November 4, 2014
As I sit in my home office with the security icon blinking on the screen of my company-issued laptop, it dawns on me how much nearly every profession relies on remote communication.
From banking, to education, and even to matchmaking, people use technology to communicate with others near and far, often making life changing decisions at a distance. The benefits of remote communication include overall efficiency, time savings, money savings, and widespread information accessibility, all of which are desirable factors in the provision of healthcare services. In fact, such benefits are magnified in the context of healthcare, where patients are often unable to travel due to a fragile physical state, and are greatly concerned about costs with what seems to be a flood of medical bills.
So, at a time when remote communication has become an indispensable part of the way our society operates, why is the healthcare industry so slow to adopt telemedicine?
Part of the reason for slow adoption may be that patients are reluctant to make critical health decisions without having an in-person examination by a professional. However, I think the true reason for slow adoption is all about: “Regulation, Regulation, Regulation.” I make the triple incantation in the same way my realtor does when she says “Location! Location! Location!” to emphasize the importance of regulation in the adoption of telemedicine. The three major barriers to adoption at this time are: (1) physician licensure (2) the definition of telemedicine (3) Reimbursement for telemedicine services.
Let’s tackle them one at a time.
To begin, it’s important to understand that the regulation of telemedicine services depends on the state where the patient is physically located, not where the healthcare provider is originally licensed. For example, if the world’s leading kidney transplant surgeon is licensed to practice medicine in Utah, and wants to perform a video consultation for a patient who lives in California, the surgeon would be unable to do so without first obtaining a California medical license. Although telemedicine regulations are created to protect patients, they often have the opposite effect by creating barriers to the delivery of high-quality care.
Here’s a look at a few state variances in licensure requirements:
- California and Florida—require a physician to hold a full-unrestricted license to provide telemedicine services to patients within their state
- Minnesota, Texas, and Alabama—created unique, shorter, and less expensive telemedicine licensing processes
In an effort to promote communication and unity among states, the Federation of State Medical Boards (FSMB), who I like to refer to as my “Superheroes,” (for their tremendous contributions in the telemedicine world) published their Interstate Medical Licensure Compact on May 5, 2014.i The proposal envisions an interstate compact for telemedicine, which would establish an abbreviated licensing process for physicians in participating states who have held a full-unrestricted license for at least five years, without any disciplinary or legal action on their record. Such a compact would be immensely helpful in removing the hurdles that providers face in delivering their services outside of their home state.
Developing a clear definition of telemedicine is critical for identifying the types of services and reimbursements that are available to patients. Yet telemedicine definitions vary substantially from state to state, making it difficult for providers to track state variances. But worry not my mHealth minions, the Superheroes have come up with a plan to address this aspect of telemedicine too.
On April 26, 2014, the FSMB published their Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine. The Model Policy is a guiding document for states in the creation of their own telemedicine laws. According to the Model Policy:
“…telemedicine is not an audio-only telephone conversation, e-mail/instant messaging conversation, or fax. It typically involves the application of secure videoconferencing or store and forward technology to provide or support healthcare delivery by replicating the interaction of a traditional, encounter in person between a provider and a patient.” ii
Limited to specific technology—The definition excludes audio-only, phone, and e-mail consultations, which doesn’t account for people who don’t own computers, or who own computers without video capabilities. It also doesn’t definitively take into account technology such as e-prescribing and secure messaging.
Ambiguous in its discussion of care delivery methods—The definition accepts both real time and store and forward technology for care delivery, but doesn’t emphasize the importance of making both options available to patients and healthcare providers.
As to the second point, there are still certain regulatory bodies that limit the definition of telemedicine to real time-only communications. Even the Medicaid.gov website states that telemedicine is the “two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site.”
So what exactly is store and forward technology, and why should states require its acceptance?
Store and forward technology temporarily stores data in an intermediary location until the receiving party is ready to view the stored message, at which time the transmission is retrieved and the data (audio, photo or video) is displayed.
As telemedicine becomes more widespread, secure messaging will play a role in connecting primary care physicians, specialists, and patients. Imagine developing an embarrassing rash on your face in your 9 a.m. meeting in Maryland, taking a photo with your phone, sending the photo to your dermatologist in Virginia through a secure messaging application such as Backline®, the doctor viewing the photograph through the application, and the doctor quickly issuing and sending an electronic prescription for a topical cream to your local pharmacy—just in time for your lunch break! Phew!
In this scenario, and countless others, store and forward technology is much more convenient than having to schedule a real time consultation. Of course, doctors are still responsible for gathering all of the necessary information to treat the patient to the best of their ability. If a photograph or video is unclear, the doctor can still ask for a real time video consultation, or even ask to have the patient come to their office in person. Telemedicine should be defined clearly, and cover all existing and potential future technologies that could benefit patients, and doctors.
Reimbursement for Telemedicine Services
The process of defining telemedicine is closely linked to another sticky subject…money. In the words of the legendary Pink Floyd, “money, so they say, is the root of all evil today.” In this case, I wouldn’t say that it is the root of “all evil” per se, but reimbursement regulations do create challenges for patients and doctors.
There are states that prohibit federal reimbursement of services administered through telemedicine, other states that allow for limited reimbursement, and a handful of states that require telemedicine services to be reimbursed in the same manner as services provided in person. The following examples demonstrate the differences between neighboring state reimbursement laws:
- Idaho—Reimbursement is available only for mental health and developmental disabilities services. A state like Idaho, which is not populated with much other than potatoes, needs to expand its very limited scope for reimbursement of telemedicine services to provide care to people in rural areas
- Washington—The law in Washington does not require private insurers to cover telemedicine services at this time
- Montana—Telemedicine services are treated like all other services for purposes of reimbursement since January 1, 2014iii
- Oregon—Private insurers must pay for services delivered telemedically the same way they would if the service was delivered in personiv
Preferably all states would follow Montana and Oregon’s examples, but some are not ready to fully commit. One such state is Arizona which has taken a step in the right direction but has not fully committed to the idea of telemedicine.
- In 2013 Arizona passed a law that requires private health insurers to cover health care services provided through telemedicine, but only in rural areas, and for a small scope of issues, including trauma, burns, cardiology, infectious diseases, mental health disorders, neurological diseases including strokes, and dermatologyv
The barriers that I’ve examined in this post can be remedied through state cooperation and acceptance of real world patient care needs. The antiquated idea that telemedicine is merely a way to bring medical services to rural communities should be discarded. Telemedicine along with the various technologies that have been developed to deploy it, are powerful tools that should be used to benefit patients and doctors.
More importantly, state regulatory bodies must realize that any protections their laws afford by forbidding or limiting telemedicine services, are outweighed by the expertise and level of care patients can access when their potential pool of healthcare providers is exponentially expanded through telemedicine. As with any service, when the consumer has easy access to different sources of information, and more options to choose from, the competitive environment between service providers facilitates a higher overall level of the provision of that service. In the healthcare world this translates to better patient outcomes through the more efficient information exchange between patients and providers, as well as between providers and their colleagues.
So, next time telemedicine calls to say hello, accept the call and embrace the possibilities!