A study published in the February 2014 issue of Health Affairs concludes that the use of telemedicine by nursing homes can reduce hospitalizations and generate savings for Medicare. However, there are several barriers to successful implementation, including the cost of the technology, the willingness of staff to utilize the service and traditional Medicare and Medicaid payment methodologies.
The researchers noted previous studies suggesting that the lack of on-site physicians in many nursing homes during off-hours (evenings, weekends and holidays) may be one cause of inappropriate hospitalizations. Typically, if a medical issue arises off-hours, an on-call physician is phoned by nursing home staff. The physician can then either travel to the nursing home or, more likely, recommend that the resident be transferred to a hospital emergency room. Could the availability of telemedicine prevent some of these transfers?
Eleven for-profit Massachusetts nursing homes, owned by a single company, and all dually certified to accept both Medicare and Medicaid, were studied. All were very similar in terms of resident characteristics, staffing and quality scores. The nursing home residents received their primary care through physician group practices; prior to the study, most after-hours medical services involved the nursing home staff phoning the residents’ on-call physicians. Telemedicine services were introduced in six of the eleven nursing homes, with five serving as a control group. The six nursing homes utilizing telemedicine services each received a cart with equipment for two-way videoconferencing and a high-resolution camera for wound care. A remote medical call center staffed by an RN, a nurse practitioner and a physician provided the telemedicine services (most of the nursing home residents’ treating physicians had signed over their off-hours coverage to this remote center). Before the telemedicine service was introduced in the six nursing homes, separate training sessions were held for the direct care staff and the residents’ physicians. The annual cost of the telemedicine service was $30,000.00 per facility.
The study was conducted over an eleven-month period during which the telemedicine service center provided a total of 1,413 conferences for the six facilities, an average of 235.5 conferences per facility. However, the number of conferences by facility differed greatly; the highest facility utilization was 545 conferences, the second highest was 425. Two nursing homes were considered the least engaged; one facility used the service only 88 times, and the lowest, only 15 times.
The key outcome measure was the rate of hospitalizations per 1,000 resident days, per facility. During the study period, the rate of hospitalizations declined 5.3 percent in the control group, and 9.7 percent in the group that received the telemedicine services, a difference that the researchers concluded was not statistically significant. In the two nursing homes that used the telemedicine services the least, the rate of hospitalization declined by only 5.2%. But in the four facilities that were the most engaged in using the telemedicine services, the rate of hospitalizations declined 11.3 percent, which the researchers concluded was statistically significant. The study estimates that the most engaged nursing homes could potentially eliminate 15.1 hospitalizations per year (out of a typical 180), with an attendant Medicare savings of approximately $150,000.
The researchers noted several shortcomings and observations. One obvious problem is encouraging nursing home staff to actually utilize a telemedicine system once it is in place; otherwise, there is probably little potential for decreased hospitalizations. More fundamental are the financial dis-incentives inherent in using telemedicine in nursing homes. Traditional Medicare and Medicaid per-diem compensation does not account for telemedicine cost; thus, absent some other payment mechanism (e.g. participation in an accountable care organization, alternative fee agreements with Medicaid managed care organizations, or receiving a demonstration grant) there is no incentive for a nursing home to bear the $30,000 cost of a service in order for Medicare to save $150,000.
Not addressed in the study, but worthy of consideration, is the potential for state surveyors simply not understanding telemedicine protocols. It may be worth a telephone call with the state’s survey office to gain their perspective on the prospect of facility residents not being rushed to the emergency room for every emergent issue. Prior to implementing a telemedicine system, facilities should also perform a risk analysis regarding potential liability for poor outcomes.
CMS certainly has an incentive to reduce the rate of hospitalizations from nursing homes. It estimates that, in 2005, 314,000 such hospitalizations were potentially avoidable, representing a potential savings of $2.6 billion for Medicare.