PTAC OKs Model to Boost Stroke Care at Rural Hospitals

Telemedicine-based ACCESS program has proven successful in New Mexico.

This article was first published on Tuesday, September 17, 2019 in MedPage Today.

By Shannon Firth, Washington Correspondent, MedPage Today.

WASHINGTON -- A telemedicine-based payment model to improve care for patients experiencing stroke and other cerebral emergencies in rural, underserved communities won support from the Physician-Focused Payment Model Technical Advisory Committee (PTAC).

PTAC voted 11-0 on Monday in favor of the ACCESS Telemedicine model. However, in accordance with a new voting protocol meant to further clarify the committee's wishes, the committee also voted 9-2 to recommend further development of the proposal in ways specified in their comments. Two members voted for implementation of the proposed model as is.

PTAC is an independent committee of health policy experts and clinicians established by Congress to advise the Secretary of Health and Human Services (HHS) on which alternative payment models (APMs) to test and to scale.

Submitted by the University of New Mexico Health Sciences Center (UNMHSC), the ACCESS model meets a significant need: Rural, underserved community hospitals can't afford to hire neurological specialists, and emergency department (ED) physicians at those same rural hospitals aren't comfortable diagnosing patients with cerebral-emergent problems, committee members agreed.

Because of these twin issues, patients are often transferred to tertiary hospitals, sometimes unnecessarily. The goal of ACCESS is to reduce unnecessary transfers to these tertiary hospitals for benign cases, while reducing the time to diagnosis and treatment for time-sensitive conditions, by leveraging telemedicine consults.

The model is built around a two-way audiovisual program, housed on an online telemedicine platform, that allows clinicians in underserved areas to connect with neurologists and neurosurgeons at tertiary care centers.

"What ACCESS does is it aims to expand ... access to expertise of a neurological and neurosurgical nature to docs in rural hospitals so that they could make more timely, and maybe more accurate, judgments about the need for hospitalization to more sophisticated hospitals," explained PTAC member Len Nichols, PhD, director of the Center for Health Policy Research and Ethics at George Mason University in Fairfax, Virginia. Nichols was the lead reviewer on the three-member preliminary review team.

For instance, in patients with acute ischemic strokes, time to diagnosis and treatment with tissue plasminogen activator (tPA) is critical, but many ED physicians in rural hospitals do not feel comfortable providing such treatment, and "rural hospitals are 10 times less likely to give tPA than their urban counterparts," according to the UNMHSC proposal.

In New Mexico, where the ACCESS model has been integrated into the state's Medicaid and Managed Care Organization's Physician Health Fee Schedule, the rate of tPA use jumped from 2% of ischemic stroke patients to 20%, which is considered "high normal use" for U.S. medical centers, according to the proposal.

Cost of ACCESS

UNMHSC proposed establishing an "APM ... in which the rural site can bill for a bundled payment for all elements (consult, technology, education, quality assurance). This would add sustainability of the ACCESS model, while still reducing overall healthcare costs to payers," and would include a follow-up consultation with the neurological expert within 24 hours.

"The payment is contingent upon delivering high quality care via telemedicine and recommendation of a diagnosis and disposition to the local [ED] provider based on discussion, audiovisual assessment of the patient and/or review of digital imaging," according to the proposal.

In New Mexico's ACCESS model, the total cost of a neurology consult is $850, while neurosurgical consults are $1,200. Payment is made to the rural hospital that is responsible for paying the tertiary hospital.

ACCESS received a Health Care Innovation Award (HCIA) from the Center for Medicare and Medicaid Innovation, but the pilot study that stemmed from that award did not include enough people to produce a statistically "rigorous analysis," noted PTAC.

However, additional materials from UNMHSC suggest the model led to a sharp decline in unnecessary transfers.

Before the ACCESS model in New Mexico was piloted, a rural hospital transferred approximately 90% of patients with neurological ailments to a tertiary hospital for care. Of those patients that were transferred, only 20% were admitted by the receiving hospital; the other 70% were discharged and another 10% were held for observation before being discharged.

After ACCESS implementation, 15% of patients with a neurological ailment were transferred, and 92% of those patients were admitted; 5% were observed and 3% were immediately discharged.

While the potential impact on patient care appeared clear based on the "totality of the evidence," Nichols said it was also reasonable to believe the model would lower costs.

'Richer Dataset'

Nichols said he did not support implementation of ACCESS as is, because the proposed payment levels need review.

"In my opinion, it's close," said Nichols who voted for implementation as specified by PTAC comments. "What needs to be fleshed out is a richer dataset, which I believe [the Center for Medicare and Medicaid Services] either has, or could acquire without a great deal of work."

"I don't think you want to take those numbers in that chart and throw them to the world," he added, referring to the suggested $850 and $1,200 payments for neurologists and neurosurgeons, respectively.

PTAC member Grace Terrell, MD, disagreed. "My feeling is close actually counts ... which is why I voted to implement because, the nature of us as economists and clinicians, is that we will never find anything perfect enough." Terrell is an internist and CEO of Envision Genomics of Huntsville, Alabama, and was on the preliminary review team. She voted for implementation of the ACCESS model as is.

Earlier in the discussion, Terrell underscored the significant access problem to specialty care in rural areas and expressed that the need for the model was "universal."

PTAC Chair Jeff Bailet, MD, president and CEO of Altais (formerly Blue Shield of California) in San Francisco, voted to recommend implementation of the model with further development. Bailet stressed that the model was beneficial to patients and could be vital in helping rural hospitals keep their doors open.

"Once these rural hospitals collapse, you will never have them come back into the community," he said.

Harold Miller, president and CEO for the Center for Healthcare Quality and Payment Reform in Pittsburgh, said that payment in the ACCESS model needs to be tied to quality. For instance, if services are not delivered in a timely manner, or if a clinician gives a bad recommendation, the payment should be lower, he suggested.

Terrell proposed that the PTAC letter to the HHS secretary include a comment about the possibility of using centers of excellence to help address the quality concerns that Miller mentioned.

Ryan Stevens, MHA, executive director of Neurological Clinical Services at the University of New Mexico Medical Group in Albuquerque, represented UNMHSC at the meeting. He said he was pleased with the committee's decision, and that he was looking forward to working with CMS to develop ways to improve accountability, "without adding too much administrative burden."

He said he liked Terrell's idea of developing centers of excellence within the ACCESS program that would set defined performance criteria to be met by program participants.