Rough Waters Ahead: Navigating Health Reform, the Future of Health Care, and Telemedicine’s Expanding RoleJohn F. DuvalVirginia Commonwealth University Health SystemMarch 18, 2013

Agenda• Quick overview of the Affordable

Care Act• What’s popular, what’s controversial• The promise and key disconnects

– Costs– Workforce adequacy– The States: Medicaid Expansion and

Insurance Exchanges

• Stay tuned– What we don’t know– Critical disconnects– What is happening in spite of reform– Telemedicine’s expanding role

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What is good about the health care

delivery system?

John’s List• Robust medical community, well represented by specialties• Strong & dedicated allied health workforce• Best education system in the world across all disciplines• Cutting edge technologies & pharmaceuticals• Strong research basis• Social safety net• Modern physical plant• Improving transparency & accountability• Improving quality & safety• Major economic engine, frequently largest employer

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What is not good about the

health care delivery system?

John’s List• Current costs and growth rate are economically not sustainable• ≈ 50 million uninsured• Racial / economic / geographic disparities in access to care• Unnecessary variations in amount / quality of care provided and some care

is not evidence based• Quality and safety accountability improving, but still too opaque• Economic incentives between provider and insurer communities not

aligned• Regulatory structure / licensure laws result in inefficient use of workforce• Sickness as opposed to wellness focused• High administrative overhead is wasteful• Education costs of healthcare workforce are borne by providers and

government payors

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• Most comprehensive change in healthcare finance since 1964 Medicare & Medicaid legislation

• Reforms the actuarial financing model for health services in the United States

• Improves access to care for most citizens and reduces the number of uninsured

• Reins in unpopular insurance industry practices• Increases quality and safety of health care• Improves transparency of health and insurance

information• Creates Health Insurance Exchanges in each state• Provides option for Medicaid Expansion in each state• And much, much more

Patient Protection and Affordable Care Act (PPACA): Signed into Law March 23, 2010

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PPACA: What is Popular?• Extends insurance coverage to 32 million people• Allows parents to cover children up to the age of 26 under their

private insurance plans• Eliminates lifetime dollar limits on benefits imposed by most

medical plans• Prevents medical plans from denying insurance and benefits based

on preexisting conditions• Limits the amount insurers spend on administrative costs versus

medical costs (Medical Loss Ratio)• Provides more transparency with publically reported metrics

related to quality, safety, and patient outcomes

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• Mandates individuals have health insurance by 2014 or pay a penalty• Expands Medicaid coverage to residents with incomes up to 133% of the

federal poverty level (FPL)– Federal government will cover all costs for this group starting in 2014 and

will phase down to 90% by 2020• Role of the States

– Health Insurance Exchanges– Medicaid Expansion

• Requires some employers with 50+ employees who do not offer health insurance to pay a penalty

• Significantly reduces Medicaid and Medicare Disproportionate Share Hospital (DSH) allocations

• New taxes on Individuals, health insurance sector, and manufacturers of pharmaceuticals and medical devices

PPACA: What is Controversial?

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PPACA: What the Law Doesn’t Cover• PPACA does not adequately address important issues facing

the health delivery system including:– Impending physician and nursing shortages– Rapidly escalating costs and their cause within our hospitals and

health systems– Large variations in medical practice observed across the nation– Financing of graduate medical education / other workforce

issues– Foreign national population– Costs of those who opt out

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Program Costs

Murphy’s Law of health care legislation:

“If it can cost more than the highest available official

estimate, it probably will.” Senate Joint Economic Commission

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Will They Be Right?

• Coverage expansions cost $938 billion over 10 years

• Federal deficit reduced by $124 billion over 10 years

Source: Kaiser Family Foundation, 201114

A Lesson from History…

Program (Estimate Year) Original estimate Actual cost

Medicare Part A (1965) $9b/1990 $67b/1990

All of Medicare (1967) $12b/1990 $110b/1990

ESRD program (1972) $100m/1974 $229m/1974

Medicaid DSH (1987) < $1b/1992 $17b/1992

Mcare Home Care (1988) $4b/1993 $10b/1993Source: Senate Joint Economic Committee, 7/31/09

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“It’s OK, Charlie Brown, You Win Some and You Lose Some.”

“That Would Be Nice”

Workforce

Health Care Labor Force• Projected shortages BEFORE health care reform• Reform makes some efforts to begin addressing

shortages

BUT• The law covers 32 million new patients nationally and

approximately 1 million in Virginia• That may not add up…

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Will There Be Enough Doctors?• Pockets of physician shortages now• 40% of practicing physicians ≥ age 55• In Virginia, a recent survey showed one-third

were ≥ age 55 and 10% ≥ age 65• How many more will we need?

– E.g., currently 6,830 geriatricians nationally• That is only 1 for every 1,900 seniors ≥ age 75• IOM indicates 36,000 needed by 2030

Sources: Alliance for Health Reform, 2011; Virginia DHP, 2009; Institute of Medicine, 2008

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What About Other Health Professionals?

• 33% of nursing workforce ≥ age 50– More than half of these plan to retire within 10

years• Will an improved economy reduce supply?• Nursing shortage projected to grow to 260,000 RNs by 2025

Source: Alliance for Health Reform, 201121

What other health professionals may be needed?

• Case Managers/Social Workers• Physical/occupational therapists• Pharmacists• Medical technologists• Clinical psychologists• Dieticians• Rehabilitation counselors• Medical coders• Health information technicians

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The States:Medicaid Expansion and

Insurance Exchanges

What States are Participating in Medicaid Expansion?

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State Action Toward Creating Health Insurance Exchanges

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Policy Issues for State Medicaid ExpansionOpt In• Long-term cost• Long-term support (Workforce, etc.)• Long-term benefits of reduced uninsured population

Opt Out• Cost of larger uninsured population• Federal leverage – What sticks still remain?• Lost dollars to state• Tax exportation

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Stay Tuned• What we don’t know• Critical disconnects• What is happening in spite of reform• Telemedicine’s expanding role

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What About What We Don’t Know?

The Secretary Shall…

1045Source: Congressional Quarterly Weekly, 4/5/10

He Wasn’t Discussing Reform, But… “There are things we

know that we know. There are known unknowns. That is to say there are things that we now know we don't know. But there are also unknown unknowns. There are things we do not know we don't know.” D. Rumsfeld

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Critical Disconnects• Cost estimates?• Economic impact• Access to providers• Graduate medical / other education• Implementation unknowns• Payment alignment with delivery goals• Tort reform• Medicaid/Medicare requirements /

provider cuts / Disproportionate Share Hospital payments

• Undocumented foreign nationals• Personal responsibility• And more…

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Ongoing efforts, even before (in spite of) reform

• Quality improvement• Increased safety• Greater efficiency• More transparency • Coordinated care• Healthier populations• Integrated providers

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Where does telemedicine fit in?

How can we use telemedicine to address critical disconnects?

• Combating the rising cost of care– Reduces emergency transport costs from rural communities to urban areas– Decreases ED admissions and readmissions through remote telemonitoring

• Providing high-quality care– Decreases mortality and length of stay with Tele-ICU coverage– Initiates more timely treatment with ED-ED consults via telemedicine

• Meeting care demands– Provides rural and underserved communities expanded access to specialists and subspecialists

• Overcoming provider shortages– Expands reach of providers who prefer to live in larger cities by giving them remote access to

rural patients– Creates additional capacity for traveling physicians by removing barriers of time and distance

• Achieving patient satisfaction– Improves patient satisfaction by providing care in a timely fashion– Keeps care local – only the most serious cases should be packed and shipped to tertiary centers

35Source: Telemedicine: An Essential Technology for Reformed Healthcare (Computer Sciences Corporation, 2011)

The Potential of Telemedicine

• Emergency Medical Services– TeleECG on ambulances transmitted to cardiologists via

smartphones or other devices– Immediate treatment started in transit before patient hits ED

• Telesurgery using robot surgical systems– MD Anderson received a $1M contribution from AT&T to seed

its venture into remote surgical care for cancer patients– If successful, surgical cases would occur in rural and

underserved Texas communities rather than Houston

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VCUHS Telemedicine Strategic Plan Mission Statement & Vision

Mission Statement:VCUHS Telemedicine supports the mission of the Health System by offering confidential, timely and cost-effective medical services to patients; removing distance barriers throughout the Commonwealth of Virginia; providing superior, compassionate and innovative patient care.

Vision:Integrate Telemedicine as a part of VCUHS’ strategy to respond to Affordable Care Act mandates and grow its relationships with community and regional providers, hospitals and community health centers.

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Goals of VCUHS Telemedicine Program• Develop and grow relationships with all correctional

facilities in order to provide access and decreases costs• Utilize telemedicine in under-served and rural areas to

reduce health care disparities• Leverage the clinical, educational and outreach efforts of

our Centers of Excellence to provide specialty expertise across the Commonwealth

• Develop innovative models of care using telemedicine that keep care local and provide care for complex patients in their homes

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VCUHS Telemedicine

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18 years experience30,000 encounters

Updated 04/11/2023

Correctional Facilities Served

VCUHS Telemedicine: Prior to 2010

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Updated 04/11/2023

Before 2010

Growth since 2010

Pending Contracts/Negotiations

VCUHS Telemedicine Expands to Meet Needs of Outlying Communities: Post-2010

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Correctional:

Community Based:

VCUHS Telemedicine provides increased access

to specialists in South Hill, Virginia

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• VCUHS utilizes telemedicine to expand access to patients at Community Memorial Healthcenter:• Clinical Telepsychiatry Services – Inpatient and Long Term Care• ICU Intensivist support • Virginia Tobacco Commission Grant expands Patient Access

• Two new wireless telemedicine units and MCU bridge • Multidisciplinary tumor conferences, clinical research and

Telemed consults • Massey Cancer Center case conference review and provider

collaboration – Southern Virginia

VCUHS is working with several outlying community providers to launch ED-ED Pediatric Telemedicine

Goal: Improve access and quality by providing telemedicine consults to pediatric patients admitted to Virginia community hospital Emergency Departments

Objectives:– Provide physician based pediatric critical care in terms of stabilization and

intervention for children in need of transfer to CHoR– Provide visual report for nursing hand-off – Physician based screening for pediatric “puzzlers” (i.e., skin rash, lab finding, etc.)– Assist with ER disposition plan for subspecialty inpatient/outpatient follow-up

care – Expand telemedicine collaboration to other specialties and services– Develop a successful ED to ED model for state-wide roll out at other referring

hospitals

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Independence at Home Demonstration• In 2012, Virginia Commonwealth University applied for a consortium site to

demonstrate the value of the Independence at Home clinical model– Partnered with MedStar Washington Hospital Center and the University of

Pennsylvania– Based on VCU House Calls program that has provided in-home primary care for

more than 5,000 home-bound patients over the past 25 years• Tests a payment incentive and service delivery model that utilizes physician and

nurse practitioner directed home-based primary care teams • The Consortium will utilize remote diagnostics and telemonitoring as part of the

IAH program– Pulse oximetry– I-STAT devices– iCard IPhone EKGs– EKG harnesses for laptops– In-home telemedicine

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Telemedicine’s Expanding Role• Many challenges are coming our way:

– Health reform implementation– Provider shortages, especially in rural and under-served areas– Aging of the Baby Boomers– Addition of previously uninsured population

• New strategies/models for providing access and quality care are essential• Telemedicine is a maturing tool that will help stretch our workforce and

ensure all patients have access to needed care– Offers opportunity to redeploy and reengineer workforce in ways that were

previously not attainable– Holds promise for dramatically improving access and reducing health inequities in

rural and economically distressed areas

• It’s not a cure-all, but will help us as we figure out how to avoid this….

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