## ­­­­PURPOSE OF MEETING

The Chronic Care Workgroup convened to discuss and agree on
recommendations for submission to AHIC. The meeting was called to order
at 1:03 p.m. by Co-chairs Tony Trenkle of the Department of Health and
Human Services (HHS) Centers for Medicare & Medicaid Services (CMS) and
Craig Barrett of Intel. All meeting materials referenced below are
available at
<http://www.hhs.gov/healthit/ahic/chroniccare/cc_archive.html>.

## KEY TOPICS

### 1. Summary of the April 26 Meeting

Two corrections were made to the summary of the April 26, 2007, meeting.
The following sentence found in section 3: "The Medicare system,
however, is misaligned to promote efficiency and patient-centered care"
was restated as: "The Medicare system, however, in its quest to promote
efficiency and patient centered care, is misaligned." The article
mentioned by Jay Sanders was published in *Telemedicine and e-Health*,
not *JAMA*. It was moved and seconded to accept the summary as
corrected.

### 2. Introduction of New Members & Review of Workgroup Charge

Karen Bell of the HHS Office of the National Coordinator (ONC) reviewed
the broad charge of workgroup:

#### Broad Charge for the Workgroup: Make recommendations to the Community to deploy widely available, secure technology solutions for remote monitoring and assessment of patients and for communication between clinicians about patients.

Dr. Bell noted that the Workgroup has yet to focus on the communications
between clinicians aspect of its charge, which is about coordination of
care. Several new members have agreed to join the Workgroup. Their input
is expected to be helpful in filling this gap. The new members are as
follows:

Cheryl Austein-Casnoff, HHS Health Resources and Services Administration
(HRSA),

alternate Dena S. Puskin

Justine Handelman, Blue Cross Blue Shield Association

John Linkous, American Telemedicine Association

Steve McConnell, Alzheimer's Association

The American Heart Association, the American Diabetes Association, and
Continua have been invited to become members, but they have yet to
respond. Several of the initial members no longer participate. The
Co-chairs asked the staff to provide a roster of current members and
alternates.

##### Staff Action Item #1: Compile and distribute an up-to-date Workgroup roster.

Dr. Bell went on to say that in preparation for the June 12 AHIC meeting
staff prepared a brief report on the status of recommendations
previously submitted (May 2006) by the Workgroup and accepted by AHIC.
She summarized the following:

Recommendations 1.0--1.2 dealt with collecting data and establishing an
evidence base on the effects of reimbursement policy on the use of
secure messaging. Plans for a pilot project have progressed. A Request
for Proposals for a demonstration project will soon be released. Awards
will be made to three separate sites with preliminary results expected
in December 2008. The demonstrations also will examine the effects of
secure messaging on workflow.

Recommendation 2.0 focused on the reduction of licensure barriers to the
provision of care electronically across state lines. On July 6, 2007,
the National Governors Association's Healthcare Practices Task Force
will submit recommendations to reduce barriers to interstate
telemedicine delivery.

Recommendations 3.0--3.1 concerned standards and certification criteria
for secure messaging. The Health Information Technology Standards Panel
(HITSP) and Certification Commission for Health Information Technology
(CCHIT) have very limited capacity to develop use cases. Secure
messaging was not assigned a high priority in the January 23, 2007, AHIC
decision on use cases. These are the only recommendations that are not
progressing.

Recommendation 4.0 asked that the Agency for Healthcare Research and
Quality (AHRQ) undertake a synthesis of current knowledge of the
barriers and drivers to the use of health IT by the elderly, ill, and
underserved. A task order was issued in May, and a contract is expected
in July 2007.

Recommendation 4.1 asked for a report on secure messaging availability
to providers and a plan and timetable to make secure messaging available
across the U.S.. The Federal Communications Commission (FCC) is tasked
with expanding broadband access across the country. Currently, 45
percent of the country has broadband access, representing approximately
75 percent of U.S. households. The goal is to have broadband access
available across the U.S. by 2014.

In summary, progress has been made in carrying out all recommendations
except for those that require a use case. Dr. Bell asked if the
Co-chairs would like to comment on the need for the use cases at the
upcoming AHIC meeting. The need must be emphasized, or it once again may
not make the priority list. It was suggested that secure messaging and
remote monitoring be combined in the recommendation for the use case.
Interoperability is basic to the other use cases and customers want this
service. No member was opposed to reaffirming this recommendation.

#### Decision: Recommend to AHIC that the interoperability use case development initially recommended be made a top priority. The use case should include both secure messaging and remote monitoring.

##### Staff Action Item #2: Draft the recommendation emphasizing the importance of making the use case a priority for submission at the June AHIC meeting.

### 3. Medicare Advantage Plans & Telehealth

Teresa Decaro, Deputy Director of the Medicare Advantage Group of CMS,
described the framework for the Medicare Advantage (MA) Plans.
Approximately 19 percent of Medicare enrollees participate in these
capitated arrangements, which are established via a competitive bidding
process. These plans provide all Medicare Part A and B services. The
plans establish prices for their products as well as benefits and cost
sharing for Parts A and B. The benefits and prices then are compared to
benchmarks in that county. Seventy-five percent of the difference
between the benchmark and the price, called the rebate, is available to
use as mandatory, health-related, supplemental benefits -- for example,
dental and vision services -- to make the plan more marketable.
Telehealth services -- for example, remote monitoring in a rural area --
could be entertained but would need to be explicitly described in the MA
plan's agreement with Medicare.

Although MA plans have considerable flexibility in the use of rebates,
these are competitive business decisions. A plan would not offer a
service unless management believed there was a demand. There are various
vehicles for communicating a vision to the plans. It is plausible to
raise the issue of remote monitoring services. CMS has talked to some
plans about the value of secure messaging.

###### Q & A

In response to a question with a specific example, Dr. Decaro indicated
that an Advantage Plan would not be precluded from establishing
telemedicine services for revolving door patients (as a means of
providing better quality care while reducing costs of hospitalization),
but the plan would have to conduct an actuarial analysis, cost the
service out, and price it competitively for the bid. The plan would want
to ensure that the service created an efficiency.

A discussion then ensued about the strength of the evidence for the cost
saving aspects of remote monitoring. The opinion was expressed that the
cost would increase, at least initially.

Dr. Decaro indicated that statutes specifically limiting reimbursement
for telemedicine do not apply to the supplemental benefits offered by
Medicare Advantage Plans. She understands that some Special Needs Plans
include telephone and other remote monitoring used to convey
information. These services may be included in the administrative fee.

The discussion then turned to the requirement under Current Procedural
Terminology (CPT) codes for face-to-face encounters. Parts A & B do not
allow a dermatologist to provide remote care, however, an MA plan could
conceivably contract for this service under their supplemental benefits
paid via the rebate.

Members discussed the value of recommending that Medicare Advantage
plans be requested to include telemedicine services. Medicare Advantage
plans were also considered as a source to research the value of
telehealth. However, it was pointed out that it is not known how many
plans pay for telemedicine. Telemedicine is very broad: it includes
telephonic contact and some MAs may provide such services but bill them
as an administrative fee so CMS would not know which plans were using
remote care service as part of their plan's benefits. One member
suggested that it would be valuable to determine whether the findings on
the benefits of remote monitoring in the Department of Veterans Affairs
can be replicated in the private sector. Ms. Decaro noted that Medicare
Advantage plans are currently under evaluation. Consequently, this is a
good time for such a recommendation.

#### Decision: Members agreed to recommend that the Secretary fund a demonstration project involving Medicare Advantage plans' use of home-based monitoring for chronic disease management.

##### Staff Action Item #3: Draft the recommendation and send it to Workforce members for a vote. The draft will be distributed by e-mail no later than the morning of June 6. A short turnaround time is essential, because the AHIC meets on June 12.

### 4. Legal Authority to Expand Telehealth

Amy Hunsberger, JD, of the Office of General Counsel was invited by
staff to give an opinion on several questions related to the Secretary's
authority under the existing statutes to expand Medicare coverage for
telemedicine services. The Workgroup members believe that reimbursement
for services should be based on the time and expertise of the providers,
not on the location where the service is rendered. The current laws and
regulations are based on the technology in use at the time of the
establishment of the Medicare program. The face-to-face requirement is
based on the American Medical Association's CPT codes. The Secretary has
some authority to add originating sites.

One member noted that the initial requirement for face-to-face was due
to the lack of a good way to define "data store-and-forward" other than
by telephone. It was generally assumed that paying for telephone
services would be expensive as well as increase opportunities for fraud
and abuse. The experiences in Alaska and Hawaii may provide the basis
for a natural experiment. Otherwise, there is not a lot of relevant
literature. It was observed that CMS considers interactive video the
same as face-to-face in certain situations.

Ms. Hunsberger and several members expressed concerns that payment for
remote monitoring may increase opportunities for fraud and abuse. In
response, it was noted that current technology does lend itself to
auditing. Services can be documented electronically. In certain
situations, remote monitoring may provide more accurate readings and
increase the quality of care.

The economic concerns were discussed such as the fact that telehealth
might reduce friction which could increase service use. Where there is
supply, there will be demand. One member commented that Dartmouth
studies have shown that quality does not necessarily improve with
greater use of services. Nevertheless, it was noted that some
subpopulations under-use preventive services resulting in higher costs
due to ED visits and hospitalizations. In these cases, increased access
to sub-acute services use would be beneficial.

Members recognized the need to have unique codes for remote services so
that the payer can determine where the service was delivered.

#### Decision: Workforce members agreed on two recommendations to AHIC: that the Secretary issue a legal guidance to expand the definition of "physician's office" to include remote monitoring services and take into account controls for fraud and abuse, and that the experience with remote store-and-forward technologies in Alaska and Hawaii be studied in order to determine if the use of these technologies should be expanded to other States.

##### Staff Action Items #4--5: Draft the two recommendations and circulate to Workforce members for feedback and voting no later than June 6.

Members discussed the possibility of another recommendation -- that the
Secretary support any bill that would widen the scope of remote services
for reimbursement. Discussion indicated that such a recommendation was
too broad. Members also discussed an action by Congress that gave the
administration pre‑approval to allow skilled nursing facilities to be an
originating site for telemedicine, but at the same time required a study
on the evidence. The report was due in 2005 but has not been submitted
to Congress. It is under review by the Secretary's office. The report
apparently is based upon a review of the literature through 2004. One
member noted that the report is likely out of date, insofar as
considerable research has been published since 2004.

The Workgroup considered whether the recommendations agreed upon could
be subsumed under a blanket recommendation that the Secretary review the
settings under which services can be reimbursed and move forward with
demonstration projects to expand the settings. Members appeared to agree
that several specific recommendations would enable the Secretary to take
a stepwise approach.

Although Ms. Hunsberger could not give an opinion at this time as to the
breadth of the Secretary's authority in making the changes recommended
by the Workgroup, she did say that the annual update of the Medicare fee
schedule, which requires publishing the draft and final rule in the
*Federal Register*, is a logical place for changing policy. In response
to a question, she said she had not had much experience with national
coverage decisions. There is a mechanism for the public to put something
forward. Several members suggested that telemedicine services could be
covered via a national coverage decision, similar to action that has
been taken regionally.

One member reported that AHRQ had convened a conference on telemedicine
at which the issue of national and local coverage decisions was
discussed. Reportedly, the level of evidence is higher for a national
decision than a local one. Several members believed this to be a
possible avenue. The CMS representatives declined to offer an opinion.
Ms. Hunsberger agreed to review the draft recommendations as they are
circulated to members.

### 5. Next Steps

### The recommendations will be submitted to AHIC. AHIC will respond, possibly with a request for revisions or clarifications. The Workgroup then will return to the broad charge and focus on the coordination of care across multiple providers for the chronically ill. The next meeting is scheduled for July 17.

### 6. Public Comments

Maria Friedman, representing RxHub, pointed out that the A-19 process
was a way to recommend statutory change. She called in to say that the
Alaska Federal Health Care Access Network is mobilizing 248 sites using
telemedicine technologies. Dr. Puskin added that she is the Project
Officer. The projects have received funding from HRSA, the Indian Health
Service, and the Department of Defense for at least five years.
Considerable data have yet to be analyzed.

### 7. Adjournment

The meeting adjourned at 3:06 p.m.

## SUMMARY OF ACTION ITEMS

##### Staff Action Item #1: Compile and distribute an up-to-date Workgroup roster.

#### The Workforce agreed to submit four recommendations to AHIC. Staff will draft the recommendations and circulate via e-mail to members for feedback and voting no later than June 6. The turnaround time is very short. The AHIC meets on June 12.

##### Staff Action Items #2--5: Draft the language of four recommendations to do the following:

##### Make the use case on interoperability of secure messaging and remote monitoring a priority.

##### Fund a demonstration project involving Advantage Plans' use of home-based monitoring for chronic disease management.

##### Expand the definition of physician's office to include remote monitoring services and establish mechanisms for control of fraud and abuse.

##### Commission a study of the experience with store-and-forward in Alaska and Hawaii and examine the feasibility of expanding to other States.

##### 

**MEeting materials**

Agenda

**[Chronic Care Workgroup]{.underline}**

**[Members and Designees Participating in the Web
Conference]{.underline}**

**[Tuesday, June 5, 2007]{.underline}**

*Co-chairs*

Craig Barrett Intel

Tony Trenkle HHS/Centers for Medicare & Medicaid Services

*ONC Staff*

Karen Bell Office of Health Information Technology Adoption

Yael Harris ONC

*Members*

Frances Dare (for Jeff Rideout) Cisco

Brian DeVore Intel

Joe Gifford (for Mohan Nair) The Regence Group

Justine Handelman Blue Cross Blue Shield Association

Eric Larson Group Health Cooperative

John Linkous American Telemedicine Association

Dena S. Puskin

(for Cheryl Austein-Casnoff) HHS/Health Resources and Services
Administration

Jay Sanders The Global Telemedicine Group

**Disclaimer:** *The views expressed in written conference materials or
publications and by speakers and moderators at HHS-sponsored conferences
do not necessarily reflect the official policies of HHS; nor does
mention of trade names, commercial practices, or organizations imply
endorsement by the U.S. Government.*