Health Care Reform, Telepractice, and
A Look at the Future of
Reimbursement for Audiologists and
SLPs
Janet Brown, MA CCC-SLP
Director, Health Care Services—ASHA
MSHA Oct. 20, 2012
Speaker Disclosure
Financial
• ASHA employee since 1997
Non-financial
• Ex officio for Business
Practices,Telepractice Committees
• Member, American Telemedicine
Association
• “America’s health care is essentially a
cottage industry of fragmented, dedicated
artisans who eschew standardization. Care is
frequently highly variable, and performance
is, in large part, unmeasured.”
Swenson, et al., 2012.The Mayo Clinic value creation system. AJMQ 27 (1), 5865.
What is the Problem?
• Health care spending has doubled as share
of GDP in 30 years

9.2 to 17.9
• Medicare population will grow by 1/3 in the
next 10 years
• Variation in spending by region without
evidence of difference in outcomes
Source: MedPAC report, March 2012: Executive Summary
Problems with Current System
• Fee-for-service creates incentives for
unnecessary care
• Variability in payment across settings
• Fragmented care (ex:VFSS)
• No penalties for bad outcomes (e.g.,
rehospitalization)
Components of the Patient Protection
and Affordable Care Act (2010-2014)
Expanded Coverage
• Dependents
• Medicaid eligibility
• Exchanges (Iowa Affordable
Insurance Exchange)
• Individual mandate
Payment
• Bundled
• Incentives for quality
Adapted from Fabius, et al. 2012.
Vocabulary of Health Care Reform.
Thomson Reuters
Care Coordination
• Medical homes
• Accountable care
organizations
Delivery Innovations
• EHR
• Meaningful use
• Disease management
Essential Health Benefits—Medicaid
and Exchanges
• 10 categories that must be included
Ambulatory patient services
Prescription Drugs
Emergency Services
Rehabilitative and Habilitative
Services and Devices
Hospitalization
Laboratory Services
Maternity and Newborn Care
Preventive and Wellness Services and
Chronic Disease Management
Mental Health and Substance Use
Disorder Services
Pediatric Services, Including Oral and
Vision Care
SLPs and Pediatric Services
• % of SLPs in health care providing services



17% to infants and toddlers
13% to preschoolers
11% to school-age children
• 27% provide Early Intervention services
• 20% of SLP caseload in autism up
considerably from 6% in 2009
Source: 2011 ASHA SLP Health Care Survey
Medicare
• Medicare Part A—hospitals, SNFs


May join ACOs
Bundled care
• Medicare Part B—outpatient




Alternative to therapy caps—
Documentation of outcomes
Bundled care, ACOs
Episodic payment?
The New Order in Health Care—
Public and Private Pay
•Value
Transition to Measures
• Accountability through programs involving
measures
• Quality reporting systems affect
reimbursement

Under Medicare
• Hospital value-based purchasing
• Physician Quality Reporting System
Outcome Measures
• National Outcomes Measurement System
(NOMS) developed by ASHA


Data collection system that illustrates the value
of SLP services
Uses Functional Communication Measures
(FCMs), a series of disorder-specific, sevenpoint rating scales to describe the change in an
individual's functional communication and/or
swallowing ability over time
ASHA NOMS
• SLPs register to become a NOMS user (free)
• Submit FCM scores at admission and discharge
•
•
•
(online database)
Submit data on diagnosis, tx frequency, etc.
Receive standard reports and national
benchmarking data
More information at
http://www.asha.org/members/research/noms/
NOMS
• In 2008, eight of the 15 adult FCMs were endorsed
by the National Quality Forum (NQF) as quality
measures
• NOMS can be used as an objective measurement
tool for home health reassessments or Part B
documentation
How Will Life Change
• Billing for services
Fee for service to episode of care
 Bundling/ACO
• Documentation systems
 EMR
 ICD 10
• Documentation/Justification of services
 Value/outcomes
 Medical Necessity

What We May See More Of
• Different levels of care within episode



Support personnel
Community
Family/caregivers
• Use of technology


Telepractice/videoconferencing
Technology apps/tools for independent practice
What You Can Do
• Look at your practice





How can you be more efficient?
• Process, documentation, practice
How do you measure your outcomes?
Are you diversified?
What are your competitors doing?
Reach out to potential referral sources, ACOs
What You Can Do
Be informed



ASHA Leader
ASHA web site: Health care reform page
ASHA Healthcare Landscape Summit
recommendations
What You Can Do
• ADVOCATE!



Respond to Take Action—ASHA Grassroots
network
Contact your representatives at home
Capitol Hill visits
Role of Telepractice in Health Care
• Increasing access



to providers
to specialists
to equipment
• Savings costs


travel
Complications from delayed treatment
Role of Telepractice in Schools
• Respond to shortages
• Efficiencies in reducing driving time
ASHA’s Definition
• Telepractice is the application of
telecommunications technology at a distance
by linking clinician to client, or clinician to
clinician for assessment, intervention, and/or
consultation.
ASHA, 2005
Speech-Language Pathologists Providing
Clinical Services via Telepractice: Position Statement
Terminology Makes a Difference
• Using telepractice as a means of direct
service delivery


Telespeech, telehealth, telemedicine, telerehab,
teletherapy
Typically via teleconferencing (“face-to-face,”
but not “in person”
• NOT distance education
• NOT distance supervision
Why This Can Be Confusing
• Telepractice: students delivering services
via teleconferencing with supervisor sitting
with them
• Telesupervision: Clinical Fellow delivering
services face-to-face with supervisor
observing via teleconferencing
And In Education…
• Distance learning may incorporate
interactive videoconferencing, virtual
classrooms
• May be used to teach SLPs
• Not used to describe SLP services
Quality Qualifier
2005 Position Statement
• "The use of telepractice does not remove any
•
existing responsibilities in delivering services,
including adherence to the Code of Ethics, Scope
of Practice, state and federal laws (e.g., licensure,
HIPAA, etc.), and ASHA policy documents on
professional practices."
“Therefore, the quality of services delivered via
telepractice must be consistent with the quality of
services delivered face-to-face." Position Statement,
2005
Challenges of Developing “Standards”
• Rapid advance of technology
• Lack of comparative effectiveness research
on different types of technology
• Scope of the professions: broad range in



age
disorders
assessment and treatment procedures
Quality Components
• Provider competence
• Patient selection
• Technology selection
• Transmission quality
• Efficiency, effectiveness of service
• Patient, caregiver, provider satisfaction
ASHA’s Telepractice Resources
• www.asha.org/teleprac
tice






Video clip
Policy documents
Articles
Model licensure
regulations
Reimbursement
information
Bibliography
Types of Telehealth
• Synchronous (real time)
• Asynchronous (store and forward)
• Self-monitoring (not typically used in SLP)
Technology Is Used To…
• Capture
• Camera, microphone,
peripheral devices
• Transmit
• Display
• Bandwidth
• Computer,videoconfer
encing equipment
Technology
• Equipment



Hardware
• Dedicated system, computer
• Camera, monitor, microphone, multisite
capability
Software
Peripheral devices
• Document camera, videoendoscope
Collaboration
• Whiteboards
• Chat
• Screen sharing
Technology
• Connectivity





Connection speed (bandwidth)
Minimum cited in research: 384 kps
Standard definition vs high definition
Influenced by others using same bandwidth
Quality consequences
• Delays, jitter, loss of data, turntaking
Licensure
• What is licensure for?
• Current status—full licensure in state where
client resides
• What are other disciplines doing?
• ASHA model regulations: general and
interstate practice
Privacy & Protections
• FERPA

School records
• HIPAA

Privacy of protected health information for
providers and their business associates
• Notification/Consent
• Secure transmission via virtual private
networks, firewalls, encryption
Reimbursement--Medicare
• Physicians, nurses, CSWs, psychologists,
dietitians for selected CPT codes
• Designated originating sites


Rural health professional shortage area
Outside Metropolitan Statistical Area
• ASHA and ATA advocacy
• http://www.cms.hhs.gov

Search Telehealth Services Fact Sheet
Reimbursement--Medicaid
• Varies from state to state
• Need approved CPT codes to receive payment for
•
•
•
using modifier
Oklahoma has established Medicaid payments
with schools receiving origination fee
Missouri, but not for schools
Kentucky and Virginia are pending
Reimbursement--Private Insurance
• Trend for state
legislation to mandate
payment for approved
services
• CareFirst Blue
Cross/Blue Shield (see
ASHA Leader story)
Reimbursement--Schools
• Largest area for reimbursed telepractice
• Within-district or contractor services
• Virtual schools—some providing special ed
and related services

e.g., North Carolina, Idaho, Colorado, PA
“It’s Not the Technology”
• Planning, stakeholder support, training



Business plan
Who are the stakeholders
• Licensure, school boards
• Administrators at all levels
• Teachers, facilitators
• Parents, clients
Training and information: managing expectations
Technology
• Available bandwidth, firewalls
• Ongoing tech support
• Other means of connection when there is a
problem
Research
• More articles being published on comparability, esp. from
•
•
Australia
 Tests for dysarthria, CELF
 LSVT, Lidcombe, voice, post-laryngectomy, aphasia,
apraxia, swallowing, fluency, early intervention
Telehealth Journals:
 Telemedicine and e-Health
 Journal of Telemedicine and Telecare
Bibliography at www.asha.org/telepractice
Other Telehealth Groups
• American Telemedicine Association
• Center for Telemedicine and e-Health
• Association of Telehealth Service Providers

Telemedicine Information Exchange
• Office for Advancement of Telehealth
(HRSA)
Questions?
Janet Brown
Director, Health Care Services
jbrown@asha.org
301-296-5679