Telehomecare: The revolution will be broadcast to your office

Declining cost, payment barriers speeding growth

Imagine a time when one home care nurse can visit 15 or even 20 patients a day. Picture having crystal clear, irrefutable documentation for the payer that just denied 25 of your 30 visits to a wound care patient. Dream of cutting your per-visit costs in half. Think about giving your patients further support and raising their satisfaction without expending more resources. Such visions may seem right out of the future, but they are here today and may be coming soon to your agency.

The home care industry has long embraced technology — some patients have virtual intensive care units in their homes; nurses document visits with various portable devices and have come to depend on beepers and wireless telephones. Connecting home care providers and patients, enabling them to exchange electronic data via plain old telephone service, however, is just now catching on. Big time.

Forward, into the past

The confluence of several major forces is propelling telehomecare technology toward widespread acceptance. Payers and providers are equally interested in cutting costs. Patients are demanding better access and communication. Innovators are doing all they can to capture some of a vast and virtually untapped market.

Soon, the constraints holding the telehomecare throttle, such as product cost, reimbursement, and medico-legal considerations, will break loose and the market will really take off, supporters say. (See chart, p. 78.)

Reported Barriers to Program Sustainability

Barrier

Number giving top rank

Number reporting

Weighted ranking

Reimbursement

43

70

179

Physician participation/interest

18

52

104

Telecommunications charges

17

31

71

Availability of grant funding

9

16

37

Lack of organizational support

9

11

24

State politics

5

7

18

Equipment costs

3

21

41

Technology obsolescence

3

19

33

Licensure issues

3

16

27

Revenue generation

3

7

14

Rural providers adoption attitude

2

5

12

Reliability of telecommunications

2

5

9

Lack of standards/interoperability

1

6

9

Liability concerns

1

6

9

Non-physician reimbursement

2

3

8

Community commitment

2

7

6

Organizational decision making

1

4

6

Total respondents: 121

Source: Association of Telemedicine Service Providers, Portland, OR.


"Telehomecare is where it’s all going. Through the centuries, care was delivered in patients’ homes, but when the [available] technologies couldn’t fit in a physician’s bag, patients went to the hospital. Now, technology will go back to patients’ homes," predicts Khalid Mahmud, MD, FACP, founder, chief executive officer and chairman of Eden Prairie, MN-based American TeleCare Inc.

American TeleCare’s Aviva SL product allows providers to make video visits, with nurses and patients communicating through telemedicine units placed in the provider’s office and individual’s home, respectively. (See related article on telehomecare technology, p. 80.)

"The field is ripe," agrees Bill Grisby, PhD, senior research associate at the Portland, OR-based Telemedicine Research Center, a non-profit organization devoted to providing telemedicine information. "The technological things are in place; it’s becoming prevalent and costs are going down. Payment’s the sticking point in home care. The programs are gravitating where they can find funding." (See main sources of telemedicine program funding, p. 79.)

Main Sources of Telemedicine Program Funding

Source Percentage
Internal/self/parent organization 35%
Grants 34%
State 14%
Hospital 7%
Member fee 6%
Federal grants/contracts 4%
Source: Association of Telemedicine Service Providers, Portland, OR.

Money. Oh that.

Telehomecare doesn’t carry the mega-price of some other telemedicine technologies like teleradiology systems, but it still costs enough that many providers find it prohibitive given today’s operating environment. Most payers, including Medicare, don’t recognize telehomecare as a reimbursable expense. But that is changing.

Greenville, SC-based University Home Care has persuaded one payer to reimburse video visits at the same rate as traditional home care visits, reports Bonnie Britton, MSN, RN, C, supervisor of special programs.

"I don’t expect that with everyone, but I am very optimistic. Medicaid pays for telehomecare in 15 states, so we’re approaching ours," she says.

As more studies show that patients using telehomecare access higher-cost services less often, managed care companies will decide themselves that the technology pays, Mahmud predicts.

Even if payers won’t reimburse for telehome-care, the cost savings may more than offset the expense of the product for providers. Medicare-certified providers operating under low per-beneficiary limits face significant losses on some chronic patients who may require as many as 100 or more visits a year.

"If you spot those patients early and know that’s where you lose all the money, you can do half the visits with a unit. You’ll never get paid for those video visits, but you’ll be cutting your Medicare losses," Mahmud says.

It’s an investment

Telehomecare may also help you get authorization for regular nursing visits. "If you allow a managed care case manager to come on-line with you and see the wound care process, she will see your predicament and participate with you and get you reimbursement," asserts Jean Robertson, president of Nashville, TN-based Rubicon. Rubicon’s WoundBase technology allows providers to transmit digital images of wounds along with computerized computations of wound characteristics over the Internet.

A picture may also be worth thousands of dollars when it comes to successfully fighting payer denials. Telehomecare products are an expense, but in comparison to the value of denied claims, they are a drop in the bucket, says Thomas Grier, RN, director of Bibb Medical Center Home Health in Centreville, AL.

"Five hundred dollars a month [spent on telehomecare] is a lot of money, but it’s not," he asserts. "If you submit $50,000 in claims and [a payer] is denying 10% of them, it outweighs the $500. You’re not guaranteed payment, and having documentation to support your claim is invaluable. What better documentation do you have than an oozing ulcer in [the payer’s] face?"

Telehomecare may even open marketing doors for providers. Rubicon’s WoundBase program has caught the eye of larger hospitals that otherwise wouldn’t be interested in Bibb, Grier reports.

As cost and reimbursement issues become resolved, other barriers to widescale use of telehomecare will also fall. Some providers are reticent to adopt telemedical technology because of liability concerns. What if the equipment fails? What if a provider misses a serious complication or gives erroneous advice?

"It’s not a critical care thing. It’s just another tool. If the equipment fails, or if the nurse isn’t sure of anything, she can make a visit in person or advise the person to seek emergency care," argues Mahmud.

Telehomecare actually gives health care professionals better information, says Jack Fisher, MD, director of medical research for Rubicon and a practicing plastic surgeon. "We take care of patients kind of blindly now. We’re put in an awkward position and we don’t have adequate information. With telemedicine, we’re given very timely information and the quality of the data is improved."

Mahmud agrees. "If you receive a patient complaint on the telephone, you make a blind assessment. But with telehomecare, you’re more informed and can relay better information to the physician."

As telehomecare becomes more prevalent, not having it will eventually become a liability, Mahmud predicts.

Others have raised concerns about patient confidentiality and data security with the use of telehomecare, especially for products that relay information through the Internet. Rubicon protects data by using passwords and encryption or by scrambling technology when transmitting it over the Internet.

The American Telemedicine Association (ATA) has adopted a set of telehomecare clinical guidelines that it hopes will become the industry standard. One of the patient-related criteria stipulates the "patients cannot be viewed through the video without their knowledge or prior written consent. If other agency personnel or visitors come into the viewing site, the patient must be made aware of their presence, and the patient’s approval must be obtained for such personnel to participate in the video visit. If a third remote site is participating in the video site, the patient must again be aware and approve of such participation."

Another current limitation on telehomecare involves state medical licensure laws. According to the ATA, in the last four years at least 14 states have passed legislation that prohibits physicians in another state from practicing telemedicine on patients in their state unless the physician has a full and unrestricted licensure in their state. Nurses face similar issues. ATA and its members are fighting for changes, but in the meantime, there is much business to be had intrastate, Mahmud notes.

Nurses may also fear that telehomecare will take their jobs, but that’s not the case, according to Mahmud. "A video visit takes only 15 to 18 minutes. Now you’ve saved the nurse’s time for more revenue-generating activity."

With so many things that have restricted its growth now falling away, telehomecare will soon be bursting on the scene. Are you ready?

[Editor’s Note: Copies of the ATA Telehomecare Clinical Guidelines are posted on the association’s Web site: www.atmeda.org; telephone number is (202) 628-4700. For a copy of the 1998 ATSP Report on Telemedicine, which costs $295, contact the Association of Teleservice Providers at (503) 222-2406.]