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Reimbursement Mechanisms, Sustainability Are Keys To Telehealth Success

New Mexico study shows promise in extending specialty care to rural areas, but new payment models are needed.

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Telemedicine has great potential for extending the reach of a strained healthcare workforce and improving care coordination, but it needs to be accepted as just another means of providing care if the technology is to be sustainable, according to a newly published study.

"To make a substantial impact on how healthcare is delivered across the United States, the model needs to be incorporated into the healthcare system so that reimbursement mechanisms are created to pay for the various services it provides," researchers from the University of New Mexico School of Medicine, Albuquerque, wrote this week in the policy journal Health Affairs.

The model they refer to is the university's Project ECHO (Extension for Community Healthcare Outcomes), which combines telehealth technology and "case-based learning" to partner with primary care sites in rural and other underserved areas of the state to extend the reach of specialists at academic medical centers and share new clinical knowledge. "These partnerships exponentially boost the healthcare system's ability to deliver specialty care to people who otherwise would lack access," the report said.

The researchers said their concept goes beyond the one-on-one connections of typical telehealth systems. "Project ECHO builds altogether new and permanent capacities by developing specialist expertise where it previously did not exist. It is not one to one, but one to many. Instead of a single university-affiliated specialist in Albuquerque treating 70 patients a year, a cadre of health professionals trained in hepatitis C care is delivering specialty-level care to thousands of patients across the state," the paper said.

Originally conceived as an answer to a serious problem with hepatitis C and chronic liver disease across New Mexico, Project ECHO has been expanded to include treatment and risk reduction for asthma, chronic pain, diabetes, cardiovascular disease, high-risk pregnancy, HIV/AIDS, pediatric obesity, rheumatology, substance abuse disorders, and mental illness.

The authors of the report said that treating hepatitis C is a yearlong process that requires 12 to 18 visits with a specialist. This is a significant problem for poor, uninsured, and underinsured patients, as well as those who live far from urban medical centers and specialty practices. Networks such as Project ECHO can help address not only this problem but additional expected provider shortages as an estimated 32 million Americans gain health insurance by 2014 as a result of the 2010 Patient Protection and Affordable Care Act.

"Given what we know about the currently uninsured, we can expect that many of these newly insured people will have had little prior interaction with the healthcare system. Many are likely to have high levels of unmet need because of chronic conditions such as diabetes and heart disease, and many live in areas that are already underserved. Thus, providing them access to high-quality primary and specialty care will be a major challenge," the UNM researchers said.

Many of these new patients will get care through community health centers, and the reform law provides $11 billion in new funding to such clinics over a five-year period. But community health centers in rural areas tend to have minimal professional staffing. "Providers in these areas have little opportunity to interact with colleagues or continue their medical education. They frequently care for patient populations with high rates of illness, including complex, chronic illnesses that they may not be fully equipped to treat effectively," according to the study. That's where telemedicine can help.

"In the aftermath of passage of the Affordable Care Act, Project ECHO has the potential to radically transform how health care is provided in the United States and to bring best-practice care to patients with chronic health conditions, wherever they are," the researchers wrote.

Through March, UNM reported that 298 care teams across New Mexico were participating in Project ECHO and that the technology had facilitated more than 10,000 patient consultations with specialists. The network also has provided more than 20,000 hours of continuing medical and nursing education. "We conclude that Project ECHO expands access to best-practice care for underserved populations, builds communities of practice to enhance the professional development and satisfaction of primary care clinicians, and expands sustainable capacity for care by building local centers of excellence," they wrote.

To date, Project ECHO has relied on grant funding from the federal Agency for Healthcare Research and Quality, the state of New Mexico, and the Robert Wood Johnson Foundation. "It is unlikely that funders will support Project ECHO indefinitely. Nor is it likely that the model can be replicated on a large scale without a structure for sustainability," the researchers said.

They believe that the Affordable Care Act may provide such a structure by changing how healthcare is paid for. In particular, the New Mexico team is intrigued by the concept of Accountable Care Organizations, which encourages healthcare providers to focus on health outcomes and thus better management of chronic diseases. ACOs, they said, "would be well suited to adopting the ECHO model."

Project ECHO also would allow academic medical centers to become leaders in training new healthcare workers, providing care in underserved communities, quickly disseminating new best practices to remote locations, and responding to public-health emergencies, the researchers added.

The Healthcare IT Leadership Forum is a day-long venue where senior IT leaders in healthcare come together to discuss how they're using technology to improve clinical care. It happens in New York City on July 12. Find out more.

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