 Thank you, Dr. Burston. That was a wonderful introduction to our day and really, I'd say, a perfect overview and outline of what we want to get into in more detail today in our discussions of the key issues and questions. So thank you all for being here. Before I begin, can we just have another round of applause for Dr. Burston? And can I also invite our reaction panel to come up to the stage? So thanks everyone for being here. We're really pleased to have such a great attendance here at the forum today. My name is Keebney Klein and I serve as senior counsel for policy issues on our government relations team in Kaiser Permanente. As part of my role, I have the privilege of working across our organization and externally on a variety of policy issues, national and state, including I have the privilege of working on our telehealth issues, which I have very much enjoyed. I've been working on telehealth and related issues as well as provider network related issues for about five years at Kaiser Permanente and I have to say I'm pretty lucky to be in that space. I get to see a lot of the cool innovations that we are doing as an organization across the program, including obviously the technology itself, but also how we're implementing it day to day as well as in pilot stages as we're testing and proving new innovations and new applications. So we titled this forum, Leveraging Telehealth to Expand Access to High Quality Care, with an emphasis on the quality. Just as not all in-person care is equal, not all telehealth is equal. As Kaiser Permanente, we work to ensure that members and patients receive the right care at the right time, at the right setting, to meet their clinical needs and their care preferences. And sometimes that setting is their home or their workplace via a telehealth modality because it is with their own doctor oftentimes who has their medical record available in front of them and has a history with that patient is more and it's more convenient for the patient and timely and more often more timely care. That patient can then get back to their day and their responsibilities after having their clinical issue taken care of. And that, in Kaiser Permanente, to Dr. Burson's point and to Murray's point earlier, it is part of it's woven together with the rest of their care. That integration is part of how we deliver telehealth. So that encounter is treated like any other where the physician's notes are made in the patient's medical record after the video visit or phone visit. Prescriptions are sent to the pharmacy, lab and imaging orders are entered and as needed follow-up or specialist care appointments are made. At the same time, it's very possible that a telehealth encounter is not what's needed. So as part of our clinical and operational workflows, we ensure that patients can get the next available in clinic appointment with their doctor or their other provider, another member of the care team as that's appropriate. So we believe that within our integrated delivery system this works very well and we'll hear more about how that works when Dr. Trong speaks later. And we know that our members and our patients want access to care through these modalities. And so as a member of our government relations team, I spend a lot of time developing our talking points and advocacy points around how we expand telehealth. And we have a number of barriers that we're working on addressing to Dr. Burston's major points. Reimbursement is a key barrier to the general expansion of telehealth. As we are, and the primary barrier as I think Dr. Miller will get into is in Medicare. And we have a situation where only a very, very small minority of patients across the country, Medicare beneficiaries can get access to telehealth. So in the Medicare Advantage space, we spend a lot of time advocating around the value for the Medicare beneficiaries. We do see our Medicare-aged members and our Medicare-eligible wanting to access care via telehealth. And so we spend a great deal of time thinking about how can we really demonstrate the value for Medicare members in the Medicare Advantage space. We've had more than one meeting with Dr. Miller and staff during his time at MedPAC. We also have expressed support for legislation that's moving through Congress now that is intended to alleviate some of the challenges around Medicare Advantage coverage that would allow for Medicare Advantage plans to include telehealth as part of their basic parts A and B bid. But Medicare is not the only area where we advocate. We certainly are attuned to what is happening at the state level and we do see more and more expansion and opportunities for plans, health plans to cover and pay for telehealth. So the doors are being opened. But again, we do have these sort of these reimbursement barriers and other key issues that we need to address in order to tip the scale for where plans and where employers will want more and more telehealth and want to be able to access. I think the idea that when there's a critical mass of patients demanding access, just like we do in the banking context, in every other context in transportation, we will see greater investment there. So the other areas where we are participating in some of policy discussions are at the state level around licensure. And so we're supporting the interstate compact, or excuse me, legislation from the Federation of State Medical Boards. That is an area where we're pushing our state regulators and legislators to act. We're also working with the state of California on their issue, their, excuse me, their effort to extend e-consults where the provider-to-provider engagement is allowed and more open for specialists to be able to engage with primary care providers potentially in more vulnerable areas of the state. And so while we, as Kaiser Permanente, do a lot of fair amount of e-consults internally already, we are working with the state to help them educate DHCS and others, Department of Health Care Services, so that that can be extended to others. So with that as an introduction, I'd like to introduce our panel who will grace us with a few minutes of introduction and then we'll be able to get into questions. So first we have Donna Kinzer, who is the Executive Director of the Maryland Health Services Cost Review Commission where she has led her staff in the field through transitioning Maryland hospitals to global budgets. They adapt Maryland's quality improvement programs to the new model, develop new payment policies, analyze potential avoidable utilization for hospitals, and implement broad stakeholder input approaches. Next we have Brian Marcotte, who is the President and CEO of the National Business Group on Health, the nation's only non-profit organization devoted exclusively to representing large employers' perspectives on national health policy issues and helping companies optimize business performance through health improvement and healthcare management. Next is Dr. Mark Miller. He is the recently appointed Vice President of Healthcare at the Laura and John Arnold Foundation. Prior to joining the foundation, Mark served for 15 years as the Executive Director of MedPAC, Maryland, excuse me, the Medicare Payment Advisory Commission, which as we know is the independent congressional agency established to advise Congress on issues affecting the Medicare program. Mark also previously served as Assistant Director of the Health and Human Resources at the Congressional Budget Office and as Deputy Director of Health Plans at CMS. And finally, Dr. Sandra Wilkness, who is the Program Director for the NGA Center for Best Practices Health Division, focusing on issues related to behavioral health and social determinants of health and the innovative integration of these into the health system transformation efforts. She leads NGA's technical assistance work with states to advance programs for high need, high cost populations. So I'd like to welcome our panel. And I think we'll begin with Donna Kisner. Kinser, pardon me. Good morning. Thank you very much to Kaiser Permanente and the Kaiser Foundation for inviting me here today to talk about what we're, a little bit about what we're doing in Maryland and to reflect on the wonderful remarks from Dr. Burston, very provocative questions and to share some of the initial observations and efforts that we're taking on in telehealth in Maryland. And I have one slide and I have one disclosure. My disclosure is I'm the Executive Director of the Health Services Cost Review Commission and we're implementing a payment and delivery model transformation. And so, of course, that colors my view of the world. And I appreciate the opportunity to tell you about briefly about what you're doing and then to delve into some of Dr. Burston's provocative questions. So I just wanted to give you a little background on what we're doing. I have only one slide, so I'm not going to spend a lot of time in the slide mode. But I think it's important to just set a context to understand what I think is that everybody keeps bringing up is the reimbursement challenge and how we're tackling that, but also some of the elements of that that make it more difficult to tackle than we might imagine on the surface. In Maryland, the reimbursement system is moving away from a volume-based model and since 2014, hospitals in Maryland have been paid on a budget that is set at the beginning of the year. Our system is driven off of a per capita approach with value-based payment and the system covers all six million Marylanders. The budgets cover hospital payments for all payers. And this is being brought forward through provider-led efforts. This is not a big government project. We're implementing this with our commission, which is seven voluntary commissioners and 37 staff. So obviously, we're not implementing the transformation that is taking place. It's the provider community that is implementing. And we're doing this under a federal demonstration that allows Maryland to set hospital payment levels for all payers. And Maryland has been setting hospital rates for all payers since 1977 under federal waivers. But in this situation, we moved away from a rate-setting concept, really, to a per capita concept in 2014. And just to give you a little view of what we've been experiencing, we have been experiencing savings to the Medicare program without cost-shifting. And we've had some very significant reductions and avoidable utilization. We've been able to stabilize rural hospitals in Maryland through this model. And I'll talk a little bit more about that, which, of course, is a big national concern. And when we started this program, we were among the, and I can't say this proudly, but we were among the highest states in readmission levels for the Medicare program. And we have now reduced down to the national average, even though we have many social problems, particularly in our urban areas. And so we have, we've been doing this since 2014. And we're currently in the process of designing a program to take us forward that will go beyond hospitals. And we see a little circle, a set of bubbles in the slide. And so now we're operating the hospital per capita program with some care redesign programs that are provider-initiated. As we go into 2019 and beyond, we will be on a per capita program for total Part A and Part B cost for about 800,000 Medicare beneficiaries in the state. This is the program that we're working on and designing now. And as part of that, we will launch a primary care program, part of which will allow telehealth and other non-face-to-face visit activities. And we will also be focused on driving population health efforts that are aligned with the model, particularly opioid and diabetes, or the first two that are of top interest to Maryland as we move forward. And we're trying to do this in, we don't have the fully integrated delivery system, and we actually are trying to do this in a virtually integrated delivery system where we use alignment approaches to align providers across the delivery system. And so as a result of that, we're expecting to have improved complex and chronic care and population health as well as increased alignment across the system. So that's just really a brief view just to try to set the stage of what we're trying to accomplish in Maryland. And so I just wanted to talk a little bit about some of the things that hospitals, since they are the first participants, have been trying to cope with and to do in the new system, particularly with telehealth support. And as you think about this from a hospital perspective on a per capita budget, so the hospital's questions are how do we afford the new treatments and the new technology? And how can we free up some money to help us address some of the population health and social determinants of care and care management needs? And so that's been what hospitals have been working on in this first four years of the Maryland model. And in that, they've been focusing on reducing unnecessary emergency room visits and avoidable admissions so that they can free up money to afford care management and new treatments. And so some of this is leading to work with emergency room providers and nursing homes. So I'll get into that in a minute. And also the growing mental health crisis is an area where Maryland is relying on telehealth to move forward its efforts. And finally, I think as we move, as I mentioned before, as we move into the second phase, Maryland will be bringing telemedicine into the primary care environment. And the rural health environment is the final area where we're seeing an increase in the telemedicine activities, combining rotating physicians into rural communities with telemedicine and trying to bring more care back into the rural communities as opposed to necessarily take more rural patients into urban settings. So I just want to step back a few minutes and tell you a little bit about some of the emergency applications and some initial observations and some continuing problems and challenges that we're going to be tackling on an ongoing basis. We have been working in the emergency, the MEMS, our emergency medical system transport that transports patients to the emergency room has been working in some demonstrations to determine what percentage of patients need to go to a hospital emergency room versus who could actually be treated in the home or in an alternative urgent care type of setting or the next day at the doctor's office. And we have seven demonstrations underway with this and the statistics that have come back from this so far are that more than 60% of the patients don't need to go to an emergency room. So to some people, this is not new news. This is old news. But now we have a system where the providers are becoming aligned to want to make sure that the patients get the treatment in the right setting at the right place at the right time. And some of the, there are some challenges to this, though, even though we have hospitals who are now aligned in this methodology in terms of wanting to make sure that the patients are getting the treatment in the right place, the emergency medical system only gets paid if they transport the patient to the hospital. So this is a problem for the emergency medical system. So we haven't solved that problem yet, but I think we're on the way. And so that's an example of what we're doing. And the challenges that we still face. And I just wanted to briefly talk about the nursing home environment, and then I'll turn over to our next speaker. But our hospitals are connecting with long-term care facilities to try to provide specialty consults to avoid unnecessary transport to the hospital and unnecessary admission. So those are a couple things that we're tackling in Maryland and some of the problems that we're still experiencing with reimbursement. So thank you very much. And I'll turn over to our next person. We can turn it over to Brian. Good morning, everyone. And thank you for the opportunity to give you an employer perspective of telehealth. And I first want to say I too am a Monty Python fan and appreciate the reference. So I'd like to do is give you, I would say an outside in look at telehealth. And the business group is really made up of large, multi-state, many cases global, self-funded employers. And I think multi-states an important element here. Self-funded is an important element here when you think about our membership, which includes 74 of the Fortune 100, 57% of the Fortune 200. These are big, multi-state, jumbo employers who are trying to address the needs of their employees on a nationwide basis. So that's the perspective that I'll come at this. And I want to start with two observations. The first is when it comes to innovation within healthcare, from an employer perspective, there is a significant lag between adoption, availability, and acceptance. Second observation is large employers are not willing to wait for the delivery system to catch up if they see a need that they find a solution that will address that need. And there are lots of examples of this. You look at centers of excellence, great example, condition management programs, medical decision support. And I would say even the emerging concierge services, all of those are resources that employers have bolted on to this healthcare delivery system in an attempt to help employees navigate a very fragmented system, help them identify and understand the treatment options and help steer them to the best place for care. And I would say telehealth fits into this category of an innovation that is available but not widely adopted or accepted to this point. And one that employers have not been willing to wait for implementation. And while I totally agree that the most effective way of delivering telehealth or the best scenario would be as an extension of a primary care's office, patient-centered medical home of a care team in a local market that's my provider, the reality is that happens in some integrated delivery models, but it's very inconsistent in terms of how it's, and you know this, distributed across the country. And for a large multi-state employer, there lies the challenge. If you go back five years ago, 7% of big companies offered telehealth as an option to their employees. And those were the early trailblazers. They contracted directly with the Teledocs, the American Wells, the other players in that space. In 2018, 96% of large companies will offer telehealth to their employees and 56% of them will offer telebehavioral health to their employees, which is a 50% increase over this year in terms of how that's expanding. And employers are doing this despite the challenges and the inconsistencies from a state-by-state legislative and regulatory structure that is very inconsistent. And they're doing this despite in the knowledge that these telehealth options aren't very well integrated with the delivery system, but they see the value, they see the value in the convenience, in the access, in the efficiency of telehealth as a solution to help employees be more productive, more efficient, save them money, save them time, save on PTO. And I'm going to give you some examples of what some companies have done as we get into this. But let's talk about consumers and consumers from an employer perspective as well. I'm going to give you some data from a few studies. There's been growing acceptance, and that's been also said, from consumers with telehealth as a alternative access pathway to healthcare. In a 2017 AON National Business Group on Health Consumer Mindset Survey, 57% of consumers stated they would be willing to consider telehealth as a new way to get better outcomes. Nearly 40% of millennials would likely use telebehavioral health services if offered by their employer. A survey conducted by the Harris poll a year ago found that of consumers with a PCP, 65% were very or somewhat interested in video appointments. And if their PCP did not offer video visits, 20% of the respondents said they would be willing to switch to a new provider who offered telehealth visits. When you look at millennials, that number jumped to about 35%. And when you looked at parents with underage children, it also jumped to 35% to 40% range. So there's considerable interest from consumers that's growing. Even in our own survey, we do a plan design healthcare strategy survey every year with our members. And we're beginning to see greater adoption and acceptance of telehealth. 20% of our members state that they're seeing 8% or greater utilization with telehealth now. And I want to give you three case studies or three examples of employers who have driven significant utilization with telehealth. The first is a company that has a significant number of drivers. Multi-state employer, all 50 states, drivers are a big part of their business. They've been able to achieve a 14% telehealth utilization. And they've done this, and you have to remember here employers have a captive audience. So they have certain levers that you may not have in the market, in the ecosystem. They have plan design levers, they have communication levers, and they have levers to use their managers as a support system. By offering free visits in aggressive communication campaign, and leveraging the concierge services, which was accolade as a referral process too, and to allow their drivers who use iPads for working to do telehealth visits, they've been able to achieve that 14%. Help save on PTO time for drivers and help drive productivity as well. And as employers think about the impact of telehealth, it's not just about healthcare and healthcare cost and the convenience and the access. It's also about productivity, the effectiveness of the workforce, the availability of the workforce as well. Another company achieved 30% telehealth utilization, again by offering free visits, auto enrollment into telehealth, and leveraging their managers to help support, talk to, and refer people, if necessary, to telehealth as a resource. And then a third company achieved 46% utilization with telehealth, in part because of its demographics, which three quarters were millennials, and their locations were San Francisco and New York primarily, and they leveraged their onsite health centers to do telehealth through those as well as referring people to telehealth, also offering free visits and also having a population that's 57% women in their company. So three examples of companies that are getting good penetration with telehealth as an option. Most companies today offer telehealth through their health plan, most of these large multi-state employers. But there is a growing number of point solutions in the market that are offering solutions that include some type of virtual health component. The business group we have a health innovations forum where we bring 30 companies together in a shark tank-like environment and we vet startups looking for innovation that can disrupt healthcare in a positive way and accelerate adoption of those solutions in the market. And I would say of the 50 or so startups we've looked at in the last three years, more than half had some type of digital or virtual health solution as either all of or part of what they were providing. And employers are beginning to bolt more of these on. Now the good and bad of that is if further fragments delivery, the good of that is it's addressing particular needs in the market that are not being dressed consistently today. We're seeing telehealth or virtual health examples in lifestyle and condition management, in musculoskeletal and physical therapy, in behavioral health, in medical decision support, in second opinion services where you can have virtual consults. These are all emerging and growing and employers are bolting these on and working actually with their health plans as an aggregator in some cases to manage and support these. You know I would say that I'll kind of end where I began and that is innovation in healthcare is slow to take ground within the healthcare ecosystem even though we're seeing real groundbreaking applications. I want to give you one provocative example and leave you with this before we move on to the next presenter. I don't know if you heard of Babylon Health. It's a UK based company and it's not a mission to make primary care accessible to and affordable for every person in the world through an AI platform that can engage with a sick patient and accurately diagnose 80% of common conditions and direct them to the appropriate site of care without human intervention. That's what they're working with the national health services within the UK to pilot this right now as well as working in a couple of other countries and they're looking to also bring this capability to the US. Obviously there's a lot of testing a lot of evidence there's a lot of work that has to be done but the new frontier of virtual health is real. We are at the tip of the iceberg of what's capable and you will see continued emergence of solutions that if we can't find a way to deliver them in the local delivery systems and integrate them in we will disintermediate in some way the delivery systems and we'll still have to find a way to integrate in but I think they're in lies the risk but they're also in lies the opportunity. Thank you. Okay a couple people have made disclosures which I didn't realize we were going to have to do and so the only disclosure I think I have to make is that I started my career as an optimistic and idealistic young man. I'm now sad and broken and so we'll start there. The other thing is is the art of being a reaction person is like to link to the comments of the main speaker but then end up saying the things you were going to say anyway which I'm definitely going to try and do here but actually this is going to be relatively easy because Helen said a few things that I think are very relevant to my comments so let me actually start there and try and do what the job was asked to do. The first thing that she said is that somewhere early on in her comments she said evidence is mixed and it's hard to translate where the evidence is coming from particularly as you may not have said this but in my mind to fee for service. The evidence is very mixed and of course in our environment people are pushing very hard Medicare I'm going to be speaking about Medicare here for the most part Medicare needs to pay for all this stuff but the evidence exactly is not really come together and the thing that I keep observing and this is not the same thing and not just true of telehealth this has been true throughout you know my career is people come with evidence out of a managed care environment or a VA environment or some other kind of environment that's not like Wild West fee for service and they say do this it will work and the answer is it will not work it will be completely sidetracked when it gets into Wild West fee for service and so there's always that disconnect and I think it's a very hard bridge to to to get across however along those lines to try and be a little bit optimistic and again to kind of go back to something Helen said is she said you know we shouldn't assume that technology leads to improvement and she said also around the same time we should be thinking more about a bundled payments and I also have had this experience over the last few years and I would think about it this way which is I have so many people in my past job approaching me saying I have this technology assign a code assign a number to it and pay for it and I think that is precisely the wrong way to be thinking about innovation whether it's telehealth or any other kind of innovation and I get I would get my background and my experience and everything and so I'm highly biased it is not about that it is about payment systems then I can accommodate change that's what we need to do because technology is going to change the way you practice medicine is going to change and to the extent you're doing it through piecemeal assignment of codes and payments you're on the wrong track because most of that is going to be obsolete in many years anyway and so why proceed that way not related to my comments but a really good one she made is that this needs to be built into the medical education process in some earlier work I saw the same thing where people are just what are you talking about I had no experience with any of that and so I don't know how to proceed once they get out into the field so I completely agree with that okay so then to kind of so the two things I've said so far is is that there are mixed results in the research and it's often coming out of environments that are hard to translate into fee for service may be very helpful in Medicare's managed care programs or other bundled payment environments but difficult to cross over into fee for service and the notion that payment systems need to work more towards larger units of payments and leaving flexibility for providers and Medicare is generally pointed to is the big problem with telehealth and everything could move forward if Medicare would just get a clue and kind of get on with it and lots of activity at the federal level in trying to integrate telehealth into to the Medicare program and so now I'm going to try and systematically address that comment so one thing to keep in mind is a third of Medicare is in managed care plans and managed care plans do have flexibility to use telehealth now there are some technical arguments going back and forth which I will be happy to get into in a lot of detail but there are some technical comments going back and forth about how bidding works or in other environments where I get approached by home health agencies who get 60 day episode payments and they say arguments like this telehealth remote patient monitoring will save you a gazillion dollars you should increase our rate and I never follow that argument they have a 60 day bundle they say it saves them money but they want Medicare to increase the payment in order to pay for the telehealth that does not logically make sense so my argument here is we should be moving to capitated managed care environments when an accountable care organization takes two-sided risks they should be relieved of the fee for service regulations and allow them to cut through and start using telehealth how they see it should be done and in bundled payment environments which I believe a lot of flexibility exists in the DRG and the home health environment providers should be moving to it now where things fall apart and things become very complex is when you hit the fee for the true fee for service environment and in particular the physician and clinician environment where you're paying service by service and things do become more difficult there and in assessing that you know you will whether you like it or not have to think about the cost and if moving to it is ultimately scored as a cost that's going to slow things down but if the case can be made on improving access and particularly access to needed services or if the case can be made that outcomes will increase then obviously the the case is more likely to go forward now one thing I want to say and Helen touched on this as well is I also think from a policymaking point of view you need to distinguish between access and convenience I think of access as getting access to a needed service convenience is different I have access to this service do I want it more conveniently or not and you might from a policy point of view think of those two situations differently and I can talk more about on question if anybody wants to to get into that so how should fee for service approach this here's a few thoughts and thinking about it if you wanted to move forward in fee for service and in a principled way and I'm trying to stay on time here so one is can you create white space in your fee for service payments CMS is definitely trying to create codes that say okay if you're involved in transitional care there's a bit of a white space here and you can engage in activities another idea is whether you move primary care payment off of a service by service reimbursement and try and give part of the payment that you give to a primary care provider on a per patient basis so each of their services not in fact driven by a service by service interaction but they have the flexibility to engage in more telehealth type of things another approach in order to move ahead but not necessarily blow the lid off of the budget is to come in on a condition basis and say there may be certain conditions where at least the exposure for fee fee for service is small enough that the risk of going in and doing telehealth is not that great so for example somebody's doing home dialysis you might say they can do their visits with their provider through telehealth and the notion there is that's not going to blow the lid off of the program because people aren't trying to become dialysis patients or Parkinson's patients or that type of thing there are certain interact or certain telehealth that is starting to prove that even in a relatively uncontrolled environment it may have an effect I am watching closely the nursing home link to the emergency room if that could be established that might work but of course the better way to go would be to start paying on a bundled basis in that environment and then saying to the provider if this makes sense go ahead and do it and then the last thing I'll say and I'm done is as I remember in the high risk areas there is always a CMMI and innovation center strategy here so the direct to consumer stuff where I touch my tablet and I connect to my doctor which could have the potential in fee for service to be very expensive could be tested through an innovation environment to see what the actual induced demand effects are and in an environment like that before it's let out into the wild west and I will yield the last 19 seconds to okay hi good morning and thank you to the Kaiser folks for the invitation today I'm Sandra Wilkness from the National Governors Association and I thought I was going to be very duplicative in my comments but I feel fortunate that I can bring the summit more of the state perspective and perhaps the Medicaid lens a little bit around as a follow-up to what Mark just presented on the Medicare side I just for folks who don't know the National Governors Association is the bipartisan organization serving the nation's governors where they come to exchange best ideas about best practices to innovations around improving state state government and also speak collectively on national policy issues I'm actually in the center for best practices which is the nonprofit side of NGA and our job is is sort of a hybrid think tank consultancy working with governors and their policy advisors so my my thoughts today are really from that perspectives and lessons learned there so the picture is a little bit different on the Medicaid side and some of the work we're doing with states and probably the best thing for me to do is just highlight some specific project areas we're working on with states and where telehealth solutions are really rising to the surface as as solutions that they're eager to engage in to figure out what is the best path forward and what is the state level solution to proliferate some of the the best practices here we work of course in a multiple areas across health and health system transformation but I would say the area where telehealth really comes up the most of course is in rural areas public health behavioral health certainly the opioids crisis tele solutions are really being sought there and then also in workforce issues so we have several cross cutting projects one that I wanted to highlight so that I can kind of get into the details of what we're hearing about in terms of challenges from states to kind of to respond to Helen's charge to talk about what some of these challenges are is in the rural health area and I just wanted to note that our projects are based on a competitive process states apply to to work with us and for us to provide technical assistance and for this rural health project states were told to apply in whatever way you like whatever you want to do in rural health is it data you know is it dealing with hospital closures that are every single state that applied for this project said we need help in behavioral health we need help in opioids we have massive work for shortages we're just not sure what to do so across the board that seems to be one of the areas where there's a really a real strong need for some solutions and where telehealth is being highlighted specifically as an area where they want some support so we're working that project with seven states and of course it's all rural facing so the issues I don't have to remind people are issues around transportation rural hospital closures massive workforce shortages especially in behavioral health and the solutions that states are pursuing are of course around reimbursement a lot of this is in the Medicaid space but not exclusively we heard a little bit about project echo and again I thought I would be duplicative but I'll talk a little bit about project echo and how valuable it's been in the state space but certainly a challenge still from a reimbursement standpoint I mean they're trying to paste together all kinds of reimbursement approaches to get tele tele to project echo like projects up and running in states and to sustain those those efforts so reimbursement is one the covered services what's covered in terms of coverage parity and reimbursement parity so those are some issues states are grappling with eligibility and sites of care and maybe this is two in the weeds but I did want to highlight it that the distance site and the originating site and actually offering those services and being able to reimburse and align with federal policies is a real challenge especially using the national health service core which a lot of rural areas are trying to engage in there are all kinds of glitches in terms of actually how do you get reimbursed you have to be in a health professional shortage area to actually offer the surface to another health professional shortage area so that's a massive challenge with respect to harnessing the human resources that are needed in those areas and then interstate licensure that was raised and so I just wanted to touch on that a little bit and maybe provide a little more texture around what's happening there okay so let me try to be brief because I don't have a whole lot of time in terms of reimbursement the picture as I understand it today is 15 states are reimbursing for store and forward kind of opportunities 21 states are reimbursing for remote patient monitoring this is all through the Medicaid program where as mark noted there's a lot more flexibility than in the Medicare program and states are eagerly pursuing coverage parity and reimbursement parity in those settings they're working with their plans to actually offer a lot more flexibility there as well I already mentioned the challenges with the National Health Service Corps this distance and I don't know if you all are familiar with this but there's a lot of effort among these states to align not only what's happening in states and it probably won't surprise you all to know a lot of times there's not a lot of knowledge about what's happening in states across even say other state agencies with respect to these kinds of services but also what's happening on the ground with providers there's as as as brian pointed out there's a lot of innovation already happening on the ground and actually feeding that up and and creating some awareness on the state level to figure out how do we align how do we not work at cross purposes and how do we use state levers to actually elevate what's working and figure out how to scale and spread it there's still a lot of need there a lot of support need there and a lot of information to flow up to the state level would be really valuable interstate licensure so this is a big issue and a big challenge for states as telehealth popularity is growing the states are eager to figure out how do we work across state lines and there are a number of challenges here again just for a little bit of context currently there are 22 states that have adopted medical licensure compact so a lot of this is operating in the compact space and for a lot of different providers so physicians nurses advanced practice nurses psychologists physical therapists and others 17 states are currently issuing licenses and 12 of those can serve as states of principal license for those of you who know what that means and then five states have passed compact legislation but have been delayed and some of the challenges here from the state perspective are concerns around the autonomy of state regulatory boards and other and other professional boards there are concerns about the additional costs costs to providers and others to engage in these compacts and to do cross-state licensure and then also issues around FBI requirements for background checks so there are a lot of a lot of federal and state and and provider level issues that are still that states are still grappling with to make these compacts reality and to move them forward and then I just wanted to end by highlighting a couple of examples of what seems to be working in states and I wanted to also underscore that I think on the state policy level there's a huge emphasis on on big data right there's a huge emphasis on data collection for a lot of purposes one is for targeting resources so there so states are actually trying to think very thoughtfully think thoughtfully they're being thoughtful about looking at their data to figure out how to target telehealth resources and others and they're using you know the business case like in reduced ed and hospital use utilization as a starting point and then they're evaluating what they're doing so there's a lot more evaluation out there on the state level than perhaps is making it into the the routine literature and I'm happy to talk with folks further about that one good example of this is North Carolina statewide telepsychiatry program it's called NC step for short if folks are familiar with it and then essentially what it is is a telepsychiatry program folks land in the emergency department with a behavioral health crisis there are I think 42 spoke sites so it's a hub and spoke model 42 spoke sites around the state seven hub sites those hub sites then deploy psychiatric support or psychological support whatever the need is and through telepsychiatry work with the ed providers to determine what the needs are does where does this patient this individual need care do they need to be held somewhere do they need to actually go into the hospital what is the issue and they found some pretty striking findings there from a patient experience standpoint there's a lot of improvement folks end up much less frequently in the edn inpatient and they're they're finding a $13.3 million savings annually for that program so I think in terms of bending the cost curve that is an example of where state's being very selective in deploying resources and also trying to evaluate the outcome of that and then finally I just wanted to say again on the project echo front that the teleconsultation model that is one that is proliferating across states I don't and internationally I don't need to tell folks that but it is a it is a very desirable model from the state perspective to really get more support out to to to rural areas in particular one example of this and and you guys are familiar probably with all the core project echo models but one more recent example is an echo model in Colorado that's around chronic pain disease management program as I said before opioids is always top of mind for governors and this model has been running for about two years and in May of 2016 they added a buprenorphine telehealth program they haven't we don't have any evaluation results from that yet but this is a model that that other states are really interested in eager to to proliferate across across the country and I guess my final word on this is from the state perspective behavioral health workforce shortages and also I mean it was really interesting to hear about the the training component there's a very strong interest in beefing up at least the Medicaid GME which we know is dwarfed by the Medicare GME but really trying to understand how better to use those resources to train in the new technology so it'll be really interesting to see how that how that continues thank you thank you it's who have another round of applause for all of our panelists thank you that was fantastic and there's a lot of food for thought so now I'd like to invite Dr. Burston back up to the stage and now we'll have an opportunity to ask questions from the audience I believe there are mics circulating do we have them on the tables oh I think there are stand mics so there's one by the tech table over to everyone's oh both sides sorry both sides of the room so if anyone has a question feel free to stand at the mic while the folks are queuing up because I know you're all burning burning questions um wanted to because we didn't have a chance to ask questions of Dr. Burston after her talk just wanted to see if you have some reactions to the reactions and anything surprising that you might have heard at from from our panelists I didn't hear anything surprising I think it all is consistent it's it's especially interesting though I think for us to really understand the different perspectives the state perspective the federal perspective and the employer perspective and what they each bring to the big policy puzzle and thinking about that holistically rather than in those narrow corridors I think is a real challenge for us perhaps you know from your policy perspective a real opportunity what's different what's the same and what could get moved forward given that the our panelists did not have a chance to ask you questions I want to encourage any any questions of Dr. Burston from our panelists before the audience joins in or any discussion that you'd like to engage from hearing each other question and this a lot of the things I as I said in my comments I tried to directly link to what Helen said and you know had similar views the thing that I hadn't thought about recently was the medical education angle which I mentioned in passing and then just immediately headed off you know several years ago MedPAC made recommendations in the medical education space to try and delink payment to hospital but you know the medical education payments on hospital admissions and to the hospital admissions to the hospital and try and make the payment around more the graduate medical education or the residency program I'm sorry the residency program itself and then try and tie those payments to the aspects of the particular medical residency program you know does it emphasize team-based care does it drive evidence-based medicine and of course at the time you know we could have also said does it have components where you're using telehealth and that type of thing and it was instead of having the payment in Medicare just driven by admissions to the teaching hospital have the teaching payments actually go be built around the residency program and look for particular criteria in the residency program before the money is just dropped on the doorstep of the hospital one huge complaint among educators is that money is used to run the hospital it's not used to educate or to change the residency program so it's just something I had not thought about for a while and so it's a really interesting piece of this puzzle there's a lot of money that goes into that space there are requirements of what are the for for GME the ACGME clearly puts forward recommendations of what should be part of training programs there's always been a component around technology it's just never been very specific and so in this new world people have to understand how you interact in this way most responsibly to get the best possible outcome so I think I think it's a real opportunity and I don't want to be even though you know I now lead an organization of doctors this is way bigger than doctors alone this is really about health professions education broadly whether it's nurses or pharmacists or anyone in that space who's going to be working in a very different environment that isn't always face-to-face I think this is on now yes thank you I think we have a question from over here hi yes my name is Cleese Eriks and I'm with George Washington's Health Workforce Research Center and one of the things we've been looking at um is that the impact I've heard you all talk about is the impact of telehealth on addressing maldistribution but I wonder if you could comment and share any evidence that you've seen whether you think it will reduce overall demand for physician services and other providers or if it if it has any potential there if you've seen any evidence of that to date and I'll add the reason I mentioned that is a lot of people when they're talking about workforce shortages point to telehealth as a way to ameliorate shortages and that's I think more from the maldistribution side of things but I wonder if there is any potential if you see it for reducing just general demand anyone want to jump in I'd like to talk about the maldistribution in rural health and I think the the rural crisis of getting specialty care to rural areas is an area where telemedicine is starting to play a serious role in bringing more specialty care into rural areas and so I think the the funding crisis in rural health of do we fund a full-time doctor who really doesn't have full-time volume and can't necessarily keep up with the changes in technology in a rural area I do actually think that the supply and demand will be helped along with telemedicine and rotations and this is something that's only possible with electronic medical records rotations and telemedicine and it is being beginning to be effectively deployed in rural areas in Maryland and I know in other parts of the country as well but definitely we're seeing a deployment in Maryland and that is reducing some of the losses that rural providers experience when they try to hire a full-time doctor to do a part-time volume of work if I could just add on to that I I mean I'm struggling because it's such a good question because it's there's this tension between the convenience versus access set of issues that were raised by my co-panelists but also there's such a desperate need in rural areas as I am learning a lot through working with this product that it's all hands on deck so I wonder if there's even a third component to this and that is do we think less traditionally about how these tele support services actually might be deployed to people who need unless it's super special these services need for let's just take behavioral health for example there are a lot of things that can be done to improve people's outcomes that don't involve you know a phd in psychology and I can say that because I am one but there are other solutions perhaps that can be augmented through tele options that don't necessarily involve the traditional workforce and and just figuring out how to realign that maldistribution yeah and I probably just don't have enough of imagination or I mean I I definitely think of it as addressing the maldistribution I definitely have feel like sometimes people talk about it as overcoming shortages and I think sometimes if there's shortages if you have behavioral health problems you can tell a health and it's not necessarily going to overcome those shortages it may help and it may help with some distribution but I haven't had the thought of oh well this will actually reduce demand I'm more of the mind that at least some of the components of it are likely to increase demand depending on if I understood what you meant by that particular comment and maybe just one last thought and I agree it's a really good question that I don't have a good answer to other than I think we have to start thinking about our workforce analyses differently right if you can incorporate in the potential for distance learning or providers off site particularly the provider to the provider side it may change our models so what we think workforce requirements are in a given area so it's a really important question thank you for asking it so I'll just add a little bit of a different angle on this I think the we often hear of how overburdened physicians are and the opportunity to leverage whether it's telehealth or retail clinics if I look at what CVS and Aetna are looking to do with their integration expanding different access points to primary care that could possibly free physicians up to take on more complicated challenging issues so theoretically you can see where or conceptually you can see where that seems to make a lot of sense whether or not it's having that type of impact I don't know if I haven't seen any data thank you all I think we have a next question from the audience hi good morning I'm Andrea shore with the school based health alliance my question is for Sandra I am curious if any of the we work with providers across the country who are either working in schools directly in school based health centers or in community health centers who are collaborating with schools and I'm curious if any of the projects that you're working with have pediatrics as either a large focus or something that you're providing some technical assistance on as it's growing in our field this yeah and it's so important and unfortunately the answer is no not currently a lot of the focus as you might imagine is really around where to make the business case so we end up a lot focusing a lot on the higher needs individuals either on the adult end of the spectrum or if it's children it's it's children born to mothers you know with addiction and and those kinds things seems to be where a lot of the acute need is and that the innovations often start there and then spread to the broader system so we aren't currently but I'm sure you're familiar with the mcpac project you're right with all of those kinds of pediatric interventions that could be used through teleconsultation tele support and I'd love to hear your thoughts about how we can support states more in that area thank you another question over here hi I'm a technologist so that's my disclosure and I've been to many health care tech conferences of the past year and a half and almost all conversation ended up with the one word reimbursement and fee for service so it's very obvious early early on that value-based care is perhaps the biggest component one observation that I wanted to share with you and have people to comment on is I started looking at senior care later this fall and I found that specifically the architecture of a senior care campus where you have skilled and assisted living co-located with residential services their tech adoption is a very interesting phenomenon they're looking at voice activated technologies through Alexa which are they're trying to integrate that with the EHRs on the back end their openness to robotics their openness to remote patient monitoring for wellness perhaps and then also to for more clinical things and the fact that you have a population where you you have the assisted living the assisted care facilities or the skill nursing facilities where you're getting care and you just move off literally across the street into your own home and the remote patient monitoring can still track you in a close proximity so when I think about the pocs that are happening in in other settings it seems like this might be an interesting setting to kind of expand on and invest time in an effort in so I just wanted to hear if you had considered that setting there are about 2000 of these what they call now life plan communities with about more than a half a million units which is about you know I would say a million people today but they're growing fast and they have implications on home health care as well because a lot of these senior care facilities are now getting licenses to operate in the community and they want to extend their services there so I just wanted to hear if you've considered this so there's a couple of differentiations I would make so and this whether this is right or or wrong this is a this is a fact I mean uh there's a stage in uh an elderly person's progression in which medicare becomes much more involved but the assisted living facility platform itself and to the extent that it's a continuous care non-acute nursing situation medicare actually doesn't play in that particular environment where medicare plays is home health and home health is usually defined as a home bound situation although I would argue to the extent that the provider takes risk that requirement could could and should be relieved or medicare plays when the person has an acute skilled nursing visit which may be a component of what you're talking about but not necessarily the day-to-day maintenance of care and to the extent that the person is um and actually people in those communities are not as likely to be medicaid eligible would be my guess but the the kind of maintenance level of nursing care really gets driven on the medicaid side and then you have these two large federal programs that are trying to interact with each other and there's a whole history of difficulty in trying to coordinate which I'd like to blame on Sandra she's sitting right here uh but that so the notion of it it is very logical to say I'm looking at this population we should be thinking about it and it's a perfectly reasonable uh thing to do but I think to the extent that that person in medicare is more of a managed care environment or in an environment where their total cost of care is being managed like in an accountable care organization ideas like that have a lot more traction that person is just kind of in wild west fee for service I think it becomes a bit more difficult to think about it in a comprehensive way and about two thirds of the medicare beneficiaries are still on the fee for service side I'll just add I think there is an opportunity as we think about moving towards more and more of population based payment particularly for populations at risk to just think very differently about what kind of outcomes you would assess and pay on so you could easily see a model that's focused for example on the multiply chronically comorbidly ill elderly in which payment can differentiate regardless of how the services are provided what are those long-term outcomes what are the functional outcomes what is the prevention of the high ticket items like ed visits and hospitalizations and then allow that innovation that that you're providing to just be part of what you can negotiate with with those settings because they know at the end if they do well on those big functional outcomes or utilization outcomes they'll do well thank you we have another question hi i'm rob sauners from the margolis center for health policy at duke and what I wanted to follow up actually on the the sort of reimbursement payment question so we do a lot of research looking at new payment models and trying to see what evidence is out there and one of the struggles we see is that for many organizations when they enter into an aco or a bundle arrangement we've removed a barrier that may have stopped them from say using telehealth but that doesn't necessarily get them over the hump to to try and something new because they may not know how to use the technology they they may not even know where to start with buying the infrastructure and there's a sort of operational guidance that they're still lacking that sort of comes along with the payment model the payment model raises awareness but then you still need to do something in order to succeed under that payment model and I wonder from the panel if there's been some thought from any of you on you know how you sort of make that transition and supporting the health systems is there try these new value-based payment arrangements while they are trying to try out these new ideas in telehealth you didn't say this and you're still standing there so you can defend yourself and all the rest of it and you know you should but and I will try and answer your question directly but I just want to say one other thing before I do it and you didn't say this just just to be clear this is usually how the argument goes you know people come in and they say you know we under well often they don't want to accept the new payment system but let's say they do there is this new payment system aco I'm willing to take risk whatever the case may be but now here's what I need I have to make an initial investment you need to pay for that you have to train me to do it you need to pay for you know explain give me technical assistance and then pretty soon the cost benefit of well if this was going to yield some benefit you know to that provider under either an aco benchmark or a capitate starts to disappear because the money has been you know in this investment or in this training so I think the question you're asking is really fair and really difficult but it also raises this question where is Medicare's responsibility should it set the payment and say you know as many people are saying the market will respond providers will respond and it's always will they and I think it's true some of them will and then some of them will have to be brought along and and how much investment should the government take on that and then if they take it on does in fact on net this come out better for the taxpayer or worse for the taxpayer and I think that's the trade-off embedded in your question and I always wonder why if the ROI is as strong as many people say it is why aren't consultants and others entering this environment and going you're going to save a gazillion dollars you give me a little bit of those gazillion and I'll you know I'll help you get it off of the ground but I think it triggers a key question how does Medicare or whatever program Medicaid how much do you pay in bringing the person along now I will say one last thing and there we did do some thinking about this the way back in my old job the way the quality support payments occur like in the qio qio environment we have some med pack had some very strong views about how to allocate that money more directly to providers to solve specific problems as opposed to the current mechanism that's used it's more detail than this exchange but it is a pot of money that could be repurposed for things like this and I could talk to you offline about that if you're still interested in these comments maybe just one thing to add and not so much on the reimbursement side but I think we oftentimes talk about a new technology a new treatment and we don't often spend as much time talking about how to implement it as we do what we think it will be and so there are examples people who have implemented it and the US unfortunately still tends to be these incredible islands of innovation and very little bridges across them and so I think as a community we really need to think about how we share those best practices share those implementation lessons whether it's with or without consultants what have you done to get your clinicians engaged what have you done especially societies to help bring your members along to help them say I want to bring this into my practice what are the five things I need to prepare for in the next year to have that move forward I would just add something you already know which may be less sexy but you know there's this whole dissemination right literature that you got to have your champion it's got to come from the top accountability metrics that are transparent and public and shared where you can show your you know this provider is doing an excellent job in this domain that we're measuring someone else isn't and fostering that friendly competition you know those kinds of things at least on some of the state initiatives seem to really allow the delivery and payment strategies to actually take hold and and and be implemented that's what we're observing you know I don't think you can look at telehealth and isolation if you're an ACO and you're taking on risk if to be in a position to take on risk you need to have other competencies in place within your organization that all come together whether it's around your cure coordination model whether it's your technology capability and ability to provide analytics to your providers whether it's around your governance model and whether it's physician driven or not there's there's a lot of different competencies that create a tipping point for a delivery system to be in a position to take on risk and to look at telehealth and isolation how do I implement on telehealth all those other things have to be there if you're going to take risk anyways and hopefully you can find a way to integrate into that model and from an employer perspective we don't have a lot of sympathy for a delivery system that wants to be paid more to take and to implement some of these initiatives when there's so much waste in the system and there's so much opportunity if you're taking on two-sided risk to win if you can execute so I think that it's it's part of the investment any if a company is making an investment outside of health care to to make their organization more efficient to launch a new product why can't we do that in health care as well why isn't the delivery system in a position to be able to make investments recognizing there will be a return if they drive the right efficiencies within their model he said that no I wanted to I wanted to comment as well in in Maryland our system started out before the 2014 experiment with 10 rural hospitals and they formed a collaborative to to work on on this together and to take a provider leadership in this and also I think some of the providers in Maryland have stolen shamelessly from some of the Kaiser Permanente ideas so for example Kaiser using a lot of technology admits 80 percent of their patients directly without passing through an emergency room and our some of our primary care collaboratives have instituted that model and are using a series of technology and communications to implement to admit directly to the floors instead of through the ERs and so this these are you know copy shamelessly where you can find better practices that can work and and really try to drive the provider initiative and and and I do think it is difficult because a lot of the providers do tend to say well now you gave us this now tell us how to do it but then that's not really provider led innovation so we really are looking to the providers to lead the innovation and and and and so that's some of the experience that we've had in Maryland thank you all for responding I think we have time for one more question thank you good morning I'm Margo Edmunds from Academy Health and I have a continuation question to what Rob started with the panel and it's particularly for Helen and Mark and my question is about what are the policy lovers to get more team-based care besides payment and Helen you alluded to the role of professional societies and I think you're uniquely positioned to talk about that but my concern is what we live through with meaningful use in EHRs and the informatics community and the real separation between clinical training and hands-on technical training so what are some of the other lovers that we can use besides just payment particularly in the professional communities to train people not only to feel comfortable with the technology the clinicians and the highly credentialed clinicians but also to train in teams where there's more lateral decision-making that's shared which is a real culture change that's a great question Margo I had the pleasure of spending the day with yesterday on the Academy Health Board I think there are some real opportunities that go beyond reimbursement I think some of this gets back to the sense that there's not much joy in practice at the moment and so can you think about team-based models where really being able to rely on each other and use people's skills to their fullest potentially allow for more effective interactions a more collegial environment not this is your job versus my job but you know some of the things we've talked about for so many years in primary care and PCMHs and others you know are you sitting next to your medical assistant are you getting their input in a different kind of way and I think the question of the and I'd love to hear Mark's perspective and others on this you know currently we're still stuck in this environment where physician payment is physician payment and a lot of it is specifically related to the individual work of that physician so you know I get paid depending on the rates of my screening tests that I provided in office setting again it's that individual physician level performance I think as the system moves away hopefully from individual physician level payment it begins to think across more bundles and system level payment I think it allows more of that flexibility but then I think it gets back to the med to the training piece as well I think we need to do a much better job of training health professionals together to fully respect and understand what we each bring to the table we had a time yet actually kind of a hard question for me but what I would would say is like you said other than payment but you know you heard my talk you heard everything I've said since then you know it's like that's going to matter a lot okay I also think and Helen and I have had some of these conversations and I can't remember how close she is to be on this and she may not be in reasonable people can disagree I also think to the extent that we move our quality measurement out of like micro process I did this my aspen after heart attack therefore I'm done that that type of thing and more to population based measures and say I'm looking for the patient not to go to the emergency room I'm looking for the patient not to go to the hospital I'm looking for the patient not to die those types of things and then be more agnostic about how systems of providers get to that goal which may force more collaboration and discussion across boundaries is something that the Medicare program could do because I I see this constant tension of trying to set a roadmap through dollars and measurement but not going below that and micro manage underneath beneath it and yet from the the provider community you get very mixed signals it's like don't tell me what to do but measure everything I do and move the money on that basis and by the way you didn't do it accurately and I don't agree with those measures and it's like how from a policy perspective and I'm being somewhat glib maybe even a lot of glib but you know how from a policy perspective you know a big government you know nearly 700 billion dollar program do you square those signals in my view is you get up to the top you try and make payments across providers and try and measure across providers and then leave flexibility to the providers to figure it out their professionalism that type of thing and then I will say again I know I said it now the third time I do think education at the front end when people matters a lot we're not just on the payment side and I will say there are two things again behave I'm coming from behavioral health world and speaking you know with my provider hat on former provider and talking with providers and I would say there are two things that often drive it and one is need for relief desperate need for relief and exposure so the the need for relief meaning we don't know what our path forward is and if we don't figure out how to get all hands on deck to solve this problem really often drives multi-disciplinary solutions and therefore is an impetus for a legitimate team-based approach and what is the answer to that run a policy I don't know but let's study it and figure out you know what can states and federal government do to support more of that and then I would say the exposure piece is based on a visit I had to Montefiore where we talked with pediatricians who said it wasn't until we got the behavioral health people in the room where we actually started to ask people if they had any mental health concerns right because we finally knew we could give it to someone else we were afraid to ask because we couldn't solve the problem now that we have exposure and we know that we can trust these people to help solve the problem we're starting to do it and I would say those two things are really driving it in a non-payment way and unfortunately that needs to be our last word we are at the at time and so I'd like to thank our panelists it's been wonderful thank you all so much for starting off our day with such a tremendous discussion