April 4, 2014

Two years ago, in anticipation of California’s new health insurance exchange, Blue Shield of California began to look for new ways to meet the needs of a growing insured population — particularly in remote areas.

“We realized that many Californians in rural areas, which lack specialty care, would qualify for subsidies on the exchange requiring an overlay of physicians,” said Juan Davila, executive vice president of health care quality and affordability for Blue Shield of California. “We were concerned we would not be prepared.”

To extend its reach and improve care access, San Francisco-based Blue Shield forged a relationship with Adventist Health, a faith-based, not-for-profit, integrated health care delivery system with 19 hospitals and 200 clinics, 53 of which serve rural communities. It is headquartered in Roseville, near Sacramento.

At the heart of the new partnership is telehealth — the growing practice of delivering health care services via telecommunications technology. All Blue Shield individual and family plan customers, including those who purchased coverage through Covered California, can seek specialty care not available in their areas through the telehealth network, which launched in March.

“It is not uncommon for members in rural communities to drive as far as 100 miles for services — especially for subspecialty care — and then again for follow-up,” Davila said. “If patients have to travel too far for care, they are likely to put it off and their conditions could worsen. With our program, they can seek care often and when needed by paying the same copayment.”

Davila said with so many different kinds of telehealth services available, it was difficult to select what to offer, but both organizations agreed they wanted to deepen their experience in telehealth in some way.

“Blue Shield of California and Adventist are both non-profit organizations with the same philosophy of investing back into the communities we serve,” said Rob Marchuk, vice president of ancillary services for Adventist. This is the company’s first telehealth partnership with an insurer.

“Because we operate the largest rural network in the state, Blue Shield reached out to us to serve its members in the communities where we provide services,” he said. “It is difficult to recruit sub-specialists in rural areas.”

Telehealth in Action

Specially trained care coordinators serve as facilitators for the new telehealth program at 25 existing Adventist clinics in Northern California.

After a primary care provider refers a patient to a specialist (or Blue Shield PPO members make their own appointment with a specialist) the care coordinator arranges the appointment, coordinating schedules for the patient, specialist and clinic, while also ensuring that specialists familiarize themselves with the patient’s medical history.

“That process takes the burden off the PCP office,” Marchuk said.

The biggest concerns, he said, have been connectivity and sufficient bandwidth to accommodate the technology, along with coordinating appointments.

Davila added that aligning the two organizations’ internal systems, building out Adventists’ clinics to accommodate telehealth and populating patient electronic health records also have presented challenges.

Once the appointment is established, a patient reports to the clinic, where a care coordinator connects the member and specialist using a clinical mobile cart outfitted with a variety of assessment tools, such as digital stethoscopes and otoscopes, examination cameras, image screens, vital sign monitors, electrocardiogram devices, retinal cameras and specialized telehealth software.

Blue Shield provided the mobile carts, which Davila said enable diagnoses, consultations, education, ear and throat exams, high-resolution images, heart rate and other vital sign measurements and mobility exams for patients with arthritis.

Physicians in the Blue Shield/Adventist program are compensated as they would be for any in-person visit.

So far, 12 physicians representing 11 specialties are participating in the program and Adventist has confirmed three appointments — two for rheumatology and one for cardiology — in the nine clinics currently operating.

“We will increase the number of specialists depending on the needs of patients, with the goal of referring patients to these physicians on a timely basis to reduce hospitalizations,” Marchuk said.

Adventist plans to conduct a needs analysis to determine gaps in specialty care and in the availability of providers, Marchuk said.

Not Babes in the Woods

Blue Shield and Adventist are not newcomers to telehealth.

In October 2012, Blue Shield developed a partnership with Teledoc to provide telehealth services to 350,000 California Public Employees’ Retirement System members insured by the health plan.

Adventist’s telehealth history dates back five years to a program providing access to specialty care for correctional facilities in Bakersfield, eliminating the need to transport inmates to other facilities for care.

Four years ago, Adventist introduced a telepharmacy initiative to fill the gap created by the lack of pharmacy oversight when small rural hospital pharmacies close their doors for the day.

Legislating Telehealth

California’s telehealth regulations are among the country’s oldest and most defined and are the basis of proposed national legislation seeking to establish a foundation for the new technology.

The California Telehealth Advancement Act of 2011 updates the definition of telehealth, describes a broader range of services and sites for telehealth, streamlines provider credentialing and gives permission for all licensed health professionals to conduct telehealth.

According to the Center for Connected Health Policy in Sacramento, 34 states and the District of Columbia have active telehealth legislation.

Forty-four state Medicaid programs have some form of reimbursement for live video, but legislation in some states places restrictions on what can be reimbursed, who can be reimbursed and when they might receive reimbursement, according to a report on state telehealth laws and reimbursement policies from the Center for Connected Health Policy.

Medi-Cal, California’s Medicaid program, reimburses for live video and for some teledermatology and teleophthalmology services, CCHP reported in its review of state telehealth laws.

Gary Capistrant, senior director of public policy for the American Telemedicine Association, said that although most states have some kind of reimbursement legislation, some laws limit coverage for physician services offered by video to only rural areas and few include telehealth in the home setting, which he said would be convenient for those who are home-bound.

Nine state medical boards issue special licenses that would allow out-of-state providers to deliver telehealth services in a state where they are not located, according to the report. California is not among them.

National legislation is brewing.

HR 3077, the TELE-MED Act of 2013 introduced by Rep. Devin Nunes (R-Calif.) addresses the telehealth licensing issue. The bill would permit certain Medicare providers licensed in a state to provide telehealth services to Medicare beneficiaries in a different state.

Based on California’s law, U.S. Reps. Bill Johnson (R-Ohio) and Doris Matsui (D-Calif.) introduced the Telehealth Modernization Act — HR 3750 — last December to provide guidance to states when developing their policies to govern telehealth.

Reactions by Consumers and Providers

Marchuk said providers in the program see participation as an opportunity to extend their service reach. They also consider telehealth as a means of providing better diagnoses.

As a neurosurgeon specializing in spinal conditions at Glendale Adventist Medical Center, Srinath Samudrala sees telehealth as a logical and efficient means of tackling the problems of patients who need his services.

Instead of examining every patient in his office, he can determine through a referral telehealth examination from a generalist which patients have complex problems and might require surgery, saving time for both him and his patients.

Samudrala said he anticipates patients will be receptive to the new system that should make the medical world seem more accessible.

Samudrala has not yet dealt with patients via the telehealth program, but expects to schedule three or four appointments one day a week and eventually increase that to 10.

Davila said he is optimistic that convenience will override any patient doubts about telehealth. “Once they understand what a real benefit it is, patients will appreciate having access to specialists nearby. However, education is necessary,” Davila added.

Blue Shield conducted focus groups last year among members who would have access to the new program and found positive reactions to the concept of a guided, in-person visit with a specialist while a care coordinator was present. Participants liked the idea of seeing a specialist close to home and then being able to consult with that practitioner post-surgery via telehealth.

“Now we need to get patients to come,” Davila said.


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