Plans, providers say telemedicine improves diabetes management

From a California safety-net plan to Mississippi's sole academic medical center, payers and providers alike cite benefits from utilizing telemedicine as a strategy for diabetes care management. Here are two success stories;

1. Partnership HealthPlan, a Medi-Cal managed care plan covering 14 rural counties in northern California, is experiencing care improvements from its $265,800 investment in telemedicine efforts, says Robert Layne, Partnership's director of government and public affairs.  

Robert LaynePartnership aims to deliver high quality care to  its 530,000 members, whether it's done through the electronic exchange of medical information from one site to another or by other approaches, Layne says. Preliminary results show the telemedicine strategy is driving down ER visits among plan members with diabetes and other chronic illnesses, and wait-times for specialists are falling, he says.

Previously, a rural health center serving as a Partnership telehealth site had an eight-month backlog for endocrinology appointments, Layne notes. But the center, by holding two telehealth clinics a month, decreased the average wait-time to nine days for such appointments.

Telemedicine “gives members the opportunity to see a specialist sooner and closer to home,” he says. “Members who may have otherwise foregone medical services due to lack of specialists in their area and or a lack of financial resources now have another option...”

2. Since the University of Mississippi Medical Center (UMMC) began leading the Diabetes Telehealth Network in August 2014, none of the first 100 patients enrolled in the pilot has had to go to the emergency room or hospital for diabetes care, says Kristi Henderson, DNP, the medical center's chief telehealth and innovation officer. Previously, many had visited the ER or hospital several times annually.

Kristi Henderson“We've had an average decrease of 1.7% in A1C [blood glucose testing], and a 96% compliance rate for medications,” compared to a national average of around 60%, Henderson says, explaining that the diabetes telehealth pilot launched in one medically underserved county in the Mississippi Delta with a soaring rate of diabetes. “And we found 11 cases of retinopathy that needed ophthalmic intervention.”

In fact, the telediabetes program-with remote monitoring in the home for patients given tablets to record data-is improving outcomes and saving money to such an extent that UMMC and its partners, including the state and technology vendors, decided to roll the program out statewide before the pilot has finished enrollment. (Out of targeted enrollment of 200, 127 people with diabetes were signed up as of July 12.)

UMMC's broader telehealth effort involves 35 medical specialties at 176 telehealth locations around Mississippi, including health departments, schools and businesses, Henderson says. The system handles 100,000-some patient visits annually.

NEXT: Reimbursement outlook

Reimbursement Outlook

Proponents assert that telemedicine helps to maintain network adequacy amid a national clinical workforce shortage disproportionately affecting rural areas. They cite technological advances giving clinicians access to real-time data useful in managing diabetes remotely-from patient-collected blood glucose levels to information on dietary intake, exercise and medication, and images of retinas, foot ulcers and more- that can be analyzed with decision-support software.

Among recent studies, Danish researchers found a higher mortality incidence for patients getting telemedical monitoring rather than standard outpatient monitoring for diabetic foot ulcers. But they found no significant difference in amputation and healing between the two groups.

To date, 29 states and the District of Columbia have enacted telemedicine parity laws requiring private payers to cover telehealth services to some extent, according to the American Telemedicine Association (ATA). Another five state legislatures still in session are considering such parity laws.

Under Medicaid, states are able to decide whether to cover-and how to reimburse-for telemedicine; and 48 state Medicaid programs have some type of coverage, ATA reports.

In July, several House members reintroduced the bipartisan Medicare Telehealth Parity Act (H.R. 2948). It aims to expand coverage of telehealth services and allow remote patient monitoring of chronic conditions such as diabetes. Also in July, the House passed the 21^st Century Cures Act (H.R. 6). It calls for the Medicare Payment Advisory Committee to study telehealth reimbursement and Centers for Medicare and Medicaid Services (CMS) to identify populations likely to benefit from the technology.

NEXT: Barriers to telemedicine as a health management option

Barriers to Telemedicine Health Management

Partnership HealthPlan has four telemedicine sites offering endocrinology services, with a fifth site slated for August, Layne says. The plan contracts with TeleMed2U, a multi-specialty physician group providing specialists through telemedicine, to offer a real-time live video connection with an endocrinologist and patient education on diabetes, he says.

Endocrinology visits totaled 153 from the telehealth program's start in August 2014 through May 2015, "and will only continue to rise," says Layne.

He cites challenges, noting Partnership is paying for telehealth as the state figures out how to reimburse for it. Partnership is working with the state on legislation to allow federally qualified health centers, which can only bill for face-to-face encounters, to include telemedicine reimbursement in their wrap-around payment system, he says. A bill enacted into law would need CMS regulatory approval.

Partnership also is providing training and pairing physicians already involved in telehealth with other doctors, Layne says.

NEXT: A Physician's Perspective on Diabetes Health Management

A Physician's Perspective

David Klonoff, MD, medical director of the Diabetes Research Institute at Sutter Health's Mills-Peninsula Health Services in the San Francisco Bay area, describes telemedicine as a promising strategy for diabetes to improve outcomes and reduce care costs.

David KlonoffAccording to Klonoff, an endocrinologist in practice 34 years, telemedicine is well-suited for diabetes, as compared to other diseases, because diabetes management requires interpretation and predetermined responses to many types of data that patients can measure at home. He notes the strategy could work for delivery models such as accountable care organizations, in which cost savings accrue back to providers in some way.

Klonoff cites advances in diabetes technology, including improvement in sensors and software to support recommendations and treatment plans. Remote monitoring of patient data "opens the door to address anything out of range," he says, explaining that a "filtered" system is key.

Klonoff envisions assigning a telemedicine nurse to patients with diabetes post-hospitalization. "Currently, when people go home, we don't have a good handle on how they're doing," he says. "... If you have a system transmitting data, and software to analyze it ... you have an opportunity to intervene with as many resources as are needed for people doing poorly: especially for people just out of the hospital."

Banner Health, a Phoenix-based nonprofit health system, recently released six-month results on its telehealth pilot in Arizona for complex chronically ill people, many of whom have diabetes. Its Intensive Ambulatory Care Program, using at-home tablets to connect 135 patients with their primary care physicians, pharmacists, nurses, social workers and health coaches, reduced care costs by 27%, driven by a 45% reduction in hospitalization, shorter lengths-of-stay and reduced outpatient costs.