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welcome to today's webinar the role of telehealth and tobacco cessation if you have questions or technical difficulties during today's webinar please use the chat feature and if you miss anything today's webinar will be recorded and now i will turn it over to andy giulia thank you whitney um and as she said my name is andy julio and i just would like to welcome you to our webinar today the role of telehealth and tobacco cessation so we hope you will enjoy it today's speakers so first you've got me my name is andy giulio i'm the national manager of lung health policy here at the american lung association i manage a couple of federal grants related to tobacco cessation both in terms of coverage and health systems change um we are here to provide technical assistance on any of these questions so we've got and my emails at the end so please feel free to type questions in or if you want to send me an email later that would be great as well i'm also joined by claire brock bank and michelle paterino so just to tell you a little bit about claire and michelle claire's worked in healthcare for over 30 years much of that focusing on public-private partnership opportunities she's worked in public health with health plans and was the lead was the head of a statewide employer coalition claire has developed and launched several new products in health care including the first partnership that engaged health plans and pain for their private use of state quit lines a new model for wellness services and the nation's first private health insurance purchasing cooperative tobacco cessation has been an important focus area throughout claire's professional life and now a little bit about michelle michelle's worked in health plans for 10 years and has worked in tobacco control for almost 20. she's worked with several states on public-private partnerships in their tobacco control program and she also works on medicaid managed care health care reform and similar projects when she's not working on health care on tobacco control excuse me um so that is who you're going to hear from today and we're going to just jump right in and get started and as we said this webinar is being recorded and so if you missed it or missed a piece please feel free to download it and send it to friends later and then of course any questions in the q a box so why are we here today to talk a little bit about telehealth and tobacco cessation so we know tobacco is smoking is the leading cause of preventable death in the united states and a study showed that in 2015 almost 70 percent of smokers wanted to quit but only a third of the smokers tried to quit with an evidence-based cessation treatment and only one in 10 smokers had successfully quit so we're hoping that there's opportunities to use telehealth to make that one in ten smokers who successfully quit closer to that number of seven in ten smokers who want to go and just over on the same page before we get started and i kind of referenced evidence-based treatment i'm going to give a quick background on kind of what a comprehensive benefit is and what the evidence-based treatments are for smoking cessation so a comprehensive benefit as defined by the uh treating tobacco use and dependence 2008 up state which is the public health service guidelines includes three types of counseling so individual counseling or face-to-face counseling group counseling so this can be a class or just a group counseling session and then phone counseling so over the telephone additionally there are seven fda approved cessation medications that are all considered first line treatment to help somebody quit smoking and there are five nrts or nicotine replacement therapies and that includes the gum patch lozenge nasal spray and inhaler bupropion which is also sold as zyban and vareniclin which is sold as chantix um in order to get any of these medications covered by an insurance program an insurance provider one would need a prescription for them unfortunately we also see a number of barriers to access care um including cost sharing prior authorization limits either on duration annual limits or lifetime limits um or dollar limits stepped care therapy so having to try with one medication before another and then required counseling meaning that you would have to get both counseling to get the medication and while we know that the best chances a person has to quit are using counseling and medications together we do recognize that that can be a barrier for some populations especially those that are potentially more vulnerable and so we're hoping with telehealth that we can potentially overcome some of these barriers and increase access to that evidence-based treatment so i'm now going to turn it over to claire brock bank to give us a little bit more information claire hi thank you everybody thank you answer that introduction and for laying the groundwork what we're going to try to do in the next 40 minutes or so is to give you an overview of telehealth talk about how telehealth and tobacco cessation might fit together and then talk about some of the different ways to consider proceeding and give you some guidelines and indicators of issues and barriers that you should perhaps be aware of uh it's a lot of content and we have a lot of attendees on the line um i know ann mentioned that we'll have time for questions at the end but if if a question comes up with with respect to a term or something like that please feel free to put it in the q a box so that you're not lost from the very get-go and we'll we'll be keeping an eye on those so before we go um much further let's level set and and and define the term you might have heard the term telemedicine telehealth while they're sometimes used interchangeably we use the term telehealth because it incorporates telemedicine which is typically the more clinical aspects as well as some of the more health-oriented prevention-oriented which fall under telehealth so throughout our conversation this afternoon we'll be talking about telehealth using the term telehealth and that covers a range of areas and technical applications if you will from live video which is the most common um way to practice telehealth to door and forward which is what happens when somebody puts information in a patient of some sort and it's reviewed by a provider at a later date the first applications of this were in radiology but we see it in other images and other even information from a patient asking for some guidance and it comes later remote patient monitoring is included in that email phone and fax to varying degrees and we're going to talk about that in a minute all the way to mobile apps and social media all of those can fall under the broad umbrella of telehealth when we think about why telehealth there's really three major reasons why there has been a lot of enthusiasm for it the first is it provides a mechanism to alleviate provider shortages and we know we face those in many different areas in this country it also provides a mechanism for more convenient access to care so better access and in addition to to convenient access it it it provides access to while we may not have a shortage of providers everywhere we it allows us to distribute those providers a little more a little more thoughtfully across need and finally from a cost perspective it's seen as a attractive way to use fewer resources on the part of the patient so less time to travel less time off from work to lower costs for the patient we'll talk about cost benefit analysis and return on investment in a few minutes but those are sort of the biggies so if those are the biggies how do we think about it in the context of tobacco cessation so ann walked through these as a as a what is a good evidence-based session benefit so i won't go through that again but let's think about those specific to telehealth both counseling and prescribing can generally be done using telehealth nothing in the current evidence-based treatment guidelines actually precludes telehealth so that's the good news um they there is not an obvious barrier um between an evidence-based cessation benefit and telehealth now that said we have a couple of things in in health care and tobacco cessation specifically um that fall into a little bit of a of a netherlands so i'll start with mobile health we know that about a third of smokers turn to the internet um there's been some evidence in in a recent cochrane analysis on its effectiveness but it has not typically been approved as a stand-alone way to approach tobacco cessation as a result it's not a stand-alone way in telehealth either from a coverage perspective so one comparable thing to think about is many of you are probably familiar with the diabetes prevention program the dpp has been approved for coverage by medicare and by many health plans um the in-person process but the app has not yet so that's sort of a classic example and that's where we probably are with mobile health and mobile health and telehealth too specific to tobacco cessation the last one i want to talk about is the quit line quitline has been a a strong component of our cessation efforts in this country and it is one of the evidence-based technologies that is that is supported by the affordable care act and the united states to prevent a service task force but in most states pure telephone services are not considered telehealth so it doesn't mean that you can't continue to provide quitline services but you wouldn't look to to telehealth coverage and reimbursement as a way to have it approved does that make sense i'm going to take silence as yes so with that if there's no particular barrier to telehealth and tobacco association what do we see in terms of actual coverage so we see on the federal side medicare the department of defense and the va all provide coverage for telehealth medicare with some limitations that we'll talk about in a few minutes department of defense and the va with really no limitations with respect to state public sector that is medicaid typically and the feds have deferred to the states and said it is up to the states to decide how much how they want to cover it and all states except massachusetts have some degree of medicaid coverage for tobacco cessation michelle's going to talk a little bit about some workarounds even on them in massachusetts on the private side we see most plans have some degree of coverage um but we don't have as good a way to actually find out exactly what so it's very similar to how we see it how we see tobacco coverage most plans have some level of tobacco coverage but we can't say for sure exactly what's covered and how it's paid for etc and that is the same with commercial carriers but that said as we survey commercial carriers most of them have some degree of um coverage for telehealth and are actually quite quite bullish on it so if it's covered to a certain extent and we didn't find any for the most part if you have tell health services covered we've found no exclusions for tobacco cessation so that's the really good news um is it being used so first we looked at providers and we're able to tell most um most accurately with respect to some of the systems in terms of how many providers have adopted telehealth capabilities so you can see that um acute care hospitals more frequently outpatient and so on it goes down the line that does not mean that they are necessarily utilizing it but they have the infrastructure we don't know so much about independent providers because for some the technology is very minimal and there's no formal way of necessarily finding out how much they've they've actually purchased if you will so what about actual utilization so we're able to report only on utilization on the public side which because these entities track it so you see department of defense and medicare really at less than a quarter third of a percent really small medicare we know some of that is because of some of the restrictions on coverage um the va provides the counter example showing that they've got 12 of their eligible individuals are using telehealth services that that's really phenomenal and a lot of that is due to a great deal of promotion of it to patients a lot of training to the providers a lot of effort to make it as seamless and easy as possible so what would we expect moving forward you certainly hear about telehealth all the time and is the hype does it match reality these numbers are a little hard to see and i apologize for that um the 2013 and 2017 data points are actual so what that shows is that in 2013 about two percent of our in the us our visits were performed via telehealth that went up by about 30 percent um in 2017 by 2017 to about 2.6 2.7 and then we get to projections and under a high projection um it's expected to triple in the next four years to about 7.5 and not quite double to 4.2 percent so we don't have to put a lot of weight on these numbers but but it's important to show that it it it's not going to be replacing care um entirely this is this is it'll it'll take its place as a viable mechanism for providing care when we think about it from a tobacco perspective um it's hard to know whether use would actually be registered because often um very few visits ice on an isolated basis are dedicated to cessation so it's it may be difficult a difficult thing for us to track in cessation you know to actually try to tease out specifically tobacco cessation visits so what are the barriers we've seen that it can be covered we've seen that the capability is there but yet we've also seen pretty low utilization whoops so the big barrier on the patient side is awareness i would suspect if each of you sort of looked at yourself and said what kind of coverage do i have you may or may not know michelle and i both had to look up our coverage when we started um working in this area um on the provider side it's it's also awareness knowledge and some concern about reimbursement and the cost of putting the program in so you can see now why maybe the va has done such a good job because they've really addressed those awareness and the knowledge and reimbursement issues an issue that is not common in a lot of the things we typically deal with in healthcare is is the technological infrastructure you have to have broadband and there are many areas in the state um in the country that don't have enough broadband um we're going to send you out a packet um ann is sending out a essentially a brief after this webinar that gives some links to the federal communications commissions and they do actual maps that show exactly what counties and what zip code areas have sufficient broadband and it's very interesting to look at from a cost effectiveness mixed results i said earlier that it's great for patients so you see the va believes it is has done a lot of research and finds that it is enormously cost effective for them um other research says that maybe it's an additive so it doesn't replace um each telehealth visit which might be less expensive doesn't necessarily replace a regular visit so depending on what you're measuring this field is still in its infancy um so but the and reimbursement as i said earlier is is inconsistent and spotty because it's up to each plan in each state the important thing to take away on this one is that there is no organized resistance to telehealth we don't see a lot of pushback the barriers to telehealth are pretty typical of new technological services and frankly the the primary patient barriers and provider barriers are not dissimilar to the issues we deal with in tobacco cessation and that's patients knowing what their coverage is and providers being comfortable with what to do and that it'll be reimbursed the one thing it's important to look at if we're thinking about new technology a new way to provide care in health care is regulation right it's a very regulated industry on the federal side we see the federal communications commission the food and drug administration and the federal trade commission all have a degree of engagement in regulating the component parts of telehealth the important part in this is that um these agencies have all indicated support for telehealth and have actually worked fairly collaboratively together to create some ded cated electromagnetic spec spectrums for medical devices and to build broadband capacity so lots of effort to promote it so not a barrier on the federal side as i mentioned before they also have given states the authority on the medicaid from a medicaid coverage perspective i mentioned earlier that medicare has had some limitations in the way it covers telehealth there was important legislation passed and signed and moved into law last year for creating high quality results and outcomes necessary to improve chronic care act of 2017. the important takeaway from that was it increased funding medicare funding it also removed some of the barriers that medicare advantage plans and accountable care organizations had so that they have more ability to expand telehealth services now and generally it expanded the ability for more entities to receive coverage via telehealth and the last piece of it that's important to note is that health and human services is instructed to solicit feedback on what should be treated as telehealth benefits and so as that proceeds down and we ask for policy interventions i'm sure that um we'll be will be kept apprised of that by our friends at ala if they need feedback specific to tobacco but that says if there's not a lot of federal regulation where is it well not surprisingly it's the state we know that in the states state typically regulates insurance and that includes plan oversight network adequacy consumer protection all of those things um are regulated by state insurance regulators the state also regulates the practice of medicine so scope of practice licensure and again medicaid has been deferred to the states for um for coverage and that's where we've really seen the bulk of activity happening and i i think if you if you track um track state activity it's this area of telehealth is an area of activity in in virtually every state to one degree or another so so as we step back and and think about this very broad perspective we've tried to give we know there are opportunities between tobacco cessation and telehealth to broaden access and address some of the barriers we talked about some of the barriers to tobacco cessation being access to providers convenience costs and many of those can be addressed by telehealth it offers a opportunity to potentially provide an option of interest to a different kind of population that is more a digital native for example who doesn't really want to deal with in-person care but certainly there are some unique challenges so as we as we step across we know that we've talked a little bit about quit lines and mobile apps both of which have a pretty strong foothold in tobacco cessation and will have to be on the wait and see list from a telehealth perspective but the other issue to think about michelle's going to talk about some important policy indicators and one that's particularly important is that in tobacco cessation we have been very successful using non-clinical providers treating training tobacco treatment specialists and others and typically because of licensure and scope of practice those are often not addressed in telehealth so understanding how to make sure we can continue to use people at the top of their their capabilities will be an important issue for us to think about with respect specifically to cessation the bottom line from a macro perspective is that this is we see this as a viable option on the menu of services but not a replacement so this is one more quiver in your arrow if you will to think about in terms of expanding access so um so with that we're going to shift our focus to now what do you do with this information how do you assess your own state environment and think about it many of you are from state health departments how do you go forward and think about it in your own environment and for that i'm going to turn it over to my colleague michelle paterino so since claire has given us really the sense of the landscape now we're going to do sort of the more practical um how-to piece of the webinar we're going to talk about how you find out about the environment in your own state i'm going to talk about how you assess whether it's positive or negative depending on what you find and then we're going to look at key populations and the role of medicaid which are also important considerations for states so first um when when claire and i started looking at all of the different ways to assess whether a state was positive or negative relative to uh the the friendliness if you will for telehealth we had a list of about 21 topics to look at and we worked with the american lung association and a group of experts in both tobacco control and telemedicine and we narrowed down that list of 21 indicators and brought it down to this list of nine indicators because these were the ones that felt the most important and the most relevant to tobacco cessation so i'm going to spend a minute and tell you what these state indicators mean relative to telehealth don't feel like you have to write down the definitions of these or anything because again when that report comes out there's a whole appendix that gives you the definitions and also recommendations um if there are some relative to any of these but we just want to make sure that that you have a sense of it so starting at the top here with physician um and clinical practice standards the first topic is defining the provider patient relationship and that really boils down to whether you have to have had a face-to-face visit between the patient and the physician to establish a relationship before you can build telehealth services or can you establish the relationship using telehealth itself the second indicator eligible technologies that's sort of that list that claire went over the ones that are most important to telehealth as she pointed out were the live video conferencing and potentially mobile health so we want to make sure that those are those are included as eligible technologies um in the state laws or regulations the patient setting is also important that's obviously where the patient is located medicare requires that the patient actually be at a healthcare facility to pay for telehealth obviously for tobacco cessation where we would potentially get the most bang for the buck is if a patient can be in their home or their office or their school and still take advantage of telehealth and tobacco cessation so next moving down to licensure um again claire mentioned sort of using using folks at the top of their um capabilities and that we are used to tobacco treatment specialists and people like that doing um counseling there will be specific licensure requirements potentially for your state if a pharmacist is allowed to bill medicaid for tobacco cessation um for face-to-face counseling visit then they could should potentially be able to to do that for telehealth as well the provider licensure specifically really gets down to state licensure from a physician in colorado can i provide tobacco association counseling for a patient in new mexico um there are states that allow for that allow border states or um state compacts to do that so that's something that you want to understand about your state internet prescribing of course is important because for the most part we want people to have access to both uh tobacco cessation counseling and pharmacotherapies so if they are using telehealth counseling we want to make sure that they have access to the medications as well the network and access indicators really have to do with distance and geography there are states that say you have to be residing a certain number of miles away from a provider before they will pay for a telehealth visit medicare says that you have to be in a professional shortage area or in a rural area so some of those things are important to understand in terms of where you can potentially use your telehealth services and then the last section there is parity and there are really two kinds of parity the first one is services and the second one is payment so services means that if my medicaid plan or my commercial health plan covers tobacco cessation counseling face-to-face then service parity would mean that they should also cover it using telehealth services payment parity means that if the physician receives ten dollars to do that counseling face-to-face then they should also receive ten dollars to use um cell health services to provide that so i know that's a lot of information but those are the um the indicators that we thought were most important in terms of looking at your state and trying to determine whether telehealth might be a strategy for your tobacco cessation program and now that you know what to look for we're going to talk about where to look for it and this is where potentially the best news of all is these are the organizations that have done the work for you so you don't have to look all of this up in your state laws or regulations for medicaid or anything like that so the first three organizations here the american telemedicine association the center for connected health policy and federation of state medical boards have um several documents online that you can access and use and figure out where your state falls what kind of grade they get on all of those nine indicators so that's where you can do the work the really important thing is that they all update that information regularly keep up with what your state legislature is doing so the information will be timely the last bullet point there health resources and services administration probably know it as hersa they have telehealth resource centers available and state health departments can can call those telehealth resource centers and see what kind of uh help they can get in their states as well so that's another important resource and again while claire and i were doing this work looking at specific states and trying to get our hands around it we didn't go to any state specifically and look at their information we use these sources so they make it really easy for you okay so this is what your homework or your working papers might look like as you're trying to decide whether your state is hospitable or not for telehealth and tobacco cessation so we started doing this really just as a test we chose ten states and we listed all nine of the indicators and we're just going to look at the top three indicators here just to give you a sense of how this would look um and we're going to do a little contrast between florida and texas here so for the um physician patient encounter we defined a state that's supportive as one that says you can establish a relationship between a physician and a patient using online services florida allows that so florida got an f there they are supportive based on that indicator texas does not allow you to establish that relationship based on a telehealth visit initially so texas is not necessarily supportive of using cell health for tobacco cessation because you have to have that relationship first the second indicator is the patient setting again florida is supportive because florida would allow for telehealth services to happen in the patient's home texas does not allow it to happen in the home so texas again is less less friendly to potentially using telehealth for tobacco cessation and the eligible providers piece has a lot of components that go into it and they were rated really on all different kinds of providers so instead of trying to sort that out we used the american telemedicine association assessment here and they gave states grades of a through f and so we just said where the american telemedicine association said a state got an a or a b they were supportive that was the case in florida where the american telemedicine association said the state got a d or an f they were not supportive and that was the case in texas so if you look down the down the column here florida is supportive on those three indicators texas is not supportive on those three indicators and um uh i guess the bottom line here is that that's not necessarily a green light or a stoplight for you there are some other factors that you need to take into account and this is just one piece of it so we're going to move on and talk about the second thing that you need to take into account this is potentially a familiar advice to all of you who've worked in tobacco control you need to think about your target population this was really important to the experts that we brought together and they really stressed this point that successful implementation of a telehealth strategy should start with who you want to serve where those those folks are in this case where those tobacco users are where they live where they access healthcare services where they spend their time and then once you know that then you can think about how you can best serve them and whether telehealth is an appropriate way for you to approach that so again when you get this report you're going to get lots more detail that we just don't have time to go over on today's webinar but we spend time with that group of experts and talked about target populations where you could potentially have a big bang for the buck using telehealth to deliver tobacco cessation so the agreement was that tobacco users who live in poverty tobacco users who have behavioral health conditions youth and young adults are probably appropriate target populations providers of tobacco cessation services who are primary care physicians or who are behavioral health providers are probably appropriate to target in terms of telehealth as well and in terms of geography rural areas poor areas stress urban areas those are potentially the right places to look at a telehealth strategy and then using um targeted venues to reach populations where there may be less access to broadband or less access to computers or phones or whatever you need we came up with pharmacies and libraries as two important places to consider as venues so again if you look at the report it kind of walked through all of these groups and the most obvious example i can give you is if you're trying to target tobacco users who live in poverty you need to consider things like do they have a laptop available do they have a bike connection available do they have minutes on their cell phones so that they can take advantage of telehealth services so we walk through some of the implications for each of these target populations in the report so now we're going to move to the third piece of information we really want you to consider when you're looking at your state environment that's medicaid obviously medicaid is often an ally to us in tobacco control so there's nothing new here but when you look at the number it's that it speaks for itself here 49 states and washington dc have some form of reimbursement reimbursement for telehealth in their medicaid fee for service program so virtually every state and and then getting past even the medicaid fee for service program medicaid managed care which is becoming more and more important as more and more people move into it um there's even more leeway and more flexibility so we know 81 of folks across the country who are on medicaid are served by managed care plans um state rfps where they're asking plans to bid for um serving those populations are starting to mention telehealth more and more often and again they have latitude besides what's in the medicaid law for fee for service they can go beyond and suggest additional strategies um and we want to show you what a couple of those might look like um this is just a subset you know based on personal experience over the last couple of years of managed care plan rfps that came out from state medicaid organizations that talked about telehealth so in 2018 north carolina is moving much of its medicaid population into managed care for the first time they preceded that move by putting out a lot of concept papers to tell folks what they were thinking of and what it would look like they said very explicitly that they would allow the use of telemedicine as an alternative to manage care plans um having to offer out of network care managed care plans don't necessarily like offering out of network care obviously they lose a little bit of control if th y don't have a contract with a provider so if i am able to send you to a cardiologist across the state using a tele-health visit as opposed to sending you to a cardiologist who is not in my network that's flexibility that i as a health plan might appreciate in new mexico last year they specified increasing telemedicine office visits with specialists and particularly behavioral health care providers for members who live in rural and printer areas that was one of their goals and so they were asking the plants to talk about how they would do that so again this gets around that whole access issue oklahoma did something similar where they said that they would waive network adequacy requirements if you had telemedicine available so if you don't have that cardiologist available in a particular county and that was the the normal requirement you could get around that if there was telehealth and in pennsylvania it was interesting they didn't necessarily lay out a particular strategy they just wanted plans to write about what their experience was with technology such as telehealth and how they were using it so that really created um what the plan saw as a need to have a telemedicine strategy and i was on a call that was with a plan not in pennsylvania per se but they were coming up with their telehealth strategy for their medicaid managed care members and the reason they gave really was just that because everyone else has one so they thought as a competitive need so if your state has telehealth included in its medicaid managed care strategy that potentially gives you two places where you can do some more homework one would be working with the state medicaid agency where you can potentially talk about whether tobacco cessation is something that they want to have goals around and include in their telehealth strategy or you can do work specifically with the managed care plans as well and make sure that they are thinking about tobacco cessation or including that in their telehealth strategy and not just that they include it but as we all know is important with tobacco cessation they need to promote it and let folks know this is this is a way that you can take advantage of these services okay that felt like a ton of information so we're gonna just step back for a minute and this is sort of our high level how to look at telehealth and your tobacco control strategy in your state so again our experts felt like it was very important to start with your target population and think about their cessation needs and identify the barriers that are experienced so if it's transportation barriers or language barriers is that something that telehealth can address and in those two cases the answer is yes once you once you've targeted then the next thing you're going to do is research your state's environment on those nine indicators that we went over um using the sources that we gave you like you said not looking that up on your own and then augment that research with your own scan in your state to see if there are additional telehealth initiatives that are important that may come from medicaid that may come from your hospital association that may come from the health information exchange so you just need to be aware of what else is important and then when you um weigh all of that and decide are there gaps here that are going to make it hard to proceed or not um you really have to you know there there's no magic formula like we said earlier there's there's nothing that says you get a green light or a red light you just have to decide how those all come together um there may be things that you can identify workarounds for um you may decide that as a health department you need to get involved from the policy side and that may be sort of outside of the scope of a tobacco control program but those are all conclusions that you may reach on your own and then again just reiterating what claire said earlier with this kind of approach um we think that there is some potential we think there's some opportunity although this is not a silver bullet there is limited data and evidence on these approaches but you should consider it another tool in your toolbox to potentially broaden your reach and impact more tobacco users through your tobacco control program great thank you so much that's a ton of information and we already have some questions in the q a box so i've got a couple quick announcements and then we will get to the q a this is ann again andy julia with the lung association um so please please please take a minute to start entering questions because we've got a good 18 minutes or so for questions but before i do before we start answering the questions i just wanted to take two quick things um first we've referred to a brief um we do have a brief on facultization and telehealth that should be coming out next week um if you've registered for the webinar the good news is we will email it to you so if you're want more information and want to dig into that that's great and so we will you will be getting an email once that is released so don't worry you'll probably get it from a couple of different places because you probably will get it however you got uh invited to this webinar and then you'll also get it because you did register but we want to make sure you have that um additionally when you do log off you'll be sent a follow-up email at some point this afternoon or tomorrow there's a link to a survey to tell us how we did and what we could do to better serve you both in terms of this topic as well as on some of the other topics um and so please please please fill out that survey to let us know if we did a good job or a bad job or other topics that you might be interested in learning about so thanks so much we have a bunch of questions um that have come in so please we'll continue to take them um our first question is from uh the county of los angeles and i think i'm going to turn this over to claire and it's can you legally provide services across state lines thanks ann um susan that's a that's a good question and it's um when you when you look at those indicators the issue of um where licensing and if providers have to have licenses um within the state or are in those list of indicators so typically the legis the regulation you need to look at it varies by state it's not a federally um regulated issue so your states may have participate in compacts again those will be clarified more in the report that ann has mentioned they have compacts that say yes if you're licensed in georgia north carolina accepts it so we can you know we'll accept it across state lines or they may say you have to have there are geographic description um limitations so in some states they don't let you receive care from across state lines and in others you do so you would need to look at it specific presumably to california um if that's the state that you're interested in and when you look at that you want to make sure you're looking at where typically where the provider is relative to the patient so it's it's really because the provider is licensed in in some state and so you want to look what does the patient say say about getting treatment from someone out of state does that make sense if that makes sense thanks um so looks like we've got some breaking news from texas um claire do you want it looks like texas may have changed some of their laws so um just remember a quick reminder and claire you can expand upon this if you'd like or michelle um you know that chart that we showed um earlier with the indicators and the different states it was just an example so states may have changed their laws and do change their laws quite frequently so if you're interested in embarking on this work i think it would probably be a really helpful to go through and kind of do that exercise um all the indicators are listed in the um report so once that's published and out and you will have that delivered to your inbox so um we are working on getting that to you so please hang tight and if you've got more specific questions um my email is on the next slide which we will get to which we'll put up in a few minutes so you can feel free to reach out and and otherwise i'll just iterate what you said one of the things that claire and i initially thought we were going to do was put a table for these indicators in the report but we realized how quickly it would be out of date and felt like it was much more important to send people to the right places where they could get the information than give that snapshot of information at the time so thanks for the update i also think it's important when you um we were only able for to show three of those indicators so and it made texas look really bad and florida look really good if you've gone all the way through the nine indicators which michelle and i did florida doesn't have any parity requirements and so that would be a negative whereas texas does so it's important to um to not take too much of a take away from just those three indicators because no state scores well on all of them and no state scores poorly on all of them it's a mixed bag and so you really need to look and say of the areas where my state didn't score so well is that fundamental to tobacco cessation or not so for example if you're in a state that doesn't allow remote patient monitoring probably not such a big deal in tobacco cessation unless you're really trying to target post-operative patients who may want to quit tobacco use but so again it really matters what your population that you're looking at is thanks claire that's a really good reminder that it's not just the indicators that are important but it's also the population and a number of the components that are important our next question is from us ucsf excuse me and it is can you please describe the difference between mobile health and telehealth in terms of tobacco station so this is claire um mobile so they can be um not all telehealth is mobile health but um they can be subsets of each other so a mobile health might be an application the one we used uh the example of was the diabetes prevention program or the quit um that quit for the uh non-blank and the name the baby quit program um which i just completely bungled um and but not all mobile health um applications require any sort of clinical intervention or even have any security requirements or connect to a medical or a clinical record of any sort so they are not necessarily different what matters is in your area is mobile health considered part of telehealth so while from a technical perspective mobile health is listed as one of the five or so components of telehealth which we put on one of the first slides in terms of it being covered with respect to tobacco cessation or anything else it matters whether your payers in your state say yes we will cover it whether the feds have said it's an evidence-based protocol so again a diabetes prevention program that's available as an online mobile app is not actually approved for coverage in the same way that the diabetes prevention program that is provided in person does same intervention but through a different medium so we go into a little more detail on the definitions but if it's if it's um purely definitional mobile health is a component of telehealth but if it's um in terms of actual application to be able to build provide a service get reimbursed then it varies and i just at a specific example a vendor that i talked to has sort of a support available through an app a mobile app you can type in i'm having this kind of trouble i'm at a bar where lots of people are smoking those kinds of things and in some of those you will get an automated response and there's no clinician involved the system is smart enough to give you the kind of response you need in some other questions if you type in then a clinician is going to get involved and chat with you so they have this this system that weighs whether you get a system generated response or a clinician response the system generated piece we would argue is you know is not a live video conference but when you're chatting with a clinician it might be so it can kind of mix those two things together yep and and even might be considered what's called asynchronous what we talked about is store and forward where you put a message in and you a clinician is reviewing all those messages and gets back to you so it may not be literally lifetime but there's just a brief lag so we probably just muddied the waters for you well it sounds like there's a lot of variability around what is telehealth and mobile health and kind of how they intersect so um i think there's a lot of information out there and a lot of options for patients to get help quitting our next question is from massachusetts general um does the patient is the patient required to be at a computer screen or can it be done on the phone and if so the person is assuming that the patient would have to use an iphone to get the telehealth service so i guess that was kind of piggybacks on the last question of you know is it an app or is it video chatting or facetime or whatever so many of the um the rules say you can't just use you know you can't just do a video chat on an iphone and have that count there are too many security rules and hipaa requirements that go along with protecting security so most of the times when you read it you know just video chatting in and of itself is not going to work you have to have some other um rules there and i don't know if claire wants to say anything else yeah almost all of the vendors though have applications that um go through a smartphone and so that essentially um encrypts security so there's a question i know we often get asked about hipaa and most of the vendor base so if you literally just pick up your phone and call your doc or clinician that wouldn't be covered but if you go through a telehealth app which most insurance companies make available or your doctor's office may have one that he or she uses or the clinic etc then those typically have a security infrastructure built in and you can do facetime or the equivalent of facetime or skyping etc but again so it can be done on a phone but you would want to go through one of the applications the vendors that do it because that gives you your security requirement it meets your security requirement great and then that kind of follows up with the next question and that asks specifically about any any hipaa considerations regarding um the use of telehealth we heard when we gathered um when we gathered with the experts we we heard um several people say that hippa is brought up and security and privacy is brought up as a as a as a barrier but that in reality and the lawyers worry about it and that's probably legitimate that they worry about it but that in reality it's probably not um a significant barrier in that again most of the vendors that are out there are hipaa compliant with the technology that they sell because it's so fundamental to our industry so i can't give a blanket there's no issues on it but if you're using a a reputable vendor the odds are they can be addressed but our understanding was that there are not any specific hipaa requirements because you're using telehealth they're just the general hipaa requirements that apply anything right yep good good clarification thanks so much so our next question is are there any is there any data on quit rates for telehealth cessation and i think there might be some within the va because the va has a pretty robust telehealth system va definitely has good results and we didn't i don't think we cited a lot of those in the paper what what i know the paper does include in terms of the endnotes is a couple of cochrane reviews that we looked at um that we actually got from folks at the cdc that we're really looking at some of the the mobile health um and internet-based applications some of those have emerging evidence um and and we didn't cite it all because obviously you know the issue is it just really varies it depends on the size of the trial what kind of trials they did so this is definitely a place where there's just you know it's just an emerging practice and when you get to some of the questions around the clinical guideline you have to think abo t um how closely some of these methodologies might follow that um and the only other thing i would add especially when we talk about va is va does have really good results and has had some success with telehealth the one caveat to that is the va is a closed healthcare system so it's a little bit different and might not while it's a really good example it might not necessarily be an apple to apples comparison for healthcare systems across the country it's more of a unique system and then we've got kind of one last question um and so if you've got more we still have a few minutes so if you've got another question that you're burning really would like to get answered please feel free to type it in um but the last question that we currently have is do we have any info information that's specific on group telehealth treatment and if there are any unique barriers with billing so mr mannis is around group counseling so if the question is specific to group tobacco cessation telehealth treatment there is such limited data right now specific to tobacco and telehealth as michelle mentioned there are some studies that we're really looking at very specific aspects of of cessation and looking at some specific cost models etc but i think that there right now the issue is more um that this it's too early and um very little published published research um so when it gets down to something as specific as a specific intervention specific to tobacco cessation great thank you um and so we've got another question that just came in and just wanted to clarify about quit lines and telehealth um and why they're not considered telehealth i believe that is the answer so can you potentially clarify that for us so it's again it varies there are a few states where where telehealth includes telephonic exchange only but for the most part it requires some sort of a more face to face yeah audio face to face audio face to face transmission of data um the exception is when you look at like what we call store and forward or asynchronous where there's a delay but there's still it still includes the transmission of image etc and so again with the exception of a few states most states and it's very ironic when you think about telehealth that telephone services aren't aren't automatically included but the general rule of thumb is most states about 90 do not include telephone only in their definition of telehealth it doesn't mean it's not covered so again telephone telehealth quitline quit lines excuse me are covered by many medicaid programs our and are one of the uspsdf evidence you know components of the evidence-based guideline um and so may be reimbursed on its own but it doesn't fall under the separate auspice of tele health and i apologize that we didn't make that clear the the report that anne's going to send out um we sort of started from that place because it feels like tobacco cessation with its use of long use of quit lines evidence-based use of quit lines is sort of the poster child for telehealth and yet it doesn't usually count well thank you so much that seems to be all of the questions we have um my contact information is um post is up there now so if you have any questions that we didn't get to or that you didn't want to ask or did have a chance to ask please feel free to send me an email and we can get back to you um again we will be um sending out a copy um that recording um as soon as the webinar you know within the next few hours or maybe tomorrow morning at the latest um again there is a link to take a survey so we would really appreciate you doing that um in addition if you've got anything that you think might be a good future topic to have a webinar on we would love to hear that um and then again as we mentioned and have referred to we will be releasing that um report in the next um probably next week so and you will get that delivered to your inbox just for registering for the webinar um so really just want to thank you so much for joining us and so much for being interested in tobacco cessation and telehealth and we look forward to talking to you soon so thank you so much um and on behalf of the lung association hope you have a really great rest of your day bye does conclude today's presentation you may disconnect at any time and enjoy the rest of your day you