Live Telemedicine: The Return on
Investment for Safety Net Providers
in Rural Indiana
Stephanie Laws, RN, BSN
Project Associate
Richard G. Lugar Center for Rural Health
Union Hospital
Advancing rural health through education,
innovation, and collaboration
• Lugar Center History
• Mission Centric Initiatives
• Family Medicine Residency
Program
• Telehealth and Innovative
Technologies
Telemedicine Services
Operational Programs
• Telemental Health
• Telecardiology
• Chronic Disease Management
• Burn Follow Up Care
• Healthy Families Indiana
• RuralConsult.com®
Programs in Development
• Telepulmonology
• Child Psychiatry
• Outpatient Cardiology
Wabash Valley Rural Telehealth Network
Landscape of Telehealth Reimbursement
• The absence of consistent, comprehensive reimbursement
policies is often cited as one of the most serious obstacles to
total integration of telehealth into health care practice.
• 39 states have some type of reimbursement for services
provided via telehealth.
• There are many factors that states use to determine the scope
of coverage for telehealth applications, such as the quality of
equipment, type of services to be provided, and location of
providers (e.g., remote rural sites).
• Most of the financing and reimbursement for telehealth services
comes from Medicare.
Designing a “Live” Telehealth Program to support a Rural
Organization’s Return on Investment
• Does an opportunity exist?
 Community Need
(Prevalence and incidence of disease, provider shortages, etc.)
 Interested stakeholders
(Providers, specialists, patients, etc.)
 Organizational analysis
(Market share, outward migration patterns, payer mix, capacity, bandwidth
availability, willingness to adopt technology, site champion, quality performance,
etc.)
If we build it will they come?
A Case Study: Telecardiology
Project Organization:
Union Hospital-Clinton (UHC)
• Chest Pain Center Accredited
(2008, 2011)
• 2nd largest employer
• Parke and Vermillion Counties
• Agricultural community
• Healthcare Provider Shortage
Area (HPSA)
• Medically Undeserved Area
(MUA)
Community Need: Problem?
• Approximately 61 million Americans are
affected with some form of cardiovascular
disease
• Leading cause of death nationally
• Leading cause of death in Indiana
Cardiovascular Death Rate per 100,000:
United States:
190.88
Indiana:
202.61
Vermillion County:
314.0 (1 out of 92 counties)
Parke County:
218.7
Community Need: Problem?
• Rural populations have certain behaviors and
attitudes that contribute to their heightened risks
of heart disease.
♥ High prevalence and incidence of modifiable risk
factors
♥ Slower rate of lifestyle change
♥ Lower perception of heart disease risk
Identified Needs at UHC
• Lack of standardized cardiology risk
stratification methods
• Lack of cardiology access
• Increased number of low-risk cardiology
transfers
Low-Risk Cardiology Transfers
30
25
20
Patients
Average Transfers
(all) 48.8
15
10
5
0
M08
J
J
A
S
O
Comprised sometimes ½ of patients transferred from ER to tertiary care hospital
Were our Findings Similar to
Others?
• Missed myocardial infarction most litigious misdiagnosis
among emergency departments nationally
• Lack of standardized cardiovascular risk stratification
methods: greater risk for those who are discharged from
the emergency department without work-up
• High number of transfers from critical access hospitals to
tertiary care centers for ongoing treatment for low-risk
cardiology complaints
Plan to Address the Issues
• Examine current work flow and process
• Implement evidence-based risk stratification
tools (Thrombolysis in Myocardial Infarction,
EKG Stratification tools)
• Evaluate methods to improve access to
cardiology care (telemedicine)
Telecardiology Program Goal
• To provide timely cardiology consults for
patients seeking care and treatment at UH
Clinton for low risk Acute Coronary
Syndromes (ACS)–(Chest pain rule in/out)
utilizing live, video interactive telemedicine
technologies.
Identify Key Project Stakeholders
•
•
•
•
•
Cardiology patients presenting to UHC
Union Hospital Medical Staff
Union Hospital Clinical Staff
Providence Medical Cardiology Group
UAP Cardiology Group
Work Flow Analysis
• Develop policies and procedures that would
coordinate and streamline implementation
with key processes already in place.
Routine Admission Orders
Consult ordered by ED
physician, primary care
physician, or hospitalist
Easy to follow checklist
Focused cardiac
assessment
Clinical Education
Carotid Auscultation Points
Cardiac Assessment Points
Process
Technical Training
Telemedicine Implementation
Initial Project Findings
Gender of Patients Jan. 2009-Feb. 2010
N=102
Min= 20
Max=94
Male, 41,
40%
Female,
61, 60%
Male
Female
Payer Source
Payer Source
Private Pay
11%
Commercial
25%
Medicare
58%
Medicaid
6%
Medicare
Medicaid
Commercial
N=102
Private Pay
Referral Pattern
Provider Group
UAP
39%
UAP
PMG
PMG
61%
N=102
Impact on Low-Risk Cardiology
Transfers from UHC
30
Patients
25
20
Implementation
15
10
5
0
J
A
O
D
Average Transfers=54.4
Education
F
A
J
A
O
D
Union Hospital Clinton Emergency Department
“Low-Risk” Cardiology Transfers
July 2008-December 2010
Clinical Education
Project Live
2008
(PP)= Pre-Telecardiology Project
2009
2010
Project Value
All patients: N=69
Medicare patients= 33
Program start to date
(all patients)
Medicare Payers
UHC Revenue Retention
$228,908
$129,228
EMS Charges Saved
$31,950
$13,950
EMS Miles Saved
1242.46
930
Cardiology Miles Saved
2815.56
**Not broken out from total**
CardiologyWindshield
Time Savings
93.6
**Not broken out from total**
Average Patient TIMI
Score
2.18
2.60
2
1
Biomarkers trending up
Chest Pain Transfers
Post UHC Admission
Actual Revenue Capture?
UHC
Fiscal Year
Visit Type
2009
ICD-Chest Pain
Primary Ins.
Group
%Case
s
Cases
Charges
Est.
Payment
Total Cost
Total
Profit/(Loss)
Direct
Cost
Commercial
26.09%
18
142,868
85,238
56,247
28,991
44,108
41,129
IN Medicaid
11.59%
8
77,482
10,802
35,796
(24,995)
28,245
(17,444)
Medicare
47.83%
33
248,072
129,228
109,997
19,231
86,579
42,649
Private Pay
14.49%
10
72,799
3,640
28,171
(24,531)
21,856
(18,216)
Grand Total:
100.0%
69
541,222
228,908
230,211
(1,304)
180,789
Total Contribution
Margin
48,119
Special Notes:
*Only chest pain patients receiving telecardiology service included in this report. Additional patients
were seen via telecardiology service during FY 2009 for other diagnoses including syncope, CHF, a-fib,
etc.*
Official program start date: January, 2009 (Fiscal Year Sept. 1, 2008- August 31, 2009)
Additional Findings…Reduced Risk?
Mean TIMI Score for Chest Pain Discharges from UHC ED
Pre and Post Telecardiology Implementation
3.5
3
2.5
2
1.5
1
0.5
0
3.14
1.38
Pre
Post
Post N=50
Pre N=50
Mean TIMI Score
A Non-Traditional Approach?
Smart Business Tactics?
• Regardless of telehealth reimbursement policy, rural
organizations must analyze the value that a “live” telemedicine
program can bring.
• Focus must be on retained market share, reduced outward
migration, enhanced quality performance.
• Demonstration of enhanced workflow for specialists through
teleconsult integration into daily office routine.
• Associated revenue: Outpatient studies, Rx fill, local resource
utilization.
• Community awareness and marketing.
• Sound program evaluation strategies can have the influence to
impact policy- just not quickly.
Impact on Rural Population
Next Steps
• Replicate “Blueprint”
• Continual performance and ROI analysis
• Develop data base for benchmarking among
multiple CAH sites
• Create additional telemedicine-based
programs following similar methodology
• Result dissemination
Special Acknowledgement
•
•
•
•
•
•
Richard G. Lugar Center staff
Indiana State Office of Rural Health
Union Hospital Clinton
Providence Medical Group
Union Associated Physicians Clinic
HRSA – ORHP – Office for the Advancement
of Telehealth (OAT)
Questions
Richard G Lugar Center
for Rural Health
www.LugarCenter.org
Stephanie Laws, slaws@uhhg.org