Transcript Cost Reimbursements (cont.)

Telepsychiatry:
What Infrastructure
Will You Need?
Mick Pattinson, Ph.D., CEO
Susan Morley, LCSW, Deputy Director
Nancy Rowe, BA, Telemedicine Manager
Northern Arizona Regional
Behavioral Health Authority
NARBHAnet
Background
NARBHA Overview
•
Private, non-profit corporation
•
Contracts with AZ Dept. of Health Services
to serve Medicaid-eligible & SMI populations
•
Monitors behavioral health services
provided by community-based agencies
•
Serves the five northern counties of AZ,
including Tribal areas; all are Mental Health
Professional Shortage Areas
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NARBHA Overview (cont.)
Northern Arizona:
•
Approx. the size of
New York plus New
Jersey
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62,000 square miles
(54.4% of AZ area)
•
Population 708,500+
(11.5% of AZ pop.)
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NARBHAnet History
Drivers for starting telemedicine network:
•
Large geographic area, sparse population
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Provider and/or patient travel times/cost
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Recruitment/retention of psychiatrists
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State Hospital monthly staffings for patients
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NARBHA staff travel to provider sites/clinics
•
Provider staff travel to outlying sites
•
Provider staff travel to trainings/meetings
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NARBHAnet History (cont.)
1996 NARBHAnet established with $250,000 Tobacco
Tax and $250,000 state funding. Six video sites.
1997 NARBHAnet has 12 sites; named to Top Ten in U.S.
1998 Connects to U of A network, southern RBHA
network, and AZ Division of Behavioral Health
Services. Named to Top Ten 2nd year.
1999 Named to Top Ten 3rd year.
2001 Central website, www.rbha.net, goes online.
2006 Celebrates 10th anniversary.
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NARBHAnet History (cont.)
2007:
• 32 video endpoints
in 21 locations.
• Newest sites are on
AZ Strip (north of
Grand Canyon),
Apache and Navajo
Reservations.
• Connections to U of A
(171 sites) & RBHA
(24 sites) telemed
networks blanket the state.
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NARBHAnet Activity
Network use (in hours) by conference type
July 1, 2006 - June 30, 2007
Training:
960 hours
(8%)
Clinical:
5862 hours
(48%)
Total hours of video
connection for the year:
12,210.5
(3,376 hookups)
Administrative:
5388.5 hours
(44%)
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NARBHAnet Activity (cont.)
•
August 2007:
10 psychiatric
providers
•
August 2007:
616 patient
sessions via
telemedicine
•
Est. total patient
services over
NARBHAnet,
November 1996 –
August 2007:
36,637
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NARBHAnet
Infrastructure
NARBHAnet
Endpoint Equipment
Basic videoconferencing setups:
•
Room has one codec (transmission device/camera)
• Pan and zoom
• Remote control
• Sits on top of TV
• Plugs into ethernet jack
• Can dial 1 to 3 other codecs
•
Microphone (basic sites have 1 or 2 table mics)
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Two TV monitors or single monitor with picture-inpicture (gen. 32-inch CRT TVs; larger for large rooms)
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Endpoint Equipment (cont.)
Basic videoconferencing setups, cont.:
• Some sites have peripheral devices:
–
DVD player/recorder
–
document camera
–
laptop/PC connected
• Network gear required:
–
router
–
switch
–
Cat5 (ethernet) cabling with dedicated jack for video
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Videoconferencing Rooms
•
For psychiatrists, office-size rooms with one TV using
picture in picture
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Viewing angle: appearance of eye contact by having
camera just above TV
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Videoconferencing Rooms
•
Fluorescent is fine, full-spectrum bulbs are best
•
Sufficient lighting is crucial, especially for darker skin
tones—facial features must be lit up
•
In this room,
faces are too
dark, background is too
bright and busy
•
Codec is not
above TV so
participants
are not making
“eye contact”
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Videoconferencing Rooms
•
Camera should not face windows, whiteboards, doors,
or busy backgrounds:
•
Robin’s-egg blue is best background for camera and
life-like skin tones
•
For large conference rooms: ceiling mics, projectors
and screens recommended instead of TVs and tabletop
mics
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NARBHA Network Design
NARBHA has a
hub and spoke
network:
• Hub: NARBHA
HQ in Flagstaff
• Spokes: clinics,
agencies, state
hospital, DBHS
• Each spoke has
telemedicine
coordinator & at
least one videoconference room
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Network Design (cont.)
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NARBHA: private network with dedicated T1 lines
carrying video & data between spoke sites and hub
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T1 line = bandwidth of approx. 24 phone calls
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Hub not necessary for smaller networks
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NARBHA video uses H.323: Internet Protocol (shares
resources with data network)
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Other network protocols and connection types are
options (fractional T1s, Public Internet, etc.)
•
Videoconferences are transmitted at 384K,
30 frames per second (some clinicals @ 512K)
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Network Design (cont.)
Network connections:
•
One T1 line to the phone co. allows video and audio
calls off-network to anywhere
• Off-network providers use this line to dial in to
NARBHA network
• Dependable, consistent 384K signal
• As secure as a land-line phone call
• Dial-in users incur long-distance charges x 6
•
Access to NARBHA through Public Internet is
extremely limited & tightly controlled
•
Connections to other networks generally through
point-to-point T1 lines
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NARBHA Hub Equipment
Videoconferencing bridge (optional)
• Only needed for multi-site or multi-protocol conferences;
smaller networks can use no bridge or small bridge.
• Allows up to 48 sites to connect simultaneously (bridges
are scalable).
• Meetings are preprogrammed in bridge with any
combination of sites (can accommodate ISDN, IP, and
different bandwidths).
• Users can request different meeting setups:
– voice-activated: participants see whoever is talking
– continuous presence: all participants see each other
• All calls have a 30-minute pretest to correct issues.
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Hub Equipment (cont.)
Videoconferencing bridge, cont.
• Sites can be added to, moved among, or removed from
multi-site calls upon request.
• Requires trained staff to run it.
Other hub equipment:
• Dedicated server to run:
–
gatekeeper (IP video traffic controller)
–
endpoint management software (optional)
• Core router
• At least one computer with bridge controller software
• Ideally, a video endpoint for testing/troubleshooting
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NARBHAnet Central Staff
Telemedicine staff of three at NARBHA HQ:
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Customer service: Make sure spoke sites remain happy
about signing up and paying for telemedicine
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Schedule and monitor all videoconferences
• Carry dept. cell phone at all times during work hours
• Stay in or near building
• All conf. rooms have “Telemed” speed dial
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Work with all site telemedicine coordinators and
telemedicine managers of all connected networks
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Technical expertise, troubleshooting
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User support, training
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Central Staff (cont.)
Telemedicine staff of three (cont.):
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Manage T1 circuits: RFPs and contracts, installation,
testing, trouble calls to telcos
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Equipment advice, quotes, purchasing, installation
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Universal Service applications, grant applications
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Interface with vendors on behalf of spoke sites
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Work with WAN Manager on tech. issues
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Responsible for staffing “Telemed” email account
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Use troubleshooting / recording video endpoints in
telemedicine offices for instant response to issues
•
Maintain and update website
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NARBHA Scheduling System
www.rbha.net
telemedicine
website:
• Information,
news, policies,
tips, links,
instructions
• Circuit RFPs
• Contact info
• Scheduling tool
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Scheduling System (cont.)
www.rbha.net
scheduling tool:
• NARBHA staff can
request meetings,
view room calendar
• Site telemedicine
coordinators can
request, cancel,
reschedule & edit
meetings and can
accept & decline
invitations
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Scheduling System (cont.)
Requesting a
videoconference:
• Can choose one or
multiple dates
• Check the video
endpoints to be
invited
• Emails go to each
invited endpoint
telemed coordinator
• Coordinators can
accept or decline
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Scheduling System (cont.)
NARBHA telemedicine
staff:
• Program video bridge
daily based on meeting
requests on website
• (Clicking on meeting title
provides names of all
sites to be connected
based on sites’ responses
to invitations)
• Assign conference rooms
at NARBHA HQ with online
room calendar
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Central Staff (cont.)
Wide-Area Network Manager
•
Needed for IP-based videoconferencing
•
Spec and purchase routers, switches
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Configure network equipment
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Troubleshoot network gear issues
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Has designated backup
•
Available by cell phone for emergencies
•
WAN and telemedicine share same equipment and
lines, so collaboration & communication are KEY!
Networks of only a few sites would not require
centralized staff, bridge, or scheduling software.
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Business Continuity
Backup plans:
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If T1 goes down or equipment fails, doctor uses landline telephone.
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If power outage, doctors use non-electric analog
phones (separate lines from telemedicine network) in
rooms with natural light.
•
If analog lines down or NARBHA headquarters
unavailable, doctors can use digital (not analog) cell
phones—as secure as a land-line phone call.
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Non-clinical videoconferences (admin. or training)
use phones to conference-call, cancel or reschedule
meetings, or travel to meet in person.
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HIPAA
Security
HIPAA Security
• Private, point-to-point leased lines
• Firewalls at NARBHA (hub) and endpoints
• NARBHA firewall allows Public Internet
access only through approved VPNs or
firewall traversal device
• Codecs (cameras) are password-protected,
set to auto-answer mute, and set to disallow
dial-ins during calls
• Codecs are turned off or camera lenses
covered when not in use
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HIPAA Security (cont.)
Clinical / privacy:
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Door signs (e.g., “in session, do not disturb”)
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Window coverings
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White-noise generators
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No tech. staff in rooms unless invited
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Duplicate client records kept in locked cabinet, in
locked office w/ private fax machine
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Staff training on lens covers, muting
•
Best if TV does not face door
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Telemedicine
Obstacles
Startup Costs
• Cost to start a telemedicine network can be
high if network is large and video bridge is
needed
BUT…
• Grant funding is available for new networks:
• http://www.hrsa.gov/telehealth/
• http://www.usda.gov/rus/telecom/index.htm
• http://www.fedgrants.gov/
• Cost of equipment can be more than offset by
savings in provider travel costs/time
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Physician Attitudes
• Psychiatric providers’ concerns:
• quality of patient care will suffer
• ability to relate using a technological interface
• sitting in a room with a TV all day
BUT…
• Interviews with NARBHAnet providers have
shown that most providers like telemedicine
more than they expected to.
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Patient Attitudes
•
Concern about how patients will react to
receiving psychiatric services from a TV
BUT…
•
Recent patient satisfaction survey showed:
•
86% said quality of care through telemedicine is
same as or better than in person.
•
60% had no preference between seeing psych.
practitioner in person or via telemedicine; 20%
prefer telemedicine.
•
79% are now more at ease with telemedicine
compared to their first sessions.
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Staff Attitudes
•
Dislike videoconferences where presenting
site shows the whole room (tiny heads, no
facial features, can’t tell who is talking)
BUT…
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Staff training to use codec remote control:
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Camera presets let participants easily pan/zoom to
whoever in the room is talking.
•
Far-end sites see one to three people at a time on
screen, focus on the speaker.
•
Much easier for remote sites to engage in meeting.
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Staff Attitudes (cont.)
Don’t
Do
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NARBHAnet
Costs and
Reimbursements
Equipment Costs
Equipment:
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$11,053 per site (router, codec, 32-inch CRT TV, cart),
plus shipping and installation
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$166,732 for MGC100 video bridge, plus installation
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$6,576 for dedicated server w/ warranty
Annual maintenance agreements:
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Highly recommended
•
Costs vary by equipment type and price
•
NARBHA’s maintenance agreements have paid for
themselves over and over
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Circuit Costs
T1 line charges
•
NARBHAnet lines range from $381 to $2,200 per line
per month (unlimited use)
•
Installation fees
• generally 1 month or waived
• more costly for microwave--$4,000
•
T1 move fees
• varies by telco
• monthly cost can change)
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Contract termination fees (usually remainder of
contract)
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Administrative Costs
Staff
•
NARBHA has three full-time telemedicine staff:
• Salaries / benefits
• Training
• Recruitment
• Office space, computers, supplies
• Liability insurance
• Subscriptions, memberships
• Travel
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Cost Reimbursements
Universal Service
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Federal program funded by fees on every phone bill
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Reimburses nonprofit, rural health care providers for
difference in cost between rural and urban
telecommunications services
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Must meet Universal Service’s definition of “rural”
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Arizona urban rate is currently $224.60/month
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http://www.rhc.universalservice.org/overview/
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Cost Reimbursements (cont.)
Universal Service, cont.
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In FY 2006/2007, clinical NARBHAnet sites paid
$252,134 for 17 T1 lines
• Not including taxes and fees
•
In same year, these sites were reimbursed $211,327 by
Universal Service
•
Net cost for 17 clinical T1s: $40,807
•
Recommend that central staff file for rebates due to
steep learning curve
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Cost Reimbursements (cont.)
AHCCCS
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Arizona Health Care Cost Containment System (Arizona
Medicaid)
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Medicaid reimbursement for services over telemedicine
is available at state’s option
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At least 34 states now reimburse
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AHCCCS has reimbursed for NARBHA telepsychiatry
services since day one (1996)
•
NARBHA provides “Telemed allowable codes”
spreadsheet for users on www.rbha.net
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Cost Reimbursements (cont.)
AHCCCS, cont.
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AHCCCS funds for behavioral health services are paid
on a capitated basis through RBHAs and are not
restricted to rural areas
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For capitated providers the 15% facility fee is 1.15 times
the service value of face-to-face
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Appropriate authorizations required but no specific
telemed authorizations necessary
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Use “GT” modifier on service code
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www.cms.hhs.gov/home/medicaid.asp
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Cost Reimbursements (cont.)
Medicare
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Started paying in 1999 and has expanded coverage
•
Covered services:
• Provided to eligible Medicare beneficiary
• Patient is in eligible facility—rural only (originating
site located in non-metropolititan statistical area)
• Real-time, interactive video
• Non face-to-face services (e.g., EKG, radiology,
pathology)
• Home telehealth services (with restrictions)
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Cost Reimbursements (cont.)
Medicare, cont.
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No limitation on location of health professional
delivering medical service (referring site)
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Eligible providers include:
• Physician
• Nurse practitioner
• Physician Assistant
• Clinical psychologist, clinical social worker
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Cost Reimbursements (cont.)
Medicare, cont.
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Payment same as current fee schedule for service, plus
rural site facility fee: $22
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Use “GT” modifier
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NARBHA provides brief “Telemed allowable codes”
spreadsheet for users on www.rbha.net
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For more info: www.cms.hhs.gov/home/medicare.asp
Private payers:
•
many are willing to reimburse for telemedicine services
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NARBHAnet
Savings and
Benefits
Provider Travel w/o Telemed
August 2007, assuming same psych. services to
same clinics without telemedicine network:
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10 providers
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33 trips / 8,009 miles
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140.6 hours drive time,
sacrificing 180 patient sessions
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$3,885 car cost (48.5 cents per mile based on gov.
mileage reimbursement rate for private vehicles)
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$1,724 for meals (based on NARBHA policy)
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$1,797 for lodging (based on federal rate for Navajo Cty.)
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$12,384 in provider salaries (based on ea. hourly rate)
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TOTAL cost: $19,790 for August ($207,943 for full year)
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Provider Telemed Cost
Annual cost of endpoints used for doctor-patient
meetings:
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10 endpoints with video codecs, routers, TVs, carts
•
Assuming 5-year life for all equipment
•
Including annual maintenance for 10 endpoints
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Including net cost of nine T1 lines after Universal Service
rebates
•
Not including costs of central staff or video bridge,
because clinical meetings could run with neither
•
Total clinical telemedicine cost for the year: $65,400
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Provider CO2 Savings
August 2007:
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Gas use: At 27 mpg, 296.6 gallons total would be used
•
Total of 2.9 tons of CO2 added to earth’s atmosphere in
one month.
• As much CO2 as driving a Toyota Prius for over a year
(14,000 miles)
Extrapolated for a full year:
•
Without telemedicine network, CO2 added to earth’s
atmosphere in one year: 30.5 tons
• As much CO2 as driving a Hummer H3 for 3 years
(12,000 miles per year—29.4 tons)
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Overall Provider Savings
For NARBHAnet clinical services alone:
• Annual cost of telemedicine network: $65,400
• Est. annual doctor travel savings: $207,943
• Net annual savings: $142,543
• Plus 30.5 tons of CO2 not emitted
• Plus 1,903 patient services not forfeited
• Plus happier psychiatric providers—no travel
• Plus happier patients—no long wait times
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Overall Travel Savings
For NARBHAnet clinical services alone:
•
10 providers traveling
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Net annual savings: $142,543
•
Plus 30.5 tons of CO2 not emitted
Extrapolated to cover all the staff travel required for
admin. and training meetings now held via video:
•
Over 100 staff traveling
•
2,797 site connections in FY 2006-07
•
Financial and CO2 savings: ??
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Telemedicine Benefits Recap
•
Psychiatric services available to areas of
physician shortage
•
Improved access to care (patients seen
sooner and more frequently)
•
Psychiatric providers see more patients with
the time they would otherwise spend driving
•
Patients treated in their own communities
•
Emergency assessments available
immediately
•
Specialty consults available
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Telemedicine Benefits (cont.)
•
Family involvement in treatment of inpatients
•
Improved recruitment and retention of
psychiatric providers
•
More training and CMEs for clinicians, staff,
psychiatric providers
•
Improved staff efficiency, productivity, morale
due to less travel time
•
Better communication/camaraderie among
clinicians, staff, psychiatric providers
•
Impromptu meetings can be hooked up at will
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Q&A
For More Information
• Susan Morley, MSW, LCSW
NARBHA Director of Administrative Services/
Deputy Director
928-774-7128, [email protected]
• Nancy Rowe, BA
NARBHA Telemedicine Program Manager
928-214-2163, [email protected]
• www.rbha.net
• www.narbha.org
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