Lauren Peters, Undersecretary for Health Policy at EOHHS and Jeremy Sherer, Co-Chairman at Hooper Lundy & Bookman at Converge2Xcelerate Conference (Boston, MA)
- The financial sector spent $552 million on blockchain in 2018
- Telehealth provides an opportunity to overcome barriers to access to healthcare
- More than 50% of all hospitals in the U.S. have a telehealth program
Jeremy Sherer – Co-Chairman, Hooper Lundy & Bookman PC: 00:00
Hi everybody. My name is Jeremy Sherer. I’m the cochair of the digital health practice at Hooper Lundy and Bookman. And this session is on tele-health and consumer protection. We intended to do this live, but unfortunately because of some scheduling difficulties, we had to move this up and tape ahead of time. So I think we’ll just introduce ourselves really briefly. I’m a digital health attorney based here in Boston. I focus my practice on tele-health and I represent mostly healthcare providers national hospital systems to physician practices, tele-health platforms from some of the largest in the country to digital health startups on regulatory issues, help with business transactions and all of the sort of state by state regulatory issues they need to deal with in telehealth as well as a reimbursement which we’ll be talking about a little bit. That’s enough about me. This is Lauren Peters. Do you want to introduce yourself?
Lauren Peters – Undersecretary for Health Policy, EOHHS: 00:56
Good afternoon. My name is Lauren Peters. I’m the undersecretary for health policy and the state’s executive office of health and human services. In my role there, I oversee any of the policies and programs related to our state’s Medicaid program, the department of public health and the department of mental health. Through this work I’m looking constantly at policies to address healthcare costs and improving access. One of the many issues that continues to come up is the use of telemedicine and how we can leverage this telemedicine to increase access and ultimately address costs the system. So happy to happy to be here.
Jeremy Sherer – Co-Chairman, Hooper Lundy & Bookman PC: 01:37
So I think we’ll start just by kind of level setting and talking about sort of the state of affairs in tele-health right now and we’re, we’re continuing to see tremendous investment in this space. I saw yesterday that by 2025, the global tele-health market is expected to be worth something like $130 billion, which isn’t really a number that I can even really process, but it seems very large. We’re seeing the Medicare program finally get on board. We’re seeing expansion of services that are covered in Medicare fee for service. There’s also expansion in Medicare advantage. We’re seeing state Medicaid programs including mass health, start to expand the benefits that they are covering via telehealth and state by state. State legislatures are starting to relax certain standards and support initiatives like the interstate medical licensure compact to help clinicians obtain an expedited path to licensure in multiple States to allow folks to practice nationwide.
Jeremy Sherer – Co-Chairman, Hooper Lundy & Bookman PC: 02:39
I think that with all of that going on, this is a really interesting time for us to be discussing this here in Massachusetts. As a lot of folks know despite being really a leader in national health policy, Massachusetts has lagged a bit behind in the telehealth space. Last January I believe it was Mass Health announced that it would cover substance use disorder treatment provided via telehealth, provided that there had been a prior in person interaction. And we’ll talk about that in a minute. But really right now we’re sort of moving toward, from what I understand from you, Lauren, toward legislation on tele-health here in Massachusetts. And I guess the first question I have is in those meetings and when you’re talking about what this is going to look like in Massachusetts, what are the biggest opportunities that you see from an access perspective that tele-health offers to you and to folks in Massachusetts more broadly?
Lauren Peters – Undersecretary for Health Policy, EOHHS: 03:38
Sure. So, we really view the use and increase utilization of telehealth as a way to grease the access for populations that many of which you have barriers to receiving services and care. If we’re talking about transportation services, making appointments medication adherence for folks living in rural areas, I think that this is another opportunity. We also see a really important opportunity in the behavioral health space. We know that there are months and months long wait list to receive behavioral health care. And we’re seeing in other States this uptick in telehealth for behavioral health services. And it’s driven by the fact that particularly for adolescents, children this is a generation that is very sophisticated with, with apps and devices. And the use of such apps and devices kind of serve as the PR provides some level of anonymity but it’s more geared towards this generation what they’re looking for.
Lauren Peters – Undersecretary for Health Policy, EOHHS: 04:54
So, we think that in the behavioral health space is one of the largest areas for opportunity in terms of increasing access. And, and that is why you saw the mouse health program we did issue a bulletin earlier this calendar year to kind of require coverage for telehealth services for behavioral health services and required rate parody in that it needs to be reimbursed. It will be reimbursed by Mass Health program and at the same rate as an in person for the same type of service. But, I think to your point, Massachusetts has lagged other States in this area which is in some ways ironic because I recently learned that Massachusetts was the home to the first tele-health device or the kind of inception of tele-health. Yet we remain very much behind other States.
Lauren Peters – Undersecretary for Health Policy, EOHHS: 05:52
And I think that is a, a product one. We have no well defined regulatory framework here as to what services could be what the services constitute and are appropriate for telehealth. And two, we have no uniform requirement on payers to reimburse for telehealth. So I think that the voids in these two areas has really led to a slower implementation, a lack of uptake because as a provider of these types of telehealth services, you want those assurances that the services before you go and build that infrastructure, you want the assurances that those services are going to be reimbursed by a health plan. So you know, I think as Jeremy mentioned, the governor and this administration will be filing a fairly comprehensive healthcare bill in the coming days actually. And we do seek to address many of these policy challenges that has that has led to low uptake, low implementation of telehealth services today. And we’re hoping to build off of some of the prior legislative proposals that we’ve seen kind of get close to the finish line but haven’t quite crossed the finish line yet. And so we’re hoping that this is this legislative session we hope can address many of those barriers to increase in telehealth services.
Jeremy Sherer – Co-Chairman, Hooper Lundy & Bookman PC: 07:22
And so as you’re doing that, you know, tele-health obviously is not a different clinical discipline. It’s a way of delivering healthcare services to patients. And as you and your colleagues are thinking through the various elements of tele-health regulations, whether it’s physician, patient relationship establishment or e-prescribing or informed consent requirements you know, we’ve been tasked with talking about consumer protection here. So what are the considerations that are on your mind and that some of your colleagues have been talking about in terms of what the way that healthcare is being delivered via telehealth, what does that maybe open up in terms of concerns that maybe aren’t there or aren’t as great in a face to face in person interaction?
Lauren Peters – Undersecretary for Health Policy, EOHHS: 08:12
So I think just in terms of like what are some of the major policy considerations one is around the cost side. I think that we need to be cognizant of ensuring that the increase in implementation of telehealth is not going to increase utilization of unnecessary services or duplicative services. So as to increase costs both for the consumer patient for employers and for you know, the health plans by passing it on through premium increases. So I think that is certainly one consideration, but more around in the space of consumer protections. I think with any new technologies, particularly with health as we have with the insurgents of new technologies to increase health information exchange the data privacy and integrity concern is a real one with respect to tele-health.
Lauren Peters – Undersecretary for Health Policy, EOHHS: 09:14
And so I think that we need to ensure that we have proper security frameworks and protocols in place to protect the data and to maintain high standards for data integrity. So that the clinician on the other end of the telecommunication is receiving kind of accurate and you know, informed data about the patient that they are treating on the other end. And then another, I think core tenant of any telehealth policy proposal is around ensuring that the same standard of care applies through the delivery of telehealth services as does apply on the in-person side. So in other words, we need to ensure that the standard of care is applicable in the same way it applies on the in-person side. So that we’re not lowering or setting a lower standard for the delivery of telehealth services.
Jeremy Sherer – Co-Chairman, Hooper Lundy & Bookman PC: 10:17
I think that all makes a lot of sense. And it makes me think of one of the hottest public health issues right now, but also one that’s getting a lot of attention in the telehealth space is a substance use disorder and the opioid crisis. It’s an interesting area legally as you know, because folks need to ensure that they’re compliant with both federal and state law and federal law. Currently under the Ryan height act, which was which came into being in 2008 currently prohibits prescribing controlled substances via telehealth unless the clinician is engaged in a prior in-person examination with the patient or if one of a number of pretty narrow exceptions is satisfied, which A, haven’t really kept up with. The way that medicine is provided via telehealth. And B don’t really help folks who are outside of traditional healthcare facilities like hospitals.
Jeremy Sherer – Co-Chairman, Hooper Lundy & Bookman PC: 11:19
Massachusetts obviously isn’t immune to the opioid crisis. And the bulletin that we talked about back in January addressing behavioral health and there was discussion in there on substance use disorder and prescribing via telehealth. Obviously the opioid epidemic had a lot to do with that. It’s a particularly interesting time right now because we’re actually expecting a special tele-health registration at the federal level to come down, which would enable clinicians to get special training so that they can prescribe controlled substances, telehealth without that prior in person examination. And so I guess what I’m wondering is, again, going back to that consumer protection perspective, obviously there’s a lot of good that can be done here, but what are the main concerns that that you think are on regulators minds when approaching this area?
Lauren Peters – Undersecretary for Health Policy, EOHHS: 12:13
Right. Well, I think the pending rule that you mentioned regarding doing away with that in person, is it requirement? I think that if that actually comes into fruition, I think PR presents a really significant a positive opportunity to really expand access to these very important medication assisted treatments for those suffering with substance use disorder. And I think particularly because when I think about this population, they often say it is you need to meet them. At the time that they are ready there’s a small window when somebody with a substance use disorder kind of acknowledges and wants to seek treatment. And if you can’t provide them that treatment at that moment in time, you may miss that window. And so I think that is one of the reasons I think that the potential federal rule could address this is that you could provide kind of that, that on demand service for that individual.
Lauren Peters – Undersecretary for Health Policy, EOHHS: 13:16
Now I think as you mentioned, there are our challenges in the space with if you completely do away with that in person requirement. So you know, how is the doctor thinking about questions like how is the doctor going to get a toxicology screening or you’re in toxicology screening or to really understand are there other opioids in this person’s system that may have an adverse interaction with and some of the medication assistant treatment that they are prescribing. And so I think those are certainly questions that need to be addressed if we are going to do away with that in person requirement. But I don’t think that they are insurmountable. Also thinking about kind of the importance of consumer productions in the space. And going back to my original comment about why the standard of care is so important, is that with medication assisted treatment, they are most effective with other interventions.
Lauren Peters – Undersecretary for Health Policy, EOHHS: 14:15
So with other therapies counseling services. And so I think it comes down to this standard of care and what the treating clinician deems as an appropriate mode of delivering these services. And there may be instances where you need to have the in person screening so that you can do that urine toxicology screening or so that you can really truly know, what other opioids are in this individual system so you can best treat them so that you avoid the adverse interaction. But again, just to repeat myself, I think it comes down to the standard of care and the clinician’s judgment.
Jeremy Sherer – Co-Chairman, Hooper Lundy & Bookman PC: 15:02
And would you say that the, the conclusion is the same? You know, something else that you and I spoke about the other day was you know, we’re, we’re here to talk tele-health, but sort of the use of synchronous audio video is pretty ubiquitous at this point. And that kind of the next frontier is artificial intelligence and figuring out, you know, there’s a ton of great work being done here in Boston throughout New England and across the country to leverage that technology in order to really help spur development in the healthcare space. But there are consumer protection issues at bottom. So is that, do you think it just comes down to that same consideration that it’s a professional clinical judgment as to what constitutes an appropriate examination and what level of interaction is needed to prescribe medication?
Lauren Peters – Undersecretary for Health Policy, EOHHS: 15:49
Yeah, I mean, I think that first and foremost none of these technologies should ever be viewed as replacing the clinical judgment of the treating clinician. And I think that with some of these new evolving technologies, particularly in the, the AI space the lines start to blur about who is actually providing and rendering the service and what standards of care then apply. But I do think that these evolving technologies, particularly in the artificial intelligence space are important because I think of kind of two areas of opportunity where they have kind of the most significant potential, one being behavioral health just because we know that there are the wait lists that exist are real. We know that there is a real shortage of, of workforce here in Massachusetts and the waitlists are a product of that workforce challenge.
Lauren Peters – Undersecretary for Health Policy, EOHHS: 16:53
I think the second area of opportunity with respect to AI is with chronic disease management. Machine learning and automation. I think make this a ripe opportunity for advances in artificial intelligence and tele-health for really medication management and facilitating, making sure that there is the ongoing monitoring and it can do away with those repeat, you know, weekly, biweekly doctor’s appointments that, that many of these folks with chronic disease have to take part in. So I think with AI, again it comes down to I think we should leverage them for their data analytics and as a way to really monitor, do remote monitoring. But again, I don’t think that they should ever replace the clinical judgement.
Jeremy Sherer – Co-Chairman, Hooper Lundy & Bookman PC: 17:51
And I think that we’re seeing that, I mean artificial intelligence also, you know, in terms of chronic care management, talk about remote patient monitoring and we, we’re seeing that on federal level. Certainly, CMS has really started to endorse that more so you can on the state level as well. Do we have time for one more question or are we right? A 20 minutes? So I guess the last one that I’ll ask then is related to the MassHealth program. Cause we’re here in Massachusetts and from that bulletin in January forward and in speaking today, there’s obviously a focus on behavioral health maybe as the launching point into the telehealth space. And certainly, assuming that this upcoming legislation is successful and that we establish a regulatory framework, you’d imagine that there will be an expansion of tele-health benefits that will be covered by Mass Health. Do you have any sense of what type of priorities there might be? Or is there just a general openness to utilizing this technology as appropriate?
Lauren Peters – Undersecretary for Health Policy, EOHHS: 18:59
Sure. So just to go back to your one portion of question, I think with this legislation, we’re really looking and seeking to address the commercial market. But on the Mass Health side, I think as you mentioned, we put out the coverage requirements for behavioral health services to be delivered through telehealth. And we are looking to kind of increase and expand the, the set of services reimbursed by MassHealth. And I think just in terms of how we think about and how we prioritize, we’re really looking at this from an access point because they’re actually, we, you know, there are costs, the Mass Health program that maybe will be netted out or offset down the road. Right. As we, you know, as we hope to see like lower ER, ed visits, readmissions rates, right. But I think that we’re looking at those services where we have identified access issues for our Mass Health members.
Lauren Peters – Undersecretary for Health Policy, EOHHS: 19:59
And I think that that there are several kind of program integrity controls too. I mean, anytime that we’ve learned from past history that anytime you kind of expand or see a kind of provider type grow quickly at a rapid pace, I think there’s more risk for kind of fraud and other issues. So I think we want to ensure program integrity controls. We need to do so in an incremental fashion. But, and so, again, starting with those services where we see access and not just kind of opening the floodgates and kind of reimbursing for any telehealth service that comes their way.
Jeremy Sherer – Co-Chairman, Hooper Lundy & Bookman PC: 20:48
Sure. And that, I mean, there’s, there’s this track record for that approach. I mean, that’s how the Medicare program started. And I think most state Medicaid programs have started that way to identify sort of early on what services they’re covering. So I think that’s it for us. I’m getting a timeout sign. So thanks for joining us. Our contact information should be available. We’re happy to follow up afterwards. Thanks.