Final
STAFF SUMMARY OF MEETING
HEALTH CARE TASK FORCE
Date:
09/27/2005
ATTENDANCE
Time:
09:13 AM
to
03:20 PM
Butcher
X
Clapp
X
Place:
HCR 0112
Gordon
E
Johnson
E
This Meeting was called to order by
McCluskey
X
Representative
Frangas
Mitchell
E
Tochtrop
X
This Report was prepared by
Todd
X
Amy Larsen
Frangas
X
Keller
E
X = Present, E = Excused, A = Absent, * = Present after roll call
Bills Addressed:
Action Taken:
Third Health Care Task Force Meeting
Overview of Telemedicine
Telemedicine and Correctional Care
Telemedicine in Arizona
Telemedicine and Orthopedics
Presentation on Telemedicine and Home Care
The Current Regulatory Environment
The Texas Hispanic Health Care Initiative
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9:13 AM -- Overview of Telemedicine
The meeting was called to order. Chairman Frangas announced that today's Health Care Task Force meeting will focus on telemedicine. Staff distributed a memorandum entitled "Current Colorado Law Addressing Telemedicine" (Attachment A). [A copy of most of the materials provided at today's hearing are available on the Health Care Task Force web page at:
http://www.state.co.us/gov_dir/leg_dir/lcsstaff/2005/comsched/05HealthCareTFsched.htm
].
Dr. Flo Raitano, CEO, Rural Development Specialists, introduced herself, and asked that Mr. Bryan Nation, with Banner Health System and representing the High Plains Rural Health Network, and Mr. Mike Riggio, with Poudre Valley Hospital also come to the table. She distributed a copy of their PowerPoint presentation (Attachment B). Dr. Raitano explained the difference between telehealth and telemedicine. While telemedicine focuses on specific disciplines and technology like tele-radiology, telehealth focuses on the application of technology for patient needs including health records, disease management, remote monitoring and patient compliance. Dr. Raitano gave a basic definition of telemedicine as the use of advanced telecommunication and information technologies to exchange health information and provide health care services across geographic, time, social and cultural barriers.
Dr. Raitano, Mr. Riggio, and Mr. Nation discussed the history of telemedicine in Colorado. Dr. Raitano described Colorado's activities in telemedicine including the multi-use network (MNT), a fiber "backbone" connecting each county seat in Colorado. The MNT is a local network designed for use by local governments, education, and health care, and was built by Qwest. She added that the health care sector has not fully utilized the MNT. Mr. Nation described some of the issues delaying the use of the MNT by the health care industry including HIPAA requirements, connectivity response time, and network expansion beyond the county seat.
Dr. Raitano explained some of the benefits of telemedicine including: decreased travel for patients, providers, and staff; increased access to specialty consults and second opinions; decreased information processing time; increased efficiency of care; and lowered costs of patient care.
Representative McCluskey asked about who pays for the initial investments and ongoing costs of telehealth. Mr. Nation responded that additional services are required to utilize telemedicine, and he views them as a cost of doing business like radiology or other tools used in providing health care. Mr. Riggio added that providers are leveraging resources to minimize costs, and indicated that the High Plains Rural Health Network is facilitating collaboration in this area.
Dr. Raitano described the Docking Institute Study completed in Nebraska which reviewed patient satisfaction with telemedicine. The study found that non-doctor related costs and total health care costs were lower in the treatment group than in control groups, and patient satisfaction was higher among the treatment group.
Mr. Riggio described Poudre Valley Health System's use of telemedicine. Cardiology is the primary area. Another major use is in radiology, with over 700 patients served each month. He identified a key to success as integrating the technology with the regular workflow of providers.
9:41 AM
Dr. Raitano described some of the challenges related to telemedicine. She stated that the lack of a robust rural infrastructure is still an issue for facilities outside of the county seat and in rural areas. Mr. Riggio explained that insurance reimbursement is also a concern particularly when providers must use equipment located outside of their normal workplace and/or network. Mr. Nation stated that work is continuing to establish standards to allow integration of systems across networks. Dr. Raitano commented on additional issues including security, connectivity, equipment costs, maintenance costs, transmission costs, and federal and state regulation. Mr. Nation stated that regulations through HIPAA, JCAHO, and the FDA determine how telemedicine can be implemented. Dr. Raitano discussed SB05-244 stating that she is concerned that it may have put telemedicine in a box and may hamper future uses. Instead, she thinks of telemedicine as a tool for the health care industry.
Representative Clapp asked if a definition of telemedicine is available at the federal level and is one necessary at the state level. (A definition exists in Section 12-36-106, C.R.S., see Attachment A.) Mr. Nation responded that there are some definitions at the federal level. Dr. Raitano expressed the potential need for definitions for insurance purposes. Representative Clapp asked if the presenters have had trouble collecting from insurance companies. Mr. Nation stated that Banner has not had trouble in this area. Representative Frangas asked if the definitions provided in SB05-244 have hampered efforts to receive grants. The presenters responded that they are not aware of problems in this area. Representative Butcher stated that a definition of telemedicine is important to protect consumers.
Dr. Raitano commented on SB05-152 in that it may be problematic for certain rural areas of the state without broadband access. She then shared some resources for further information on telemedicine. Representative Frangas asked the presenters to provide some follow-up information on HIPAA compliance, system reliability, Medicare and Medicaid compliance, cost neutrality and MNT uses.
Representative Butcher asked for clarification of the concept of patient compliance. Mr. Riggio explained that when a patient can go to a local provider's office for follow-up care with a telemedicine speciality consultation, the patient may be more likely to correctly follow care instructions. Dr. Raitano gave an example in the area of physical therapy, and responded to additional questions on the billing and payment of expenses by explaining that the patient would be referred to the physical therapist in the normal way. Then, the therapist would bill for time as usual, and technology expenses would also be incurred and billed.
10:15 AM -- Telemedicine and Correctional Care
Dr. Allan Liebgott, Denver Health, introduced the topic of Telemedicine and Correctional Care and distributed a copy of his PowerPoint presentation (Attachment C). Dr. Liebgott stated that there is a definition in Colorado statute of telemedicine. He noted that in addition to high-tech telemedicine systems, some telemedicine can take place on low band width technology like telephones or cable systems. Dr. Liebgott explained that he would provide the committee an overview of Denver Health's organization, a description of the concepts and applications of telemedicine, and then specific information on correctional care.
Dr. Liebgott stated that Denver Health includes the Denver Health Medical Center, public health programs, the 911 system, school based health, and correctional care. Telemedicine at Denver Health includes clinical consultation, educational activities, homeland security related projects, and miscellaneous other activities. He noted that clinical applications of telemedicine includes primary care, specialty care, emergency/trauma care, tele-radiology and home health care. Dr. Liebgott explained that telemedicine is a resource to utilize during times of natural and man-made disasters. He noted that the same interactive video conferencing used in telemedicine applications can be used in corrections to reduce travel to court appearances for inmates.
Dr. Liebgott stated that Colorado has over 60 hospitals with telemedicine capability, and the Colorado Coalition for the Advancement of Telemedicine (CCAT) should be revitalized as a network of networks. He identified the three big issues for telemedicine to be financial, legal, and sustainability. Financial issues include high start-up and maintenance costs and reimbursement of expenses from Medicare and Medicaid. Dr. Liebgott explained that to date, there have not been significant lawsuits in this area; however, telemedicine is included in the definition of "practice of medicine" in Colorado and 21 other states. He also explained that telemedicine's sustainability is determined by health care providers, and their ability to bill and receive reimbursement for its use.
Dr. Liebgott described some potential options for the future technology in telemedicine, but noted that applications must drive the technology.
10:37 AM
Dr. Liebgott described the nature of correctional care. He explained that there are currently 2 million inmates in U.S. jails and prisons with $3.3 billion in health care costs. Governmental entities generally contract with correctional care companies to provide correctional care. Dr. Liebgott noted that Denver Health contracts with all Denver metro counties, the Colorado Department of Corrections, and the U.S. Marshals to provide health services. They provide about 120 telemedicine visits annually through their correctional program.
The Denver Health Correctional Care unit is located in the new wing of Denver Health Medical Center and includes a sally port, control center, and secure patient rooms. Dr. Liebgott described some of the costs and resources required to increase the amount of telemedicine performed for correctional patients. Telemedicine must blend with the other missions and goals of Denver Health. The strategic vision of Denver Health's Correctional Care program includes improving case management, increasing the use of telemedicine, and increasing public and community health education.
Dr. Liebgott gave some cost estimates for establishing a telemedicine center. He explained that if existing employees and resources can be utilized, a fully functional hub site can be established for about $360,000. Remote sites can be established for as little as $7,000 depending on the existing communication lines.
Dr. Liebgott described some possibilities for telemedicine in Colorado including statewide kiosks in local hospitals for Medicaid patients. Licensure, reimbursement, "last-mile" connectivity, and a network of networks remain key issues.
10:51 AM -- Telemedicine in Arizona
Mr. Kevin Pitzer, Vice President of Operations with Pediatrix Medical Group discussed the Pediatrix outreach program in cooperation with the Arizona Telemedicine Program and distributed a handout of his presentation (Attachment D). Mr. Pitzer explained that Pediatrix is a nationwide physician organization focusing on high risk obstetrics.
Mr. Pitzer explained that the Arizona Telemedicine Program started in 1979, and in 1996, the Arizona legislature appropriated $1.2 million to fund the start-up of the Arizona Rural Telemedicine Network. Today, the program has over 160 sites used by over 50 health care organizations, and it has served over 150,000 patients. Mr. Pitzer explained that ongoing funding is from state, federal, and private sources. He stated that the State of Arizona has saved millions of dollars annually through reduced or avoided emergency transports, behavioral medicine admissions, patient travel and per diem, and inpatient admissions. In addition, telemedicine allows for more intensive follow-up care resulting in improved patient compliance with disease management. Mr. Pitzer noted that Arizona's Department of Corrections has used over 8,000 telemedicine visits since it began, saving over $1 million in travel and admissions costs.
Mr. Pitzer described Pediatrix's Arizona telemedicine experience with tele-ultrasounds. In their system, the ultrasound is performed by a local technologist, and the image is stored at the local hospital. Then the image is transmitted to a physician of the Arizona Telemedicine Network where the still images are read by a perinatologist. Afterward, the report is printed and faxed back to the remote facility. This is known as "store-forward" technology. Mr. Pitzer stated that the start-up cost for this technology ranges from $10,000 to $25,000 depending on the system capacity. He said that the charge for service is comparable to non-telemedicine service, with the physician billing the professional component, and the hospital billing the technical component.
Mr. Pitzer explained that in Arizona telemedicine services are covered by nearly all commercial plans and the state Medicaid program. The program improves access with comparable quality and cost. Mr. Pitzer stressed that the program facilitates pro-active management of high-risk OB patients, reducing incidents of premature delivery and related complications and costs.
Mr. Pitzer concluded his remarks and provided some additional resources for the committee as printed in Attachment D.
11:18 AM -- Telemedicine and Orthopedics
Ms. Brenda Zorn, RN with Hanger Prosthetics and Orthotics, introduced herself and her colleagues Terry Noffsinger and Pamela Hale, also with Hanger Prosthetics and Orthotics. Ms. Zorn distributed a copy of her PowerPoint presentation to the committee (Attachment E).
Ms. Zorn explained that they started their experience with telemedicine in 2000 with the Shrine Hospital in Salt Lake City in partnership with The Children's Hospital of Denver. The Shrine Hospital provides health care to underprivileged children. Ms. Zorn noted that The Children's Hospital provided the facility including access to x-ray and telemedicine equipment, Hangar provided a prosthetist and a physician's assistant, and the Shrine Hospital provided the physician via teleconference.
Ms. Zorn described some of challenges they faced including billing payers across state lines, reimbursement, and liability. Since the Shrine physicians are not licensed in Colorado, some insurance companies refused to pay for their services. Ms. Zorn added that they found liability was decreased since the physician was present at the evaluation. Ms. Zorn described some of the factors which make their telemedicine program cost-effective including shorter evaluation times, reduced travel costs, and reduced wage loss for the patients' families. Ms. Zorn stated that their start-up costs for this program were just over $13,000.
Ms. Zorn stated that providers, patients and clinical facilitators have been satisfied with the results of their telemedicine program, and she provided results of satisfaction surveys as listed in Attachment E.
11:27 AM
Chairman Frangas announced that the committee would discuss the draft bill concerning hospital infection rates prior to the lunch break.
11:32 AM
Representative McCluskey and Michael Dohr, Office of Legislative Legal Services, presented a proposed bill related to hospital-acquired infection reporting that the committee had requested at the September 1 meeting (Attachment F). The committee needed to decide whether to forward the bill to the Legislative Council Committee which is meeting on November 15 to consider proposed interim committee legislation. Representative McCluskey stated that the bill is similar to a bill that was introduced last session. It is a modest start to address this issue for Coloradans, and there has been input from many groups in its formulation. Representative McCluskey moved an amendment to page 5, line 10, after "FORMATTING," insert "TYPES OF CASES,", and on page 6 strike line 27 (subparagraph III). The motion was adopted without objection.
Representative Clapp asked whether the bill's reporting requirements would be covering some of the same issues the Executive Director of the Department of Public Health and Environment, Douglas Benevento, recently addressed in rule. Representative McCluskey responded that he is not aware of recent rules implemented by Director Benevento or how they may impact the bill.
BILL:
Telemedicine and Orthopedics
TIME:
11:38:35 AM
MOVED:
McCluskey
MOTION:
moved to forward the bill on hospital-acquired infection reporting, as amended, to the Legislative Council Committee. The motion passed on a 6-0 roll call vote.
SECONDED:
Frangas
VOTE
Butcher
Yes
Clapp
Yes
Gordon
Excused
Johnson
Excused
McCluskey
Yes
Mitchell
Excused
Tochtrop
Yes
Todd
Yes
Frangas
Yes
Keller
Excused
Not Final YES:
6
NO:
0
EXC:
4
ABS:
0
FINAL ACTION:
PASS
Representative McCluskey and Senator Keller were designated as the bill sponsors.
Co-sponsors were identified as Senator Tochtrop, Representative Todd, Representative Butcher, and Representative Frangas.
Representative Frangas moved, and Representative McCluskey seconded, to allow the drafter to make any needed technical corrections to the bill. There was no objection.
11:40 AM -- Recess
The committee recessed for lunch.
1:00 PM -- Call to Order and Presentation on Telemedicine and Home Care
Chairman Frangas called the committee back to order and called Erin Denholm, RN at Centura Health at Home, and Immediate Past President of the Home Care Association of Colorado to the table. Ms. Denholm introduced herself and distributed a copy of Senate Joint Resolution 04-038 and some other materials (Attachment G). Ms. Denholm talked about telehealth and how it provides an efficient quality of care to people with chronic illnesses. She noted that the chronically ill make up about 70 percent of health care costs, and are seen in the emergency room far more than necessary.
Ms. Denholm discussed a grant that Centura Health was given two years ago from the Penrose Hospital Foundation to purchase telehealth equipment. She stated that with the funding they received, Centura Health took 15 of their most acutely-ill, congestive heart failure patients who had the most hospitalizations and emergency room visits over the course of twelve months and provided them with home care telemedicine. She explained that the video the committee was going to watch showed one of those patients using home care telemedicine with the help of her neighbor. The committee then watched the eight minute video on telemedicine home care.
1:20 PM
Following the video, Ms. Denholm stated that although individuals with chronic illnesses cannot be cured, they can reach a level of wellness that can keep them out of costly acute care. She explained that when patients feel sick and are unable to see a doctor right away they often go to the emergency room or wait for care which can cause their condition to deteriorate. However, with telehealth they can catch the downward spiral quickly and bring the patient up to the level of wellness they need. Ms. Denholm listed some of the results Centura Health saw with their telehealth study: a 100 percent drop in ER visits; a 90 percent reduction in hospitalizations; high patient satisfaction; and an increase in the amount of patients nurses could see.
Ms. Denholm stated that Medicare and Medicaid do not reimburse for the telehealth program. She added that currently no reimbursement model exists, rather cost is determined by what technology the patient uses. Ms. Denholm stated that the average cost is $400 a month for the sickest, most expensive patients. She explained that as telemedicine progresses it will move to a less expensive system. She mentioned that Medicare is currently working on a revenue model and there are pilot programs across the country.
Senator Tochtrop asked if there was a protocol for the patient's helper to follow if the nurse finds a problem with the patient. Ms. Denholm responded that a nurse would initiate the protocol and get a change in the patient's care immediately. Ms. Denholm discussed how the nurse can perform a physical exam through telemedicine technology and input the information into an electronic report that can be sent to the doctor. The doctor can then see how the patient has been over a period of time through trend graphs and can recognize changes in health that need attention.
In response to a question, Ms. Denholm explained that the nurse can measure a patient's weight using a flat scale that connects to the telephone line and the patient simply gets on the scale where the weight is recorded and sent to the nurse.
Representative Todd stated that many seniors have to go to the doctor to check coumadin levels. She asked whether there was a blood chemistry piece to the telemedicine machine. Ms. Denholm responded yes, and in addition to checking coumadin levels it can also check patients with diabetes, emphysema, asthma, and other illnesses. Senator Tochtrop asked how blood is drawn. Ms. Denholm replied that it can be taken through the machine. She added that the technology is growing beyond their ability to care because the revenue models have not been produced to pay for it.
Senator Tochtrop asked how the legislators can compel Medicaid to reimburse telemedicine. Ms. Denholm stated she did not know, but that she would be more than happy to would work with any group on policies or procedures in order to have even a pilot program somewhere in the state and explained how it would save considerable amounts of Medicaid dollars.
Representative Todd asked what happens to the machine once the patient no longer needs it. Ms. Denholm explained that they have people who deliver and pick up the machines, disinfect them, and then the machines are used again. Ms. Denholm concluded.
1:38 PM
-
The Current Regulatory Environment
Ned Calonge introduced himself as the President of the Colorado Board of Medical Examiners and Susan Miller introduced herself as the program director of the same, and stated that Rosemary McCool, Director of the Division of Registrations would also be speaking. The speakers distributed four handouts: 1) Colorado Senate Bill 98-036 (Attachment H); 2) Telemedicine Overview by State Chart (Attachment I); 3) a Report for the Ad Hoc Committee on Telemedicine (Attachment J); and 4) New Mexico Senate Bill 473 (Attachment K).
Mr. Calonge mentioned that most telemedicine is used in radiology where images such as x-rays and MRIs are sent to remote areas for reading, and pathology where the same is done for tissue slides. He stated that these areas of medicine are put into one broad category called store and forward where the information is stored in a machine and forwarded to the health care provider for analysis. Mr. Calonge explained how telemedicine allows a real time consultation through a television set and stated the ideal use of telemedicine is between a patient and doctor in a rural area and a specialist in an urban area. Mr. Calonge then went through and listed the many areas of specialty medicine that have worked well with telemedicine such as pediatric primary care, cardiology, rehabilitation, and psychiatry.
Mr. Calonge stated that as good as the technology is there is still the need for the in-patient, hands-on approach. He explained that telemedicine is very successful in its use for case management and self monitoring of chronic diseases in both urban and rural settings. He gave the example of a patient with diabetes who, through telemedicine, can do blood monitoring that goes into a computer that sends the information to the patient's remote provider. He explained how this type of monitoring is very successful but stressed the fact that emergency rooms are still needed in case the patient's condition worsens. Mr. Calonge then stated that while participating in a health sciences center study he was cautioned by a rural stakeholder to be careful about assuming the care of rural patients in a metro area because it takes that revenue out of the local setting and takes away the primary care from the local physicians because the care is going elsewhere.
Mr. Calonge discussed the barriers to telemedicine. He stated that reimbursement levels are the greatest barriers to telemedicine. He mentioned that the Centers for Medicare and Medicaid Services have severe restrictions for Medicare reimbursement and most private insurers do not cover telemedicine. Another barrier he discussed was malpractice liability, and how because of telemedicine, remote care is being judged at the same level as direct patient contact. He also stated there is some concern with the technology itself causing a loss of hands on care. Mr. Calonge added that another barrier to telemedicine is licensure, and the need to be licensed in the state where you provide care. Then Mr. Calonge addressed the problem of illegal prescribing and that no state he knows of has the resources to monitor and address the numerous violations of illegal internet prescribing.
Representative McCluskey commented that although it seemed as though telemedicine would take away money from rural area hospitals and doctors, it would also fit well in some rural areas where it is hard to find doctors. Mr. Calonge agreed and added that not all rural areas are exactly the same. Therefore, policy in telemedicine must be strategic and allow local health care providers to thrive while at the same time providing medical care services where there are none.
Representative Butcher asked where the areas not served with telemedicine are generally located. Mr. Calonge stated there are ways to get that information, but explained it is a complex issue. Mr. Calonge concluded.
1:52 PM
Susan Miller explained that she would be discussing the current status of telemedicine regulation both in Colorado and in the nation. Ms. Miller stated it is important to understand that the regulatory view of telemedicine means that the practice of medicine occurs where the patient is located. She explained that is important because it determines who has jurisdiction over the care provided. She gave the example that Kansas rules and regulations would cover a Colorado doctor giving care via telemedicine to a Kansas patient.
Ms. Miller referred to Senate Bill 98-036 (Attachment H), legislation that regulates telemedicine in Colorado. She explained that Senate Bill 98-036 requires physicians who practice medicine in Colorado by means of telemedicine to have a valid Colorado medical license to legally do so. She then noted a couple exceptions to that rule: 1) physician to physician consultations; and 2) pathology services.
Ms. Miller discussed the second handout (Attachment I) regarding the status of telemedicine by state. She stated that currently 38 states, including Colorado, require physicians to hold full medical licenses in that state to legally provide telemedicine services but some, like Colorado, have exceptions to that rule. She explained that nine of the states on the list have adopted the Federation of State Medical Board's Model Act that provides for a limited telemedicine license. She mentioned that one of the states that allows a limited telemedicine license is New Mexico which offers the license to physicians who only practice telemedicine. She stated that the national trend, however, is to require physicians who practice telemedicine to hold full medical licenses.
Ms. Miller pointed out recent legislation passed by New Mexico (and pending in New York and Texas) to create telehealth commissions and referred the committee to the handout of the legislation (Attachment K). She explained that the legislation creates the New Mexico Telehealth Commission and referred the committee to the first page where the purpose of the commission is laid out. She explained that because the commission is so new there is not a lot of information about it available.
Ms. Miller discussed two projects the Colorado Medical Board of Examiners is currently involved in. One is a meeting with the Four Corners Telehealth Consortium to find ways to advance license portability between the four corner states that will be held October 18, 2005, in Phoenix. The other is a federal demonstration pilot project to advance telehealth and license portability by establishing a central database.
Mr. Calonge responded to Representative Frangas' request for clarification on the concerns of the rural stakeholder mentioned earlier.
2:03 PM
Rosemary McCool, Director of the Division of Registrations at the Department of Regulatory Agencies, explained that she has the broad oversight of all the professional occupational licensing and that she would be discussing where Colorado is with the nursing compact. In 1998 the National Council of State Boards of Nursing implemented a process where states could enter into a compact that would allow nurses licensed in one of the 18 states in the compact to practice freely within those states. Ms. McCool stated that Colorado is not yet part of the compact, but the Department of Regulatory Agencies supports the compact.
Representative Butcher asked how the "bad actors" would be monitored through the compact so that they would not just move to another state to avoid discipline. Ms. McCool stated that she believes, now that they are 6 years into the program, the problems with bad actors have been fixed. Representative Butcher asked what impact the compact would have on the nursing shortage and restrictions that come along with it and if the compact would cause more nurses to leave Colorado. Ms. McCool stated that she had just attended a national conference and the council was very clear that this was not a model to fix the nursing shortage, but that it allows nurses to move freely from state to state.
Representative Todd asked if any of the 18 states involved in the compact are neighboring states. Ms. McCool stated that Arizona, New Mexico, Nebraska, and Utah
are currently members of the compact. In response to a question posed by the committee, Ms. McCool stated some of the drawbacks of the compact. One drawback is that it may be hard to track bad acts of nurses from one state to another, and another is the revenue issues as to which state receives the licensing fees from the nurses. She gave the example that New Mexico will receive the revenue from a nurse who pays for a license in New Mexico but who practices in Colorado thus taking those fees away from Colorado's revenue.
In response to Representative Butcher's question about continuing education for licensed nurses, Ms. McCool stated that continuing education is not required for nurses in Colorado at this time, but it could be an issue in another state.
2:09 PM - Recess2:12 PM
- Medication Therapy Management in Practice - The Texas Hispanic Health Care Initiative
Kim Roberson introduced himself as the Senior Director of Professional Affairs with the Texas Pharmacy Association and member of the Texas Hispanic Health Care Coalition. C.J. James stated that he represents the Texas Hispanic Health Care Initiative and the Texas Pharmacy Association and that he is the Senior Account Director or AstraZenica. The speakers distributed a handout of their PowerPoint presentation entitled, "MTMS: The Pharmacist's Medicare Role" (Attachment L).
Mr. Roberson explained that the Medicare Modernization Act of 2003 requires services from the prescription drug plans in each region to provide certain services to groups of people who receive Medicare benefits. He added that part of those services are designed to insure that medications are used correctly and have the appropriate outcomes. He stated that he would be discussing Medication Therapy Management Services (MTMS), listing criteria that must be met to receive the MTMS benefit, describing three MTMS benefit programs, and giving a current example of a pilot project that is running in San Antonio that fits the criteria.
Mr. Roberson explained that the Medicare Modernization Act of 2003 specifically calls for a Prescription Drug Plan (PDP) to have in place a Medication Therapy Management program. The program may be furnished by a pharmacist and is designed to assure that Part D drugs are properly used, meaning, the pharmacist ensures that the patient receives the medication, starts and continues to take the medication, and that the medication has the appropriate outcome. Part D eligible patients are those patients who have multiple chronic diseases, who take multiple covered Part D drugs, and who are identified as likely to incur annual drug costs that exceed the level specified by the Secretary of the Department of Health and Human Services. Pharmacy fees for the MTM services are paid for through the administration fee that the PDP has within their region.
Mr. Roberson went through the elements of the MTM program which are: enhanced enrollee understanding to promote the proper use of medication; increased enrollee adherence with prescription medication regiments; and detection of adverse drug events and patterns of under and overuse of medication.
Mr. Roberson explained the five core components of an MTM model. First, the pharmacist completes a medication therapy review consultation with the patient and/or care giver in order to establish a pharmacist/patient relationship and observe any signs of health problems. Second, the patient receives a personal medication record to be used by the patient in medication self management. Third, the patient receives a medication action plan that includes: the patients date of birth; an identifier for the patient, physician and pharmacist; date of the medication action plan; medication related issues; proposed actions; person responsible for the action; and the result of the action including the result date. The fourth step is called intervention and/or referral where the pharmacist provides consultative services and intervenes to address medication related problems, and/or refers the patient to other health care providers when needed. Lastly is the documentation and follow-up component where the Medication Therapy Management services are documented on a consistent manner, and a follow-up MTM visit is scheduled with the patient and/or care giver.
Mr. Roberson listed some resources the committee can use to learn more about Medication Therapy Management. He then concluded his portion of the presentation and introduced Mr. James who would be discussing the specifics of how the broad concepts of Medication Therapy Management were placed it into a specific program.
2:30 PM
Mr. James briefly explained what Medication Therapy Management services are, and referred the committee to the definition provided in the handout (Attachment L). Mr. James discussed the Texas Hispanic Healthcare Initiative, a Medication Therapy Management pilot program in San Antonio, Texas. Mr. James explained that the Texas Hispanic Healthcare Initiative pilot program focused on Hispanics with Type II Diabetes and began enrolling patients in 2004. Mr. James mentioned the program's goal is to complete enrollment by December of 2005 and would like to receive publication by 2007.
2:48 PM
Mr. James explained that through motivational interviewing they found the patients fall into one of four categories when they are given prescriptions: 1) the patient is resistant and will not follow the doctor's orders no matter what; 2) the patient needs more information before they feel they can follow the doctor's orders; 3) the patient that has sufficient information but needs to be shown how to use the medication; and 4) the patient does everything they are told to do.
Representative Butcher asked how long the program will run and how much the program will cost. Mr. James explained that the pharmacists set up appointments with the patients early in the morning or, in some cases, pharmacies have pharmacists who only handle case management rather than prescription filling all day. He stated there are three ways you can cover costs: 1) on a fee for service basis; 2) capitation; and 3) a per member per month basis. Mr. James stated that the cost for the pharmacist would be comparable to their hourly wages and would be a dollar per minute per intervention.
Mr. James continued his discussion on the Texas Hispanic Healthcare Initiative pilot program. He stated that the study consists of 300 patients: 150 are active patients and 150 patients are in a control group. He added that the patients are given a quality of life survey at the beginning of the program that includes obtaining the patient's blood pressure, weight, height, body fat, and hemoglobin A1C levels.
Mr. James discussed the intervals the active patients go through in the program. He stated that throughout the six scheduled visits with the pharmacist the patient is tested to see if they have been compliant. The pharmacist uses a form at the beginning and at the end of the visit and documents his/her findings. Mr. James concluded his presentation and asked if the committee had any questions.
2:55 PM
Representative Frangas asked if the 34 percent reduction in costs were projected savings. Mr. James replied that the 34 percent reduction in costs are realized. Representative Butcher stated she was concerned with the cost and asked if more pharmacists will be needed, how much time is involved, and how much will that care cost the patient. Mr. James responded.
Representative Butcher commented on how pharmacists have changed over time and asked what would happen to people who have Pharmacy Benefit Managers. Mr. James stated that because it is only a pilot program, they have not seen a big shift.
Representative Frangas asked what the pharmacists think about the program and if there has been any resistance from them. Mr. James stated that there has not been any resistance from the pharmacists at all. Representative Todd asked for some clarification on the three ways to cover costs. Mr. James covered costs again and concluded his presentation. Mr. Roberson gave a closing statement about the pilot program being not just for San Antonio, but reproducible in other areas of the country.
3:13 PM
The committee discussed what bills it wants to see at the October 13 meeting at which time the committee will decide what legislation it wants to send forward to the Legislative Council. Representative Frangas mentioned the issue of a trauma care bill. There was no objection to this idea. Senator Tochtrop expressed interest in looking at telehealth and the home health care industry related to Medicaid reimbursement. There was no objection to this. Representative Frangas and Representative Butcher requested a bill related to telemedicine and corrections.
3:15 PM
Michele Hanigsberg, Office of Legislative Legal Services, came to the table to ask a few questions including who would serve as the contact for each of these proposed bill requests. She also asked about the telehealth and home health care and whether there was any additional detail or whether Senator Tochtrop would be the contact. Representative Todd asked to be a contact on this bill as well.
3:18 PM
Representative Butcher requested information about the restrictions on nursing in Colorado law. What are requirements to train an RN in a community college, does it need to be a masters nurse that provides the course work to train RNS, etc. This will be provided for the next meeting.
3:20 PM -- Adjourn
The committee adjourned.