Telemedicine's next big leap

This information is part of a Medical Economics exclusive ranking of the top 100 EHR companies. (medicaleconomics.com/top-100-EHRs)

Seth Eaton, MD, recently conducted an annual appointment with a long-time patient. They went over lab results and Eaton answered the patient’s questions.

Sounds routine, like the kind of appointment a physician conducts multiple times per day. The difference is that the physician was in Maryland and the patient was in Arizona. The two connected using the power of telemedicine, bridging the 2,000-mile distance with streaming video and high-speed Internet.

Eaton, a self-described “early adopter,” earlier this year began integrating telemedicine appointments at his family medicine and pediatrics practice, MedPeds in Laurel, Maryland. Since March, Eaton has conducted 15 virtual appointments. He plans to unveil a faster, more “patient-friendly” telemedicine service later this month, and expects that the service will take off.

With sweeping policy changes, declining reimbursements, and new care models that favor quality over quantity, physicians like Eaton are looking for ways to find new revenue streams and move from reactive care to proactive management of their patients.

Advocates say telemedicine can play a big role in the care models of the future. But there are still hurdles when it comes to reimbursement, policy, and legal grey areas, not to mention physician and patient buy-in.

“There is a cultural expectation when I go to see my doctor,” Eaton says. “He looks me in the eye, puts the stethoscope on my skin. It’s a real touchy-feely experience. That’s something I believe will change slowly as telemedicine becomes more technically feasible and easy to implement.”

Old concept, new promise

Telemedicine, also known as telehealth, has been around for decades. The concept started as a way to connect rural primary care physicians (PCPs) with specialists. But telemedicine has morphed into a broader term and is now also used to describe live video appointments, real-time remote patient monitoring, storing and forwarding of diagnostic images, and mobile applications.

“Telehealth is not a distinct service, but is an enhancer and a tool for physicians,” says Mario Gutierrez, executive director of the Center For Connected Health Policy. “You are getting a triple benefit of using technology to provide better healthcare and more reach.”

Eaton thinks telemedicine will ultimately be successful at his practice because it will meet his patients where they want to be met. Many of Eaton’s patients are working families with kids. They are busy, and stressed out, and often can’t miss work to make a doctor’s appointment.

“People have lives. Let’s face it: physicians practices don’t really accommodate the two-workers family situation,” Eaton says. “We are looking at using telemedicine to reach a number of our patients that have an unrecognized need.”

Eaton uses telemedicine for follow-up appointments for diabetes and hypertension, for well-child exams and sometimes even urgent care so long as the on-call physician approves it. Other ways he wants to use it include mental health visits required for prescription refills, lactation consultations for new mothers, and virtual group visits where patients can share success stories in managing diabetes or weight issues, right from their own homes.

Once the service becomes more established, Eaton says he plans to use telemedicine for more pro-active population management. For example, he can identify all of his patients with hypertension and find those who are not controlling their blood pressure. Then he can have his staff engage with those patients using telemedicine to help get them on track.

Another way telemedicine can help is with transfer of care. Eaton plans to use virtual appointments to connect with patients who are leaving the hospital, and ensure a seamless transition of care.

Eaton sees population management and better transfer of care as key pieces to helping keep healthcare costs down while improving patient outcomes, and telemedicine can play a big role in both.

But do patients want telemedicine? Telemedicine advocacy groups, including the American Telemedicine Association (ATA), say that as the public become more dependent on using the Internet and mobile technologies in their daily lives, they will expect telemedicine services from their physicians the way they expect patient portals with online scheduling and lab results.

Reimbursement varies by state

States will have to get on the same page when it comes to reimbursement before the benefits of telehealth can truly be realized, Neuberger said. 

“The number one, two, three issues continue to be reimbursement, reimbursement, reimbursement,” says Neal Neuberger, CISSP, executive director of the Institute for e-Health Policy.

21 states have parity laws that require private insurers to reimburse for telemedicine visits, and 44 state Medicaid programs reimburse in some form for telemedicine, though no two state laws are alike and reimbursement policies vary wildly. Medicare reimburses for telemedicine but only for patients who live in a designated rural Health Professional Shortage Area or in a county outside of a Metropolitan Statistical Area.

Eaton says he has never had a reimbursement issue with a payer. Maryland is one of the states that have laws requiring payers to cover telemedicine.

Neuberger says he has been involved with telemedicine for 20 years and that the reimbursement issue remains unresolved. But that may be changing as new care models emerge.

“Fast forward 20 years and we are still arguing about that, but now the policy environment has changed,” Neuberger says. “Now it has less to do with fee-for-service. With the movement toward accountable care and shared services, it may be changes in health policy that drive adoption quicker.”

Barriers remain

Despite the technological possibilities, barriers still remain to more widespread telemedicine use. The number of physicians who use telemedicine in their practice remains low. The Deloitte Center for Health Solutions conducted a survey of U.S. physicians last year and found that 18% of PCPs surveyed use telemedicine for follow-up or diagnostic visits. 

Eaton says there are eight providers at his practice, including himself, and that he is the only one using telemedicine so far. The others, he says, have concerns, ranging from effectiveness to malpractice issues. “There is a wariness on the part of clinicians to embrace this,” Eaton says.

There are legislative and licensing issues that must be resolved before telemedicine can become a major cog in the healthcare system, Gutierrez says. In July 2013, the Center for Connected Health Policy published a report that details where telehealth laws and reimbursement policies stand in all 50 states.

The problem is that no two states are alike in their laws, Gutierrez says. Some have very progressive policies that require private insurers and Medicaid to reimburse for telemedicine, while others do not.

Another major hurdle is state medical board licensing, Gutierrez says. Physicians need to be licensed in the states where they practice, and each state has different rules and regulations. This becomes a problem since state borders become irrelevant in some ways when doctors can visit with a patient across cyberspace.

“I think about telehealth in the concept of social equity,” Gutierrez says. “It allows any family and individual to have equal access to care no matter where they are in the country. But we have this thing called state licensing, which does limit the practice to what those medical boards in each state allow.”

Is telemedicine right for your practice?

Physicians thinking about using telemedicine in their practice need to realize that it is a large undertaking that means re-thinking how they operate, Gutierrez says. “A physician or provider has to be willing and committed to really thinking about how health care is delivered and managed, and how data is managed,” he says. “It’s not something you can overlay on an existing practice. You have to re-think everything.”

Neuberger says that every state has physicians who are ahead of the curve when it comes to telemedicine. Physicians should seek out their advice and expertise first. 

“Start to learn about best practices, and cobble together your own programs based on your own needs, but using proven technologies and proven settings,” he says. “It’s getting easier and easier to pick and choose what’s best for your practice. There are models out there.”

From a practical standpoint, Eaton says physicians should answer a few questions first before they do anything else:

• Do you have unscheduled time? Physicians with already full schedules may not see the income benefits of telemedicine. Eaton says he uses it to fill in unscheduled time between and after his face-to-face appointments. “If you’re fully scheduled, you won’t gain income,” he says.

• Do you have patients who embrace, or can embrace, technology? Eaton says that patients have to be willing and able to take the technology leap with their physician. If most of your patients are Medicare beneficiaries, you might have a tougher time getting patient buy-in than if your patients are younger mothers and fathers. Just as important is whether your geographic area supports high-speed Internet.

• Are you willing to try and fail? “Not every situation is going to work, and you have to be willing to say that’s not going to fly and try something else,” Eaton says.

Eaton is confident telemedicine will have a role in the emerging healthcare system. It’s another step toward patient-centered care.

“Population management is about meeting patients where they are,” Eaton says. “That’s the game changer that telemedicine provides.”  

TELEMEDICINE LEGAL ISSUES

Telemedicine technologies can eliminate healthcare barriers, but
new technologies have uncovered many legal and ethical issues that must first be addressed. The following issues were identified by the National Telehealth Policy Resource Center (NTPRC):

1. Physician Licensing:
When you can meet with a patient in cyberspace, state borders become irrelevant. Except that providers are, in most cases, limited to practicing in states where they are licensed. Each state has different licensure policies, and while some states allow interstate delivery of healthcare, others do not.

2. Malpractice Liability:
There is little precedent on what telemedicine means for malpractice liability.
As telemedicine becomes more widespread, liability issues are expected to increase, according to the NTPRC.

3. Online Prescribing:
Online prescribing policies vary by state. Furthermore, “concerns are emerging over quality and practices of for-profit provider entities entering the marketplace who many be treating patients and prescribing inappropriately,” the NTPRC writes.

4. Informed Consent:
Several states require informed consent for telemedicine services for their Medicaid services. NTPRC writes: “Requiring a prior written or verbal informed consent for any telehealth consultation and treatment misrepresents telehealth as a different form of service, rather than as a useful tool ...”

5. Credentialing and Privileging:
The Centers for Medicare and Medicaid Services has issued a rule on credentialing and privileging for telehealth providers but it conflicts with some state policies.

Source: National Telehealth Policy Resource Center

DOES YOUR STATE REIMBURSE FOR TELEMEDICINE?

20 states plus the District of Columbia mandate some private insurance coverage of telemedicine
(as of September 16, 2013): 

• Arizona (partial)

• California

• Colorado (partial)

• D.C.

• Georgia

• Hawaii

• Kentucky

• Louisiana

• Maine

• Maryland

• Michigan

• Mississippi

• Missouri

• Montana

• New Hampshire

• New Mexico

• Oklahoma

• Oregon

• Texas

• Vermont

• Virginia

44 states have some form of reimbursement for telemedicine live video in their Medicaid program,

but each state’s policies vary. The six states that DO NOT are: 

• Connecticut 

• Iowa 

• Massachusetts 

• New Hampshire 

• New Jersey 

• Rhode Island

• D.C.

Sources: American Telemedicine Association and Center for Connected Health Policy