Tuesday, March 10, 2015

What Mississippi, Telemedicine, and CVS have in common.

In 2013, Mississippi passed a major telemedicine bill (see here, here).   A February 2015 article at Politico describes Missisippi as a leader in telemedicine (here; see also the University of Mississippi Center for Telehealth, here.)

In June 2014, I attended a CVS presentation on advances in healthcare delivery at the annual Washington healthcare conference, Health Datapalooza (2015 meeting website, here.)   I was impressed by the CVS presentation and asked the Minute Clinic President Alan Sussman what would be the most important policy changes he'd like to see.   Better coverage for telemedicine was one of the five policy topics he rapidly named for the audience:

1. It's very hard to enroll needy qualified Medicaid patients in some states

2.   The enrollment of Medicare providers at multiple sites - e.g. at three CVS locations - can be very slow error prone cumbersome

3.  The existence of a pay disparity for nurse practitioners -- when doing exactly same work as an MD -- makes no sense

4. There should be better coverage for telemedicine outside of rural areas (a CMS rule.)

5. CMS should incentivize and reward compliance (such as a patient's complicance with prescriptions.)

For an article on rapid care clinics at Health Datapalooza 2014, see here.

What does a policy wonk (or lobbyist) make of CVS's five concerns?

  • Regrading NP enrollment and compensation.  
    • Medicare does make it hard to enroll a provider at multiple sites, because of the fraud risk.  (Someone fraudulently enrolls Dr. Smith, of Maple Street, in a fictitious clinic on Oak Street and sends in fake bills).   However, nurse practitioners at CVS clinics, billed to Medicare by CVS, are an unlikely fraud risk.  
    • Medicare pays nurse practitioners at 80% of physician rates.  There is less justification for this, as some 20 states have providing increasing equality for nurse practitioners, most recently Nebraska (here; for review at Forbes ee here.)  
  • Medicare's rules for telemedicine have generally required the patient be at an originating location in an underserved area.  For an HHS/HRSA report on telemedicine licensure barriers, here;  fpr a discussion of arbitrary barriers, here; for CY2014 priorities of the American Telemedicine Association, here.
  • I'm less familiar with Medicaid enrollment problems, but it's easy to imagine they exist. 
  • Rewarding patient compliance directly is an interesting idea for further exploration.

I like the term dHealth, which is broad enough to encompass electronic medical records, decision support, big data, mobile apps, and more.   Between 2013 and 2014, the "International Congress on Telehealth and Telecare" changed its name to the "International Digital Health and Care Congress" (here).   UCSF has an early but impressive and steadily program under the title "dHealth," here and here.

In a related article, "Billionaire tech investor Mark Cuban said healthcare entrepreneurs would be better off pursuing the direct-to-consumer market rather than trying to get their technology into hospitals. He views sensors and big data analytics as potential game changers in healthcare."  Medcitynews, March 17, 2015 (here).

On July 12, 2015, the New York Times ran two articles related to this posting: an article on the transformation of CVS into a spreading healthcare giant (here) and an article on the growth of dhealth medical services via new organizations and Skype (here).