Andrey Ostrovsky: Use of telehealth for children with special healthcare needs faces limitations [Q&A]

Telehealth effectively can provide services to children with special healthcare needs, but the Lucile Packard Foundation for Children's Health in California found it's not being used to its full potential.

Researchers from RAND and the University of Pittsburgh School of Medicine also recently called telemedicine an underused technology in pediatric emergency settings.

Andrey Ostrovsky, M.D., an attending physician at Children's National Medical Center in the District of Columbia and software entrepreneur, recently discussed with FierceHealthIT the barriers to more effective use of telehealth in pediatrics, especially for children with special healthcare needs.

Ostrovsky (pictured) sits on the Federal Advisory Committee on Health IT Standards and the Home- and Community-Based Services Quality Committee of the National Quality Forum.

During his residency at Boston Children's Hospital and Boston Medical Center, he and his mentor, Richard C. Antonelli, M.D., medical director of integrated care at Boston Children's Hospital and assistant professor of pediatrics at Harvard Medical School, convened a salon for the Verizon Foundation, and in June 2013 released the results in a white paper, "Empowering Care Coordination with Technology: Opportunities To Transform Pediatric Care Delivery."

FierceHealthIT: What do you see happening in terms of telehealth and pediatrics generally?

Andrey Ostrovsky: I don't see too many projects that are going to have a scalable difference. What I am seeing are some exciting bursts of energy and inspiration with hackathons, Shark Tank initiatives and conferences. But in terms of having telehealth really embedded and used scalably in children's hospitals, there are some major limitations, and a lot of that comes down to the financing of healthcare for children, and specifically the healthcare of children with special needs.

FHIT: How is the financing different from that of adults?

Ostrovsky: It's very different. Adults over 65 benefit from Medicare, and Medicare is at the leading edge of innovation. The Affordable Care Act has created some pretty impressive incentives and disincentives that are pushing massive changes in the way that healthcare systems are doing business. Medicaid is five to 10 years behind Medicare in terms of systematic innovation.

Children's care is either employer health plan-funded or it's Medicaid-funded. The more complex a child's healthcare is, the more likely it is to be funded by Medicaid. That puts pediatric delivery models and innovation for children who really need it at a serious disadvantage in terms of benefiting from the real cutting-edge innovation. It's not just tech, but about how leadership thinks, what investments are made and ultimately the innovation ecosystem. For-profit companies that need to grow massively and quickly, incentives to go toward pediatrics is really hindered when you look at the massive amounts of money available in non-pediatric--Medicare-funded--delivery models. 

FHIT: Are employer-funded plans disallowing a lot of things for children with special healthcare needs?

Ostrovsky: Employer-sponsored insurance companies are not facing as much of an impetus to change as Medicare players. Medicaid is starting to come around. Employer-sponsored insurance companies are facing some competitive pressures because of lower-cost options on health insurance exchanges, but if you look at insurance companies focused on adult care involving Medicare Part C dollars, there are requirements for how much they spend on quality improvement, spending on certain quality measures, etc. ... There's a lot at stake for insurance companies spending dollars for the elderly, so they create more innovative processes to make up those investments. Insurance companies not facing those requirements aren't as creative. They don't have to be.

Fee-for-service Medicare dollars also have very different incentives than fee-for-service Medicaid dollars. When it comes to Medicaid fee-for-service, there's very little innovation going on. There's very little incentive for Medicaid-funded delivery models to do interesting things--and telehealth would be one of them.

Pediatric or elderly care reimbursement pretty much comes back to the same bucket of money, which is Medicaid approval, particularly Medicaid waiver approval for telehealth reimbursement. The Medicaid 1915(c) waiver for home-based and community services, though largely applied to the aging or adult with disability population, it's absolutely applicable to the pediatric population, but a lot of people don't connect those dots.

I sit on the National Quality Forum, I sit on their home and community-based services committee and I raise my hand and say, "Why is no one talking about the pediatric population?" They need home care, they need transportation, they're people too. They're kids.

FHIT: Beyond reimbursement, what would you like to see happen with telehealth to improve pediatric care?

Ostrovsky: There's a lot of things. Payers and providers increasingly are on the hook for outcomes. Insurance companies make more money if people are healthier. Technology companies make money regardless--they just need good salespeople. There are almost no examples of where technology companies will take a financial hit if they're not contributing to some aspect of the Triple Aim. If there were gutsy enough payers or state Medicaid leaders that would make technology vendors accountable for what they claim in their marketing materials, I think that would change how telehealth is perceived. The telehealth vendors that are actually demonstrating impact will be sought after and the noise of all the other vendors that really can't deliver will go away.

Evidence for telehealth is really lacking in many regards. There are a lot of quality measures focused on medical care, but not on the non-medical side of healthcare. There certainly aren't good quality measures that incorporate what impact technology--and more specifically telehealth--have on improving care.

Pediatrics is pretty underrepresented. Fortunately, there are some awesome advocates for quality measurement in the pediatric space. The National Quality Forum and the NCQA (National Committee for Quality Assurance) have both taken a strong leadership role in that regard. But we're pretty far away from a holistic view of measuring quality including the role of technology and including supports and services of the community. How well is the family supported when their child experiences complex healthcare needs? Those types of quality measures don't exist. So it's hard to incentivize tech or anything outside of tech when you can't really measure the quality of care, at least from a payer perspective.

Editor's Note: This interview has been condensed for clarity and content.

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