Poor broadband and out-of-step Medicare policies relegate Maine’s use of telehealth to small niches when it should be in the mainstream.
By: J. Craig Anderson, Portland Press Herald
Information technology should be revolutionizing the way patients in Maine interact with their health care providers, but poor broadband infrastructure and outdated federal policies are slowing progress to a crawl.
Many people believe the best way to increase access to quality, affordable health care in Maine is to connect more patients and providers in real time over the internet and cellular networks via an approach known broadly as telehealth, but there are major obstacles.
Broadband communications are essential for providing telehealth services, and many areas of rural Maine still don’t have reliable broadband internet or cellular network access. An equally big problem is that despite Maine’s recent passage of a parity law requiring Medicaid and private insurance to cover most telehealth and in-person services equally, the federally controlled Medicare does not cover many telehealth services.
Advocates say telehealth should ideally account for at least 25 percent of all patient-provider interactions based on Maine’s demographics. Currently it is estimated to comprise less than 5 percent.
“It’s still considerably smaller than it could and should be,” said Danielle Louder, executive director of the Augusta-based Northeast Telehealth Resource Center. “A big part of that is the variation in policy. We have one set of policies for Medicare, and then our MaineCare and private payer policies in the state are getting closer (to full acceptance).”
All four members of Maine’s congressional delegation say they would support policy changes to promote rural broadband expansion and make telehealth more accessible to Medicare recipients. Ironically, one lawmaker said, the biggest potential hurdle to expanding Medicare coverage of telehealth is that some congressional leaders fear telehealth is so effective at improving access to care that it would result in higher Medicare spending overall.
Without greater buy-in from Medicare, Maine’s health care networks are unwilling to make large investments in telehealth programs that advocates say could make the difference between life and death for many chronically ill, elderly and rural residents in the state.
Health care providers in Maine say the Medicare restrictions are based on a faulty assumption that adding telehealth services would make health care more expensive because it involves the purchase of additional equipment, and more patients would use it. While that might have been true initially, the providers said telehealth has advanced to the point where it can actually cut costs overall by reducing the need for emergency care while making health care services more widely available.
They already have proved that telehealth can be effective at keeping patients out of the emergency room – and out of the morgue.
Improving health care access among isolated populations such as rural residents and seniors who live alone is a top priority for health care providers in Maine. They said telehealth can reduce the rate of health emergencies among those populations via videoconferencing, mobile apps and home health-monitoring devices. The technology is already available and improving exponentially.
“I believe that it’s going to become more ubiquitous in respect to it’s a tool in the toolbox, and it’s a must-have,” Louder said. “It becomes part of a larger strategy.”
TELEHEALTH AT WORK
Up until a year ago, 68-year-old Scarborough resident Raymond Dube was constantly bouncing back and forth between his home and the emergency room.
Dube, who suffers from chronic obstructive pulmonary disease, or COPD, has regular episodes during which he cannot catch his breath. In the past, those bouts of breathlessness would cause him to panic, and the only way he knew to restore normal breathing was a trip to the ER for a dose of morphine.
“I was practically living there,” Dube said.
His health care providers decided to try something different. They enrolled Dube in a telehealth program at South Portland’s Northern Light Home Care and Hospice that places specialized tablet devices in patients’ homes. Each tablet is connected wirelessly to home health-monitoring devices and a cellular network.
At least once a day, Dube responds to audio prompts about his current condition using the device’s touchscreen: Is he having difficulty breathing? Has he developed a cough? Does he feel the need to limit his physical activity? The device also can check Dube’s breathing, pulse, heart rate and other vital signs. All of that information is sent automatically to Northern Light in real time.
If there’s a problem, a nurse calls Dube immediately and talks him through the necessary steps to restore his breathing, including the use of medication he keeps at home. At least once a week, Northern Light cardiopulmonary nurse Stacey Laqualia also visits Dube in his home for a more thorough examination.
“It’s saved me a lot of trips to the ER,” Dube said. “I can quickly get in touch with the nurse, who tells me what to do.”
Laqualia said there are many benefits to the technology. It can be used to monitor any patient’s health, anywhere. It also keeps a historical record of each patient’s responses, so any provider with access can view the data and make a diagnosis.
“We monitor patients all the way up to Presque Isle in The County,” Laqualia said. “We end up talking more to the patients, as well.”
A reduction in emergency room visits has the benefit of reducing costs to health care providers and insurers, but Bill Whitmore, Maine market vice president for Massachusetts-based insurer Harvard Pilgrim Health Care, said the push for telehealth has more to do with a desire to improve access to care.
Health care access is a nationwide problem, he said, but it is particularly acute in Maine.
“This state is way, way ahead of the country as far as the percentage of the population that’s over 65 years old, and with that comes more and more health services,” Whitmore said. “I think that alone is going to really require that more services are delivered from a telehealth perspective.”
Fitch Ratings, one of the country’s leading bond rating agencies, has said that by 2026, Maine will have the highest percentage of people 65 and older in the country, a status it calls “super aged.” It estimated that nearly one in four Mainers will be 65 or older.
Another issue that is likely to require expansion of telehealth services in Maine is the trend toward small, rural hospitals eliminating areas of specialized care and referring patients to the nearest large hospital in their system, which can be located hours away. For example, St. Andrews Hospital in Boothbay Harbor closed its emergency room in 2013, and other small hospitals have eliminated specialty services such as maternity care in recent years.
“By doing that, they’re going to have to find ways to deliver those services to the people in the rural areas, and (telehealth) is a way that that will happen,” Whitmore said.
Maine is regarded as a pioneer in the field of telehealth, with a handful of programs developed in the state long before the advent of smartphones and tablet devices.
MaineHealth Care at Home, formerly known as Visiting Nurses, was using bulky computers with dial-up modems to remotely monitor elderly patients’ health conditions all the way back in 2001, said the organization’s vice president, Mia Millefoglie.
Under the program, the home care service has upgraded its technology several times and has been able to reduce COPD, diabetes and heart failure patients’ 30-day hospital readmission rates from the industry average of 20 to 25 percent down to a low of 3 to 8 percent, Millefoglie said.
“It’s significant,” she said. “The technology is really a tool that extends our expert critical services. It really is just a tool – it’s a conduit to services.”
Another program, created in 2001 by the Maine Seacoast Mission, involves a boat outfitted with telehealth equipment and staffed by nurse Sharon Daley, the mission’s director of island health. The mobile telehealth service regularly visits 10 inhabited islands east of Boothbay Harbor, including Frenchboro, Isle au Haut and Matinicus.
Daley said the program has saved island residents countless hours of costly travel for routine medical appointments.
“It costs a couple hundred dollars to go off-island,” she said. “You miss a day of work.”
Despite the success of those programs, major health care providers in Maine have only recently begun to take telehealth more seriously, said MaineHealth Telehealth Director Tom Caswell.
MaineHealth, the state’s largest health care system, has in the past encouraged individual providers to start their own telehealth programs, but the programs usually would die if the providers leading them left the MaineHealth system, Caswell said.
“If the provider left, the whole (program) that they were doing would kind of evaporate, because it would only be one champion, and that champion would leave,” he said.
But that changed about 18 months ago, when MaineHealth decided to take a more structured approach to telehealth, Caswell said. Now, its telehealth programs are no longer at the whim of individual providers and are designed to withstand turnover.
About 16,000 patient visits in 2018 were conducted via telehealth within the MaineHealth system, he said – a growing number, but still just a tiny fraction of all health care interactions.
The major limiting factor to the growth of telehealth in Maine is Medicare, Caswell said. The federally subsidized health insurance program will not reimburse providers for telehealth services offered to patients in their homes, or to patients in urban areas, he said.
About 336,000 Mainers – roughly one-fourth of the state’s population – were on Medicare or Medicare Advantage plans in 2018, according to the Centers for Medicare and Medicaid Services and the Kaiser Family Foundation, a nonprofit health care research group.
But there is strong evidence that Medicare comprises an even higher share of annual health insurance claims filed in Maine. Recently, the Maine Health Data Organization, a state agency that collects health care data from health insurance companies and hospitals, undertook a project to examine all private insurance claims filed in the state from July 1, 2016, to June 30, 2017. Of the roughly 16 million claims it examined, roughly 10 million were Medicare and Medicaid claims, and only 6 million were for private insurers.
In most cases, Medicare patients in rural areas must go to a medical facility to receive telehealth services in order for Medicare to reimburse the provider, Caswell said. In other words, they must travel to a local doctor’s office or other health care facility just to communicate remotely with a health care provider located farther away.
The only exceptions are for some patients on home health monitoring, and for those receiving home-based treatment for opioid abuse.
“So you can imagine in our state, as old as it is, if you take oncology, cardiology, orthopedic joints, you take all these practices that literally will not do telehealth because such a large portion of their practice is Medicare,” Caswell said. “And to tell a person with cancer that they have to go to a primary care practice to see someone with telehealth is not good care.”
Maine’s Medicaid program, known as MaineCare, does reimburse providers for most telehealth services, as do private insurers. The Maine Legislature recently passed a “coverage parity” law that requires insurers to cover telehealth services, but it does not mandate “payment parity,” or equal compensation to providers for both types of service. It also does not apply to the federally controlled Medicare.
Since Medicare is primarily for seniors, much of the current telehealth focus in Maine is on pediatric care, Caswell said.
Members of Maine’s congressional delegation said they are aware of the Medicare problem and have been working on a variety of possible solutions.
U.S. Rep. Chellie Pingree, a Democrat, is a member of the the Congressional Telehealth Caucus and co-sponsored a bill in 2018 called the Medicare Telehealth Parity Act, which would have broadly expanded the types of providers eligible to provide telehealth services under Medicare and allowed more Medicare patients to receive telehealth services at home.
That bill failed, but Pingree said she expects it to be reintroduced this year under the U.S. House of Representatives’ new Democratic leadership following the August recess.
U.S. Rep. Jared Golden, a Democrat, is a co-sponsor of two bills that are aimed at addressing the Medicare issue. One would expand Medicare reimbursement to providers for mental health treatment provided via telehealth, including home-based treatment, and the other would create a three-year pilot program for Medicare to cover home-based respiratory therapy for COPD patients through telehealth.
“I’ve heard from doctors and health care providers in Maine about the importance of telehealth initiatives to bring high-quality, affordable care to more Mainers, particularly in rural areas,” Golden said in a statement. “Expanding access to affordable rural broadband is essential to improving rural health care, but we can’t take full advantage until we change the Medicare rules to bring telehealth into more homes.”
U.S. Sens. Angus King, an independent, and Susan Collins, a Republican, both expressed frustration over the fact that Medicare’s current policies restrict access to telehealth.
“Telehealth has the potential to revolutionize the way we provide health care to rural America – but only if the federal government can get out of its own way,” King said in a statement. “Right now, its transformative potential is being hindered by inadequate broadband connectivity and Medicare regulations that limit access to telehealth services.”
Collins pointed to recent success by the U.S. Department of Veterans Affairs in rolling out telehealth services for treating war veterans with post-traumatic stress disorder. She said it “makes absolutely no sense” that Medicare patients cannot access telehealth services at home.
“The federal government shouldn’t be a barrier,” Collins said in an interview. “They should be promoting this.”
Collins said one positive development is that starting in 2020, providers of Medicare Advantage plans will have greater flexibility in defining coverage, which could open the door to more telehealth services. About 100,000 Mainers had Medicare Advantage plans in 2018.
However, she said another development that could have adverse consequences is that the Congressional Budget Office is working on a report to summarize the likely fiscal impact of opening up Medicare coverage to telehealth.
Collins said she fears that if the CBO report determines telehealth coverage would increase Medicare expenditures overall, it could be used by some lawmakers as justification for maintaining the status quo.
“We live and die by the estimates provided by the CBO,” she said. “It could be that if there are more services used, that it would increase costs under the Medicare program. I would argue that it’s more likely to decrease costs, because if we can keep people healthy and out of hospitals and long-term care facilities … and keep them in their own homes, that seems to me to be not only more in line with patients’ preferences, but also a cost-saver.”
Another problem holding back telehealth expansion in Maine is the lack of reliable broadband communications infrastructure in many rural areas of the state.
Islesboro resident Frank Start said his teenage daughter recently enrolled in Maine Behavioral Healthcare’s telehealth program for her counseling needs.
The program, which Start said has saved his family from many hours of missed time at school and work, is only accessible because of a municipal broadband project approved in 2016 that brought gigabit fiber-optic internet service to the island.
Because the island community relies on a ferry service to access the mainland, a round-trip visit to the behavioral health practice takes three to four hours, he said. That means his daughter would have to miss school, which would only exacerbate her anxiety problems.
Being able to use telehealth services from home has made it possible for her to receive treatment once a week in the evening, Start said, and she is more relaxed because she isn’t missing school and can discuss her mental health issues in a safe and familiar place.
“We couldn’t do this telehealth without a good internet connection, and what we had before wouldn’t have worked,” he said. “It has been extremely beneficial.”
Many rural communities in Maine have been waiting decades for the major internet service providers to bring broadband service to their areas, a situation exacerbated by the state having one of the slowest average internet speeds in the country.
The lack of broadband in areas that would hypothetically benefit the most from telehealth services is another significant deterrent to investment in telehealth, the providers said. Some rural Maine communities are in some stage of planning their own broadband projects, but others still have no clear prospects for broadband in the foreseeable future.
There are some federal bills in the works that could make it easier for Maine communities to access funds for rural broadband expansion projects. Collins is a co-sponsor of the bipartisan American Broadband Buildout Act, which would offer up to $5 billion in matching funds for rural broadband projects, and King helped successfully push for a funding increase from $25 million to $350 million for rural broadband in the December 2018 Farm Bill.
In the Maine Legislature’s most recent session, a $239 million bond package that included $30 million for rural broadband expansion failed to receive the two-thirds majorities needed to send it to voters.
All four of Maine’s federal lawmakers said they support efforts to expand rural broadband services in the state.
“Telehealth can help bring top-of-the-line medical care to some of the hardest-to-reach communities across Maine, but bringing this expert medical care to areas where it’s otherwise difficult to access means our state needs better connectivity,” Pingree said in a statement. “Right now, Maine ranks 49th in the nation for broadband access, which is why I’ve worked in Congress to change that through greater access to federal grant programs and loans.”
In 2011, Bangor-based trauma surgeon Dr. Rafael Grossmann had an idea to use consumer technology to supply small, rural hospitals in Maine with trauma surgery expertise.
Grossmann, a self-described “health care futurist” and telehealth evangelist, reasoned that video chat-enabled mobile devices such as tablets and smartphones would make it easier to share medical expertise during emergencies, because they were far more affordable and ubiquitous than the expensive telemedicine equipment other health care providers were using at the time.
He set up a pilot program involving seven sites in the former Eastern Maine Healthcare Systems network, now part of Northern Light Health. Medical staff at each location had smartphones and tablets equipped with special Health Insurance Portability and Accountability Act-compliant software that allowed them to consult remotely with an on-call trauma surgery expert when needed.
But Grossmann said the pilot program ultimately was scrapped. He said participating providers failed to see the value in it, and he doesn’t understand why.
“Unfortunately we’re not doing that anymore,” he said. “We still have the capability. We actually have the hardware capability to connect to all these sites, but certainly the impetus, the interest, the continuous work on the telehealth pillar of care, was really not developed.”
However, within the past year or so, Grossmann said he has been approached by health care executives who are looking to implement telehealth programs similar to the one he envisioned nearly a decade ago.
In his spare time, Grossmann is an avid public speaker, giving lectures on how exponential growth in the advancement of technology will alter the health care landscape in unimaginable ways.
He believes a telehealth revolution is coming, and that all health care providers – in Maine and around the globe – will need to embrace it.
“We know that we don’t have the person power – the demand for health care services is too much for (what) we have,” Grossmann said. “The numbers are astonishing. We know that five billion people in the world don’t have access to safe and affordable surgery.”
This article appears in Kennebec Journal & Morning Sentinel.