Housecall

Data and Telemedicine: MACRA, MIPS, and Your Data

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MACRA, The Medicare Access, and CHIP Reauthorization Act of 2015 changed the way that Medicare rewards clinicians for value over volume.  It supports multiple quality programs under the new Merit-Based Incentive Payments System (MIPS)
and gives bonus payments for participation in eligible alternative payment models (APMs).  In general, it moves payment from a fee-for-service payment model to a value-based system that encourages quality and more efficient/effective patient care.  This system also is tailor-made for the incorporation of telemedicine into a value-based payment system.  Each year, we move closer to a value-based system and away from a fee for service system.  How can you dip your toe in the water of a value-based system to try it out? The Center for Medicare/Medicaid Services (CMS) gave us the answer as of January 2018.

Medicine doctor working with modern tablet computer and virtual

CPT code 99091:  Remote Patient Monitoring allows patient-collected physiologic health data that is digitally stored and/or transmitted by the patient to be securely sent to the provider.  This involves patient-collected heart rate, blood pressure, weight, glucose readings, CPAP usage, EKG readings, and pulse oximetry readings to be shared directly with the provider for monthly review.  This must be transmitted using a HIPAA-compliant, secure system like Housecall Telemedicine and cannot be transmitted by insecure mechanisms like email or text. It pays an average of $59 per patient per month nationally. Not only has remote patient monitoring been shown to improve outcomes and access to care, it also has been shown to improve cost-effectiveness and reduce hospital readmission rates.  This study from 2015 showed in COPD and CHF patients that 30-day readmission rates were reduced 50% and showed a 13-19% reduction in 180-day readmission rates. This finding was made even more impressive given that the study population consisted of underserved patients and included many who had no insurance.  Indeed there are numerous studies that show telemedicine, remote patient monitoring, and transitional care programs along with care management programs can drastically reduce 30-day readmission rates by as much as 50%.

Remote Patient Monitoring can also be used with Chronic Care Management (CCM) services (CPT codes 99490 and 99487).  These codes were introduced in 2015 to compensate providers for the routine care of complex chronic conditions that providers have delivered for years without compensation.  CCM Patients must have multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, and chronic conditions that place the patient at significant risk of death, acute exacerbation, decompensation, or functional decline.  This includes (but is not limited to) conditions such as Alzheimer’s disease and related dementia, Arthritis (osteoarthritis and rheumatoid), Asthma, Atrial fibrillation, Autism spectrum disorders, Cancer, Cardiovascular Disease, Chronic Obstructive Pulmonary Disease, Depression, Diabetes,  Hypertension and infectious diseases such as HIV/AIDS.   CCM requires at least a visit in-person yearly that can be billed separately.  It also requires a formal care plan for each individual patient that is reviewed and revised as needed.  CMS even loosened its prior restriction on telemedicine to allow Chronic Care Management Care Planning to be done directly with the patient by a care manager via an unrestricted telemedicine conference (CPT G0506) as of January 1, 2018.

Chronic Care Management for “non-complex” cases (CPT 99490) pays an average of $49 monthly nationally.

Chronic Care Management for “complex” cases (CPT 99487) pays an average of $86 monthly.

Chronic Care Management Care Planning (CPT G0506) pays an average of $59 monthly and can be done via telemedicine between a care coordinator and the patient.

Remote Patient Monitoring (CPT 99091) pays an average of $59 monthly.

A complex patient enrolled in both CCM and RPM generates an average revenue of $204 per patient per month or $2448 per patient per year to a practice.  This is in addition to in-person visits with the provider that are charged separately.

Reimbursement Update on Remote Patient Monitoring, and Chronic Care Management Codes for 2018

CMS Fact Sheet on Chronic Care Management Services

Frequently Asked Questions About Chronic Care Management

Housecall Telemedicine is a data platform that allows you to connect patient data to a direct telemedicine visit.  From the very beginning of the company, the idea of connecting patient-collected personalized data to a provider has been “THE IDEA” behind the company.  That idea was fairly out there in 2014.  Now in 2018, it is becoming mainstream.  Now that the CMS has come around with recent CPT codes that support the data connection between patient and provider, the expansion of telemedicine has clearly begun.  Good ideas from the CHRONIC ACT that were recently incorporated into law with the latest budget act passed in February 2018,  make the use of telemedicine in Medicare patients even easier.  These new rules expand the use of telemedicine in end-stage renal patients, and for tele-stroke.  It also greatly expands the use of telemedicine for use in Medicare Advantage plans and ACOs.  The use of the Next Generation ACO telehealth waiver allows ACOs to waive the geographic restriction for telemedicine use in Medicare and allows the patient to be anywhere to make a telemedicine connection to a provider.  The use of telemedicine for Chronic Care Management care planning in an unrestricted fashion continues to expand the use of telemedicine and provides improved access to care for our patients and that care is more consistently delivered.  It seems like CMS finally Cares Enough To Care and has finally begun to really answer the question Why Telemedicine?

 

Responsibility

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Healthcare Security“Do the right thing even when no one is watching.”  That was always one of my father’s axioms.  It is a philosophy of being responsible and accountable to your own personal standard and having a standard that is independent of the setting.  “The right thing” is something you know in your heart.

In business, “the right thing” is sometimes confused with “the right thing for our business” or “the right thing for our profits”.  It is easy to cut the corner in business to make things more profitable.  It is easy to focus on a short-term gain more than a long-term relationship.  It becomes easy in business to not hold your company’s standard up to your own.  It’s “just business” for many companies…

In telemedicine, we have a responsibility to get certain things exactly right every time.  Security is critical! We are entrusted with safeguarding your personal information and your electronic health data.  It is a responsibility that is not only vital to our company but a sacred responsibility to our customers.  We have our servers hosted on the most secure cloud servers in the world at Armor (http://www.armor.com). This is a company that goes the extra mile to provide top-notch security for your data.  They are responsible for the infrastructure of our servers, while we are responsible for the data put into those servers.  Our team at iHeartDoc is up to date on the latest threats and phishing/social engineering schemes that are a daily threat to data security.  Your electronic protected health information (ePHI) is safe in our HIPAA compliant, HITRUST certified servers.  Our security team undergoes regular audits and remediation analysis to ensure the most secure environment possible for your data.  Your data security is our responsibility.

As a physician, I often tell patients that the most important aspect of a doctor-patient relationship is trust.  If you can’t trust your doctor, you need to find another doctor.  The same goes with any company providing telemedicine or keeping your health data.  If you can’t trust that company to “do the right thing even when no one is watching”, you need to find another company you can trust.

Why Telemedicine?

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TelemedicineMy daughter is a senior in high school.  She is busy completing her college applications and the most common question is “Why (insert school name here)?  It is a classic question that puts the prospective student on the spot.  Do you know enough about your prospective school to say what specifically appeals to you?  Do you know enough about yourself, to know what is important about a prospective school?  I think that question is a basic question that must be answered for any important decision.  Why??  It certainly applies to a paradigm change like telemedicine.

Why would you use telemedicine as a patient?  That question is pretty easy for most patients to answer.  Do you like the experience at your doctor’s office?  Is the parking easy?  Is the wait reasonable?  Do you get a valuable exchange for the time, energy, money and general hassle that going to a doctor entails?  Was it worth it?  Would you prefer to meet with your doctor from the comfort of your home or your office?  If you have chronic medical conditions, how much time have you spent waiting on a short provider visit, how much money have you spent, how much time off work or away from your friends and family have you lost waiting for a few minutes from your healthcare provider?  Telemedicine provides a solution for many patients.  You can send your data about your health from your app, smartwatch or mobile device.  You can connect to your provider from the comfort of your home or office.  You can forget about the hassle of parking and finding your way around a hospital or medical office.  You can skip the hours spent waiting.  You can connect on your terms as a patient.  It can’t replace an in-person visit but it can certainly supplement that visit for many patients.  Telemedicine makes a lot of sense for patients.

For a provider, the question of “Why Telemedicine?” is harder.  Doctors and nurses are creatures of habit.  They don’t easily change habits that have served them well for years.  Changing a paradigm of care is certainly a big thing to ask of a healthcare provider.  Most are as busy as they can stand.  They don’t have enough hours in the day to do the work they are asked to do now.  Why would they want to learn to work in a different way?  The answer is found in almost every survey of healthcare providers today:  Doctors and nurses are not happy with the way healthcare is delivered today.  Their job satisfaction is at an all-time low.  They are asked to see more patients, spend less time with each patient, and get paid less for each visit each year.  The paperwork and EMR time is increased and the time “being a doctor” is less and less.  The answer for most is to work harder.  That just leads to longer hours and less job satisfaction.  I would propose that the real answer is to work smarter and more effectively.  One of the most valuable (and least valued in my opinion) aspects of today’s healthcare system is the concept of physician time.  The goal should be to maximize the most expert care by a physician for the treatment of the sickest patients and to allow routine preventive care that moved outside the hospital years ago, to move outside the doctor’s office today.  Telemedicine makes sense for chronic and preventative care.  It can be performed by nurses, nurse practitioners, and physician assistants as well as physicians.  It can time shift appointments to a time that works for both the patient and the provider.  The sickest patients still need to come in for an in-person appointment but the chronic, preventative care that is reviewing data from lab work, and tests, counseling about lifestyle modification, and asking questions searching for the early symptoms of disease, can all be done over a high definition mobile connection.  Telemedicine frees up the provider’s schedule to see those patients that require an examination while allowing quality care to be performed remotely by several members of the care team.  Much of that remote care is currently provided over the phone, is unreimbursed, and still carries a malpractice risk.  Telemedicine allows a higher level of care for those visits and a much more personal connection and a higher level of satisfaction for both patient and provider.

Why Telemedicine?  It is moving healthcare into the 21st century using advanced mobile technology to supplement the patient-provider connection, not replace it.  We will look back one day and wonder how we worked in healthcare the way we currently work.

Frequently Asked Provider Questions About Housecall

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I pity the fool that does not bother to ask the question…

Provider Questions:

  • How does this app work?

You must sign up as a provider and notify your patients of your availability to see them via Housecall.  The patient can then make appointments with you through the scheduling portion of the app.  A provider can also manage appointments through the web scheduling portal at http://www.iHeartDoc.com/Housecall.  This web portal does not contain the video conferencing portion of the app, just the scheduling portion.  It allows for your medical staff to help manage Housecall appointments much like any appointment is handled in your office.

  • How do I bill for my services?

Housecall is covered by a growing list of private insurers but you must check with your local carrier as coverage varies widely from state to state.  It is not currently covered through Medicare.  Medicaid coverage varies from state to state as well.  In situations where coverage is not provided you can bill the patient directly provided you notify them before providing the service.  For Medicare patients you must have a signed Advance Beneficiary Notice prior to providing services to bill the patient directly for non-Medicare covered services.  Credit card and insurance data is available through the app if the patient has filled out that data in their profile.  No billing is done through the app.  You must bill the insurance or credit card as you usually do.

  • How do I document the visit?  Is there an EMR in the app?

No EMR or documentation is done through the app.  You use your existing EMR or dictate a note to document the visit just as you would during an in-office visit.  The ability to archive the videoconference is not currently available but will be available in an upcoming version.  The wellness and health data from Jawbone or Withings can be screen captured and printed if necessary.

  • What health and wellness services are currently supported?

Withings is supported as well as Jawbone.  Withings makes wireless scales as well as wired and wireless BP cuffs.  Their Pulse activity monitor is not currently supported but we plan to support it in the future.  Jawbone’s UP band is currently supported and provides exercise data, sleep data, and dietary data in graphic form.  Any app on the patient’s iPhone can be captured via a screen shot and sent to the provider for review.  This gives some support within the app for a wide variety of health uses and connected apps.

  • What is the cost of the app for a provider?

The app services are free for the first 30 days for a patient or provider after initial app purchase.  At 30 days, a provider must purchase addition time on the app to continue their use.  Current cost is $9.99 per month via an in-app purchase.  Discounts are available for longer range purchases up to a year of app time for $99.99 per year.  Patient use is free.

  • How do most providers use the app?

Most providers use the app in the same manner as a regular office appointment.  The visit can be scheduled on an iPad or iPhone that can be used to conference with the patient privately in their office or an exam room.  The provider can make notes in the EMR or chart during the visit.  At the conclusion of the visit a nurse can arrange follow up visits via the app prior to the conclusion of the teleconference.  Many providers have used the app for short visits after previous procedures or testing.  It can also be used for rapid follow up of ill patients recently hospitalized to prevent readmission to the hospital.

  • What kind of connection is required to use the app?

The app is capable of working on a cellular connection alone but the video quality can suffer from a noticeable lag with a poor non-4G signal.  It does perform well on a reliable 4G cellular connection.  For optimal quality, a good WiFi signal is preferable.

 

Frequently Asked Patient Questions About Housecall

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Patient Questions:

  • Why do I have to enter private information like my social security number and credit card information into my profile?

Private information is used by the provider to verify identity in the case of the social security information, and for billing purposes in the case of credit card information.  You can share this with your provider online during your visit and just enter “1s” for the social security number.  This will not be a required field in an upcoming version.

 

  • Is my private data secure?

Data entered into Housecall is encrypted and stored on a secured cloud server.  The video, audio, and data stream between you and your provider is an encrypted one to one session that requires authentication of an encrypted secret code in the background between the two parties to share data in a session. Any intercept of that data would not have the shared code and thus would not be a party to the shared stream.  No security breeches have been reported using this secure format.

 

  • Can I try Housecall without entering profile data?

Yes, we have set up a trial account so you can get a feel for how Housecall works.  Use the username “Patient” and the password “patient” to log on to our trial account and explore Housecall before you ever spend your time entering your data into your profile.  This account will not be useful for an actual provider visit however.

 

  • Is Housecall HIPAA compliant?

Yes it helps providers maintain HIPAA compliance, but as a business that provides only telemedicine access it is not required to be HIPAA compliant under the law.  Please see our Privacy Policy for more details:  http://iheartdoc.com/housecall/privacy.aspx

 

  • How do I find my doctor in Housecall?

We are rapidly adding providers to Housecall.  Search the provider listing by name or search to find providers near you by pressing the location key in the upper right of the provider search screen and giving Housecall the right to use location services on your device.  At present we are seeking providers to use Housecall for their patients.  If your doctor is not yet using Housecall, on your next office visit take a picture of his or her business card with your device and send it to us at Provider@iheartdoc.com.  We will get in touch with them to let them know patients are interested in interacting with them via Housecall.  Let your provider know that you are interested in seeing them via Housecall!  They can email us at Provider@iHeartDoc.com and we will be glad to get them set up on Housecall.

 

  • How do I add a picture to send to my provider?

When you click “appointment” to make an appointment with a provider, you are taken to the screen that allows you to make an appointment on a certain date or time, send lifestyle data or send a picture to share with your provider.  To share a picture you must click the picture icon on the middle, far right of the appointment screen.  You are then taken to the picture gallery.  You can add a picture to the gallery by tapping the upper right “add” icon.  You are given the choice of importing a existing picture from your photo library or taking a new picture with your camera.  Once you take or choose a photo, it is added to the gallery.  You can add multiple photos to the gallery and send multiple photos to your provider for review.  You must then tap the bottom left of each photo to choose it putting a “check” in the bottom left box and hit “send” at the bottom of the screen.  You are then taken back to the appointment screen.  To finalize your appointment hit “schedule” to complete the process.  Your provider will then be able to review any photo prior to, or during your Housecall appointment.

 

  • How do I send data from my Withings scale, BP cuff, or Jawbone Up band to my provider?

You must first add any connected devices to your profile account by giving your username and password for your Withings or Jawbone account in that section of your profile.  Before you exit your profile screen, you must save it by tapping the disk icon at the upper right of the screen.  You can test to see if it works by going to the “wellness” section and seeing if your data is imported.  To send your wellness data to your provider for review,  just click the apple wellness icon in the appointment screen when making a provider appointment.  Save the wellness data for your provider by clicking the “save” icon at the upper right.  You are taken back to the appointment screen to complete the appointment by hitting the “schedule” button.  Your provider will then be able to review any wellness data prior to, or during your Housecall appointment.

 

  • I have wellness data in an app that Housecall doesn’t yet support, or health data that I keep in a note on my device.  How can I send that data to my provider?

You can send data from your iOS device from any app or program by taking a screenshot of the data.  To do this you must bring up the data screen you wish to share with your provider.  With the data onscreen, press and hold the large button at the bottom of your device while then pressing and releasing the power button at the top of the device.  You should have heard the sound of a camera taking a picture.  You just took a screenshot of your device.  Share that like you would share any picture from your photo album with your provider.  Your screen shot is located in your camera roll.  This gives Housecall the ability to share data from any program with your provider.