The Chesapeake Children's Therapy Center started as a small private practice in 1979 and is now a major outpatient provider, with 35 staff members serving 300 to 400 children a month in the Washington, D.C., area.
Key to that growth, says Chesapeake Executive Director Patricia Rogers, has been keeping up with clients' changing needs. "If we were doing things today the way we did five years ago, we wouldn't still be in business," she says.
And right now, the center sees a pressing need for remote treatment among busy parents struggling to shuttle kids to appointments, says Rogers, a speech-language pathologist.
"Telepractice is clearly one of those trends that is here to stay," says Rogers. "More people are doing it, universities are on board, and the market's ready to accept it."
So, after Virginia passed a 2010 law mandating that private insurers cover telepractice, Rogers and colleague Mary Wood-Maloney got to work developing a telepractice program for Chesapeake. Then, with added momentum from a new Maryland telepractice mandate (The ASHA Leader, July 3), they approached insurer CareFirst BlueCross BlueShield with a plan to provide some of Chesapeake's rehab services via Web conferencing, and get reimbursed for it.
Their plan closely follows the Virginia and Maryland telepractice guidelines, including criteria for patient selection and a system for staff training. And, in its early trial-and-error stages, it allows families to try telepractice services for free.
CareFirst Senior Medical Director Daniel Winn immediately signed on to the Chesapeake plan, noting his support for the recent Maryland legislation. With his blessing for CareFirst reimbursement, Chesapeake moves forward with pilot testing the program this fall.
The Leader spoke with Winn about why he backs Chesapeake's telepractice program and where he sees telemedicine headed, generally.
Why does CareFirst support the Maryland legislation covering services delivered by telepractice?
We've been interested in telehealth for a number of years. Our entrée into telemedicine was with the University of Maryland (UMD), getting high-risk obstetrics patients in rural areas access to perinatalogists and high-risk obstetricians at UMD. It made a lot of sense to us, and we were very excited about it. We had some of our mental health people using telemedicine and teaching us about it. And we had a lot of interest from our physician network in e-visits—e-mail visits back and forth—and getting CareFirst to reimburse for that. We wanted to leapfrog that and go right into telemedicine.
So we developed our own policy that predated the Maryland legislation to requisition how we were going to pay for this—"this" meaning not e-visits, but actual telemedicine. Then the legislation came along, and we were very supportive. We always saw the need.
What sort of need were you seeing, and how was your policy helping meet it?
Initially it was the rural areas. Besides the high-risk obstetrics group, there was interest from UMD's shock-trauma emergency services for stroke. How can we get patients needed services, fast, when they're miles away? How can we get hooked up with neurologists who can give clot-busters in three or four hours? We got very involved in a CareFirst-funded telepractice pilot program in hospitals that didn't have their own ICU physicians. Some plans reimburse for telemedicine, but only for certain specialties. Based on our pilot program's success—and the success of hepatology and dermatology programs in other parts of the country—we wanted to open that up.
How did CareFirst develop its coverage guidelines for telehealth?
We use as many elements as possible from regular in-person visits. It's not just a phone call or e-mail. It's a combination of visual, audio, and interactive elements. It's as close to in-person as we can get. The day is not far when we can listen to heartbeats and do other similar high-tech things from afar.
With our guidelines, initial visits are done in person. Telemedicine isn't so much for new patients as more established patients. It makes consultations easier and more convenient. Patients don't have to drive 40 miles to see their provider.
Our guidelines are more clinically focused than reimbursement-focused. We want people using telemedicine to be mindful of the challenges, such as selecting the wrong patient. And the flip side of convenience is that it's too convenient—we can miss some subtle but important cues that we more easily pick up on in person.
What services—not just speech-language pathology—do you anticipate are most likely to be delivered by telehealth?
Occupational therapy (OT) and physical therapy (PT) have not done this yet. There's a big difference between talking about it and actually taking the step and doing it. Insurers like CareFirst are reimbursing for time and service—paying the same as if services were provided in an office setting. We're still looking at the reimbursement codes and how to match them up. And we're not paying for equipment and technology used to deliver service remotely. That could be a practice or a hospital that's paying for those. It depends who is providing the infrastructure.
I don't know if OT and PT could provide this via telemedicine. They're more hands-on, so I don't know if it's a good fit, but I am open to it. From a practice perspective, telemedicine has to be something used enough that it's worth it to staff and patients.
What was your reaction to Chesapeake's presentation on delivering speech-language pathology services via telepractice?
Very positive. They are doing a lot of things I've already mentioned. Their program is very well thought out. They have a method to select patients very carefully, which is key, and selecting parents is part of that. They make sure parents understand the benefits and limitations of telemedicine. And it's only for current patients, not new ones.
Also having no charge for the initial session is a good idea, so people can try it and see if they like it. And what really impressed me is the amount of staff training they're doing, only with staff who really want to do it. Plus they have a good quality-improvement process, with staff conducting reviews to make sure the service is worthwhile.
What makes for good telepractice patient selection?
It's important that the patient has a good attention level and is focused. When someone's in your office it can be easier to maintain their attention by using touch, for example. And there are the logistical requirements—that they have the right technology and can use it. And you don't want the patient to have a history of missing appointments, unless it's completely transportation-related.
What do you foresee in the short and long term in terms of the role of telehealth in health care delivery?
My own opinion is that, as with a lot of technological advances, this will be a slow uptake. I'd be happy to be proven wrong. But, I think there will be early adopters like Chesapeake, and over time it will continue to a tipping point. Then lots of folks will start using it. But there'll be a period of trial and error, of trial and tribulation. We'll find it works well for some disease processes and maybe doesn't work as well for other things.
Also, if through the Affordable Care Act more people have access to more services, and there aren't enough providers in whatever specialty, then maybe telepractice could help.
Will telemedicine help with cost containment?
We'll see. Getting people the right care at the right time certainly does reduce costs of care. I'm not expert enough to know exactly how much these cost-savings would be. But going forward, we can see the trend is that we won't have enough providers across many specialties, especially primary care, mental health, general surgery, and geriatrics. Telehealth may help with all these, except, say, general surgery.
What's the incentive for the service provider, such as in the case of Chesapeake?
Chesapeake felt strongly that so many parents are so busy that it's hard for them to get from work to a 5 p.m. appointment. So they're thinking of helping their patients, that this could be a selling point that could potentially make them more competitive with other providers. A lot of the motive for providers and CareFirst is improving care. That's what we're all about.
And with all telepractice programs—Chesapeake, anybody's—you monitor outcomes. I'm interested in talking with them about their outcomes down the road. They are pioneers. And if they have good outcomes, I imagine we'll have other SLP practices call.
Daniel Winn, MD, is vice president and senior medical director in the Medical Affairs Division at CareFirst BlueCross BlueShield. Patricia Rogers, MA, CCC-SLP, executive director of The Chesapeake Children's Therapy Center, is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education, and 18, Telepractice. Contact her at firstname.lastname@example.org.