodny is an accomplished Healthcare/HIT Physician-Executive and has successfully introduced his concepts into the marketplace as the Chief Medical Officer (CMO) of Clark Information Services, Inc., a software, applications and data warehousing company for pharmaceutical industry and other health care organizations; as the Executive VP & Chief Medical Information Officer of Superior Consultant Company, Inc., an integrated health care, pharmaceutical industry and information technology management company; as the Executive VP of Business Development for ICN, Pharmaceuticals, Inc., Eastern Europe.

Prof. Dorodny is Board Certified by the American Academy of Pain Management, Diplomate and Distinguished Fellow of the American College of Ethical Physicians, Associate in Medicine of the American College of Legal Medicine (ACLM), Diplomate and Distinguished Fellow of the American College of Hospital Physicians, graduate of USC Executive Management Institute in Health Care, and Registered Arbitrator.

Prof. Dorodny made significant contributions on diverse topics in major mass media publications, peer review journals and trade publications. He authored monographs and books. Among his editorial board appointments: Managed Healthcare, US Pharmacist, ADVANCE for Health Information Executives. As Reuters Healthcare Expert he often presents at national and international conferences, and guests on national TV and radio.

TeleMed Partners (www.TeleMedPartners.com) is physician –owned consulting company with over 17 years of consulting and integration experience offering tactical and strategic, medical & HIT guidance to all Telemedicine stakeholders.