Mario Gutierrez, Part Two: "The practice of healthcare would turn on its head."

The Center for Connected Care Health Policy, or CCHP, has worked for nearly a decade now to advocate for the use of telehealth as a means to streamline care, lower costs, and put patients at the center of the healthcare system. Initially begun to advocate for legal telehealth reform in the state of California, the CCHP has since become the leading, federally-designated national body for the movement.

In the first half of HCA News’s conversation with Mario Gutierrez (pictured), the CCHP’s executive director, he spoke of the need for systemic changes in approach to advance telehealth. In this second part, Gutierrez goes on to talk about how telehealth policy is evolving nationwide, and what an ideal outcome would be for the CCHP’s mission.

In terms of telehealth policy, do you see some regions of the country pushing ahead and others lagging behind?

It’s kind of like a dog race, some state will emerge and do something interesting and another state will do something that goes backwards. The problem is that, in order to really reform how telehealth is used in a particular state and particularly for their Medicaid patients, there has to be a couple of things. One is a real commitment to moving away from fee-for-service to a more value-based approach, working with payers to serve a population. Telehealth becomes very attractive when it’s not just another fee to bill.

Secondly, we define the policy areas into several key budgets, and unless the state is willing to look at all of that rather than just piecemeal it, they’re not going to make much progress. Basic things like redefining “telemedicine” as “telehealth” to cover the full spectrum of healthcare, incorporating the ability to pay for not just live video but also store-and-forward and remote monitoring, and eliminating any unnecessary barriers to utilizing telehealth. Some states will say “you have to demonstrate that there’s no other service available” and make you jump through hoops. That dis-incentivizes its use, and is going to result in the technology not being utilized. Those are important.

And then again, it’s the reorientation of the system, and creating incentives in the system, whether it’s cost savings or actual evidence of better health outcomes. There are states like Minnesota, Colorado, California, of course, and even places like Mississippi are doing very innovative things when it comes to telehealth policy. No one state has gotten a corner on the market. Hawaii is another one that has really embraced it.

Actually somewhat surprised to hear Mississippi in that mix, but perhaps not so much given how rural much of it is.

Rural and poor, and I think the key in Mississippi is that they had very strong, enlightened leadership at the University. Being a small state, they were able to convince their policymakers that this really makes a lot of sense. It takes leadership and champions.

Are there better openings for policy improvement at the state level than at the federal level in your eyes?

They certainly can do a whole lot more and not have to wait for the feds to reform their laws and regulations at CMS. States have full discretion to encourage the utilization and payment for connected care services.

What impact, if any, did the Affordable Care Act have on telehealth when it was passed?

Not much. I think the Affordable Care Act meant a lot more people were insured that needed care, but I think what we found was that states were scrambling because it’s on the fee-for-service basis and you’re expanding the number of people who are generating fees. There hasn’t been the catchup to think about how they can do this in a more organized, effective way. It just means that there’s greater demand on the healthcare system.

I think that any reform to the ACA, which is probably where you’re going with this question, is going to create greater incentives at the state level to change their laws and regulations, because we definitely will see a net reduction in Medicaid dollars across the states, particularly if we eliminate the expanded Medicaid for states that chose to join in. That, along with more of a recognition of creating a managed care model for Medicaid, is going to make it much more attractive to incorporate telehealth.

You’re correct, the next question was going to deal with the outlook for telehealth in a current climate of political uncertainty…

I think states are actually starting to think that way. They see what’s coming down the road. For example, Florida’s governor has appointed a council to do an in-depth study and report back regarding legislation changes and policy changes to prepare for the next step in healthcare reform.

We’re seeing in more states, like here in California, much more receptivity by the Department of Healthcare Services, which receives the Medicare contracts, to encourage more than just diagnosis and treatment but things such as econsult, which is a way for a specialist to provide backup support for a primary care physician and make a determination as to whether or not that patient needs to be seen by the specialist themselves. It’s not a diagnosis, but it’s a web-based, secure email system for a primary care physician to be able to access that resource and that expertise. It allows the patients to stay in the home, it’s convenient for the primary care provider because they’re also learning from specialists and able to use that knowledge for other patients with similar issues, and for the specialist, they are able to work much more efficiently because they’re not clogging their waiting rooms with people who could be seen and treated by their primary care provider. And you can do that across state lines, it’s not limited to the state, it’s a way of being able to be more responsive with the kind of specialized support needed to manage people in their primary care home.

I think those are the kinds of things we’re seeing more interest in, ways to use technology not just for diagnosis and treatment but also for care coordination.

The final question is kind of hypothetical, or idealistic if you want to be that: what would it look like if the mission of the CCHP was fully realized?

What it would look like? The practice of healthcare would be turned on its head, with the consumer at the center, and policymakers and practitioners would really truly believe in the triple aim of reform and would be using these technologies to their maximum, full potential while at the same time ensuring that there were adequate safeguards for patient safety and preventing fraud and abuse (which is what we always hear from policymakers). I think that, across the states, we would see uniformity in standards and guidelines for how telehealth is used from state to state, so we don’t have this patchwork of every state being different.

Then, the more radical idea would be to allow for a supplemental license for physicians and other professionals to practice across state lines using telehealth. Right now, compare the US to Europe, or Australia, where wherever you are in the continent, if you’re licensed as a physician you can practice anywhere. We have this kind of outdated system where every state determines who can practice medicine in that state, and we have such a severe shortage of specialists and even primary care providers. Why not create the opportunities so you get the maximum benefit of the great talents we have across the country, and not just be limited to your own state?

Those are, I think, key, important areas that would make a big difference in our healthcare delivery system.