Why Congress should support the Medicare Telehealth Parity Act

Why Congress Should Co-Sponsor and Support
the Medicare Telehealth Parity Act

Legislative background

The Medicare Telehealth Parity Act can expand opportunities for Medicare beneficiaries to improve health outcomes by adding new originating sites, practitioners and services.

  • Licensed respiratory therapists are covered as qualified practitioners in addition to audiologists, physical therapists, occupational therapists, speech-language pathologists and certified diabetes educators.
  • Chronic Obstructive Pulmonary Disease (COPD) is one of three chronic conditions covered under remote patient management services that include patient monitoring, training, clinical observation, assessment and treatment. Other chronic conditions include congestive heart failure and diabetes if furnished at Federally Qualified Health Centers.
  • Respiratory services are covered as well as audiology and other therapy services such as physical therapy, occupational therapy and speech-language pathology.
  • Home telehealth services in conjunction with hospice care, home dialysis, home health services or durable medical equipment are also covered.
  • Originating sites in Metropolitan Statistical Areas with populations of less than 50,000 up to at least 100,000 will be added over a phased-in period of time offering additional benefits to Medicare beneficiaries, including those with chronic lung disease.
  • Studies called for in the bill have the potential to show how respiratory therapists and other practitioners and services can reduce hospital readmissions, lower costs and improve health outcomes.

 

Respiratory therapists can make a difference

Access to respiratory therapists via telehealth communications for Medicare beneficiaries with chronic lung disease adds another dimension toward improving care and reducing hospital readmissions.

  • COPD ranks fourth among the most costly hospital readmissions, according to the Medicare Payment Advisory Commission, and has been added to the list of conditions subject to hospital readmissions penalties effective October 1, 2014.(1)
  • In 2010, Medicare beneficiaries with two or more chronic conditions including COPD and asthma accounted for almost 98% (1.9 million) of all hospital readmissions.(2)
  • Fifty-two percent of Medicare beneficiaries with COPD have five or more other conditions; 47% of those with asthma have five or more other conditions.(3)
  • Medicare beneficiaries trained by respiratory therapists via telehealth to recognize and reduce the symptoms and triggers of their chronic lung disease can lead to reduced exacerbations and lower the incidence of costly acute care interventions.
  • Respiratory therapists are the only allied health professional educated, trained and competency tested in all aspects of pulmonary medicine and the value they can bring to patients via telehealth services can be immeasurable.
  • A 2014 update to evaluate the effectiveness of self-management interventions in COPD showed improved health-related quality of life, a reduction in respiratory-related hospital admissions, and improvement in dyspnoea.(4)
  • A one-year randomized controlled trial at five VA medical centers led by a respiratory therapist case manager implementing a simple disease management program reduced COPD-related hospitalizations and emergency department visits by 41%.(5)
  • Respiratory therapists are already making a difference in their hospitals by establishing best practices to reduce COPD readmissions that can also be applied via a telehealth delivery system.
  • Medicare beneficiaries suffering from COPD and other respiratory conditions will have greater access to respiratory therapists’ expertise via telehealth that is not available to them now.

 

New telehealth services can help meet
pulmonary patients’ unmet needs

Better training and education via telehealth can improve medication adherence and oxygen utilization for Medicare beneficiaries with chronic lung disease.

  • Medication non-adherence has been estimated to cost the U.S. health care system between $100 billion and $289 billion in direct costs.(6)
  • Due to the complexities of inhaler devices and oxygen systems, respiratory therapists’ expertise can help bridge the gap between pulmonary patients’ needs and their ability to minimize unnecessary, ineffective or wasteful interventions.
  • An evaluation of an oxygen therapy clinic managed by respiratory therapists suggests that home oxygen patients can significantly decrease inappropriate supplemental oxygen use which can result in significant cost savings while improving health-care delivery.(7)
  • Proper device selection together with patient training and education on proper inhaler techniques and appropriate oxygen saturation levels can improve medication adherence and oxygen utilization.
  • Up-front investment of personnel in patient training in inhaler techniques can save time and resources by preventing uncontrolled exacerbations because of poor technique.(8)
  • Respiratory therapists can improve utilization and medication adherence while lowering costs via telehealth services and remote patient monitoring.

 

Summary

  • Expanding telehealth services to include respiratory therapists as qualified practitioners, coverage of respiratory services, and remote patient monitoring for Medicare beneficiaries with COPD offers new opportunities to improve patient outcomes, reduce hospital readmission rates, and lower costs.
  • Studies show that respiratory therapists’ expertise in pulmonary medicine can improve medication adherence, oxygen utilization, and help patients reduce acute exacerbations leading to costly acute care interventions.
  • We urge Congress to co-sponsor and support the Medicare Telehealth Parity Act.

 

Sources

(1) Medicare Payment Advisory Commission: Report to the Congress “Promoting Greater Efficiency in Medicare.” June 2007. Chapter 5: Payment policy for inpatient readmissions. Table 5-3, page 116.

(2) Centers for Medicare and Medicaid Services, “Chronic Conditions among Medicare Beneficiaries, Chartbook: 2012 Edition” (2103).

(3) http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/CCDashboard.html, accessed 12.8.14.

(4) Zwerink M, et al. Self-management for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2014 Mar 19;3::CD00290. doi: 10.1002/14651858.CD002990.pub3.

(5) Rice KL, et al. Disease management program for chronic obstructive pulmonary disease: a randomized controlled trial. Am J Respir Crit Care Med 2010 Oct 1:182(7):890-6. doi: 10:1164/rccm200910-15790C. Epub 2010 Jan 14

(6) Agency for Healthcare Research and Quality. Evidence Report/Technology Assessment Number 208.4. Medication Adherence Interventions: Comparative Effectiveness. Closing the Quality Gap: Revisiting the State of the Science. Executive Summary. AHRQ Pub. No. 12-E010. Sept. 2012.

(7) Chaney JC, et al. Implementation of an Oxygen Therapy Clinic to Manage Users of Long-term Oxygen Therapy. Chest 2002:122:1661-1667.

(8) Papi A, et al. Editorial: Inhaler devices for asthma: a call for action in a neglected field. Euro Respir J 2011:37-982-985.

 

Respiratory Care and Telehealth

Studies show that telehealth services are beneficial and can reduce costly acute care interventions for patients with chronic lung disease

A telehealth system combined with care management has the potential to improve health outcomes in Medicare beneficiaries with COPD. (1)

  • Medicare beneficiaries with Chronic Obstructive Pulmonary Disease (COPD) who were part of a demonstration project from 2006 to 2010 were enrolled in the Health Buddy Program, a content-driven telehealth system designed to enhance patient education, self-management and timely access to care. Those in the program were associated with 23% lower quarterly all-cause hospital admissions and 40% lower quarterly respiratory-related hospital admissions.

Telehealth for COPD patients appears to have a positive impact on quality of life and the number of times patients are admitted to the ED or hospital. (2)

  • In an analysis of 10 clinical trials, telehealth for COPD showed a significant reduction in the number of patients with one or more emergency department (ED) visits over 12 months.

Patients with more severe asthma managed predominantly in secondary care settings with telehealth interventions had a significant reduction in hospitalizations. (3)

  • Twenty-one trials were evaluated to assess the effectiveness of telehealth interventions in individuals with asthma.

Home telehealth (HT) in elderly, severe COPD patients with multiple comorbidities is safe and efficacious in reducing healthcare resources utilizations. (4)

  • This controlled trial study design involved participants with a prior diagnosis of COPD with a post-bronchodilator forced expiratory volume (FEV1) % predicted <50%, age ≥ 50 years, who were on long-term home oxygen therapy and non-smokers. After 7 months of monitoring vital signs on a daily basis which were transmitted automatically to a Clinical Monitoring Center for follow-up, there was a significant reduction in ER visits (20 in the HT group vs. 57 in conventional care), hospitalizations (12 vs 33), length of hospital stay (105 vs 276 days), and need for non-invasive mechanical ventilation (0 vs 8).

Implementation of a tele-ICU intervention in a single academic medical center was associated with reduced adjusted odds of mortality and reduced hospital length of stay, as well as with changes in best practice adherence and lower rates of preventable complications. (5)

  • With respect to respiratory-related conditions, the tele-ICU intervention period compared with the pre-intervention period was associated with lower rates of preventable complications for ventilator-associated pneumonia (1.6% vs. 13%).

Tele-assistance (TA) in chronic respiratory failure patients on oxygen or home mechanical ventilation prevents hospitalizations while it is cost-effective. (6)

  • A total of 240 patients (101 with COPD) were randomized to two groups: an intervention group entered a 1-year TA program while controls received traditional care. The TA group experienced significantly fewer hospitalizations (-36%), urgent general practitioner (GP) calls (-65%), and acute exacerbations (-71%). Only COPD patients, as a separate group, had fewer hospitalizations, emergency room admissions, urgent GP calls or exacerbations. After deducting TA costs, the average overall cost for each patient was 33% less than for usual care.

The preponderance of evidence from studies using rigorous research methods points to beneficial results from telemonitoring in its various manifestations for chronic diseases such as COPD, congestive heart failure and stroke. (7)

  • These chronic diseases were reviewed because of their current and increasing importance relative to prevalence, associated morbidity, mortality and cost. The benefits of telemonitoring include reductions in use of service. Hospital admissions/readmissions, length of hospital stay, and emergency department visits typically declined and there were often reductions in mortality.

Spirometry self-testing by asthma patients during telemonitoring is valid and comparable to those collected under the supervision of a trained medical professional and can be implemented in a group of patients with no computer background. (8)

  • A telemonitoring study conducted in 31 asthma patients’ homes in a low-income inner city area concluded telemedicine is useful when reviewing and updating self-management asthma plans. After a 40-minute training session, patients completed an electronic diary and performed spirometry testing twice daily on their own from their homes for 3 weeks. The majority of patients (71%) had no computer experience. The results showed no difference between unsupervised and supervised home spirometry self-testing.

 

Sources

(1) Au DH, et al. Impact of a Telehealth and Care Management Program for Patients with Chronic Obstructive Pulmonary Disease. Annals ATS. First published online 02 Feb 2015 as doi: 10.1513/AnnalsATS.201501-042OC.

(2) McLean, et al. Telehealthcare for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD007718. doi:10.1002/14651858.CD997718.pub2

(3) McLean, et al. Telehealthcare for asthma. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD007717. doi: 10.1002/14651858:CDC007717.pub 2

(4) Segrelles Calvo, G, et al. A home telehealth program for patients with severe COPD: The PROMETE study. Resp Med. Volume 108, Issue 3, March 2014, Pages 453-462. doi:10.1016/j.rmed.2013.12.003.

(5) Lilly CM, et al. Hospital Mortality, Length of Stay, and Preventable Complications Among Critically Ill Patients Before and After Tele-ICU Reengineering of Critical Care Processes. 2011;305(21):2175-2183. doi:10.1001/jama2011.697.

(6) Vitacca M, et al. Tele-assistance in chronic respiratory failure patients: a randomized clinical trial. Eur Respir J. 2009 Feb;33(2):411-8. doi: 10.1183/09031936.00005608. Epub 2008 Sep 17.

(7) Bashshur RL, et al. The empirical foundations of telemedicine interventions for chronic disease management. Telemed JE Health. 2014 Sep;20(9):769-800. doi: 10.1089/tmj.2014.9981. Epub 2014 Jun 26.

(8) Finkelstein J, Cabrera MR, Hripcsak G. Internet-based home asthma telemonitoring: can patients handle the technology? 2000. Jan;117(1):148-55.