Good morning. This is Alan Pitt with Healthcare PittStop. Today I have with me a friend, Krista Drobac, who’s going to talk to us about telehealth legislation and healthcare legislation more broadly. I thought it was very timely to have this conversation because we have so much going on in the media about healthcare et cetera. Krista, welcome to Healthcare PittStop.
KD: Thank you.
AP: First, I know you’re a health lobbyist back there in Washington, and I turn to you often for advice about what’s happening. How did you get into being a lobbyist for the telehealth community?
KD: I was in government for many years. I worked on Capitol Hill. I worked in state government. And my last job was running the National Governors Association Health Division. And though telehealth was always something that was on our list, it was never at the top of the list. So I started thinking, how do we get people more invested and interested in telehealth because it could actually solve a lot of problems.
One of the things that I landed on was that it’s seen as a rural issue. The champions in Congress and around Washington are the Rural Health Association and members of Congress from rural areas, so I said we should just highlight the fact that this really impacts all Americans. That way we would generate more champions for it. So I started advocating for a better understanding of telehealth, and eventually it became more reimbursement for telehealth so that more seniors in Medicare would have access to it.
AP: I couldn’t agree with you more. If it takes three hours to get to the doctor, it’s an equal access issue to somebody who lives in small town America. The legacy of telehealth really did come out of rural more than urban environments.
You know I’m an early adopter. I like technology, and I’ve always been surprised at the reluctance of the federal government to deploy telehealth. You’d think there would be a lot of advantages there. I know there’s something called the OMB (Office of Management and Budget), which comes out with budgets. Can you tell me why the federal government has been reluctant to approve telehealth, particularly for the Medicare population who would seem the most difficult in terms of getting to see the doctor?
KD: If Washington operates on budget it is imperative that we save money in Medicare. It is eating up more and more of the federal budget every year. Members of Congress care about it. HHS (Health and Human Services) cares about it. And the Office of Management and Budget cares about it. So proving that telehealth can save money has been challenging not because we don’t have the data to prove that but because we’re working against conventional wisdom. Some people believe that if you allow telehealth in Medicare it will make it so easy for seniors to go to the doctor that they’re going to sit on their couch all day long and dial up doctors, and it’s going to increase federal outlays for Medicare. So we’ve been spending a lot of time with the Congressional Budget Office and the Office of Management and Budget, sharing the data with them to show them that telehealth would actually save money, not cost money.
AP: You bring up a really good point. You have to have a return on investment for everything you do. You just can’t keep adding on services. You have to show that there’s some value. Are there some particular use cases, some particular data that the telehealth community should be gathering to support the idea that telehealth improves care and at a lower cost?
KD: The biggest thing is to show replacement of more expensive care. So if we can show that we’re replacing an urgent care visit or an emergency room visit with telehealth, or we’re substituting for more expensive care, or we’re averting more expensive care, we will make progress. The main concern of the Office of Management and Budget is that we’re not replacing care; we’re simply creating a new benefit and new forms of care that won’t necessarily reduce more expensive methods. So the main way is for the community to contribute data.
AP: That point has been brought home by a number of folks. Dr. Rick Vaughn from SSM, a large healthcare system, told me that there’s a difference between tele-visits—general online visits—and telehealth. Tele-visits are for new customers where telehealth deals with the chronically ill who need access to care. Any thoughts on separating these two—this kind of direct-to-consumer online care that doesn’t involve a sick person from the real meat and potatoes of how telehealth might help? How do we have that conversation with people?
KD: Health systems across the country are using telehealth to great effect, and we try to highlight data from health systems rather than from the commercial market where they’re using much more of a primary care based model. Because you can’t save money you’re not spending. And the big money we’re spending in Medicare is on people with chronic disease. So I think the big bang for the buck in Medicare is really about reducing readmission and keeping people healthier longer—in their homes. You can use telehealth to achieve that goal. So we try to focus on that data.
AP: I think there’s a lot of confusion in the investment market in terms of tele-visits versus telehealth. And that’s been difficult. I know the ACA—what some people call Obamacare—had some provisions supporting telehealth that got rolled into these next generation ACOs (Accountable Care organizations) or other things like that. Can you speak about what the goal of some of those provisions was?
KD: When Congress created the ACO program in 2010, they wanted to give the secretary as much flexibility as possible to make it work. And the idea that you could waive telehealth restrictions for ACOs was not something that was really thought up by Congress. CMS (Centers for Medicare and Medicaid Services) started using that broad blanket authority that the Congress gave to CMS. So it’s not like Congress said ACOs should be able to use telehealth. They basically said the secretary could waive anything she wants related to Medicare in order to achieve the goals of telehealth. So the CMS has decided to waive telehealth restrictions for next-gen ACOs and for ACOs that take risk. But they have still not allowed ACOs that are not taking risks—Track 1 ACOs—to get reimbursed for telehealth.
AP: Is that kind of like a stick and carrot? We’d really like you to go to these next-gen ACOs so if you do that we’ll give you reimbursement?
KD: Exactly right. We make the argument that, in fact, you’re going to be in a lot better position to take risk as a hospital system if you have some of these tools already implemented. So we think it’s actually the opposite of what they’ve done. They should give them the tools to enable them to move to more risk taking.
AP: For folks out there who might be listening to this, a lot of rules and regulations that we face in health care—how we bill patients in terms of when they come to the hospital—get bypassed when you’re in a next-gen ACO. And it allows many doctors to take care of patients in the way they think is in the best interest of the patient. A lot of times telemedicine would be the best way for me to see somebody but it’s forbidden in older rules. Do you have any sense of how many healthcare systems are in this next-gen ACO world? Is it a small number, a big number? Where are we with that?
KD: I don’t know the number off the top of my head but it is under 100.
AP: So, very small in the relative marketplace. It’s almost that patients should be asking the question to their healthcare system, am I in a next-gen ACO or am I in a traditional system because my doctor may have additional flexibility in taking care of me in some ways.
AP: The health care bill has died the death of a thousand deaths, and it keeps dying and then being revived. And the Republicans continue to try to figure out a way to, frankly, meet the demands of their base. Do you have a sense of what’s going to happen with the current legislation that’s underway?
KD: I don’t think that they have the votes to move forward. They’ve already announced that they’re going to be doing some hearings in the health committee. So we will probably go back to having some hearings and talking about market stabilization. There is some discussion of putting some market stabilization provisions into the CHIP (the Children’s Health Insurance Program) re-authorization bill. That’s going to run out of money at the end of September. So they need to fund that program; it’s a bipartisan priority. They’ll probably put some language into that bill that would help stabilize the market.
AP: I’m going to presume that if the ACA stays in place that things will kind of slowly move forward for telehealth. Any thoughts on how the Republican legislation would impact telehealth?
KD: It doesn’t really.
AP: It doesn’t? It’s not a negative or a positive?
AP: So many folks in the telehealth industry are waiting for this turning point when telehealth becomes something that’s a more acceptable alternative to in-person visits. Do you expect that just to gradually occur or do you think that there’ll be kind of a switch that gets turned on at some point? How do you see that transition happening?
KD: I think that if Medicare covers it, it will take off in the marketplace. That’s why we’re working so hard to get Medicare to cover it.
AP: Is there anything imminent that you think will make that happen? Will the secretary of HHS kind of get control of that decision-making or where do you think that sits?
KD: That is where our lobbying is primarily focused right now—to give the secretary the authority to waive those telehealth restrictions in Medicare. Currently if you want to get paid for telemedicine and Medicare, you have to be in an originating site in a rural area. “Originating site” is defined in the statute, and it’s generally a hospital or health center or physician office. And that place has to be in a rural area, and those rural areas are redefined every year.
We’ve worked for years in Congress to try to get them to lift those restrictions. But again, we’re running up against this conventional wisdom that if we do that, it’s going to cost Medicare lots of money. So our current work revolves around how we transfer the authority to the HHS to allow the secretary to determine whether telehealth should be used for certain Medicare billing code. The proposal in Congress right now is to allow the secretary to waive telehealth restrictions as long as the actuary for the CMS—and CMS does have an actuary—deems that it would either improve quality and maintain costs or reduce costs while maintaining quality. Hopefully that standard is enough for Congress to turn over some of the authority to the secretary to actually treat those respective concerns.
AP: I’ve always found you to be one of the most informed and passionate people in bringing forward some of these transitions. But most of your support seems to come from industry. You have Intel; the company I advise, Avizia, has used you; a number of folks from the remote patient monitoring space support what you’re doing. But I don’t see involvement from large healthcare systems, even healthcare systems with large investments in telehealth like Banner and Mercy, kind of rolling up and leveraging your efforts. What’s in it for a hospital system to support this legislation?
KD: Currently if you use telehealth in your hospital system it’s most likely coming out of your operating budget. There are many codes in Medicare right now that are or could be used by a hospital to actually get payment for telehealth. But we have to lift the restrictions. And if we’re successful in lifting those restrictions and presenting CMS with the evidence that using telehealth for these codes could reduce cost, then it doesn’t have to come out of their operating budget any more. The hospital could actually get reimbursed for telehealth. So it could be a boon to hospitals that want to provide their patients with more access and outpatient options.
I know hospitals have a lot of different issues that they are grappling with, and I think in some cases they’ve just decided that it’s not worth the resources. But we certainly need hospitals to step up because they are extraordinary lobbyists and, you know, we’re out here as the industry saying this needs to happen. If hospitals—who are often the largest employer—and a member of Congress district were to stand up with us, I think we would be much more effective.
AP: I talked to one of the large healthcare systems, and they said they had a single lobbyist in D.C. for all of their issues. And yes, telehealth mattered but they were just overwhelmed with other things. What about the senior community—nursing homes, things like that? I would think that would be an obvious benefit to being able to provide care to folks in nursing homes as opposed to forcing them to come into the hospital. Have they come into the fold at all and been supportive of it?
KD: We have the same issue. It’s just that they’re fighting so many battles on so many fronts. The cuts to Medicaid that were in both the House and the Senate ACA repeal bills would have decimated the nursing homes. When you’re fighting for your life, it’s hard to think about different ways to improve access.
AP: I guess people forget that older Americans often have both Medicare and Medicaid because they just don’t have much in terms of resources. So they would be adversely affected with some of these big cuts in a big way. What is your ideal state? Will lifting these restrictions against telehealth put you out of a job? What does it look like to you in five to ten years?
KD: We’re in a pretty difficult position because this issue remains at the staff level in Congress. Members of Congress care about telehealth, but there haven’t been many members of Congress other than Brian Schatz from Hawaii who have really rolled up their sleeves, dug in and said, this is an important issue and we need to get this done. As long as we continue not having a politician who’s willing to go to the Speaker or the leader in the Senate and say, I’m not voting for this bill unless you put this in, we’re going to be stuck in the same position. So we really need to step up our lobbying power and pass this and Medicare. If that happens, yes, I will be out of a job and happily so because they will have accomplished the goal.
AP: That would be awesome, wouldn’t it? I guess it really relies on educating people to allow them to access this technology, and we’re going to need to say something to the people who represent them in Washington that this matters.
Krista, I really appreciate your being here today. I know this is an important, super complicated issue. But I want to thank you for your time. Any final thoughts?
KD: Yes. If anybody is interested in learning more, you can go to our website, which is http://www.connectwithcare.org/.
AP: Excellent. And I’ll absolutely push that as well. Thank you again for your time. I appreciate it.
KD: Thanks Alan.