Private health insurance companies are increasingly paying for telemedicine services, but public payers like Medicaid and Medicare continue to include restrictions, while other opportunities remain to improve the telemedicine ecosystem through more streamlined regulation and provider education.
I recently had the opportunity to moderate a panel on telemedicine at a conference focused on health care and technology. The timing was good since I had also recently begun a small, unrelated telemedicine engagement. Although I had helped develop an early round of telemedicine policy for the Texas Medicaid program, had worked on state telemedicine legislation after that as an advisor to Texas Governor Rick Perry, and had been keeping tabs on the telemedicine landscape since then, it had been a while since I had really gotten my hands dirty in the details of state and federal telemedicine regulations and reimbursement policy. The conversation among the panelists included examples involving primary care, specialty care, international telemedicine, regulatory issues, ongoing telemedicine litigation, and much more.
While the panelists identified new opportunities for telemedicine, they also identified ongoing obstacles. One of the better and most succinct summaries of the barriers to the more widespread use of telemedicine that I’ve heard was provided in a different context by Nora Belcher, the Executive Director of the Texas e-Health Alliance – reimbursement, regulations, and rhetoric. As became clear through the panel discussion, while progress seems to be occurring on the reimbursement and regulation of telemedicine, rhetoric (read: people’s opinions, tribal knowledge, and public controversies) remains a challenge. Although in many cases challenges to the greater use of telemedicine blur across these categories, they remain a useful way to talk about many of the more salient issues regarding telemedicine.
While specific legal definitions vary, telemedicine is generally recognized as the delivery of medical services via telecommunications technologies. An example of telemedicine might be connecting to your primary care physician via an audio-video communications application on your computer, to discuss the results of the lab tests that the physician ordered at your recent in-office visit. Another example might be contacting a physician via a mobile app on your phone that enables audio and video communication in order to receive consultation regarding a medical issue.
Although not integral to this discussion, it is important to note some of the other terms used in this context, particularly ‘telehealth’ and ‘remote monitoring’. Specific usages vary, but one approach is to define telemedicine as the practice of medicine via telecommunications technology. This specifically ties the service that might be provided to the practice medicine, and thus constrains the pool of eligible health care providers to physicians or physician extenders. Within that framework, telehealth is then the delivery of other clinical services through the telecommunications medium via non-physicians (e.g., psychologists, dieticians, speech therapists, etc) and remote monitoring is the sending of patient data (e.g., weight, blood pressure, etc) from the patient site (generally the home) to clinicians for monitoring of health indicators.
One of my main take-aways from the panel was the agreement among the panelists that private-sector payment for telemedicine has really become mainstream in the last 12-18 months. While this observation was made regarding private health insurance companies, also described was the direct sale of telemedicine services to large self-insured employers and even smaller employers offering health benefits featuring high-deductible health plans or other novel health benefit structures. Panelists noted that, while payment for telemedicine services may finally be maturing, the broader patient engagement ecosystem to support it still has room to grow, with opportunities for identifying gaps in care, reaching out to patients, and patient self-scheduling.
One of the lingering issues noted with respect to public payers, and in some cases, the regulatory framework itself, is their requirement that the patient, in some situations, must be in a health care facility or the office of a health care provider to receive services from a remote physician. A typical example of such a situation might be a patient being in the office of their primary care doctor in a small town and connecting to a specialist at an academic medical center in a nearby city. On the other hand, technologists tend to favor a broadly permissive regulatory framework that would permit telemedicine to connect any physician to any patient, regardless of location, but there tend to be regulatory impediments to such an open approach.
One of the panelists, a practicing psychiatrist, offered a contrary opinion, noting that in situations where a psychiatric patient might be suicidal, unless the patient is in a facility with other health care professionals who can intervene, there might not be any way for a remote psychiatrist to ensure the patient’s safety. While this situation may be amenable to technological solutions (e.g., requiring the telemedicine consultation to be done through a smart phone with its GPS turned on and a feature to alert first responders at the direction of the physician), there may also be clinical opportunities to screen mental health patients for suicidal thoughts prior to the telemedicine encounter. In fact, a recent experiment performed by the Veteran’s Administration did just that and found no difference in outcomes between individuals receiving counseling services via telemedicine in their homes and those receiving in-person counseling.
The regulation of telemedicine currently follows the regulation of the practice of medicine itself, defined through each state’s statutes, and enforced by a state medical board. The Center for Connected Health Policy at the National Telehealth Policy Resource Center recently issued an environmental scan of all 50 states’ laws on telehealth. One of the key issues in the regulation of the practice of medicine, which translates awkwardly into the practice of telemedicine, is the question of what it takes to establish a patient-physician relationship. In the normal practice of medicine, to establish a patient-physician relationship generally requires an office visit that includes a physical exam. One of the key questions in the regulation of telemedicine is whether a patient-physician relationship can be established via only a remote telemedicine encounter, and then what kinds of technology (i.e., audio only, or audio and video). States seem to be moving in the direction of permitting the patient-physician relationship to be established via telemedicine that includes audio and video, but there remains some variation in technology requirements and general permissibility.
Here in my home state of Texas, there has been some regulatory drama over the last year with telemedicine vendor Teladoc suing the Texas Medical Board (TMB) to prevent enforcement of TMB’s regulations regarding telemedicine. The key issue in that case has been whether a patient-physician relationship can be established through a phone call alone. The TMB has said no, Teladoc successfully sued for an injunction, and both sides have now sought a stay in the case, which is being viewed as a sign of a possible settlement. In addition, several key stakeholder groups here in Texas have been meeting to negotiate a revised telemedicine statute for joint submission to the legislature for consideration. At the same time, the largest state-level business organization in the state, the Texas Association of Business (TAB) has issued a report calling on the legislature and TMB to deregulate telemedicine.
All of this state-level jockeying may become less significant depending on how certain national efforts evolve. In particular, multiple states have endorsed the Interstate Medical Licensure Compact (IMLC), which would facilitate easier interstate recognition of physician licensure, the development of which has been facilitated by the Federation of State Medical Boards (FSMB). This is particularly important for telemedicine because, under current regulatory interpretation, a physician must be licensed in the state in which the patient resides. The problematic implication of this sort of regulatory regime is that it would require a physician to be licensed in every state in the country to provide telemedicine services nation-wide, which is clearly an untenable situation. The IMLC will make it easier for a physician licensed in one state to provide services to patients in other states without having to go through full licensure in each other state.
In addition, the U.S. Senate just passed the Expanding Capacity for Health Outcomes (ECHO) Act, which directs the U.S. Department of Health and Human Services to develop a report on the applications of Project ECHO, a New Mexico based telemedicine program, across the country. Although the bill has yet to pass the House, and would not create any new telemedicine programs or activity directly, it may create some momentum toward greater emphasis on telemedicine from the federal level.
One of the challenges identified by the panel was the relative lack of knowledge among clinicians about telemedicine – about what is permissible, about how they might participate, about how they can get paid for telemedicine, etc. Some telemedicine vendors seem to have found a particular niche addressing this lack of knowledge by including legal and educational components of their service offerings focused on regulatory compliance and reimbursement assurance. On the patient side, patients report finding remote connectivity with physicians positive and convenient. In addition to the benefit to patients in terms of convenience, telemedicine has the potential to increase access by establishing geographic liquidity in some specialty physician services.
Although issues involving regulations, reimbursement, and rhetoric have created barriers to the greater use of telemedicine in the past, the clinical outcomes demonstrated by actual telemedicine experience to date have been good, providers have been slowly getting on board with the concept, stakeholders are working together to improve the telemedicine policy framework, and patients enjoy the convenience and cost of telemedicine services. In short, telemedicine is a growing part of the U.S. health care ecosystem and is likely to have a very significant presence in the future.