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Chapter 8: Health and Human Services
Expand the Use of Telemedicine to Help Disabled Children
Summary
Seriously ill and disabled children enrolled in Texas’ Children with
Special Health Care Needs Program (CSHCN) and related state programs often need
to travel to specialty medical centers to receive expert care and consultations.
Travel can be hard for parents, take a health toll on children, and can be
costly for the state. Texas should use telemedicine to provide cost-effective
care to children with special health care needs. Telemedicine will increase
families’ satisfaction with medical care and improve customer service in
essential services.
Background
The Texas Department of Health operates the Children with Special Health Care
Needs Program (CSHCN), which pays for physician services, drug benefits,
hospitalization, and other medical costs for disabled children in families whose
incomes are 200 percent or less of the federal poverty level. About 5,300
children received care through this program in
1999.[1] CSHCN pays for medical treatment of
these children who are seriously ill, often with cancer, heart defects, or other
chronic disabling conditions. They sometimes need to travel to specialty medical
centers or physicians to receive expert care and consultations. Travel can be
hard for parents, take a health toll on the children, and can be costly for the
state.
Telemedicine services are not covered by CSHCN, but could be used to provide
certain beneficial health services in the CSHCN program. This would minimize
travel costs reimbursed by the state and reduce the physical and mental stress
to families. Presently, families and their disabled children travel to
designated CSHCN health care providers to receive care. This may involve
significant planning by the family, taking into consideration the health of the
child, obtaining special medical care or transportation during the trip, or
making parents take time off from their jobs. CSHCN pays for transportation to
the medical expert and for room and board while the family is away from home. A
recent assessment of Medicare telemedicine reimbursements found that a typical
Medicare beneficiary would have had to make a round trip of 197 miles (median
number) to receive medical care in an urban center if they had not had local
telemedicine facilities.[2]
Telemedicine Examples
There is no doctor, hospital, or clinic in the small community of Hart,
Texas. But a pediatrician from the Texas Tech University Health Sciences Center
visits children every Wednesday, and another doctor visits via a telemedicine
satellite link on Fridays. The school nurse, Retta Knox, has used her resources
to piece together a number of health services for children. Knox said that
prior to the implementation of the telemedicine link, “...the kids were
always sick and missed lots of school....” The telemedicine and medical
connections with Texas Tech have helped provide rapid treatment for a
third-grader’s ruptured appendix and a diagnosis of diabetes for a
teenager.[3]
Reimbursement for telemedicine has been expanded in recent years. Now, 17
states authorize Medicaid reimbursement for physician consultations and other
services.[4] The 1996 Comptroller’s Texas
Performance Review, Disturbing the Peace, recommended allowing Medicaid
to reimburse for telemedicine services, and state law was changed to allow the
service. Some states have laws requiring private health maintenance
organizations or health service plans to reimburse for telemedicine services.
Under the federal Balanced Budget Act of 1997, the federal Medicare program has
begun paying for consultations in areas designated as health professional
shortage areas.[5]
The University of Texas Medical Branch (UTMB) in Galveston provides
telemedicine consultations for children with special health care needs who live
in Nacogdoches and Jefferson Counties. Almost all of approximately 113 children
in the program have multiple diagnoses like spinal bifida, cerebral palsy,
seizure disorders and others. UTMB reports that Medicaid reimburses physician
consultation services for children who are Medicaid-eligible only if specific
conditions are met. Generally, the conditions include provisions regarding the
type of medical provider who provides the teleconsultation; where the provider
is located; whether the services are consultative in nature or involve
evaluation and management; and other criteria.[6]
Medicaid will not pay for care provided via telemedicine when a number of
different types of providers see a disabled child. For example, a severely
disabled child may need to see a specialty physician, an occupational therapist,
a respiratory therapist, or another type of therapeutic practitioner, but
Medicaid will not reimburse a telemedicine provider for the entire number of
services provided. However, if the child travels to the medical center, Medicaid
will pay for the additional services, including the cost of transporting the
child to the center.
These conditions tend to limit Medicaid reimbursement for telemedicine.
Providers will not provide Medicaid telemedicine services if they do not receive
reimbursement, as they would have if they provide the services in a traditional
medical office setting. In fact, Medicaid reimburses about $20,000 per quarter
or less for telemedicine services statewide.[7]
Due to Texas Medicaid’s overly restrictive terms, potential costs savings
from transporting patients and other savings have been minimized.
The health insurance provided under the new Children’s Health Insurance
Program (CHIP) also does not cover telemedicine consultations for children with
special health care needs.[8] The federal
Balanced Budget Act of 1997 created CHIP to improve insurance coverage for
low-income children. In addition to expanding Medicaid eligibility for teenagers
under CHIP, Texas designed a state CHIP insurance plan for children in families
with incomes of up to 200 percent of the federal poverty level. Texas receives a
federal match, about 72 percent for 2001, to help families purchase insurance
coverage for their uninsured children.
Effectiveness of Telemedicine
A recent study of the University of Georgia’s telemedicine program
established that families find telemedicine an acceptable way of receiving
pediatric subspecialty consultation services for their children with special
health care needs when the telemedicine is used as one part of an integrated
treatment program for the child. The study’s authors argued that a
statewide telemedicine system would reduce the cost of delivering medical care
to CSHCN patients by improving access to subspecialty pediatric care and by
decreasing transportation time and costs.[9]
A telemedicine study involving the Physician’s Family Health Center in
Cuero, Texas demonstrated that each telemedicine consultation saved an average
of $122 in travel costs. Dr. Dan Dugi, a family practitioner at the health
center, and HealthCare Vision, Inc. studied telemedicine consultations in
clinics in Nixon, Kenedy, and Cuero. More than 60 percent of patients surveyed
during the study indicated that telemedicine allowed them to see a physician
earlier, and 20 percent said that the video consultations prevented lost work
time.[10]
Recommendations
- Texas law should be amended to require the Texas
Department of Health to reimburse certain telemedicine costs for children with
special health care needs under the Children with Special Health Care Needs
Program.
Under this recommendation, state law would be amended to require Children
with Special Health Care Needs Program (CSHCN) to develop policies allowing
reimbursement for telemedicine. Reimbursements would be equal to the amounts
those providers currently receive for care delivered when a disabled child
visits a medical center or physician’s office. Reimbursement for multiple
services provided by different providers in a single instance would be allowed
when it is cost-effective to do so, compared to the cost of reimbursement for
individual providers and travel and transportation costs. CSHCN should consult
with UTMB, other major Texas telemedicine hub sites, the state Medicaid Office,
the Texas Health and Human Services Commission (HHSC), and major CSHCN providers
in developing the policies.
- Texas law should be changed to require the Health
and Human Services Commission to expand the use of telemedicine in Medicaid and
the Children’s Health Insurance Program for children with special health
care needs.
HHSC would be required to develop cost-effective policies for reimbursing
telemedicine services from Medicaid and Children’s Health Insurance
Program (CHIP) for children with special health care needs. The policies would
include allowing reimbursement for multiple health care providers to provide
telemedicine services at the same time.
Fiscal Impact
The fiscal impact of these recommendations cannot be estimated. Some savings
would result from decreased travel, food, and lodging costs currently paid by
CSHCN, and transportation costs paid by Medicaid. Long-term savings should
result from more timely treatments and comprehensive reviews of the medical
requirements of children with special health care needs.
[1 ] Memorandum from Lori
Roberts, Texas Department of Health, Children with Special Health Care Needs
(CSHCN) Program, to Jack Baum, associate commissioner, Community Health and
Resources Development, Texas Department of Health, June 15, 2000.
[2 ] US Department of Health
and Human Services, Health Resources and Services Administration,
“Medicare Reimbursement for Telehealth: An Assessment of Telehealth
Encounters January 1, 1999 – June 30, 1999, Preliminary Report,” by
Joe Tracy, Thelma McClosky-Armstrong, Rob Sprang, and Sam Burgiss (Washington,
DC, October 15, 1999) (http://telehealth.hrsa.gov/pubs/reim2000.htm).
(Internet document.)
[3] Barry Shlachter,
“Nurse Provides Care by Using Telemedicine,” Fort Worth Star
Telegram (February 20, 2000), p. 18.
[4] US Health Care Financing
Administration, “States Where Medicaid Reimbursement of Services Utilizing
Telemedicine is Available”
(http://www.hcfa.gov/medicaid/telelist.htm). (Internet
document.)
[5] National Conference of
State Legislatures, “Telemedicine,” by Marla Rothouse and Elana
Mintz, Denver, Colorado, May 23, 2000. (Issue brief.)
[6] Email from Patricia
Jakobi, Center for Telehealth and Distance Education, University of Texas
Medical Branch, Galveston, Texas, September 8, 2000.
[7 ] Telephone interview with
Kay Gharemani, Texas Health and Human Services Commission, Austin, Texas, July
6, 2000.
[8] Telephone interview with
Dr. John Hellerstedt, Medical Director, Children’s Health Insurance
Program, Austin, Texas, November 2, 2000.
[9 ] Warren Karp, R. Kevin
Grigsby, Maureen McSwiggan-Hardin, Suzanne Pursley-Crotteau, Laura N. Adams,
Wyndolyn Bell, Max E. Stachura, and William P. Kando, “Use of Telemedicine
for Children with Special Health Care Needs,” Pediatrics (April
2000), pp. 843-847.
[10] Presentation by Dr. Dan
Dugi, Jr., at the Conference on Rural Telemedicine as a Clinical Tool, sponsored
by the Center for Rural Health Initiatives, Austin, Texas, July 7,
2000.
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