November 18, 2003 Feature

Meeting The Challenge of Rural Service Delivery

Last month clinicians in North Dakota won a major reimbursement victory when Blue Cross and Blue Shield agreed to cover telepractice speech-language pathology services. This is the story of their pilot project and their successful advocacy with a major health insurer.

In January 2002, the Speech Therapy Department at St. Alexius Medical Center, Bismarck began exploring the possibility of providing services through the Tele-Care Network after receiving several requests to provide direct services to various communities within the state of North Dakota. These rural communities lacked access to local speech-language pathology services. We were unable to provide these services directly due to staffing, reimbursement, and travel constraints.

Five months later, we began providing speech services using telepractice, and launched a pilot project in collaboration with Ashley Medical Center in Ashley, ND, which is 120 miles from Bismarck. The project started with only one patient, but quickly grew to serve four patients.

A woman who suffered a stroke while visiting her daughter in California became the first patient to use telemedicine for speech-language pathology services. After returning to North Dakota, her need for services continued. Because she could not drive, she needed her family to take her to Bismarck twice weekly, and told us that she "would not have attended therapy if it meant driving several times a week." She was very pleased with the services she received and "graduated" from speech services after three months.

The second patient, from Gackle, ND, also received speech services after suffering a stroke. She received speech services three times weekly for six weeks. She also said that she would not have traveled the 96 miles to Bismarck for therapy, and was pleased that services could be provided through the Tele-Care Network.

The process of delivering speech-language pathology services using telepractice is quite simple. The equipment installed at each facility allows for full-motion video consultation with spontaneous audio and video interaction, much like the interaction that takes place with two people talking in the same room. Prior to conducting a session, we fax and/or mail written material to the rural tele-health coordinator. During the session, we use an Elmo overhead-projector stand, located in the consultation room, to display the materials over the television monitor. If additional materials are required, the rural tele-health coordinator provides them upon request. A facilitator is always present with the patient to assist throughout the session.

According to Ashley Medical Center's Tele-Health coordinator, this service saved the Ashley residents 56 trips to Bismarck, which is equivalent to 13,440 miles. Using a cost of 31 cents per mile, the cost savings to the patients and their families was $4,766.40. This did not include the lost wages of the family members transporting the patients.

We continue to provide speech services over the Tele-Care Network and over the past year have expanded our service to include seven medical centers and one school. We have treated approximately 20 patients. This has been a very positive experience and appears to be beneficial for everyone involved. We feel telepractice provides an opportunity for St. Alexius Medical Center as well as other telehealth providers to reach patients that would otherwise not receive speech-language pathology services.

Next Step: Reimbursement

After seeing patients and realizing how successful the pilot program was, we decided to approach Blue Cross and Blue Shield of North Dakota, Medicaid, and Medicare about adding speech-language pathology to their list of covered services offered through telepractice. We wrote letters and provided examples to each third-party payer. In April 2002, we met with Medicaid staff at the state capitol to discuss the proposal. They informed us that telehealth speech services would be approved if prior approval requests were made. In July and again in November of last year, BC/BS of ND notified us that services would not be covered until ASHA set specific standards.

At this point we turned for support to ASHA staff, who wrote a letter to the North Dakota State Insurance Commission endorsing our position with citations from various state regulations, national accreditation, training requirements, and supporting outcomes data. In May 2003, we again received notification from BC/BS of ND that services would not be covered. At this point we felt discouraged, but were determined to succeed.

With continued successful outcomes using telehealth, we knew our sevices clearly benefited our patients. Richard Tschider, chief executive officer of St. Alexius Medical Center, also believed our services were beneficial and supported us by repeatedly taking our request to the BC/BS of ND board of directors. Finally, last month, a BC/BS of ND committee added telehealth speech services to their list of covered services. We are very excited about this reimbursement victory and wanted to share our excitement with all ASHA members.

Bobbie Houn, is a senior speech-language pathologist at St. Alexius Medical Center in Bismarck, ND. Contact her

Kolette Trottier, is a telehealth nurse coordinator at St. Alexius Medical Center.

cite as: Houn, B.  & Trottier, K. (2003, November 18). Meeting The Challenge of Rural Service Delivery. The ASHA Leader.


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