How Telemedicine May Change the Landscape of Health Care In New Jersey

Technological advances such as EMR, remote patient monitoring, and the use of tablet based patient registration have revolutionized the health care industry. Today, a patient can use an app on their phone to schedule an appointment, obtain their medical records, and locate physicians in the area. It is no surprise that over the past five years, telemedicine has become a popular form of treatment for physicians and patients. New Jersey recently unanimously passed legislation that establishes the requirements for the practice of telemedicine in the state of New Jersey. The passage of this legislation signals the importance of telemedicine to the state of New Jersey and the health care field.

The New Jersey bill defines key terms as follows: “health care provider” as an individual who provides a health care service to a patient, which includes, but is not limited to, a licensed physician, nurse, nurse practitioner, psychologist, psychiatrist, psychoanalyst, clinical social worker, physician assistant, professional counselor, respiratory therapist, speech pathologist, audiologist, optometrist, or any other health care professional acting within the scope of a valid license or certification issued pursuant to Title 45 of the New Jersey Statutes; and “Telemedicine” as the delivery of a health care service using electronic communications, information technology, or other electronic or technological means to bridge the gap between a health care provider who is located at a distant site and a patient who is located at an originating site. The term telemedicine, as explained in the bill, does not include “the use, in isolation, of audio-only telephone conversation, electronic mail, instant messaging, phone text, or facsimile transmission.”

The New Jersey legislation sets standards that those providing telemedicine services must follow. Prior to engaging in telemedicine, a provider-patient relationship must be established. The provider must (i) properly identify the patient using, at a minimum, the patient’s name, date of birth, phone number, and address; (ii) disclose and validate the provider’s identity and credentials, such as the provider’s license, title, and, if applicable, specialty and board certifications; (iii) review the patient’s medical history and any available medical records before initiating the telemedicine consult; and (iv) determine whether or not he/she will be able to meet the same standard of care as if the services were provided in person. When necessary, the provider also must refer the patient to appropriate follow up care, including making appropriate referrals for emergency care, if needed.

The newly passed law allows telemedicine to be covered under New Jersey Medicaid and commercial health insurance plans. As currently written, the law does not go as far as to require that the reimbursement rates for telemedicine be equal to the reimbursement rates that would be paid if the service was provided in-person. The language of the bill reads, “The State Medicaid and NJ FamilyCare programs shall provide coverage and payment for health care services delivered to a benefits recipient through telemedicine or telehealth, on the same basis as, and at a provider reimbursement rate that does not exceed the provider reimbursement rate that is applicable, when the services are delivered through in-person contact and consultation in New Jersey.” The language for commercial plans reads the same regarding parity of payments for telemedicine. As expected, the law sets the in-person reimbursement rate as the maximum reimbursement for telemedicine services. The law allows reimbursement to be paid to either the provider or the facility/organization with whom the provider is associated with, depending on the appropriate billing practices.

The emergence and acceptance of telemedicine as a viable option in the health care setting is extremely beneficial to patients who find themselves within the service area of a community hospital. Many community hospitals do not offer the array of service lines that large facilities offer. In situations where time is of the essence, telemedicine saves lives. One example of telemedicine at work in the community hospital setting is with pediatrics. Prior to telemedicine, when a child was brought into an emergency department without pediatric capabilities, the hospital and the patient’s family was faced with quickly transporting the patient to a facility with pediatric capabilities. Often, had the hospital had the ability to diagnose the patient, the transport would not have had to occur. Telemedicine allows the hospital to connect with a pediatric physician at another facility for a quick and accurate diagnosis. It must be noted that once a diagnosis is made, the patient may still require transportation, but the transportation is now only made in situations where it is medically necessary. For other situations, a physician, via telemedicine, can diagnose and prescribe treatment options that can be carried out in the community hospital or through prescription medicines, eliminating the stress and cost of transportation for the patient and the patient’s family.

Teleneurology, another important use of telemedicine, makes prompt neurological care available to patients in even the most remote locations—an important consideration since, with the treatment of stroke symptoms, every second counts. Teleneurology allows a patient, presenting to a hospital without a neurologist on-site, to have his or her symptoms observed by a physician via tele-conference for diagnosis purposes. The diagnosing physician can observe and converse with the patient and obtain close images of the patient’s eyes to determine if the patient is expecting or has experienced a stroke. Ischemic strokes, which are most commonly treated by giving the patient an injection of tissue plasminogen activator (“tPA”). tPA is used to dissolve the blood clot to improve blood flow to the part of the brain being deprived of blood. tPA, while highly effective, must be administered within three hours of the patient experiencing a stroke. Subtracting the time that it takes for a patient to arrive at a hospital for treatment, the patient may now have less than two hours to be given lifesaving medication. Given this shorter timeframe, it is essential for a hospital to quickly and accurately diagnose stroke symptoms. The use of teleneurology gives the patient the best possible chance of receiving a quick diagnosis and obtaining tPA within the three hour timeframe.

Telemedicine can also be utilized in hospitals to facilitate patient discharge. Often, a patient is ready to be discharged, but continues to wait at the hospital until his or her physician can physically discharge the patient from the hospital. For physicians with robust offsite practices, this step may not be immediate. A patient waiting to be discharged can cause patient flow and capacity issues for the hospital and can cause frustration for the patient and their family, ultimately leading to low patient satisfaction scores for the hospital. Allowing a physician to evaluate the patient via telemedicine would alleviate some of these issues. The physician could have a face to face discussion with the patient, asking the necessary questions prior to discharge, while not having to leave his or her office.

As technology advances and health care becomes more reliant on technology, the uses of telemedicine will continue to grow. Telemedicine will become engrained in the culture of providing top level care to patients, regardless of geographical location. Providers seeking to utilize this technology to implement this new means of delivering medical services must be sensitive to the current laws regulating this area and the fact that this area is continually evolving and developing, especially in New Jersey where the law is brand new.

The Senate Continues to Shape Its Version of A Health Care Insurance Bill

Recently Republican Senate Majority Leader Mitch McConnell released the Senate’s updated version of the Better Care Reconciliation Act (“BCRA”). Although a similar version of the bill passed in the House, the BCRA failed to obtain the necessary support in the Senate, leaving Republican leaders and the American people asking the question of “what next?” A summary of the key provisions of the BCRA are below. While this list is not exhaustive, it serves as the Republican party “wish list” of changes to the Affordable Care Act. Any further legislation will most likely have all, if not many, of the below provisions included.

  • The BCRA eliminates Employer and Individual Mandate Penalties enacted under the Affordable Care Act (“ACA”). The Individual Mandate Penalty has been a hot topic since the ACA was enacted.
  • The BCRA repeals taxes that were enacted under the ACA such as the excise tax on medical devices, the health insurance tax, the Medicare surcharge tax, the net investment tax, the branded prescription tax, the health insurance executive tax, the Medicare tax on high income taxpayers and the tanning tax. The bill would also temporarily repeal the “Cadillac tax” through 2026.
  • The BCRA ends the exclusion of coverage for over-the-counter medications from HSA or FSA funds, allows individuals to use HSA funds to pay insurance premiums, allow individuals to use HSA funds to cover health care related expenses incurred up to 60 days before HSA coverage becomes effective, and increase the amount that an individual can contribute annually to an HSA.
  • The BCRA eliminates the ACA’s small business tax credit by the year 2020.
  • The BCRA amends the IRS code to allow small business health plans to be treated as a group health plan.
  • The BCRA provides $45 million in federal funding to combat the current opioid crisis.
  • The BCRA will restructure the premium tax credits beginning in year 2020. Subsidies will be available to those below 350% of poverty. Subsidies are geared to a plan with an actuarial value of 58%, just below a bronze-level plan. The current subsidies are tied to the silver plans, which cover 70% of costs for most customers.
  • Cost Sharing Reduction (“CSR”) payments will be fully repealed by year 2020.
  • An additional $70 billion in stabilization funding will be provided to insurers as a way of reducing premiums and reducing out of pocket costs. This is an increase from the first version of the Senate’s BCRA, which provided for $112 billion dollars in stabilization funding.
  • The BCRA begins to phase out the enhanced federal match for Medicaid expansion over a three year period beginning in calendar year 2021.
  • Medicaid payments to beneficiaries will be capped for each Medicare beneficiary beginning the calendar year 2020. Blind and disabled children are not subject to the cap.
  • BCRA provides safety-net funding over a five years period to states that did not expand Medicaid under the ACA.
  • The BCRA has an incentive program in the form of a bonus payment for states in if states can demonstrate that on a set of child and adult quality measures, they were able to achieve results while also showing lower-than-expected aggregate Medicaid expenditures during an annual performance year.
  • The BCRA, like the AHCA will impose more frequent eligibility redeterminations. Although the BCRA makes this an optional exercise, the Senate bill would increase by 5 percentage points the federal contribution to state costs in connection with a more frequent eligibility redetermination process.
  • The BCRA allows the states to impose work requirements on non-disabled, nonelderly, and non-pregnant adults using the TANF work rules as the basis of a new Medicaid work policy.
  • The BCRA allows states to offer Medicaid coverage of “qualified inpatient psychiatric hospital services” to persons age 21 through 65. Under this provision, qualifying stays cannot exceed 30 consecutive days in a month or 90 total days in any calendar year.
  • As with the AHCA, the BCRA prohibits using tax credits to purchase health plans that cover abortion.
  • Also the same as the AHCA, the BCRA prohibits for one year any Medicaid, CHIP, Maternal and Child Health Services Block Grant, and Social Services Block Grant funding for Planned Parenthood.
  • The BCRA loosens 1332 waiver requirements.

Ted Cruz’s amendment to the BCRA will allow consumers to buy health insurance plans that do not meet the current requirements for health plans under the ACA. In essence, these plans would be cheaper and offer less coverage. Insurers could offer these plans if the insurer also offers a plan that does include all of the current ACA requirements, allowing those with pre-existing conditions to obtain coverage at a reasonable rate. This is a heated topic in the discussions surrounding the passage of the BCRA. One of the most population functions of the ACA is that individuals with pre-existing conditions can obtain affordable health insurance.  Because all Americans are currently required to purchase health insurance, risk shifting takes place between those with preexisting conditions and those who are generally healthy but still paying high premiums. Opponents of the Cruz legislation argue that all Americans will purchase the bare bones plan, essentially making health insurance costs rise for those purchasing the more comprehensive plans. With less being collected by insurance companies in the form of premiums, the funds will have to be recaptured elsewhere.

After the failure of the BCRA, Senate Republicans attempted a “skinny repeal” of the Affordable Care Act, repealing only some of the provisions of the ACA, allowing further legislation to be passed in the future. The skinny repeal would have included repealing the unpopular individual mandate, defund planned parenthood while diverting funds to community health centers, eliminate the medical device tax for three (3)  years, allow for increased contribution to Health Savings Accounts, allow states to have more flexibility in determining waivers for essential health benefits, and eliminate the employer mandate for eight (8) years. The hot button topic of Medicaid was not discussed in the skinny repeal. Even without some of the more controversial topics being included, the skinny repeal of the ACA did not pass. Again, Republicans and the American people are asking themselves the question of what will happen next. Regardless of what side of the political spectrum you fall, health care and health insurance affects every American.

There is great uncertainty surrounding the Republican effort to repeal and replace the Affordable Care Act. Thus, it is unclear whether the Republican “wish list” outlined above or any other version can ultimately muster up sufficient votes to make it through both chambers of Congress to get to the President’s desk.

Has the DOJ Investigation Into eClinicalWorks Opened a Can of Worms?

eClinicalWorks, a provider of electronic health record software (“Software”) to physician offices and hospitals nationwide, recently reached a settlement with the United States government for its alleged involvement in falsely certifying the capabilities of its Software.  After Brendan Delaney, a former employee of the New York City Division of Health Care Access and Improvement alerted the government of perceived issues with the Software, the Department of Justice brought suit against eClinicalWorks for violating the False-Claims Act, more specially for allegedly misrepresenting the capabilities of the software and for allegedly paying kickbacks to customers in exchange for those customers certifying its product.

The American Recovery and Reinvestment Act of 2009 established the Electronic Health Record Incentive Program, which offered incentive payments to health care providers that switched from traditional paper medical records to an electronic health record system. In order to obtain an incentive payment, the health care provider was required to switch from paper records to an electronic medical record system that had been certified as having met certain technological specifications.

eClinicalWorks has held itself out as having certification for its Software under the requirements set forth in the American Recovery and Reinvestment Act. The Department of Justice stated that when obtaining such certification for its Software, eClinicalWorks did not disclose all information to the certifying body, ultimately rending the certification null and void. By creating and selling non-compliant Software, it is also alleged that eClinicalWorks knowingly caused health care providers who purchased its software to submit unknowingly fraudulent claims seeking incentive payments under the Electronic Health Records Incentive Program. 

In explaining the deficiency with the Software, the Department of Justice alleges that the Software does not comply with data portability requirements. Data portability is essential in patient care because it allows health care providers to exchange data. The Department of Justice gave the following example of a deficiency in the Software, “in order to pass certification testing without meeting the certification criteria for standardized drug codes, the company modified its software by ‘hardcoding’ only the drug codes required for testing. In other words, rather than programming the capability to retrieve any drug code from a complete database, [eClinicalWorks] simply typed the 16 codes necessary for certification testing directly into its software. [eClinicalWorks’s] software also did not accurately record user actions in an audit log, and in certain situations did not reliably record diagnostic imaging orders or perform drug interaction checks.”

So what now? As part of the settlement, eClinicalWorks entered into a five-year Corporate Integrity Agreement, which requires that the company retain an independent software quality overseer, and provide semi annual compliance reports to the Office of the Inspector General. eClinicalWorks must also provide free software updates to the Software to all current customers. Current customers will also have the opportunity to transfer their patient data to another electronic health record provider. This data transfer will be free of charge to customers who make this choice. Customers choosing this option must be cautioned, while switching vendors free of charge may appear on its face to be the best solution, the provider has to consider the pitfalls associated with switching to a different electronic health record system, including but not limited to time and capital spent on training staff and physicians on the new system, any hardware or software upgrades to ensure compatibility with the new electronic medical record system, and the resources that will be needed to back up the current system prior to migration.

The investigation into eClinicalWorks also raises the question of whether other electronic health record software vendors will undergo heightened scrutiny when submitting for certification or if those vendors will be required to submit for recertification under a heightened set of security standards. If it is found that other vendors are also non-compliant, health care providers could be at risk of unknowingly violating HIPAA.