By David Pittman, eHealth reporter, POLITICO Pro
dpittman@politico.com, @david_Pittman
Telemedicine is the use of telecommunications for clinical care. The American Telemedicine Association defines it as two-way video, email, smartphones, wireless tools and other forms of telecommunications that provide primary care, specialty care, remote monitoring, consumer and medical information and medical education.
In writing and reporting on telemedicine, exact definitions matter because patients, organizations and policymakers see it differently. It can be very broad and open-ended or very precise. The explanation of exact uses can be finagled to manipulate payment and legality.
RESOURCES:
The American Telemedicine Association’s state gaps analysis: http://bit.ly/25LUUt0
The Center for Connected Health Policy: http://cchpca.org/
Health Affair’s Feb. 2014 issue devoted to telehealth: http://content.healthaffairs.org/content/33/2.toc
WHAT IS DRIVING THE GROWTH?
· Advances in technology—almost everyone today owns a smartphone
· Move to value-based care and the drive to find savings in health care
· Consumer demand for convenience
· Employer demand to lower premiums
· A shortage or maldistribution of doctors
HOW IS IT BEING REGULATED?
State licensing boards regulate the health care providers (doctors, nurses, psychologists, therapists, etc.) who treat patients in that particular state. They set the standards that doctors and nurses must follow. Many state’s regulations don’t recognize telemedicine, but they have taken action to define proper care via telemedicine. This year alone, it includes West Virginia, D.C., Louisiana, Illinois, Arkansas, Wisconsin and others.
Telemedicine is problematic because some regulators are uneasy about doctors treating patients they’ve never laid hands on and can’t easily follow-up. The Texas Medical Board, most notably, has fought for several years to prevent Teladoc from seeing patients in its state. (See some Dallas Morning News coverage of it.) A lawsuit is currently pending before the Fifth Circuit.
The Federal Trade Commission has said, and the U.S. Supreme Court agrees, that the work of licensing boards must have some sort of “active supervision” by an outside body like the state legislature or governor’s office or else it runs the risk of being anticompetitive. Telemedicine advocates say some states restrict commerce by placing a higher standard of care on them than in-person providers. The advocates say doctors in those states are protecting their financial interests by limiting outside doctors rather than protecting patients. Opponents say they are trying to ensure patient safety.
WHO IS PAYING FOR THIS?
· Medicare pays almost nothing for telemedicine — $17.6 million last year — because of limitations on what’s an eligible visit. Efforts are underway in Congress to expand what Medicare reimburses.
· Private health plans’ payment varies wildly from state to state and plan to plan. See a recent Health Care Cost Institute report.
· Medicaid coverage also varies from state to state.
WHAT PATIENT SAFETY ISSUES ARISE?
Questions to ask: How is follow-up care delivered? Are records shared with patients’ regular doctors? How is it possible to treat a patient you’ve can’t lay hands on? How is it possible to diagnose an ear infection over a webcam? How is the quality of camera mitigated? How role does user error play?
Recent research: Variation in Quality of Urgent Health Care Provided During Commercial Virtual Visits (Schoenfeld et al, JAMA Internal Medicine, April 4, 2016) http://bit.ly/1qk5Yxq
Prescribing rates of antibiotics: Telemed docs more likely to prescribe broad-spectrum antibiotics (Bowman, Fierce Health IT)
Researchers: Telehealth companies could benefit from attention to detail on antibiotics use, other services (Johnson, Modern Healthcare)
WHERE’S THE PROOF TELEMEDICINE DOES WHAT IT SAYS IT’LL DO?
The evidence around telemedicine isn’t well researched. Individual studies vary and on the aggregate show mixed results. (See a 2015 Altarum Institute report http://bit.ly/1XfZAS5 and a December draft report from the Agency for Healthcare Research and Quality http://1.usa.gov/1J06h2Q). The Congressional Budget Office has long said paying for more telemedicine within a fee-for-service system will increase Medicare spending. http://1.usa.gov/20FlSgH
Questions to ask: Is this saving money? Is it making people healthier? How is it changing the way people interact with the health system?
Relevant study: Analysis Of Teladoc Use Seems to Indicate Expanded Access to Care for Patients without Prior Connection to a Provider (Uscher-Pines and Mehrotra, Health Affairs)
ANOTHER ISSUE TO LOOK AT: LOBBYING
With state medical boards slow to act or unfriendly to their cause, telemedicine advocates (vendors, hospitals, insurers) are turning to state legislatures to pass laws that allow them to treat first-time patients via telemedicine. The issue blew up in Mississippi over a Teladoc-backed bill that would have allowed the practice there. The state’s doctors fought the bill, which died in committee in early April. http://bit.ly/1YefFb9
SOME NOTABLE RECENT STORIES:
Telemedicine fans point to CBO’s history of cost overestimates (Pittman, POLITICO)
Virtual reality: More insurers are embracing telehealth (Herman, Modern Healthcare)
Big business backs virtual doctor visits as Texas loses fight for limits (O’Donnell, USA TODAY)
The FDA Just Opened Up Abortion Pill Access. Next Up: Webcam Prescriptions (Zhang, Weird)
