Q&A with Health First Colorado (formerly Medicaid) Medical Director, 朱迪·泽赞，医学博士，公共卫生硕士
Where has the Health First Colorado/Medicaid system adopted or encouraged telehealth?
我认为远程医疗最困难的事情之一就是要表达我们的意思. 对我们来说，远程医疗中的视频交互思想被称为“视频医学”.然后是“远程医疗”,“对我们来说”, 意味着远程家庭健康监测-发送人的体重秤, 诸如此类. 我要说的是，在此之前，我们觉得自己走在了潮流的前面. 我有2009年1月远程医疗政策手册的初稿. 所以我们来早了. 话虽如此, I think we’re behind the curve now in terms of how we deliver telemedicine and what that looks like. Probably the biggest barrier we still have in here is that where the member is, 比如调查摄像机, 房间里必须有一个原始提供者. 所以这就不包括“坐在家里沙发上”的例子.
这是如何成为道路上的障碍的? 这是你的决定吗?? 是联邦法令吗??
这是一个有趣的问题. 我们一开始就是这样设置的. In 2009 we didn’t have face time and fancy things on our phone; the technology really was located in doctors’ and nurses’ offices. 这已经改变了，但我们并没有真正更新我们的政策. Some of the places it was so important in Colorado was those rural and frontier places; this was originally designed for someone in a Canon City office to talk to a specialist up here in Denver.
你说我们现在落后了. 这是否意味着你想要做出改变?
Yes, we’ve been looking at what other states are doing and how we might modernize. One place we will be looking at early is the places where mental health care providers could be included, since telepsychiatry and telemental health have been two areas that have worked well. 另一个我们还没有加入的例子是养老院护理. 那肯定太棒了, 当养老院的工作人员问你, “这个病人需要去急诊室吗? Can I figure out what’s wrong with him or her from the nursing home instead of packing them up and moving them?“所以我们正在关注一些领域.
我们一直致力于的远程医疗领域之一是“电子咨询”.本周开始了一个测试小组. 旧金山和俄克拉何马州有一些很棒的数据. It allows for a primary care provider to send an email and attach pictures to a specialist, 然后说, “我能听听你对下一步的意见吗??“我们向初级保健提供者支付10美元，向专科医生支付20美元. 我们刚刚从风湿病学开始，看看这个系统是如何工作的. Early data from places that use it shows it really cuts down on the time it takes to see the specialist; 70 to 80 percent of cases are able to be taken care of by the email interaction, 这意味着这部分人永远不用去看专科医生.
我们正在做的这个试验, 我们希望一旦看到这个系统是如何工作的，以及人们是如何喜欢它的，我们就会扩大它的规模. The specialists and primary docs where it’s been done love it because it gets a lot done, 通常初级保健提供者会学到一些东西, and they do get paid something for it; you get it down to a couple of minutes because the specialist just knows the information. And the member likes it because they don’t have to wait forever to get into a specialist. 这是三赢.
How close are you to a scenario where Medicaid clients could consult with a provider on their own smartphone, or take a picture of something related to their condition and send it directly to a provider? 是关于报销规则吗?
有几件事需要做好. 规则需要改变，这是一个固定的过程. The medical services board, our rulemaking body, has to approve it after we make a proposal. 它还涉及到我们如何支付. 你们可能知道, 即将到来的预算年度看起来不太好, so anything involving Medicaid expansion would have to be carefully thought out. A third piece that needs to be in place that’s another potential barrier is that there needs to be HIPAA (Health Insurance Portability and 问责制 Act) compliant software. Figuring out how to get the existing systems onto your phone could be a data cost, 我们的一些客户并没有大数据计划. 如何获得正确的技术并确保其有效?
The telehealth law passed in the last session only applies to private insurers, not to Medicaid. But still it’s worth looking at how we can go about it – do we wade in on our own or learn from private insurers’ experience?
你提到需要知道是否有预算影响. 为什么医疗补助计划会有新的成本udget? 如果这些人已经被发现了, why does it matter to Medicaid whether you reimburse for an office visit or for a video visit by their smartphone?
We need to have pieces in place to make sure that visit really happened: What’s the documentation? 我们如何审核这样的东西呢? Or how might the federal government come in unasked (laughs) and audit it for us? 我们想要确保一切都是以一种我们可以监控的方式设置的, 确保高质量的事情发生, 确保使用了符合hipaa的软件——所有这些部分. 这是棘手的部分.
One reason it’s difficult to assess is that in the private sector that has tried telehealth, 很多都是在管理式医疗环境中完成的, 哪个与我们的设定不同. States like Maryland that have begun telehealth expected some increases in usage but also expected savings in places like the ER. They decided it was worth it, but those are only educated guesses until you see it in operation.
And it’s harder for us to assess that guess here because the telemedicine benefit we do have is not used that much yet. It’s mostly done by small rural hospitals and for a benefit we have in speech and language assistance. 因此，打开这扇门必须仔细考虑.
多年来，您是否有其他长期远程医疗职能?
我们有一条护士咨询热线已经好几年了. 它是免费的, and now those providers do have the ability to prescribe over the phone for certain conditions. A urinary tract infection is a good example; the questions and responses are pretty straightforward. (Patients) can call the nurse advice line; the nurse can get the medication prescribed and ask where they want it sent. 所以绝对有非面对面的方式来提供医疗保健. We contract with Denver Health to provide the staffing for the nurse advice line.
你们将如何在远程医疗中做出这些改变? 你们内部有蓝带委员会吗?
我们有一个过程，我们从观察其他州的做法开始, 其他保险公司是怎么做的, 这方面有联邦政策吗, 老年医保是做什么的, 把这些放在一起看看是什么样子. Then we have internal discussions to talk about what are the most important things to change. 然后(我们有)外部利益相关者讨论. 然后是更多的问题. Then we have a final policy and it enters the rule-making process and a budget review and a rate review. 整个过程通常需要一年的时间. 我们还需要从医疗保险中心的合作伙伴那里获得授权 & 医疗补助(服务)，这还需要六个月的时间.
联邦官员对远程医疗有何看法? 他们不情愿吗?? 他们在推动吗??
我会说这是一个中立的答案. 我是国家医疗补助主任小组的一员. It’s been a pretty heated topic for the last couple of years – how are people doing it and what does it look like. Places that have learned a lot include Alaska – where if you don’t do telehealth, 你在一架小飞机上旅行——在怀俄明州. 这些都是我们可以借鉴和学习的地方. We’re getting a new Medicaid management and billing system up and running October 31 of this year. 我们的旧系统在20世纪70年代是最先进的. 很难添加或更改内容. The new system will be – should be – much more flexible, and we’d be able to do a lot more. 这为我们改变(远程医疗)福利带来了一些希望.
This article was originally published in the Fall 2016 issue of Health Elevations.