Report 2009-107.2 Recommendation 6 Responses

Report 2009-107.2: California Department of Corrections and Rehabilitation: Inmates Sentenced Under the Three Strikes Law and a Small Number of Inmates Receiving Specialty Health Care Represent Significant Costs (Release Date: May 2010)

Recommendation #6 To: Correctional Health Care Services, California

To determine whether the additional expansion of telemedicine is cost-effective within the California correctional system, Prison Health Care Services should further analyze the cost-effectiveness of telemedicine through a more robust estimate of savings, including considering factors such as the percent of telemedicine consultations that required subsequent in-person visits because the issue could not be addressed through telemedicine.

Annual Follow-Up Agency Response From November 2015

The institution utilization management teams follow a standardized process to approve referrals and determine appropriateness of telemedicine services before the consultation. The cost effectiveness of telemedicine in prison health care has been shown through an analysis of medical guarding and transportation costs from 2013-2014. The analysis showed a cost avoidance of $7,222,574 based on 19,351 telemedicine encounters. For 2014-15 the figure is closer to $8.9 million in cost avoidance based on 23,900 specialty encounters, which reflects a 64 percent statewide utilization of Telemedicine. (see attachments)

An analysis looking at the percent of telemedicine consultations requiring subsequent in-person visits because the issue could not be addressed through telemedicine is not applicable as a traditional, in-person visit may still be needed for a specific physical examination, diagnostic studies or procedure. These visits can then be followed by a telemedicine visit for follow up. For example, a patient may be followed in Telemedicine by dermatology for a full year before the dermatologist decides, based upon a morphological change observed on a dermatology camera, that a wide-margin excision of a lesion is indicated. The telemedicine cost savings for that entire year remain actual savings and are unchanged based on the later surgical excision.

There are also times where the specialist prefers to see the patient face-to-face initially, which are then followed by telemedicine visits. The cost savings for the telemedicine follow-ups is unaltered by face-to-face visit. In addition, specialty encounters may be scheduled offsite due to the unavailability of a specialty provider network, or compliance date requirements. According to the American College of Physicians, Policy Recommendations to Guide the Use of Telemedicine physicians should use their professional judgment about whether the use of telemedicine is appropriate for a patient.

California State Auditor's Assessment of Annual Follow-Up Status: Resolved

Corrections' Health Care Services stated that an analysis considering the percent of telemedicine consultations requiring subsequent in-person visits that could not be addressed through telemedicine is not applicable as an in-person visit may still be needed for a specific physical examination, diagnostic studies or procedure. However, Health Care Services has established a standardized process to approve referrals and determine the appropriateness of telemedicine services before the consultation. This process includes specific documented policies and procedures, updated in May 2015, which provide guidance to the field when utilizing telemedicine services for medical specialty and primary care.

Annual Follow-Up Agency Response From November 2013

CCHCS cannot fully implement this recommendation because the needed IT and personnel resources are not currently available to provide this level of in-depth data analysis.

Within Telemedicine Services' current resources, implementation of this recommendation would yield unreliable data. For example, the current system does not distinguish whether a follow-up encounter is scheduled in accordance with the patient's routine conservative plan of care or of the efficacy of a previous telemedicine encounter. Needed IT and personnel resources are not currently available to provide this level of in-depth analysis.

Rather than rely on retrospective data to determine efficacy of telemedicine encounters, Institutional utilization management teams follow a standardized process to approve referrals (Attachment 6) and determine appropriateness for telemedicine services before the consultations. Those referrals deemed not appropriate for telemedicine are routed for in-person office visits.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Annual Follow-Up Agency Response From September 2012

Please see response to 2009-107.1 Recommendation 2. Although some telemedicine cost center information (e.g., claims payments; equipment costs, service, and depreciation; IT connectivity costs) is available, other cost elements such as the value of increased community safety, improved patient access to specialty care, access-to-care litigation costs avoided, and others are difficult to estimate/quantify.

The future implementation of an enterprise electronic medical record system creates the opportunity to follow patient-inmates receiving telemedicine specialty and primary care to review health outcomes and subsequent utilization as compared with similar patient-inmates receiving specialty and primary care that is not delivered through telemedicine, to refine comparative cost analyses.

Telemedicine Services is investigating cost analyses methods used by other government and non-governmental agencies that may be usable in trying to quantify some of these intangible variables to inform a cost comparison model. Systems to collect these sorts of data in a standardized way have not been identified or implemented to date. Once cost center modeling, improved data, and staff expertise to perform analyses are developed, more detailed comparisons will be done on an ongoing basis to inform policy decisions.

The insufficiency of cost center data and inadequate cost analysis methodology and technical analysis expertise have delayed implementing this recommendation. CCHCS is trying to address both of these deficiencies in order to improve efficacy and quality assessments for telemedicine services to inform policy decisions.

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

All Recommendations in 2009-107.2

Agency responses received after June 2013 are posted verbatim.