Healthcare is a busy space, with lots of new companies trying to gain a foothold. A new referral network launched by NeuroFlow, bringing together several innovative services onto one platform, may be the answer for health systems looking to expand their behavioral health resources.
The shifting sands of the healthcare sandbox have attracted new players, as telehealth companies, payers and retail giants like Amazon and Google all look to compete for healthcare dollars. But while the line between a vendor and a provider gets murkier, new strategies are emerging that emphasize collaboration rather than competition.
One such example is NeuroFlow, a Philadelphia-based digital health company that has worked in the past with large networks like Jefferson Health and Magellan Federal. Recognizing that the behavioral health service they offer is just one part of the puzzle, the company launched a referral network this past July with a group of similar companies offering behavioral health services. The idea was the create a digital health platform that could be accessed by consumers looking for help as well as health systems seeking resources for their providers and patients.
"The impetus for the referral network is to improve access to behavioral healthcare for all populations, streamlining the relationship between providers and technology platforms, as the adoption of new tools continues to accelerate in the industry,” Chief Executive Officer Chris Molaro said in a press release announcing the partnership with LifeStance Health, Array Behavioral Care, Brightside Health, and Marvin.
“The formation of these referral partnerships will complement the needs of the existing – but evolving – healthcare infrastructure," he added. "Bottom line: if someone needs to see a licensed mental healthcare professional, we will ensure that it happens when it's needed, whether in-person or remotely.”
To understand how this type of platform might be a resource for health system leadership, HealthLeaders sat down for a virtual chat with Parker Reynolds, NeuroFlow's head of strategic partnerships:
Q. How do you choose the healthcare organizations with which you want to partner?
Reynolds: All partners are companies whom we believe have strong clinical expertise and good user experiences. When choosing partners we tried to maximize for a breadth of insurance and state eligibility as well as a breadth of conditions and severities covered. Together, these companies have behavioral health providers in all 50 states and across a variety of health insurance options, and we are in active discussions with several other companies.
Q. Are organizations more receptive to partnerships these days?
Reynolds: I think you’re going to get a different answer from every company, but from NeuroFlow’s perspective, we’re definitely encouraged by the conversations we’re having and alliances that have been formed. Organizations are seeing a need to have connected resources for their patients/members to increase utilization and minimize confusion. There needs to be more education in the market about what technologies are available to providers, and this is one way to achieve that. By aligning these partners, we are helping to dismantle the bureaucratic notion of a patient needing to be 'in network' to receive the right care at the right time. This model allows for different partners to be activated for specific, tailored patient care.
Q: As evidenced by the recent Amazon-One Medical news, competition is increasing in the healthcare space. How do you address that?
There is a healthy competition in the industry as a whole, but Amazon still has a long road ahead. An acquisition comes with a lot of serious, hard to answer questions. For example, what’s the best way to integrate behavioral health into the primary care clinics One Medical owns? This will have massive implications, many which are still unknown.
Q: Has the pandemic changed how healthcare organizations view these partnerships, or how they address access to care for those facing barriers?
Reynolds: I think partnerships like this are a reflection of the industry’s willingness to collaborate and support the various operational needs of healthcare providers today – from large systems to clinics, and even government organizations. We know that the pandemic accelerated the use of digital tools for things like behavioral health care screening. But these partnerships help create a more palatable way for organizations to approach behavioral health integration for the first time.
Q: How will these types of referral networks evolve? What more can they do or what other networks can be created?
Reynolds: We plan to continue to expand our partnerships into more specialty condition areas. For example, chronic pain, OCD, and substance use. Additionally, we will continue to evolve existing partnerships through deeper technical integrations to enable more seamless user experiences that ensure all providers have a complete picture of patient care.
Q: Are large health systems or hospitals interested in these types of arrangements?
Reynolds: We have seen that even large health systems who have their own in-house behavioral health resources are still facing capacity constraints and are open to partnerships to help with segments of their population. Furthermore, these partnerships are not exclusive and by building out the infrastructure and processes, we are able to more effectively triage individuals into the right care providers within the system.
The pharma giant has unveiled DTx Connect, which will enable clinicians to prescribe, through their EMR platforms, select digital health treatments and manage care and adherence.
Pharma giant AmerisourceBergen is jumping on the digital therapeutics bandwagon, with plans to create a platform through which healthcare organizations can access and prescribe novel digital health treatments.
The Pennsylvania-based drug wholesale company this week announced the launch of DTx Connect, an ordering, dispensing, and fulfillment platform designed to help both prescribing clinicians and the growing ranks of digital therapeutics companies offering digital health alternatives to the traditional standard of medication or in-person care.
“While digital therapeutics and diagnostics offer tremendous potential, addressing challenges across the provider workstream and patient journey remain critical to unlocking the value these products have to offer,” Jason Dinger, SVP of Strategy and Innovation at AmerisourceBergen, said in a press release. “Given our role in the supply chain and our portfolio of commercialization services, we are uniquely positioned to build a solution that aims to address unmet needs and helps patients start and stay on physician-ordered products. DTx Connect, in addition to AmerisourceBergen’s patient support and market access consulting services, enables us to deliver enhanced support across the product lifecycle, helping to advance accessibility.”
As defined by the Digital Therapeutics Alliance, digital therapeutics are software-based interventions delivered directly to the patient to treat, manage or prevent a wide range of disorders and diseases, including behavioral health concerns and chronic conditions. Officials say the US market is expected to grow roughly 25% per year through 2030.
The service is designed to integrate with electronic medical records (EMR) platforms, enabling clinicians to ePrescribe through the EMR. With patient engagement technology developed by Twistle, the DTx Connect platform delivers a welcome message to the patient on behalf of the care team via text or a patient portal, along with a link to download the digital therapeutic product and access educational resources.
The platform also enables the care team to text, call, or deliver messages through a companion app to ensure proper use and engagement, along with adherence monitoring, and it allows for patient status alerts, including notifications for patient fulfillment.
Several digital health companies plan to offer services on the platform, according to AmerisourceBergen executives, including pediatric behavioral health company Cognoa, chronic care management company Mahana Therapeutics and Videra Health, which offers AI-assisted video assessment and remote patient monitoring services.
By a near unanimous vote, the US House of Representatives has passed a bill expanding telehealth access and coverage for Medicare services until the end of 2024, while making those flexibilities permanent for FQHCs and RHCs. The bill now goes to the Senate.
Congress is halfway toward extending telehealth flexibilities enacted during the pandemic until the end of 2024.
The US House of Representatives this week passed the Advancing Telehealth Beyond COVID-19 Act of 2021 (HR 4040) by a 416-12 vote, sending the issue on to the Senate. The bill, introduced more than a year ago by US Rep Liz Cheney (R-Wyoming), expands the definition of "originating site" to allow more locations to use telehealth, eliminates facility fees for new sites, expands the list of healthcare providers able to use telehealth, adds audio-only telehealth to the definition of "telecommunications system," and makes permanent the ability of federally-qualified health centers (FHQCs) and rural health clinics (RHCs) to use telehealth under the Medicare program.
These flexibilities were put into place by the Centers for Medicare & Medicaid Services (CMS) at the onset of the COVID-19 crisis to help healthcare organizations expand access to and coverage of telehealth services, with the caveat that they be terminated at the end of the public health emergency (PHE). The bill's goal is to give providers a better idea of how long they have to use those flexibilities before they either end or Congress takes more action.
The bill's passage drew immediate praise from the American Telemedicine Association (ATA) and its lobbying group, ATA Action.
“Today, we took a significant step forward in providing much needed stability in access to care for millions of Americans, with the US House vote to extend key telehealth flexibilities implemented during the COVID-19 Public Health Emergency (PHE) until the end of 2024," Kyle Zebley, the ATA's vice president of public policy and executive director of ATA Action, said in a press release. "We cannot allow patients to lose access to telehealth post-pandemic, and this bill will provide stability through 2024, while giving Congress time to address how to make the policies permanent."
“Telehealth has long been a bipartisan healthcare issue and we now turn to the Senate to ensure this important piece of legislation makes it to President Biden’s desk so he can sign it into law,” he added.
The American Medical Association also weighed in on the issue.
“Increased Medicare-covered access to telehealth has been a lifeline to patients and physicians throughout the COVID-19 pandemic, and the American Medical Association (AMA) is pleased by today’s bipartisan vote in the House," AMA President Jack Resnick Jr., MD, said in a statement. "The COVID-19 public health emergency made plain that care via telehealth should be available to all Medicare patients, especially with their own physicians, regardless of where they live or how they access these services. From continuity of care, broadened access to care, and removing geographic and originating-site restrictions, our hope is that the flexibilities afforded during the public health emergency will be made permanent."
Passage of the bill is significant not only because of the margin of victory in the House – indicating strong bipartisan support for telehealth – but because Congress has taken action on the issue. Dozens, if not hundreds, of bills have been proposed in both the House and Senate these past few years aimed at expanding telehealth access and coverage, many seeking some or all of the flexibilities outlined in the Cheney bill, but very few have seen any votes.
Passage in the Senate is no done deal, even with the House's strong support. But Senator Joe Manchin's (D-West Virginia) recent shift to support the Inflation Reduction Act may hint at a willingness to move forward on other issues as well, including healthcare. And the bill does have the backing of the Biden Administration.
"It is important to continue the availability of expanded telehealth to meet the needs of Medicare beneficiaries and health care providers," the Executive Office wrote in a Statement of Administration Policy shortly before the House vote, noting that telehealth visits increased 63-fold in 2020, especially in rural areas and for behavioral health services. "As we emerge from the worst stages of the COVID-19 pandemic, H.R. 4040 will ensure that the Medicare program continually adapts to provide convenient, quality, accessible, and equitable healthcare."
The Senate can now vote on the House bill, vote on its own version of the bill, combine the two, or do nothing.
And while Senate passage of the bill is now top of mind, advocates will continue to push for permanent expansion for some or all of those flexibilities, arguing that telehealth has proven its value during the pandemic.
The two large health systems are joining forces to use 'the most current data science and years of deidentified patient outcomes to find diseases earlier and start patients on paths to better health more quickly.'
Mercy and the Mayo Clinic have announced a partnership to use data and technology to improve care management.
The deal brings together two large health systems with long and storied track records in innovation and aims to combine their talents in using "the most current data science and years of deidentified patient outcomes to find diseases earlier and start patients on paths to better health more quickly."
“This unique collaboration will eliminate the barriers to innovation in healthcare by bringing together data and human expertise through a new way of working together,” John Halamka, MD, an emergency medicine physician and president of the Mayo Clinic Platform, said in a press release issued this morning. “By working together, we will be able to find the best paths for treatment and diagnosis to benefit patients everywhere. Our union has the potential to transform medicine worldwide.”
We have a unique opportunity today to transform mountains of clinical experience into actionable information that optimizes patient care,” added John Mohart, MD, a cardiologist and president of Mercy communities. “This gives physicians, providers and operational leaders critical information that can ensure patients receive the right treatment at the right time based on millions of previous patient outcomes, while simultaneously improving operational efficiencies and lowering costs. We believe bringing technology and data science to the bedside can provide better patient care, shorter hospital stays and overall better health for people everywhere.”
The collaboration will focus initially on data-sharing for patient outcomes, a natural goal for two early adopters of electronic health records technology. Their work will target two domains:
Information collaboration. Mayo and Mercy will work with data that has been de-identified and secured in a distributed data network accessible to both organizations. They'll use that information to "analyze patterns of effective disease treatment and, more importantly, disease prevention in new ways based upon longitudinal data review over an extended period of time."
Solution and algorithm development and validation. These algorithms, executives say, "will provide proven treatment paths based on years of patient outcomes, representing the next generation of proactive and predictive medicine that can be used by care providers around the world to access best practices in medical care."
Officials say the project may spawn other collaborations involving neuroscience, cardiovascular and complex cancer care and precision medicine, to name a few.
Experts say that obesity rates have doubled over the past two decades, with roughly 42% of the American adult population now fitting that description, and they anticipate that half of the world's population will be obese by 2030. Obese Americans run a much high risk of developing chronic conditions like diabetes and heart disease, and they account for roughly $480 billion in annual direct healthcare costs.
Yet the healthcare industry has long struggled to define obesity.
"Obesity has not been traditionally seen as a disease," says Maria Daniela Hurtado Andrade, MD, PhD, a specialist in endocrinology with the Mayo Clinic and part of the research team. "That limits treatment options" as well as how payers view treatments. "Our goal is to collect all this data to understand how it can lead to a very good understanding of predictors to weight loss and weight loss interventions."
The biobank registry collects biological and clinical data from patients, including DNA, metabolomics, hormones and observational information such as behavioral assessments. The data will help researchers gain a better picture of obesity, and has already been instrumental in mapping out four specific obesity phenotypes.
The Mayo Clinic's Rochester campus is contributing patient outcomes from 2,000 patients undergoing treatment for obesity to the biobank, and it will be participating in the nationwide study aimed at monitoring the phenotypes of patients undergoing a variety of treatments in health systems across the country.
Hurtado sees biobank registries as the next step in the ever-growing precision medicine movement, which aims to not only perfect the gathering of individual data but design treatments that address specific patients or groups of patients.
From that point, researchers focus on phenotypes, or the combination of genes and environmental and behavioral factors that cause certain conditions. Hurtado calls this activity of studying and mapping the function of genes "the Snapchat of the state of health."
"We don’t have that understanding of obesity yet," she says, because the healthcare industry has been slow to characterize it as a disease. "Too many [providers] have a view of obesity as 'You caused it.' They don't see it like they see cancer" or other chronic conditions like diabetes, asthma, and COPD.
According to Phenomix and the Mayo Clinic, there's a movement within healthcare to take obesity more seriously and classify it as a chronic condition, caused by not one specific disease but "a constellation of diseases." While its roots may lie in the DNA, they feel that outside factors including age, race, gender, education, and socioeconomic status also have an impact.
Hurtado says the partnership between Phenomix and the Mayo Clinic is important because it legitimizes the biobank at a time when other research institutes may be developing their own resources, which in turn leads to data silos that hinder research. Officials hope the Mayo Clinic's participation will spur other health systems to join.
“This is an exciting time in the evolution of obesity medicine,” Mark Bagnall, CEO of Phenomix Sciences, said in a May press release announcing the Mayo Clinic partnership. “Our biobanking agreement with Mayo Clinic is an important opportunity to make vast strides in how we understand the complexities of obesity treatment. We believe the biobanking registry investment will better support obesity centers by providing concrete evidence and insights into how DNA and other factors need to be considered in treatment. The upside is significant for patients and payers. Patients get the right treatment the first time and payers avoid paying for a costly trial-and-error approach.”
Hurtado says both the registry and study will be "life-changing."
"In the past, treating obesity has been like shooting in the dark," she says. "Now we're beginning to take it seriously. This will lead to positive outcomes in treatment, which will make payers take interest ... and become more open to coverage."
Vanderbilt University Medical Center has designed an innovative care management program that has helped Metro Nashville Public Schools save thousands of dollars and improve outcomes for its pregnant teachers.
A bundled payment program developed by Vanderbilt Health for the Metro Nashville Public Schools (MNPS) health plan saved more than $400,000 in its first year, while dramatically improving clinical outcomes for expectant teachers and their babies.
The success of the MyMaternityHealth program, says CJ Stimson, MD, JD, chief medical officer at Vanderbilt University Medical Center and Vanderbilt University Employee Health Plans, is based on the idea that patients and their care providers are a team.
"People don't feel like their health systems are going with them on their journey," says Stimson, who's also senior vice president of value transformation in VUMC's Office of Population Health. "So we told them we'll take all the risk."
Bundled payment programs were once considered the future of healthcare and the foundation for value-based care, but there have been just as many failures as successes. In their most basic form, they assign a certain payment that a care provider will receive from a payer for a care path, such as surgery or acute care treatment. The care provider creates a treatment plan based on the knowledge that they will be paid that one amount, accepting the risk that treatment won't become complicated and cost more than what was paid.
The program compels providers to focus on improving outcomes and ensure that each treatment offers value. And it creates an incentive for trying new strategies that reduce costs and boost outcomes.
Stimson, who spent several years as an advisor to the Center for Medicare & Medicaid Innovation, which defined Medicare's bundled payment strategy, says the program gives care providers the freedom to map out how they want a treatment plan to work.
"Our providers were the ones who really designed that clinical experience," he says. "It really kind of liberated them."
CJ Stimson, MD, JD, chief medical officer at Vanderbilt University Medical Center and Vanderbilt University Employee Health Plans and senior vice president of value transformation in VUMC's Office of Population Health. Photo courtesy VUMC.
In this program, providers are given the freedom to follow their care plan without, as Stimson puts it, "asking for permission all the time."
"How you pay for care matters," he says. "This changes how you deliver care. You throw out all the old payment rules and start with a clean slate, and you design the best patient experience that you can."
The program recently earned a KLAS Research Points of Light Award for Vanderbilt Health and Cedar Gate Technologies, which provided the technology infrastructure that allows Vanderbilt to gather and track data and manage their patient population. According to KLAS, the award "celebrates success stories—or points of light—from payers, providers, and healthcare technology companies that work collaboratively to align care delivery with health plan sponsor initiatives to reduce inefficiencies and improve the patient experience."
Stimson says he'd initially proposed musculoskeletal care as an ideal service for a bundled payment plan, but the MNPS health plan suggested maternity care. The health plan was seeing high rates of C-sections and neonatal intensive care unit (NICU) services, two expensive services that are sometimes linked to a lack of preventive care or gaps in maternity care.
The key to an effective bundled program, he says, lies in the data. Care providers need that information to map out a care management plan that anticipates needs before they occur and reacts to trends before they develop into concerns.
"Predictability is important," he says. With that data in hand, providers have a better chance of identifying gaps in care and correcting them, or recognizing that a certain patient may be trending toward a complicated birth and putting resources in place to ease those complications.
Vanderbilt and the MNPS health plan have seen some measurable results since launching the bundled payment program. The c-section rate dropped from 40% to 29%, a 25% reduction over the historical marketplace experience, while NICU spending decreased about 16% in the first year. That amounted to about $400,00 in savings during that first year, alongside an increase in healthy births and a Net Promoter Score in the 90th percentile.
In addition, the program removed out-of-pocket costs for patients, saving each mom-to-be as much as $2,500.
"That's a significant savings," Stimson says. And it's a key metric for this population. Eliminating those out-of-pocket costs reduces stress on new or soon-to-be mothers and their families, taking away a factor that can lead to complex or complicated births and healthcare challenges.
Stimson says the program works because it eliminates one of the biggest hassles in care—who pays for what and when—and gives patients and their care providers the freedom to focus on care. And with data in hand from their technology platform, care teams are more confident in knowing how each patient is doing and can spot trends before they become concerns. Patients, meanwhile, get help when they need it, and are encouraged to follow doctor's orders and maintain healthy habits.
Vanderbilt now has several bundled payment programs up and running: Total joint, spine, bariatric, and cochlear implant services were launched in 2021, and medical weight loss, osteoarthritis, and shoulder pain were added this year. Across these bundles, the health system is seeing roughly 250 enrollments per month so far in 2022.
"We want to keep expanding our portfolio to other service lines," Stimson says.
He'd also like to introduce more telehealth and digital health services, even remote patient monitoring, to create what he calls a "care package" around patients. There might also be room for care navigators to help patients identify and access healthcare services and additional resources.
And he'd like to show off the program to other health systems and explain how it works.
"We don’t have it all licked," he says. "These programs only work if everyone is on board … but this proves that [bundled payment programs] can make a difference."
Amazon has announced plans to buy concierge care company One Medical for almost $4 billion, positioning the retail giant right in the middle of an ever-growing battleground for primary care.
Amazon is getting into the primary care business.
The retail giant has announced that it is acquiring One Medical, the concierge-styled primary care company with a telehealth platform and more than 125 brick-and-mortar locations scattered across the country. The deal, valued at roughly $3.9 billion, would be Amazon's third-largest acquisition, giving the company a physical footprint alongside Amazon Pharmacy and Amazon Care, a virtual care platform for businesses.
“We think healthcare is high on the list of experiences that need reinvention,” Neil Lindsay, Amazon's senior vice president of Amazon Health Services, said in a press release. “Booking an appointment, waiting weeks or even months to be seen, taking time off work, driving to a clinic, finding a parking spot, waiting in the waiting room then the exam room for what is too often a rushed few minutes with a doctor, then making another trip to a pharmacy – we see lots of opportunity to both improve the quality of the experience and give people back valuable time in their days.”
“There is an immense opportunity to make the health care experience more accessible, affordable, and even enjoyable for patients, providers, and payers," added One Medical CEO Amir Dan Rubin, who will continue as CEO.
The announcement fits with the idea that primary care is becoming a hotly contested battleground, featuring competition from traditional healthcare organizations as well as telehealth companies and payers with their own provider networks and retail behemoths like Amazon, Google, Walmart and Walgreens.
All are trying to lay the groundwork for on-demand primary care services, either in person or through virtual care channels. Amazon's strategy is to make that encounter as ubiquitous as buying something on its website.
Nathan Ray, a partner in the healthcare segment of national management and technology consultant West Monroe, said the deal makes Amazon a major player in the ever-shifting healthcare market.
"Amazon continues to make forward progress towards being a broad and dynamic healthcare entity with the acquisition of One Medical, their activity here and in recent past within many of the most actively evolving areas of healthcare has shown they have an evolving strategy towards developing their role in the healthcare marketplace and now entering primary care (and risk contracting) the true center of focus and change after incrementally building relevance in DME, pharmacy, virtual care and employer health," he said in an e-mail to HealthLeaders.
"Amazon and One Medical will have some great opportunities to continue to improve on today’s technology and in particular evolving digital intelligence and engagement technologies that drive intervention, clinician effectiveness, and action based on both historic and real-time data and analytics that underpin the ability to develop and scale successful care models," he added.
Ray noted further that the deal does have some concerns.
"This move tells us both that Amazon is aware of what they lack, but also that they really may not have a grand strategy as of yet but are continuing to find value buying (particularly on the downbeat of the market here) and developing both solutions and services within the healthcare space that give them options," he said.
"The biggest questions I have are when will we begin to see more of Amazon’s signature of technology enablement, easy access, low cost and service quality begin to reveal itself within healthcare through this acquisition, and how might Amazon’s skill with those design elements yield market advantage," he added. "Primary care is a highly dynamic space with payers, providers, and healthcare services and technology organizations all focused on many of the same population health and risk attribution tools and concerns and a slow war of care models, utilization, and financial performance playing out as significant capital has entered from both private and public markets over the last 3-5 years particularly motivated by growth coming from managed care, particularly Medicare Advantage."
The characteristics are part of a Special Fraud Alert issued by the Health and Human Services Department's Office of the Inspector General, and give healthcare organizations an idea of what to look out for in dealing with telehealth companies.
Federal officials have issued a Special Fraud Alert targeting contracts with telehealth companies and offered seven characteristics of an arrangement that could be illegal.
The notice, issued by the Health and Human Services Department's Office of the Inspector General, follows several recent investigations into companies claiming to offer what they define as telehealth services, but which often constitute illegal marketing schemes.
"While the facts and circumstances of each case differed, often they involved at least one practitioner ordering or prescribing items or services for purported patients they never examined or meaningfully assessed to determine the medical necessity of items or services ordered or prescribed," the OIG notice reads. "In addition, telemedicine companies commonly paid practitioners a fee that correlated with the volume of federally reimbursable items or services ordered or prescribed by the practitioners, which was intended to and did incentivize a practitioner to order medically unnecessary items or services. These types of volume-based fees not only implicate and potentially violate the federal anti-kickback statute, but they also may corrupt medical decision-making, drive inappropriate utilization, and result in patient harm."
Telehealth advocates like the American Telemedicine Association have long argued that many of these cases don’t involve telehealth, and they've worried that the industry will be tarnished by a few bad actors. In a blog post analyzing the OIG notice, Nathanial Lacktman, a partner with the Foley & Lardner law firm, chair of its telemedicine and digital health industry team and a national expert on digital health law, also noted that difference.
"[The] OIG was careful to state that not all telemedicine companies are suspect, and this alert is not intended to discourage legitimate telemedicine arrangements," he wrote. "Indeed, in 2021, [the] OIG previously noted, '[f]or most, telehealth expansion is viewed positively, offering opportunities to increase access to services, decrease burdens for both patients and providers, and enable better care, including enhanced mental healthcare.' [The] OIG is aware that many practitioners have appropriately used telehealth services during the current Public Health Emergency (PHE) to provide medically necessary care to their patients."
To help healthcare organizations identify potential problems in their telehealth arrangements, the OIG highlighted these characteristics:
The purported patients for whom the practitioner (clinician) orders or prescribes items or services were identified or recruited by the telemedicine company, telemarketing company, sales agent, recruiter, call center, health fair, and/or through internet, television, or social media advertising for free or low out-of-pocket cost items or services.
The practitioner does not have sufficient contact with or information from the purported patient to meaningfully assess the medical necessity of the items or services ordered or prescribed.
The telemedicine company compensates the practitioner based on the volume of items or services ordered or prescribed, which may be characterized to the practitioner as compensation based on the number of purported medical records that the practitioner reviewed.
The telemedicine company only furnishes items and services to federal healthcare program beneficiaries and does not accept insurance from any other payer. (Lacktman pointed out that [the] OIG noted instances in which a telemedicine company requires the practitioner to use audio-only technology to facilitate engagement with purported patients, regardless of their preference, and does not provide the practitioner with other telehealth modalities. Additionally, a telemedicine company may provide a practitioner with purported 'medical records' that reflect only cursory patient demographic information or a medical history that appears to be a template but does not provide sufficient clinical information to inform the practitioner’s medical decision-making.)
The telemedicine company claims to only furnish items and services to individuals who are not federal healthcare program beneficiaries but may in fact bill federal healthcare programs. (As noted by Lacktman, an attempt to carve out federal healthcare program beneficiaries from arrangements with telemedicine companies may still result in criminal, civil, or administrative liability for a practitioner’s role in any resulting fraudulent activity that involves federal healthcare program beneficiaries.)
The telemedicine company only furnishes one product or a single class of products (e.g., durable medical equipment, genetic testing, diabetic supplies, or various prescription creams), potentially restricting a practitioner’s treating options to a predetermined course of treatment.
The telemedicine company does not expect practitioners (or another practitioner) to follow up with purported patients nor does it provide practitioners with the information required to follow up with purported patients (e.g., the telemedicine company does not require practitioners to discuss genetic testing results with each purported patient).
The alert comes as healthcare organizations are trying to navigate the murky waters of the Public Health Emergency brought on by the pandemic, which prompted federal and state regulators to issue waivers allowing for expanded use and coverage of telehealth services. It also led to an increase in criminal activity, and to confusion around what could and couldn't be done with virtual care.
That confusion will likely escalate when the PHE ends.
"As the pandemic’s intensity diminishes, many telemedicine companies that were previously cash-only retail medicine are now billing health insurance and the federal healthcare programs (including Medicare, Medicaid, and TriCare) in order to diversify their sources of revenue and addressable market," Lacktman pointed out. "This is a good thing for patient access to care and continued growth of digital health services. At the same time, this diversification in patient-payer mix, the expiration of PHE waivers, and the abatement of the pandemic will encourage {Department of Justice] and HHS-OIG to increase investigations of telemedicine companies and target arrangements and practices the government agencies believe are illegal."
"The alert emphasizes the risk of illegal kickbacks posed by suspect arrangements between telemedicine companies and practitioners," Lacktman continued. "If one purpose of the payment arrangement is to induce referrals of Medicare patients, that arrangement – particularly if notorious and not protected by a statutory/regulatory Safe Harbor – can place all participants at real risk of civil and criminal enforcement. Even subtle suspect arrangements can cause an employee or other knowledgeable person to file a qui tam / False Claims Act action under seal in court. If that occurs, DOJ is required to investigate the allegations in order to decide whether or not to intervene and take over the prosecution. Even non-criminal civil actions are a serious enforcement tool DOJ regularly relies upon to stop health care companies from entering into such arrangements."
The American College of Emergency Physicians is partnering with PA Consulting on a new platform aimed at helping emergency care providers access data and resources to improve services and outcomes and reduce administrative burdens.
ACEP will partner with PA Consulting on the platform, which will form the foundation for ACEP's newly launched Emergency Medicine Data Institute (EMDI).
“The ACEP Emergency Medicine Data Institute will transform information that physicians and others can rely on to support clinical innovation and patient management,” ACEP President Gillian Schmitz, MD, FACEP, said in a press release. “We are very excited to launch a resource with the potential to transform care delivery and empower clinicians at the bedside with analytics from emergency departments around the country.”
"This is a fantastic opportunity for us to build a multi-year engagement around data and analytics in healthcare," added Nilesh Chandra, a healthcare expert with PA Consulting and the ACEP project lead "We know that large scale datasets are critically important to solving the most pressing challenges in healthcare. This was true in the 1840s when John Snow used incidence and address information to trace a cholera outbreak to a water well in London, and data’s importance has been made abundantly clear in the last few years with the Covid-19 pandemic. Emergency department data has the potential to fundamentally transform the care of patients and improve lives."
The new data platform is expected to integrate with more than 1,000 hospitals, collecting clinical and billing data on emergency care. The information will be used in EMDI's Clinical Emergency Data Registry (CEDR), offering healthcare providers a resource to identify best practices, new treatment and therapies, and other services aimed at reducing the reporting burden and boosting outcomes.
David Danhauer, MD, is retiring after 37 years in healthcare, the last decade spent as chief medical information officer at Kentucky-based Owensboro Health. He talks to HealthLeaders about the challenges and successes and his role as an enabler for innovation.
Danhauer has served as chief medical information officer and senior vice president at Kentucky-based Owensboro Health for more than a decade. While with the health system, he oversaw the implementation of an electronic health record platform, supported the growth of an ambulatory care group that now comprises 180 providers in 30 locations, and helped design a $500 million, 450-bed regional hospital.
Prior to that, he was a pediatrician, first running a solo practice for 11 years, then as part of Owensboro Pediatrics.
Danhauer recently spoke about his experiences in an e-mail Q&A with HealthLeaders.
Q: How has the role of Chief Medical Information Officer changed over the years?
Danhauer: CMIO roles have been evolving from an EHR enabler to a strategic clinical IT leader/expert. This transition has required the development of skill sets in leadership/management, project management, and contracting, as well as the ability to network at regional and national levels. The need to stay current with evolving technologies and trends is critical to the success of any CMIO.
David Danhauer, MD, chief medical information officer and senior vice president of Owensboro Health. Photo courtesy Owensboro Health.
Q: How does the CMIO fit into a health system's leadership structure, and what are the CMIO's responsibilities?
Danhauer: The CMIO is the lead clinician in all things IT. It is the true blending of clinical expertise with IT expertise. The CMIO must be a master of language translation between clinical and IT roles.
Q: How has innovation played a part in your role?
Danhauer: Having the passion for always improving how we provide care has helped me stay focused on innovation. Keeping my clinicians' point of view in the forefront allows me to challenge IT be innovative and patient safety-minded.
Q: What are the biggest challenges you now see in healthcare that innovation can address?
Danhauer: Our regulatory burden on clinicians is a constant challenge. IT is looked at to minimize the impact on clinicians, but finding new ways to mitigate this has been challenging. Cyber security vs the need for access keeps me awake at night.
Q: Could you list the 3 or 5 most impactful innovations in healthcare that you've seen, and why they've made such an impact?
Danhauer:
EMR adoption: This has been the most disruptive change in medicine ever.
Interoperability: Providers now have immediate access to the clinical info they need at the time of care.
IT Mobility: Providers can now access data when and where they need it.
AI and Data Modeling: Collections of massive amounts of clinical data with intuitive research allow for trending at levels never before possible.
Q: What are you most excited to see in healthcare going forward?
Danhauer: For my providers, I look forward to the advanced computerization that allows them to treat patients rather than deal with computers. This ambient environment allows for seamless documentation without the interference of a computer. AI will allow for improved diagnosis and therapy for all our patients.
Q: What has surprised you the most about what you've seen happen in healthcare?
Danhauer: My dream of simplified workflows for providers has been upended by the regulatory burdens now placed on providers. Certainly the advancement of data availability has helped, but many are overwhelmed by too much data.
Q: What worries you the most about the future of healthcare?
Danhauer: I hope the future will allow for better ergonomics, improved AI for data presentation and simplified workflows.
Q: What are you biggest accomplishments?
Danhauer:
EMR adoption and usability.
Development of a provider support team specifically related to the IT needs of providers with top notch ratings.
IT governance structure.
Regional CMIO group meetings.
IT patient safety engagement.
State and national HIE interoperability.
HIMSS National Physician Committee Chairmanship.
HIMSS Fellow.
Many regional and national presentations on top IT issues.
Q: Any regrets, or things you wish had been done differently?
Danhauer: I feel the CMIO should have a larger seat at the leadership level as it comes to organizational strategy.
Q: What are your plans for retirement?
Danhauer:
More family time!
Travel.
Scuba diving around the world.
Explore new hobbies.
Dedicate more time to my church and local charities.
