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13 Feb 2019

AMA Survey Finds Medical Practices Are Slow to Embrace Telehealth

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The American Medical Association has found that physician practices aren’t using telehealth or telemedicine in large numbers, often because they’re having problems paying for the new technology.

January 14, 2019 – Telemedicine and telehealth may be the norm rather than the exception in hospitals and health systems, but smaller medical practices still aren’t embracing connected care technology.

A recent survey of some 3,500 physicians by the American Medical Association finds that roughly 15 percent are using telehealth in their practice for patient care, while just 11 percent are using telemedicine to communicate or consult with other healthcare providers.

The findings, culled from the AMA’s 2016 Physician Practice Benchmark Survey and published in the December issue of Health Affairs, also indicate larger practices are more likely to use telehealth or mHealth.

“This suggests that despite regulatory and legislative changes to encourage the use of telemedicine, the financial burden of implementing it may be a continuing barrier for small practices,” study co-authors Carol K. Kane, the AMA’s Director of Economic and Health Policy Research, and Kurt Gillis, PhD, the AMA’s principal economist in the Economic and Health Policy Research division, said in the study.

Kane and Gillis found that provider-to-patient telehealth and provider-to-provider telemedicine were favored in particular pockets of healthcare delivery.

Among those using connected care platforms to interact with patients, almost 40 percent are radiologists followed by psychiatrists (almost 28 percent) and cardiologists (roughly 24 percent).

Radiologists (39.5 percent) have the highest use of telemedicine for patient interactions, followed by psychiatrists (27.8%), and cardiologists (24.1%). For those using the platform to connect with other providers, emergency medicine physicians came out on top at almost 39 percent, followed by pathologists (about 30 percent) and radiologists (25.5 percent).

According to the survey, video-based telemedicine is the most popular modality, used by 12.6 percent of physicians. Of that group, almost 32 percent are emergency medicine physicians, followed by psychiatrists (almost 30 percent) and pathologists (about 24 percent).

Asynchronous or store-and-forward telehealth is only being used by 9.4 percent of physicians, the survey found, and primarily by radiologists (almost 43 percent), pathologists (almost 23 percent) and cardiologists (about 15 percent).

And while remote patient monitoring may be in the spotlight this year with new reimbursement opportunities from the Centers for Medicare & Medicaid Services (CMS), the survey found only 7.3 percent of physicians using RPM. The top users in this category are cardiologists (almost 18 percent), followed by nephrologists (a little more than 15 percent) and neurologists (almost 13 percent).

Original article:

Reposted by: Physician Licensing Services

19 Dec 2018

Telemedicine demand spurs rural broadband push in Texas

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Many say that federal agencies and Congress aren’t doing nearly enough to help rural areas connect to high speed Internet for telemedicine. 

AUSTIN, Texas — Texas Republicans don’t usually look to Lyndon Johnson for inspiration.

But the need for improved broadband services in rural areas — to spread telemedicine, viewed as the next frontier of medicine — has caused some to look to the former president’s efforts to connect those same areas to the electrical grid.

“I’m a conservative Republican and believe private enterprise should do that,” said Texas Agriculture Commissioner Sid Miller. “But we kinda got a unique problem in rural Texas.

“I can compare it to when electricity first became available and we had [Johnson’s] Rural Electrification Program,” said Miller, an avid supporter of President Donald Trump whose reelection was endorsed by far-right groups. “There’s not enough profit. As a matter of fact, there’s probably not any profit to bring that out to remote areas for the private sector.”

Rural areas have long suffered from the lack of broadband connectivity. But the demand for telemedicine, which can virtually bring doctors and nurses to poor, rural areas with few clinicians, is renewing state and federal efforts to improve internet infrastructure.

Last year, Texas lawmakers passed bills that made telemedicine legal and improved the reimbursement process to help rural counties contend with provider shortages and hospital closures. When they next meet in 2019, the legislature will take up bills to help rural areas get connected to high-speed Internet services, said Blake Hutson, associate state director for advocacy at AARP Texas.

“We definitely see broadband as big barrier,” said Hutson. “A lot of cutting edge concepts in telemedicine are not available to people in rural areas.”

The chief obstacle for rural providers is the cost of laying lines.

Texas lawmakers are filing bills that broaden the use of telemedicine to provide mental health counseling and deliver forensic care to sexual assault survivors. Yet as Texas and other states open the doors to telemedicine, providers can’t afford the high-speed connections they need to install the remote service.

More than a quarter of Texas’s rural population lacks fixed broadband access, according to an August report from the Texas Health Improvement Network. Nationally, more than 30 percent of rural people lack access, according to the Federal Communications Commission.

Earlier this year the FCC boosted a rural broadband grant fund to $581 million from $400 million — the first funding increase since Congress created the program nearly 20 years ago. The FCC also approved a $100 million pilot to fund projects that connect low-income Americans to telehealth services.

That’s still a fraction of what the FCC makes available to school and libraries under a separate $4 billion fund.

Many say that federal agencies and Congress aren’t doing nearly enough to help rural areas connect to high speed Internet for telemedicine.

“Botswana has a plan for universal broadband,” said Susan Dentzer, CEO of the Network for Excellence in Health Innovation. “It’s just unspeakable that we don’t have that and it’s not even on the agenda.”

Lack of coordination in building out broadband for health care is one of the biggest problems in Texas, said Republican state Sen. Charles Perry, whose district includes 51 counties over 48,000 square miles.

Last year the state made $25 million available to help school districts tap into federal funds to pay for installing high-speed internet in classrooms. Sometimes local entities would apply to lay lines where fiber already existed, while passing over areas that needed connections for health care.

“[W]hen you put government money to a problem and you don’t give some direction to vendors engaged in applying for those dollars, you don’t get the outcome” you want, Perry said.

Health care providers in Texas have been on their own when it comes to getting federal cash for laying broadband cables.

Take Culberson Hospital in the town of Van Horn, which sits on a busy stretch of highway in remote West Texas yet has only one doctor. To help handle a regular influx of car crash victims, Culberson contracted with a company that connects the trauma center’s staff to a nurse and physician in South Dakota with the push of a red button.

The hospital worked with the state health department to get around a regulation requiring a physician be physically present at the trauma center within 30 minutes. But the state did nothing to help the hospital lay the fiber optic cables needed to connect the facility to a broadband connection fast enough to make remote surgery workable.

In the end the hospital applied independently for a federal grant that covered the costs of laying the lines. The group that runs the Van Horn hospital has connected six additional hospitals and received grants totaling more than $200,000 over three years.

The growth of telemedicine so far, especially in rural areas, “is a direct result of the proactivity of hospital administrators,” said Don McBeath, director of government relations for the Texas Organization of Rural and Community Hospitals.

There hasn’t been enough coordination between state facilities to take advantage of existing lines and technology, he said.

“The state needs to get a handle on this issue,” said McBeath. “Nobody knows who is doing telemedicine and what kind of telemedicine they are doing.”

The lack of state coordination disproportionately affects smaller clinics that lack the resources to apply for federal grants.

Methodist Healthcare Ministries places nurses in more than 80 sites, including churches, around 74 South Texas counties, to offer health screenings and outreach. But when the organization tried to broaden the nurses’ reach with telemedicine, it faced challenges in getting broadband access directly to the church. Sometimes it resorted to installing a satellite on a church roof to get a signal.

Ideally, said Pete Otholt, senior IT manager at Methodist, the group would like to use telehealth to make sure patients with chronic conditions such as diabetes, obesity or behavioral health issues receive frequent check-ups. But in the areas where his organization works, lack of connectivity is still a major obstacle.

“One of the things that is so important is having contact with patients,” said Otholt. “If they don’t have access to that, they are missing out on where health care is headed.”
Original post:

16 Nov 2018

New Group Lobbies for More Telehealth, mHealth in Medicaid Programs

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HealthTech4Medicaid (HT4M), comprised of roughly 40 healthcare technology companies, aims to support state Medicaid efforts to improve access and outcomes through telehealth, mHealth and other new technologies.

 – Dozens of health technology companies have formed a non-profit aimed at lobbying for more telehealth and mHealth in Medicaid.


Spurred by recent federal and state efforts to expand Medicaid programs targeting underserved populations, HealthTech4Medicaid (HT4M) aims “to further improve quality and access to care for Medicaid recipients by rapidly changing the pace of innovation.”


“Medicaid recipients and traditionally disadvantaged populations are often overlooked by new technology,” Leah Sparks, the group’s co-chair and CEO of Wildflower Health, said in a press release. “Our goal is to use technology innovation to reimagine how these patients are served.”


Roughly 40 percent of the nation’s Medicaid programs are taking a progressive approach to telehealth and telemedicine reimbursement, according to a state-by-state analysis earlier this year by the Manatt legal and consulting firm.


“A growing body of evidence suggests that telemedicine will be critical to delivering healthcare in the future, and state Medicaid policies are evolving – in some states more quickly than others – to accelerate adoption of telemedicine models,” the report, written by Manatt Health executives Jared Augenstein, Jacqueline D. Marks and Randi Seigel, states. “As technology advances and the evidence base for telemedicine expands, state policy will continue to evolve to integrate telemedicine into payment and delivery reforms that support overarching program objectives related to access, quality and cost of care.”


Telehealth and telemedicine proponents say state Medicaid programs could be particularly effective in using connected care technologies to improve outcomes in low-income and elderly populations, as well as with children. Telehealth could also prove useful in programs addressing the nation’s ongoing opioid abuse epidemic.


“If we are going to combat the opioid epidemic in this country, we need to close the treatment gap,” U.S. Rep. Ben Ray Luján (D-N.M.) said in introducing the Medicaid Substance Use Disorder Treatment via Telehealth Act in December. “Leveraging telehealth is one commonsense way we can increase people’s access to care as we work to grow the number of treatment facilities in rural and underserved areas. This legislation provides tools to states like New Mexico so they can expand treatment for Medicaid beneficiaries. It’s one step in a number of comprehensive actions Congress needs to take so that more families get the care they need and deserve.”


The Centers for Medicare & Medicaid Services has also taken notice. In June, the agency issued a pair of guidance documents urging Medicaid program directors and healthcare providers to leverage telemedicine and telehealth to improve care management and coordination.


“Access to substance use disorder (SUD) treatment providers remains a challenge for states and, appropriately, the President’s Commission supports leveraging telemedicine and telepsychiatry to facilitate more coordinated care,” one of the guidance document states. “States are reminded that they need not necessarily submit a state plan amendment to begin delivering covered Medicaid services through telehealth modalities. State plan amendments are only required if a state decides to reimburse for telemedicine services differently than they pay for face-to-face services, visits, and consultations.”


HT4M’s leadership says the group will strive to reinforce the role that connected care technology can play in developing and enhancing new programs.


“Our members and Advisory Council bring a broad range of expertise, resources and innovation to HT4M,” Abner Mason, the group’s founder and co-chair and CEO of ConsejoSano, said in the press release. “We’re thrilled to bring the group together to drive real change in technology innovation for Medicaid.”


Original posted by Eric Wicklund on November 16, 2018.


Reposted by Physician Licensing Service

18 Oct 2018

How Intermountain Healthcare is Moving the Needle on Virtual Care

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Treating patients locally, rather than making them travel hundreds of miles for care, was a core driver for Intermountain’s new virtual care initiative


In March, Salt Lake City, Utah-based Intermountain Healthcare announced the launch of one of the nation’s largest virtual hospital services, bringing together 35 telehealth programs and more than 500 caregivers to enable patients to receive remote medical care.





The virtual hospital, called Intermountain Connect Care Pro, provides basic medical care as well as advanced services, such as stroke evaluation, mental health counseling, intensive care, and newborn critical care. “While it doesn’t replace the need for on-site caregivers, it supplements existing staff and provides specialized services in rural communities where those types of medical care usually aren’t readily available,” officials said in the March announcement.



Michael Phillips, M.D., Intermountain’s chief of clinical and outreach services, says that a core reason why the health system went in this “virtual” direction was because its leaders saw the evolving healthcare landscape and wanted to get out in front of it. “Our thought process behind this was that the world has changed from the days where you can only take care of people who [physically] make it to you. But literally every person on the planet is pretty much within the distance of a cell tower now. So we feel people should be able to benefit from [remote] care,” says Phillips.



Offering an example of how these services work in the clinical setting, Intermountain officials brought up the instance of an infant at a southern Utah hospital who was being supported via Connect Care Pro services and received a critical care consultation that allowed the sick baby to stay in that facility instead of being transferred to a newborn intensive care unit (ICU) in Salt Lake City. This single avoided transfer would have cost over $18,000 dollars. The parents of this baby were able to remain in their community, surrounded by their support system, instead of traveling what would have amounted to 400 miles and seven hours round-trip every time they wanted to see their baby, noted officials.


Indeed, as Phillips puts it, when most rural hospitals think about big health systems, their vision is a helicopter scooping in and flying away from the rural facility with its complicated patient. “But we believe that many of those patients can be treated locally, and there are clear benefits to that. First off, it’s better for the patient—having their family separated by 200 miles to drive to a major medical center is not good for their care and doesn’t tallow for a good support system. If they can be treated locally, they should be,” he attests.


As of now, notes Phillips, Intermountain’s virtual care services—inclusive of the Connect Care Pro, which is a direct provider-to-provider service and Connect Care, which is a direct-to-consumer service—covers all of the health system’s hospitals and another nine facilities outside of the system. “We are really covering more than 30 ICUs in all, and we have a stroke service, a neonatal resuscitation service, and [other services]. Our tele-ICU services are covering a few hundred beds with this process,” Phillips explains.





Reposted by Physician Licensing Services

09 Oct 2018


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The physician suicide rate is double that of the general population and even higher than the military veteran suicide rate.


Doctors are afraid to admit mental health problems for fear of losing their licenses.


Washington state’s medical community is changing licensing application questions to combat this.

Image result for picture of nurse crying


Original by: Evie Fordham | Politics and Health Care Reporter

3:13 PM 09/15/2018

Reposted by: Physician Licensing Service  – 10/09/2018


The Washington State Medical Commission (WMC) is taking a step to combat the high suicide rate among physicians by making physician licensing questions more friendly to doctors who have sought psychiatric help.


Updates to Washington state’s licensure questions will focus on an individual’s current impairment rather than if a doctor has had mental health problems at any point in the past. Many doctors fear their reputations and even licensure are at risk if they seek help from a psychiatrist for feelings of burnout or even suicidal thoughts.


Currently, many doctors are “having to sneak out of town, pay cash and use a fake name” when seeking help from a mental health professional, family physician Pamela Wible told Kaiser Health News. She is a self-proclaimed “voice for ideal medical care” and has gathered more than 1,000 stories of doctor suicides for her website to help people better understand the issue.


The WMC expects to update the questions in December after the changes were voted on in June, WMC Executive Director Micah Matthews told The Daily Caller News Foundation via email.


“Historically, medical license applications asked if the applicant has ever had any medical conditions or substance abuse that may impair their practice,” Matthews told TheDCNF. “The updates alter those questions to if they have current conditions or substance abuse issues.”


Many medical organizations are rethinking the policies they have in place because the physician suicide rate is double that of the general population and even higher than the military veteran suicide rate. The physician suicide rate is 28 to 40 per 100,000 individuals per year compared to approximately 12 per 100,000 individuals per year in the general population, according to data presented at the American Psychiatric Association’s 2018 annual meeting.


Licensing question changes like the ones that WMC is making are in line with 2018 wellness and burnout recommendations from the Federation of State Medical Boards, spokesman Joe Knickrehm told TheDCNF via email.


“The FSMB has heard encouraging news from a number of state boards that they are in the process of actively reviewing their licensing application questions,” Knickrehm told TheDCNF. “It is too early to tell how many boards have changed their questions, but we have heard from at least a dozen boards that are discussing it. It’s also important to note that not all boards do ask about an applicant’s mental health.”


The WMC’s updates also includes a safe harbor provision that operates in tandem with the Washington Physicians Health Program (WPHP).


“WPHP participants can answer ‘no’ to questions about impairing illness if they are ‘known to WPHP,’ which means that they have informed WPHP of their behavior or condition and they are complying with WPHP’s requirements for evaluation, treatment, and monitoring,” Matthews told TheDCNF.


“[This] creates an added layer of confidentiality [and] provides prospective license applicants with a powerful incentive to proactively seek assistance if needed,” he continued. “These changes are intended to reduce the fear of professional sanction and public disclosure of health information that are barriers to help-seeking among physicians.”


The WMC and WPHP hope the changes will encourage doctors to confront any mental health problems head-on. More than half of physicians have symptoms of burnout, which “manifests as emotional exhaustion, loss of meaning in work, and feelings of ineffectiveness,” according to a 2014 Mayo Clinic survey. Burnout can harm physicians’ mental health and even make them feel like taking their own lives is the answer.


Factors such as increased pressure on physicians and lack of contact with other physicians is contributing to burnout and other symptoms, Dr. Chris Bundy of WPHP told TheDCNF via telephone


“Health care is a rapidly changing and dynamic environment, and it’s been hard for organizations to keep up,” Bundy told TheDCNF. “A lot of the changes have fallen squarely on the shoulders of physicians on the front lines of patient care, and now we need to redesign those systems.”



Original link:

07 Sep 2018

New York University Makes Tuition Free for All Medical Students

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Image result for new york university medical school

New York University said Thursday that it will cover tuition for all its medical students regardless of their financial situation, a first among the nation’s major medical schools and an attempt to expand career options for graduates who won’t be saddled with six-figure debt.




School officials worry that rising tuition and soaring loan balances are pushing new doctors into high-paying fields and contributing to a shortage of researchers and primary care physicians. Medical schools nationwide have been conducting aggressive fundraising campaigns to compete for top prospects, alleviate the debt burden and give graduates more career choices.



NYU raised more than $450 million of the roughly $600 million it estimates it will need to fund the tuition package in perpetuity, including $100 million from Home Depot founder Kenneth Langone and his wife, Elaine. The school will provide full-tuition scholarships for 93 first-year students—another nine are already covered through M.D./PhD programs—as well as 350 students already partway through the M.D.-only degree program.



“This is going to be a huge game-changer for us, for our students and for our patients,” said Dr. Rafael Rivera, associate dean for admission and financial aid. The school will refund out-of-pocket tuition payments already made for the current year, and return loans students may have taken out.



The move dwarfs efforts by other schools, including Columbia University and the University of California, Los Angeles, to alleviate the financial strain of a medical education. Earlier this year Columbia’s Vagelos College of Physicians and Surgeons announced it would eliminate loans for all students who qualify for financial aid, while UCLA’s David Geffen School of Medicine expects to provide more than 300 full scholarships between 2012 and 2022, based on merit.



The Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, with just 32 students a year, has paid full tuition and fees since 2008 in an effort to encourage graduates to pursue academic and research careers.



Nationally, 72% of graduates from the class of 2018 had debt from medical school, with a median of $195,000 in loans, according to student surveys by the Association of American Medical Colleges. More than one-third of medical students also have student loans from prior academic programs.



Sixty-two percent of NYU medical school’s most recent graduating class had student loans, averaging $171,908 for medical school and $184,000 overall. Most medical students will still need to pay for about $29,000 in annual room, board and other living expenses; tuition had been set at $55,018 for the coming year.



“There’s really a moral imperative to reduce the amount of debt people have,” Dr. Rivera said, citing concerns that loan burdens are shaping career choices and might even be scaring some prospects away from going to medical school at all.



Schools are also seeking to better reflect the population of U.S. patients in terms of race, ethnicity, gender and socioeconomic backgrounds. Asians make up a disproportionate share of medical-school classes, but other minorities are vastly underrepresented.



The median parental income for new medical-school students is $125,000, according to the AAMC.



Most medical students who want to go into lower paying practices like family medicine and endocrinology can take advantage of federal programs in which their monthly loan payments are tied to discretionary income; their loan balances are then forgiven after 10 or 25 years, depending on where they work. With compounding interest, they often don’t make much dent on the principal balance.



The salary disparity for doctors can be stark. The four lowest-paying specialties, all in pediatrics, had average annual compensation of $221,900 or below, according to a survey of more than 65,000 doctors by Doximity, a medical social network for clinicians. Doctors specializing in internal medicine had average annual compensation of $260,000.



Meanwhile, neurosurgery was the top-paying specialty last year, with average compensation of $662,755. Thoracic surgery and orthopaedic surgery rounded out the top three, at $602,745 and $537,568, respectively.



There’s no guarantee that schools’ new scholarships will push more students into less lucrative specialties or underserved communities, as the tuition payments aren’t tied to any career commitment after graduation. But school officials are hopeful.



“If you’re faced with debts that you’re likely to have into your 50s, it’s got to have an influence on what you choose to do,” said Dr. Lee Goldman, dean of Columbia’s Faculties of Health Sciences and Medicine. Published tuition for that school is $61,146 this year; including living expenses, students can expect to shell out between $92,311 and $100,665, the school says.



Former Merck & Co. chairman Dr. P. Roy Vagelos and his wife, Diana, gave Columbia’s medical school $250 million last winter, with $150 million earmarked for the endowment that funds the new no-loan financial aid package. About half the class receives need-based aid.



Generous aid packages are a powerful recruiting tool.



Columbia’s yield, or the share of admitted students who actually enrolled, increased by 1% this year in the wake of the financial aid announcement, and the school anticipates an even higher yield in the future.



UCLA boasts on its website that students have turned down offers from the University of California, San Francisco, Harvard University and Stanford University to attend its medical school, thanks to merit scholarships covering all costs for up to 20% of students. Those are funded by a $100 million gift made in 2012 by entertainment mogul David Geffen.



“I don’t know of any schools that would not want their students to graduate debt-free,” said Dr. Roy Ziegelstein, vice dean for education at the top-ranked Johns Hopkins University School of Medicine. “All schools are aiming for that end result.”



Median debt for Hopkins medical students who borrow is around $110,000, well below the national median.



Dr. Ziegelstein commended Columbia and other schools for their financial aid initiatives. “I love it. And I’m trying to do the same thing,” he said.



Write to Melissa Korn at



Corrections & Amplifications NYU will provide full-tuition scholarships for 93 first-year students—another nine are already covered through M.D./PhD programs. An earlier version of this article incorrectly gave the numbers as 92 and 10.


Reposted by: Physician Licensing Service


01 Aug 2018

Internet freedom is crucial to Alaska telemedicine

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The year-old health clinic in the Southwest Alaska village of Chevak includes modern telemedicine equipment, numerous exam rooms and a bunkroom for visiting providers. Many patients arrive on four-wheelers, as seen from the outside on Thursday, Aug. 11, 2016. (Lisa Demer / ADN)

The year-old health clinic in the Southwest Alaska village of Chevak includes modern telemedicine equipment, numerous exam rooms and a bunkroom for visiting providers. Many patients arrive on four-wheelers, as seen from the outside on Thursday, Aug. 11, 2016. (Lisa Demer / ADN)


For residents in many rural communities, few necessities are more difficult to obtain than affordable health care. This problem is especially severe in Alaska, where health insurance premiums are the highest in the country — almost 40 percent higher than the national average, according to federal figures released last year.


No single solution will solve health care affordability and access, especially in small towns without easy access to a hospital. But hope is on the horizon. New telemedicine programs leverage the internet to provide patients with diagnoses and monitoring that previously were only possible at a doctor’s office.


These services are beginning to appear elsewhere in the U.S., so for Alaskans — and most especially for their leaders in Washington, D.C. — the challenge will be to encourage federal policies that promote this trend.


Three years ago in Missouri, a new hospital opened with 330 staff members and no beds. Today, health workers contact patients using high-speed internet service and two-way cameras. Patients measure vital signs with medical tools that plug into iPads. And all the data is relayed directly to the hospital for immediate diagnoses.


In one instance, an 80-year old rancher with a history of heart problems felt his lungs filling up and thought he was having heart failure. Before calling an ambulance for the hour-long hospital trip, he placed an urgent video call to his doctor.


The doctor reviewed the rancher’s vital signs and made the diagnosis: No need for an ambulance or a hospital trip. The doctor prescribed new medication and the rancher improved, without ever leaving his cattle farm.


Telemedicine’s benefits are almost boundless and include both mental and physical care. But to keep this progress going, federal regulation must be more encouraging.


Take opioid treatment. Last year, 127 Alaskans died from opioids, and 141 died in 2016. Sens. Lisa Murkowski and Dan Sullivan recently asked the U.S. Drug Enforcement Administration to expand professionals’ ability to treat opioid addiction via telemedicine. This will be especially helpful in rural communities.


But advances such as this will never happen without better high-speed internet service. Three years ago, the previous administration approved rules tying down internet service in complicated regulations from a 1934 rotary telephone law.


The harm these “Title II” rules caused in rural communities was significant and immediate. Within months, plans for better rural internet service had been cancelled or delayed in a half-dozen states. Late last year, when “Title II” rules were finally withdrawn, a CNN headline summarized the sad situation: “In rural America, building the internet for everyone has stalled.”


This problem is clearly being felt in Alaska, as nearly 40 percent of state residents lack high-speed internet service. Alaska also ranks 44th among the 50 states in terms of its overall internet connectivity.


Soon, Rep. Don Young will vote on re-imposing Title II rules on the internet. Just as in 2015, the harm from doing so will be immediate.


Problems will be especially severe with telemedicine services that require “prioritized” communication for proper diagnoses. Patients should not lose their ability to have real-time communication with a nurse or doctor because of an outdated federal rule from the 1930s.


The National Grange has spoken out repeatedly on this issue because of the impact on rural communities. We have documented these communities’ need for internet services that provide health care and education.


Alaska has tremendous opportunities from better internet service, especially in health care. Rep. Young should consider the negative impact that onerous regulations will have here and reject reinstating Title II.


Original posted 07/25/2018 on Anchorage Daily News:

14 Jun 2018

Telemedicine use spikes during natural disasters

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Nemours CareConnect is a telemedicine service available to Floridians. (Nemours Children’s Hospital)
If Dr. Timothy Hendrix had any lingering doubts about telemedicine, they were erased during last year’s hurricane season.
As Central Florida began to brace for the arrival of Hurricane Irma in September, and doctors’ offices and urgent care centers closed, Nemours Children’s Hospital and Florida Hospital decided to offer their telemedicine services for free.
Both services were flooded with calls from people seeking a virtual visit with a doctor.
There was a 554 percent jump in the number of people who installed the Nemours’ CareConnect app during the days before, during and after the hurricane.
“We saw 270 kidsduring the day-and-a-half before and the day-and-a-half after the hurricane,” said Carey Officer, operational vice president of Nemours CareConnect and the Center for Health Delivery Innovation at the health system.
Florida Hospital’s eCare went from an average of four to five calls a day to 40 to 50 a day, said Hendrix, medical director of Florida Hospital Centra Care urgent care centers.
Hendrix has been practicing medicine for a quarter century and until two years ago, when Florida Hospital introduced its eCare consumer telemedicine service, his patient exams involved the actual presence of the patients in his office.
“I was resistant to the whole idea of eCare,” Hendrix said. “I’m an old-school doctor.”
But then in the days leading up to and after Hurricane Irma, he saw how a virtual doctor visit was the saving grace for the worried parents or the elderly who couldn’t access their doctors.
“It really made me realize the potential of [telehealth] in medicine and the potential ways we can use technology in unique situations like natural disasters,” said Hendrix. “I’m a total convert.”
Neither telemedicine is new, nor is its use during natural disasters. But advancements in technology and widespread access to smartphones and tablets have pushed telemedicine beyond the hospital walls and available to the masses.
Most current telemedicine services are provided via secure apps. Not all insurance companies cover telemedicine calls, so instead of waiting for new regulations and laws, the companies charge patients a flat fee, usually less than $100, to give them access to a provider. Depending on the service, the conversation may start with text messages and turn into a video call for further assessment.
The use of telemedicine has grown rapidly, with more than 1.2 million visits reported nationally in 2015, according to the policy think tank RAND Corporation.
Last year’s active hurricane season helped establish telemedicine as a viable alternative to in-person doctor visits during natural disasters.
In addition to Nemours and Florida Hospital, at least five other telemedicine companies, including Doctor on Demand, MDLIVE, Teladoc, American Well and LiveHealth Online also offered free services to consumers during the 2017 hurricane season, according to a study by RAND Corporation.
The study, which only analyzed data from Doctor on Demand during the month after Hurricanes Harvey and Irma, concluded that telemedicine services are a new way to deliver routine care to people in immediate aftermath of natural disasters.
They study found that 63 percent of the more than 2,000 people who called Doctor on Demand after the hurricanes were first-time users.
It also highlighted another advantage to the use of telemedicine during disasters: out-of-state providers can be tapped to expand workforce quickly.
Doctors who were outside the affected states handled nearly half of the visits to Doctor on Demand, the study found.
Data show that most of the patient calls, during a disaster or other times, are for routine concerns such as common cold, respiratory problems, rashes and infections like pink eye.
“It’s the same stuff that I see in the office, except that I sometimes asked them to do the exam. And you function more based on ‘Can I do this on this visit or should I ask them to see a doctor?’” said Hendrix.
He said he had to refer less than 5 percent of his eCare visits for a complete workup at the doctor’s office.
That said, telemedicine has its pitfalls.
Timely access to a pharmacy to fill prescriptions remains an issue. What if the patient is trapped at home? And what if all area pharmacies are closed? Can hospital pharmacies handle the outpatient demand?
And what if the patient — or doctor on call — doesn’t have access to power and Wi-Fi?
“[Telemedicine] is a good idea, but unfortunately, the very nature of a disaster makes the delivery of the care problematic,” said Dr. Antonio Velardi, director of critical care at Orlando Health’s Health Central Hospital.
In preparation for the hurricanes last year, Hendrix made sure that the eCare team had power and backup generators to get through the outage. He had access to Wi-Fi and could juice up his phone to answer calls, but still he had no power at home.
“At one point I realized I was answering calls in the dark in a T-shirt,” he said with a chuckle.
So maybe better lighting would be something to consider for the coming hurricane season. But there’s not much else he would need to do to prepare, he said.
“The beautiful thing is that [telemedicine] is so easy. It’s already up and running, so it’s just a matter of having doctors and nurse practitioners available to cover it,” he said., 407-420-5158, @naseemmiller

Reposted by Physician Licensing Service, June 14, 2018



30 May 2018

Do Most Hospitals Benefit from Directly Employing Physicians?

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How can hospitals and health systems generate a return on their investment in their physician enterprises? may18-25-82143495-Peter-Dazeley

According to the most recent figures, from the American Medical Association, over 25% of U.S. physicians practiced in groups wholly or partly owned by hospitals in 2016 and another 7% were direct hospital employees. Yet, according to the Medical Group Management Association, hospitals’ multi-specialty physician groups lost almost $196,000 per employed physician.


As a result, some larger health systems’ physician operations are generating nine-figure operating losses, which are major contributors to the deterioration in hospital earnings.  It is time for hospitals or health systems to rethink their strategy for their physician enterprises.


Let’s first revisit why independent physicians were receptive to becoming employees and why hospitals and health systems felt the need to hire them.


The surge in hospital employment of physicians predated Obamacare by at least six years, and had two key drivers. The first was independent baby-boomer physicians — particularly those in primary care — found themselves unable to recruit new partners. Newer physicians, heavily burdened by student debt, were not inclined either to take on entrepreneurial risk or the 60-hour work weeks independent practice entailed.


The second was cuts in Medicare payments for office-based imaging. Thanks to the Deficit Reduction Act of 2005, specialties such as cardiology, orthopedics, and medical oncology that relied on the revenue that imaging generated were hit hard. As a result, many found it advantageous to be employed by hospitals. Under Medicare rules, in addition to professional fees, hospitals can charge a Part B technical fee for their services and therefore can pay practitioners more than they could earn in private practice.


Then, beginning in 2009, the Obama administration’s policies increased the exodus of physicians from private practices to health systems. The “meaningful use” provisions of the HITECH Act of 2009 provided both incentives and penalties for physicians to adopt electronic records, but hospitals and very corporate enterprises had more resources to comply with meaningful-use requirements.


The value-based-payment schemes created by the Affordable Care Act also markedly increased documentation requirements and, as a result, the overhead of practices, driving more physicians into hospital employment models.


There have been a number of reasons hospitals have been hiring physicians. Some, particularly those in rural areas, had no choice but to turn physicians into employees. Retiring independent physicians were leaving large gaps in care in their economically challenged communities. Consequently, hospitals that did not step in to fill the gaps were in danger of closing.


Separately, some hospitals or systems sought to grab business from their competitors by acquiring physicianswho hospitalized their patients at competing facilities. These physicians’ inpatient and, particularly, outpatient imaging and laboratory volume generated additional revenues for the acquiring hospital or system.


A third apparent motivation was to corner the local physician market in order to obtain more favorable rates from health insurers. This seemed to have been a major rationale for St. Luke’s Health Systems acquisition of Seltzer Medical Group, Idaho’s largest independent, multi-specialty physician practice group, which led to an anti-trust action.


Yet another reason for making physicians employees was to position the organization for capitated, or value-based, payment. Hospitals believed that “salarying” physicians would help control clinical volumes and thus make it easier to perform in capitated contracts.


Finally, some hospital and system CEOs were tired of negotiating with local independent physician groups or national physician-staffing firms like MedNax and TeamHealth over incomes and coverage of the hospitals’ 24/7 services such as the emergency department, the intensive care unit (ICU), and diagnostic services like radiology and pathology. Building an in-house staff of physicians seemed like an attractive alternative.


Many health systems have gotten into trouble because their strategic rationale for hiring physicians became a moving target.  A hospital system we followed morphed from a ““grab market share” strategy to a “respond to competitive acquisitions” strategy to a “bailout” strategy for loyal independent physicians to a “increase bargaining power with payers” strategy to a “position for value-based care” strategy over a period of eight years. By the time it was done, it was the proud owner of a 700-plus physician group and losses of more than $100 million per year.


Hospitals lose money on their employed physicians because physicians’ compensation plus practice expenses and corporate overhead significantly exceed the collections of practices. These direct losses are, to a degree, an artifact of accounting, because hospitals frequently do not attribute any bonus for meeting “value-based’ contract targets, or incremental hospital surgical, imaging, and lab revenues to physician practice income.


However, even factoring in the accounting issues, much of the losses are attributable to “hosting,” rather than managing, practices effectively.  Many systems employing physicians have done so without developing a cohesive physician organization and lack standardized staffing and operational support functions, such as effective purchasing and supply chain operations, effective scheduling systems, and centralized office locations.


Managing up the return, rather than managing down the loss, is the key to a successful physician strategy. Here’s how to do that.


Establish a clear strategic goal and a target return on investment. Physicians reside at the core of any successful health system. Yet as the Cheshire Cat said in Alice in Wonderland, “If you don’t care where you are going, then it doesn’t matter which way you go!” If you establish strategic goals for the physician enterprise, then the physician organization can be sized and located appropriately. As a result, the physician group may end up either a lot smaller or with a more defensible specialty and/or geographic distribution. Management should then quantify and budget the expected return on the practice’s operational loss.


Strengthen operations. Effective management of the physician group then becomes the essential challenge. For example, revenue-cycle issues such as inconsistent coding or missing data often damage the profitability of the medical group. Are systems in place to assure that medical bills are defensible and correct, and that patients understand what they owe and agree to pay? Seeing that encounters are adequately documented and translated into a fair and timely bill that patients are willing to pay is not rocket science. The return on investment for getting the revenue cycle right is often 3X to 5X.


Revamp compensation and incentives. Medicare’s policy for paying employed physicians will likely come under fresh scrutiny during the Trump administration. It is possible that Medicare’s relatively favorable payment for hospital-employed physicians will be reined in. If that happens, it might require a painful revisiting of employment contracts when they come up for renewal.


Performance incentives in those contracts should also match the strategic goals established above. For example, compensating physicians through a production-based model that encourages them to increase visits, procedures, or hospital admissions, while value-based insurance contracts (like those for accountable care organizations) demand reducing them could damage the overall performance of the health system.


Pursue reality-based contracts with insurers. The Affordable Care Act ushered in a profusion of narrow network, performance-based contracts with private insurers, with significant front-end rate concessions by hospitals. These discounts often far exceeded the potential rewards from the “value based” incentives in the contracts! Larger health systems also rushed to assemble “clinically integrated networks” (CINs), comprising their employed and contracted physicians as well as private practitioners in their markets, to participate in these new contracts. Treating physician group losses and CIN expenses as loss leaders for value-based contracts and then losing yet more money on those contracts, as is happening in many places, doesn’t make sense.


Both enrollment and financial performance under these contracts have been disappointing in most markets. Reviewing and pruning back these contracts, or renegotiating them to provide more adequate rates or to compensate hospitals for patient non-payment is an essential element of an effective physician-enterprise strategy. Hospitals and health systems also should ask: “Is the CIN functioning as intended? Is it adding value that patients notice or is it just an additional layer of administrative expense without compensating benefits for clinicians or patients?


Motivate employed and independent physicians. Finally, hospitals and systems must understand the value they are creating not only for their employed clinical workforce but also for the two-thirds of their physicians who are not full-time employees — those who are contracted, independent participants in CIN’s or in part-time administrative roles. What would motivate all these physicians to want to work with the organization over the long term?


Hospital and systems need a unified physician strategy and operating model that encompasses all these diverse arrangements. Beyond that, they must  engage their physicians in planning and organizing care. Physician are complex, highly trained professionals. They cannot be mere employees; they must be owners of the organization’s goals and strategies.



Reposted by: Physician Licensing Service

Written May 29, 2018 by:



25 May 2018

How telemedicine is providing in-home psychotherapy for veterans

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At the American Telemedicine Association conference in Chicago, clinicians came together to discuss how video-to-home technology can help deliver psychotherapy to veterans.

veterans affairs telehealth


Despite the fact that the Department of Veterans Affairs is the largest healthcare system in the country, for a lot of veterans coming into to a clinic, is difficult. It would be impossible for a clinic to be in every veteran’s neighborhood — that’s where telemedicine comes in.


At the American Telemedicine Association conference in Chicago, clinicians came together to discuss how video-to-home technology can help deliver psychotherapy to veterans. But it turns out that distance isn’t the only hurdle in treating patients with living with mental health disorders.


Terri Barrera, a research psychologist at the Department of Veterans Affairs, said that she works with patients with Obsessive-Compulsive Disorder. The condition causes patients to have recurrent unwanted thoughts as well as ritualistic behaviors, which the person feels drawn to complete in order to get rid of the thought, according to Barrera. Patients usually experience triggers, such as germs.


All of this means that for some patients, coming into a hospital or clinic creates an extra layer of anxiety. But Barrera discussed how the “gold standard” of care can be implemented in video-based therapy.


Currently, exposure therapy, where a client is exposed to the stimuli that is linked to the obsession or fear is introduced, is one of the main treatments, along with preventing the ritual.


“What I love about video apps for OCD, is not only is it increasing access to care but exposure therapy for OCD requires 20 sessions and usually 90 minutes and that is a lot of time,” Barrera said. “These patients also have very high anxiety levels and some are unable to come into the clinical because of anxiety.”


She discussed a case study involving a young female veteran who had a fear of blood, illness, dirt and germs.


“With ‘Mary’ the hospitals were a huge trigger for her, so coming into the hospitals [wasn’t] an option for getting her the care she desperately needed,” Barrera said.


Instead “Mary” was able to get the services she needed in her home with virtual based care. It also let her practice exposure therapy with stimuli that she faced every day. For example, she didn’t like to touch any mail that the mail person touched, so the therapist was able to walk her through this practical application, Barrera said.


Remote therapy is also being used to help veterans who have experienced sexual trauma, whether that be in the form of assault or harassment. One in four women and one in 100 men who serve in the military experience some type of sexual trauma, according to Julianna Hogan, a psychologist and research health scientist at Baylor College of Medicine who works with veterans and presented during the session.


Many of the veterans who have experienced the trauma aren’t in a place where they want to discuss the event, she said. But there are options for people who aren’t ready to revisit the experience but need tools for managing their symptoms. Hogan discussed a specific tool called webSTAIR, which is a self-guided platform where the user can work interpersonal relationships and coping strategies. Users of the tool can also add their therapist or coach.


The goal is to eventually get people to a place where they can talk about their experience with a therapist.


Addiction is another concentration where clinicians have tapped into telemedicine. Currently, Jan Lindsay, a psychologist at the Department of Veterans Affairs, uses telemedicine to treat people with addiction. Currently 11 percent of veterans who are receiving care at the VA have a substance abuse disorder; however, Lindsay said during the panel that this is a relatively conservative number.


Lindsay went on to talk about a patient who was referred to her by the Veterans Justice Operation, after he was arrested. The patient was a combat veteran in his early 30s and had served in both Afghanistan and Iraq. She was able to meet with him over video in his home, but it was a multifaceted approach during which she worked with multiple providers on the case.


This type of psychotherapy was also implemented for a woman who was living with homelessness. She was able to use a tablet at her shelter to attend therapy sessions for her addiction, after refusing to come in for treatment.


While all of these therapies have given new avenues for patients to receive care, there are even more technologies coming out, the panel noted. But as more innovation come into the space, the clinicians said it was paramount that the therapies get tested and vetted on a veteran community.


Original by Laura Lovett – May 03, 2018 – 10:07 AM


Reposted by Physician Licensing Service