Telemedicine Works for Texas Tech-
The Hurdle For Nursing Homes: Doctor Reimbursements

Telemedicine would be an especially helpful and economical tool for elderly patients in skilled nursing facilities or for residents of assisted living communities who have difficulty getting to a doctor. Transporting those individuals to a physician’s office or clinic for even basic-care consultations usually requires an ambulance and, perhaps, an escort.
If the senior care facility had the option of offering telemedicine, patients could easily — and relatively inexpensively — get their periodic exams, some treatments, and associated follow-up consultations without having to travel. In addition, easier access to a doctor might catch problems — and perhaps treat them — before those problems get to the point where the patient must be transported to the hospital on an emergency basis.

So what’s the problem?
The biggest obstacle to telemedicine in the skilled nursing environment is that Medicare will not pay for telemedicine originating from a nursing home.
While telemedicine reimbursements are otherwise fairly liberal, Medicare rules define specific locations where a patient using telemedicine must be situated in order for the provider to be reimbursed. If a telemedicine consultation originates from a rural health clinic, a federally qualified health clinic, or a hospital, for example, it’s reimbursable. Nursing homes are not on the list.
“If we could ever get over the reimbursement problems, having telemedicine in nursing homes, assisted living centers, and retirement communities would be a great way for those people to access their doctors without having to travel,” says Debbie Voyles, director of telemedicine at Texas Tech Health Sciences Center (HSC) in Lubbock, Texas. “The reimbursement issue is the big stumbling block for telemedicine in the nursing home environment.”

The correctional facility experience
When Texas Tech’s HSC first started using telemedicine back in 1990, a handful of other universities and health care organizations were also getting involved. Some stopped due to the lack of continued funding needed to keep their projects going, but more and more groups are gearing up for telemedicine every year, according
to Voyles.
“We have a unique situation here at the HSC,” she says. “The majority of the telemedicine that we provide has been in the correctional setting. We have a contract with the State of Texas to provide health care services to the inmates in our state prisons, along with a specified amount of money to use for that purpose. Part of that funding is used to support our telemedicine program.”
Telemedicine is used in the correctional setting for safety reasons, to reduce the need to travel outside the facility to see the doctor, and as a cost-saving issue. The doctors cooperate with HSC’s program, because they’re getting paid through HSC’s contract with the state.
In fact, an increasing number of states are starting to look at using telemedicine in correctional settings and, perhaps, branch out from there, according to Voyles.

Applying the experience to senior care
So Texas Tech has facilitated telemedicine in Texas prisons for years. “With no disrespect intended in the analogy, what we have learned through that program can definitely be applied in a nursing home environment,” says Don McBeath, who now works on pandemic flu and emergency management at the HSC but was director of telemedicine before Voyles took over the job at the beginning of this year. “While it may be for different reasons, you don’t want to remove residents from the facility if you can avoid it,” he says.
In more than half of the situations in which HSC provides telemedicine consultations into a prison, the inmate is not removed from the prison for any further care. The onsite provider delivers the medical care by being directed by an offsite physician via telemedicine. “We did some pilot projects in nursing homes,” says McBeath, “and found similar favorable results.”
The pilot project completed a few years ago at Carillon Senior Lifecare Community, a CCRC in Lubbock, “was very successful and showed that telemedicine is doable,” adds Voyles. “The residents loved it. They would actually dress up when it was time for them to be seen by ‘the doctor on TV.’”
More importantly, they understood that they would get to see the doctor faster and more frequently — and they wouldn’t have to travel to the doctor’s office to do it.

The costs involved
Telemedicine certainly has associated costs, such as buying the equipment and maintaining connectivity. Can a facility or even an individual simply use a personal computer with a digital camera and video card? Perhaps, but the resolution that they would achieve on a personal computer would not really be sufficient for thorough medical examinations. Current telemedicine technology requires high-quality video conferencing over a digital network and high-resolution peripherals as the appropriate standard in the medical field, according to McBeath.
The video-conferencing component allows communication between the patient and the physician. They can each see each other and talk back and forth. That particular component, in fact, is becoming rather inexpensive, relatively speaking. A video conferencing unit suitable for telemedicine currently costs about $3,500 on
each end.
The examination peripherals — e.g., high-resolution camera, electronic stethoscope — can be extremely costly. The high-quality exam camera that HSC uses in its telemedicine program, for example, costs $5,000.
Like any other technology, though, the prices continue to come down. “Five years ago, we would spend $70,000 to put telemedicine communications equipment in a nursing home,” McBeath says. “Today, we would probably spend about $25,000. But not-for-profit organizations can usually find other sources — grants or bequests — to cover equipment costs. In addition, the operator of a nursing home or other type of senior living facility might see the intrinsic marketing value of offering telemedicine as an advanced form of care.“
Equipment costs, then, are not a significant barrier to telemedicine. But if the physician can’t get payment for services rendered, telemedicine in nursing homes is not going to move off the dime.
Turning the political screws
While Medicare reimbursement policies for telemedicine are much more liberal than those for Medicaid, nothing much will change in terms of senior care access until the list of approved reimbursable sites includes nursing homes. “We’re trying to convince the politicians to make telemedicine a reimbursable item no matter where it’s located,” says Voyles.
“My personal opinion is that you won’t find anyone who’s against using telemedicine,” adds McBeath. “Rather, I think it’s more a case of the folks at CMS (which oversees Medicare) fearing that more claims will be filed.” However, when patients, especially those in a rural nursing home, fall ill and are sent to the hospital emergency room, that’s far more costly for Medicare or Medicaid than the cost of a primary care visit via telemedicine — one that might entirely preclude the hospital visit.
“It’s just a matter of educating the politicians to the need and making them understand that it won’t break the bank,” Voyles continues. “That, of course, is their big concern. They’re afraid that telemedicine costs will just inundate the system, whether Medicare or Medicaid, instead of looking at the long-term perspective. Having easier access to primary care — and even the specialty systems — and catching and treating problems sooner will save money in the long run by reducing the number of emergency room visits, hospitalizations, and the associated transportation costs.”

Looking to the future
The senior care industry has been very slow to adapt technology other than for record keeping and billing purposes. McBeath and Voyles are both convinced, however, that telemedicine will become a reality one day in nursing homes and other senior care facilities. They expect that, eventually, Congress will mandate payment for telemedicine delivered in nursing homes, because there’s no negative side politically. But like anything else, the politicians won’t make it happen without a nudge.
“Candidly, people need to call up their Congressmen and push the case,” suggests McBeath.
“It’s very frustrating,” adds Voyles. “Those of us who deal in the telemedicine community understand its benefits and its importance as a way to provide health care to people who have problems accessing it due to their remote location, the lack of transportation, or a health condition that makes travel difficult. We know that telemedicine could be used so effectively in those situations.”
As time goes on and baby boomers learn more about this technology, they’ll demand changes to the regulations so that they can have access to it in their senior care facilities, Voyles predicts. In small or rural communities, in particular, elderly people needing skilled nursing care or suffering from other medical problems often have to relocate to a facility in another town or city in order to have closer access to medical treatment. By using telemedicine, they could remain in a home or facility located in their own community and nearer to their family and friends.
“Down the road, we may actually find telemedicine in the individual’s home or CCRC unit,” Voyles says. “The communications could run through their PC, a TV screen, or even cable. That functionality would allow seniors the opportunity to stay in their homes longer and delay having to move to an assisted living center.” Voyles isn’t the least bit surprised, in fact, when research indicates that 80 to 90 percent of the seniors who are moving to traditional CCRCs are bringing personal computers with them.
“A lot of untapped potential is not being utilized because of the regulatory issues,” she says. “I believe, though, that telemedicine is the wave of the future — especially with technology-savvy baby boomers wanting to remain independent as long as they possibly can. Telemedicine will be one of the options that everyone will want to access. So I think, in time, it will all pan out.” And, of course, some well-placed pressure on Washington will move it along, as well.