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This week, we are joined by Sumona Das Gupta, assistant director of pharmacy audit and compliance at University of Washington Medical Center and Harborview Medical Center. As part of the UW Medicine health system, the hospitals operate in the first region of the U.S. that experienced community transmission of COVID-19 last year. Sumona discusses how her hospitals quickly expanded their telehealth capacity to serve patients, how this transformation impacted their 340B program operations and compliance, and the benefits telehealth brings to both patients and providers.
340B Insight provides members and supporters of 340B Health with timely updates and discussions about the 340B drug pricing program. The podcast helps listeners stay current with and learn more about 340B to help them serve their patients and communities and remain compliant. We publish new episodes twice a month, with news reports and in-depth interviews with leading health care practitioners, policy and legal experts, public policymakers, and our expert staff.
Announcer (00:05):
Welcome to 340B Insight from 340B Health.
David Glendinning (00:13):
Hello from Washington DC and welcome back to 340B Insight, the podcast about the 340B drug pricing program. I'm David Glendinning with 340B Health. Our guest today is Sumona Das Gupta, assistant director of pharmacy audit and compliance at University of Washington Medical Center and Harborview Medical Center. Both hospitals are within the UW medicine health system which serves one of the first regions in the US that saw COVID-19 community transmission at the start of the pandemic.
David Glendinning (00:46):
As such, UW moved quickly into expanding its telehealth capacity to serve patients who could not come into the hospital for care. We were interested in hearing from Sumona about how this transformation affected the system's 340B program and the broader work of its pharmacy department. But before we go to that interview, has your health system or hospital weighed in yet on the administration's proposal to continue deep Medicare payment cuts to many 340B hospitals in calendar year 2022?
David Glendinning (01:18):
The deadline for submitting public comments on this proposal is September 17th, just days from the release date of this episode. 340B Health has set up a convenient online template your system or hospital can use to draft and submit comment letters to the Centers for Medicare and Medicaid Services. Please check out the show notes for the link to that online template. And now, for our feature interview with Sumona Das Gupta with UW medicine.
David Glendinning (01:47):
Sumona has more than eight years of experience with all aspects of the 340B program, working primarily with disproportionate share hospitals. Prior to getting into the 340B compliance field, she was an associate at a major law firm where she focused much of her work on regulatory affairs. She brought this expertise to a 340B Health webinar about telehealth and Miles Goldman recently sat down with Sumona to go into more detail about that topic. Here's that conversation.
Miles Goldman (02:17):
Thank you, David. I'm joined by Sumona Das Gupta. Telehealth is a fascinating topic. I'm excited to dive further into it today with you, Sumona, and discuss what it means for 340B. Welcome to 340B Insight.
Sumona Das Gupta (02:31):
Hi, Miles. Thank you so much for having me here today.
Miles Goldman (02:34):
Can you provide us background about UW Medical Center in Harborview Medical Center's telehealth programs prior to the pandemic?
Sumona Das Gupta (02:41):
As one of the first places in the country that had community transmission of COVID-19, we are one of the first organizations that really pivoted into telehealth, but we had a lot of the infrastructure prior to the pandemic. To give you a scope of our hospitals, we have about 300 outpatient clinics. We have four acute care hospitals and a partnership with a local cancer hospital and a children's hospital as well. We've been relaying on telehealth in kind of building out our program in reaching a lot of our underserved communities.
Sumona Das Gupta (03:14):
We are localized and supportive of patients who are in multiple states and have difficulties in terms of transportation to get to the medical center, especially for specialty care. A you're going into telehealth, you're looking at specifically in certain specialty areas where we could find advantageous ways to utilize that program. But as you know with telehealth prior to the pandemic, there was a lot of regulations about where the patients had to be, the providers, and the type of care we could provide.
Sumona Das Gupta (03:41):
We saw a lot of those limitations get loosened as we were going into the COVID-19 pandemic era.
Miles Goldman (03:47):
Before the pandemic, the telehealth program was a lot smaller.
Sumona Das Gupta (03:52):
Absolutely. We were really looking at specific providers and specific clinics, so specifically one for wound care. We were seeing patients that were coming into the provider care, significant burn or treatments. And that was one way that our providers were utilizing care because of the availability of video and telehealth. We were seeing it some in dermatology as well, but it was much more specialized and much more nuanced compared to what our current program is and where it is today.
Miles Goldman (04:16):
Tell us more about what it looks like today.
Sumona Das Gupta (04:19):
Thinking back to when the pandemic started back in February, we realized the necessity to have a really big pivot, not only in terms of accessing our patients, but also protecting our health care providers as well, as we were unsure in terms of the transmission and how it was occurring within the hospitals. With that, the federal government came up with an act that really loosened out the provisions of how you utilize telehealth, and they looked at it in a multiple different ways. One, they looked at what type of practitioners can be providing telehealth.
Sumona Das Gupta (04:49):
Mostly it was focused on physicians, but post-pandemic, you were looking at non-physician practitioners, so occupational therapists, vocational, pharmacists that could provide these telehealth services. Second, they took a look at where is the originating site for the patient. Before it was mostly focused on rural or underserved communities. They expanded out where the originating site could be and really focused on the patient's home to make sure that the patients could be there and seek care where they were closely resided especially during the pandemic.
Sumona Das Gupta (05:21):
CMS had also allow telehealth to be for COVID-19 treatment. But what Department of Health and Human Services did is they expanded out to other treatments outside of COVID-19. We really saw across specialty availability that was available for our practitioners and for our providers. They also change in terms of who was an eligible patient for telehealth. Before it had to be a patient who had been seen in the last three years, but now they expanded it out to new patients as well. We really saw a whole spectrum of patients who could now access this telehealth services.
Sumona Das Gupta (05:55):
And finally, they changed the technology. Before it always has to be HIPAA compliant, but there was limitations in terms of computers, but now they also expanded out to patients' personal phones and tablets. So now we have telehealth services in oncology, in primary care, in specialty pharmacy, in anticoagulation. We've really seen a wide swath of router telehealth services that we're able to provide to our patients.
Miles Goldman (06:21):
Thank you for the overview. Can you tell us a little bit more about the specific benefits patients and providers have been reporting
Sumona Das Gupta (06:29):
In terms of the pandemic, we really wanted to make sure that our healthcare and our workforce was healthy and able to provide care to their patients. We were seeing that we were restricting patients on their visitors and the visitor types. But with telehealth, the patient could now have as many caregivers in the room during that appointment to make sure that the information is digested and that they're able to share the information and have support with their caregiving team.
Sumona Das Gupta (06:52):
And also it provides safety to our practitioners as well and making sure that they feel safe and they can also do it from the comfort of their home and the office and have much more flexibility in providing care to their patients. Also, in many cases, it's very similar to an in-person. And given where we're located and the types of facilities that we have as a level one trauma center and a multidisciplinary and specialty care, especially with tertiary care that we provide to our patients, we see patients from localities that are local, multi-state, and even across the country.
Sumona Das Gupta (07:23):
And now patients are able to access their care in multi-states as well without having the travel or the burden to be able to come into the Northwest to seek their care. We've seen a lot of patient satisfaction of being able to come in as well. I also think for a lot of our patients is they feel like, especially through telehealth video and audio, they still feel connected to the practitioners as they used to both as returned and new patients.
Miles Goldman (07:46):
Let's turn our attention a little bit more to how this all relates to 340B. Prior to the pandemic, what were some of the overall 340B considerations that you were focused on when operating telehealth?
Sumona Das Gupta (07:59):
When we were thinking of telehealth, in many cases, telehealth was a type of encounter or a type of way to see a visit in an actual clinic. You would have the wound care and you'd have in-person visits, phone visits, and telehealth visits. We use it as a separate encounter type, but we wanted to make sure that they show the responsibility of care so much the way a patient would come in person.
Sumona Das Gupta (08:21):
The documentation expectations were reviewed by our auditors to make sure that they show the responsibility of care, that they're billed appropriately, depending on the payer coverages, making sure that the patient and the provider had an existing relationship. We had a little bit more detailed eyes in terms of 340B compliance, also in terms of our contract pharmacy relationships as we were looking at encounter types that were eligible and what to send over to our third-party administrators.
Sumona Das Gupta (08:47):
We had to make sure we had an encounter type that captured telehealth to understand there was an eligible encounter type and show the relation so we could follow it through the logic to make sure we could get those 340B prescriptions captured in our internal pharmacies and our contract pharmacies as well.
Miles Goldman (09:01):
You mentioned earlier that Washington State was one of the first places in the US to see COVID-19 cases. Can you describe your hospital's transitions to a greater reliance on telehealth?
Sumona Das Gupta (09:14):
I think a lot of the times, especially when we saw the legislations pass that provided the flexibilities, we had a ton of interest in a lot of our patients and a lot of our clinics about how do I access care and how do I provide care to our patients. With the joint commission, they said that anybody who was credentialed [inaudible 00:09:31] the hospital could provide telehealth services. We had a number of providers, and we also had a number of pharmacists who are credentialed in privileges through a collaborative drug therapy agreement.
Sumona Das Gupta (09:41):
We really utilized the practitioners across the spectrum and providing care to those patients. Then we needed to train them. We provided a two module training that really provided the whole gamut of services, video etiquette, adverse of that reporting, how to use interpreter services, how to precept individuals on telehealth, how to provide guidance to patients on how to use those services. Then we looked at our technology support. We had to make sure we had technology that was video enabled, microphone enabled to make sure our practitioners have the service.
Sumona Das Gupta (10:12):
We had to make sure the internet bandwidth to make sure that we could support everyone using video conferencing to be able to reach out to their patients, and that we had enough computers and stations and support staff to be able to help. Then we also looked at scheduling. We also wanted to make sure we had longer first visits to anticipate any potential technology issues, whether it's with the patient or the practitioner, and working through to make sure that the patient had a great service line and didn't feel like their care was cut short because of technology issues as well.
Sumona Das Gupta (10:40):
We also created a hotline specifically for patients to make sure that patients had a resource to make sure that they could download the services, understand the HIPAA compliant technology, and make sure they could test anything prior to their appointment or at their appointment to make sure that they had services that were available to them.
Miles Goldman (10:57):
You mentioned about pharmacists having the ability to prescribe through telehealth. Is that unique to Washington State?
Sumona Das Gupta (11:06):
It's not necessarily unique to Washington State, but there are other states that have a collaborative drug therapy agreement. What that allows for is for prescribers to delegate prescription authority to one or multiple pharmacists within a certain specialty. For example, we have collaborative drug therapy agreements that require for anticoagulation. We have it specifically for diabetes management. We have it for primary care. And within that, the pharmacists have independent prescription authority.
Sumona Das Gupta (11:34):
They're able to look at whether it's drug therapies, lab values, adjustment in therapies, new therapy indications, and are able to prescribe that to the patients. What we've seen really valuable in telemedicine is that pharmacists are really able to see the patients in their home. They're able to pull up the medication sheet. They're able to reference it to make sure that the patients understand. They're able to see the patient in their home preparing their injections. I'm able to provide direct feedback.
Sumona Das Gupta (12:04):
And also with a visual connection, they have a connection to the patient. They're able to recognize is the patient understanding, which is much more valuable than some of our phone visits where you don't have those visual cues to understand if there's communication as well. Also, we have interpreter services that are able to join into the conversation to help the patient make sure that they're understanding that therapies and making sure that they have answered any questions that they may have.
Sumona Das Gupta (12:27):
Especially with patients, it's really the community that could help support them in their care. It's great to be able to see parents, children, other loved ones who can be part of those appointments and provide a supportive environment as well. We've seen this quite utilized with a lot of our pharmacists. Even as we've seen throughout the pandemic and even as we're heading into the fourth wave, we're seeing patients continuing to want to seek out telemedicine services with our pharmacy team.
Miles Goldman (12:53):
What were some of the challenges that the hospitals experienced with the increased in telehealth and how were those challenges addressed?
Sumona Das Gupta (13:01):
I think one of them is making sure that we have integration in our technology systems. As we have a lot of telemedicine videos and recording, it does take a lot of technology capabilities to make sure that those recording, adequate documentation, making sure it comes in through our EMR systems. It does take up a lot of bandwidth and IT capabilities to have so many individuals on video. Now it's much more familiar to talk about Zoom and HIPAA compliant, but back then, Zoom was brand new for a lot of our patients.
Sumona Das Gupta (13:30):
So making sure that they download a HIPAA compliance Zoom, making sure that they're able to have the access to the technologies, and the steady internet stream is really important to those areas as well. I think we're also seeing sometimes, especially in appointments, it may drop and you're halfway through the visit. And then all of a sudden, you can't reach the patient and you're trying to get reconnected, which is different than when you have an in-person visit as well.
Sumona Das Gupta (13:51):
In some cases, when we have drop patients of getting them rescheduled and balancing that out can cause scheduling difficulties. But with refinement over time, we found our processes to be able to support that. We also have a lot of our clinical staff who's helped. We have medical assistants who make sure that patients are in the waiting room on time, that they have any questions answered before. We have a consent process. We have an identification process.
Sumona Das Gupta (14:15):
For example, we make sure that the patient is the individual, any date parameters, date of birth, to make sure that we are the individuals that we're talking with. Different patients have different technology capabilities. There's background noise and et cetera that can sometimes cause difficulties in hearing, but it's all part of our new normal and we're making it work.
Miles Goldman (14:32):
Were there any 340B specific challenges?
Sumona Das Gupta (14:35):
Yeah, I think especially at the beginning, we were looking at telemedicine as a type of visit, but now we have actual clinics that we consider virtual clinics. Rather than scheduling as an encounter type, we have actual clinics that just provide virtual telemedicine services. We needed to make sure for some of those areas to make sure that they qualified as 340B eligible. We worked with [inaudible 00:14:59] to be able to make sure that we can make these virtual clinics that were tied to our in-person clinics 340B eligible clinics.
Sumona Das Gupta (15:06):
We also worked with our EMR systems to make sure we had separate encounter types for phone visits and telemedicine visits to make sure... Even though the documentation standards were the same, we wanted to make sure that they were considered to be different visit types, that we understand the documentations and the types of encounters that we were seeing. We also worked with our IT systems to make sure that we had the correct data in any of our files that we sent to our contract pharmacy administrators.
Sumona Das Gupta (15:28):
And then we also had our contract pharmacy administrators make sure they could receive the additional data and have additional capture. The other thing that we were seeing, especially early on in the pandemic, is that we saw many patients start to delay their care. We were seeing patients who were asking for refills on their prescriptions without being able to come in for a visit or requesting it via phone.
Sumona Das Gupta (15:46):
We expanded our documentations to really look at 18 months from the order date to look at eligible encounter types and visits and relationships with those providers, understanding that the normal of how patients interact with a healthcare system was changing minute by minute for the patient's safety and the provider's safety. We updated our policies and procedures to be able to document that during the public health emergency of some of these exceptions and changes in processes that we made.
Miles Goldman (16:10):
I'm glad you mentioned updating your 340B policies and procedures during the public health emergency. Can you tell us a little bit more about that process?
Sumona Das Gupta (16:20):
We updated our policies and procedures. Some of them were in terms of some of these changes [inaudible 00:16:25] One, regarding the GPO prohibition, especially with supply chain issues where you could acquire the drug at GPO and potentially not at the other classes of trade and the documentation portion to make sure that we have a documentation trail for those purchases. We also provided an exception for abbreviate in medical records.
Sumona Das Gupta (16:43):
We were seeing that sometimes our providers were going into communities during emergencies, especially during COVID protocols, and changes and regimens and therapies. They had sometimes abbreviated records that they would additionally put in additional documentation at a later date. We did have policies for abbreviated records or paper records that were put in, especially in some of these remote clinics where the patients weren't directly interacting with our healthcare system. But it was our healthcare providers that were going out into the community.
Sumona Das Gupta (17:10):
We also look at our encounter types. Even though telemedicine is a different modality, the type of care is very similar, if not exactly the same as in-person care. We really saw the documentation mirror in many cases of what an in-person visit was.
Miles Goldman (17:25):
And are you hoping these flexibilities continue when the pandemic ends?
Sumona Das Gupta (17:29):
Absolutely, because I think telehealth is really here to stay. I think we're going to see a subset of our patients who are going to continue using telehealth as a modality to be able to seek their care, not only from physicians, but from other non-physician practitioners, including pharmacists, who are able to prescribe.
Sumona Das Gupta (17:44):
We're hoping as we kind of continue on whether it's lending phones or technology to patients who may not have access to it so they can use telemedicine is been one area that we've been taking a look at or providing communities in shelters or areas where patients can use that across the board as a communal source. I think there'll be some long-term strategies that will work with our community partners to develop to make sure that we can make sure for those who want to access telehealth have the resources in order to do so.
Sumona Das Gupta (18:09):
But one change we're seeing, especially recently, is that especially for out-of-state, we had a lot of emergency waivers that allowed telemedicine to be able to be used for out-of-state patients. But we're seeing those start to construct where those are not being renewed or those are no longer in place. The way our telemedicine is really now focused on Washington State patients and providing limits to our out-of-state patients.
Sumona Das Gupta (18:33):
I'm hoping that as we continue to look at telemedicine as a long-term strategy we can see how we can use telemedicine to be able to better serve our out-of-state patients and these types of waivers for practitioners in those communities as well.
Miles Goldman (18:46):
Have you heard any specific feedback from patients about just their overall satisfaction levels they've experienced from going through telehealth?
Sumona Das Gupta (18:54):
I think what we're seeing a lot is about 85 to 90% of patients who are offered telehealth accept telehealth, which I think is a real clear indication for those individuals who want telehealth as a modality of services are using that methodology and finding it to be an effective tool. I think especially what we're seeing is for some of those patients who have to travel a long ways, they're coming into the labs, they're getting their values, getting check-ins on a much more scheduled and much more regulatory basis.
Sumona Das Gupta (19:19):
But one of the metrics that we're taking a look at is whether telehealth is corresponding and relating to increased medication adherence. It'll be interesting to see some of those studies in terms of the long-term to see some of those patient outcomes that we can see as part of telehealth.
Miles Goldman (19:33):
Definitely looking forward to hearing more about those study results when they come. What role do you see for 340B in terms of helping telehealth continue post-pandemic?
Sumona Das Gupta (19:45):
I think some of those areas where I highlighted are looking at some of those underserved areas is really where our 340B Health dollars are going into a benefit. Being able to provide technology resources for those who are underserved. I think now we're able to see a wide spread of interpret services that we're able to provide because we're looking at an online modality. We're seeing individuals who can be across the country who can be able to provide services for some of those languages that we may not be able to provide on a day in and day out basis.
Miles Goldman (20:12):
Sumona, I've enjoyed hearing from you talk about your hospital's telehealth experiences and how it's relating to 340B. Thank you for taking time out of your schedule to speak with us today.
Sumona Das Gupta (20:24):
Absolutely. I encourage anyone who's looking at telehealth, whether it's in the short-term and the long-term, please reach out. We're happy to share some of our learned experiences and help any of our community hospitals and partners accelerate their telehealth program to be able to provide those services to our community. It's a great way to see our 340B dollars at work. I think the more that we provide care and access to our patients, the better we can all be.
David Glendinning (20:45):
Thanks, again to Sumona Das Gupta for discussing the expanded role that telehealth is playing during the pandemic, as well as the 340B challenges and flexibilities that have come with it. As health providers throughout the nation are grappling with another surge of COVID-19 patients, we are heartened to hear how they are maximizing their use of technology to continue reaching all patients in need.
David Glendinning (21:09):
If you have any questions about 340B and telehealth or any other issue we cover on this show, please email us at podcast@340bhealth.org. We will be back in a few weeks. As always, thanks for listening and be well.
Announcer (21:30):
Thanks for listening to 340B Insight. Subscribe and rate us on Apple Podcasts, Google Play, Spotify, or wherever you listen to podcasts. For more information, visit our website at 340bpodcast.org. You can also follow us on Twitter at @340bhealth and submit a question or idea to the show by emailing us at podcast@340bhealth.org.