Telemedicine - Convenience Versus Caution
Telemedicine is not a new concept. Its proponents say it will reduce costs and improve access to medical care. In other words, it’s intended to be inexpensive and convenient. Unfortunately, that promise has only been partially realized.
Let’s review the literature over the past decade and determine where telemedicine has helped and where improvements are still needed. Douglas, et al., reported that Medicaid patients very rarely utilized telemedicine. When it was used it was to predominantly obtain treatment for behavioral health issues like bipolar disorders and attention deficit (hyperactivity disorders), including ADD and ADHD.
In a recent study of privacy and security practices that reviewed 21 published papers, Waltzlaf, et al., concluded that there were no randomized controlled trials that would assure patients and providers that their data was kept private and secure during and after telehealth services.
Moore, et al., report that family physicians want to use telemedicine, but their use has been very limited due to several barriers including the low adoption rate of telehealth services in primary care. This can be attributed to poor payment ¾ or no payment ¾ for services, and lack of education and training in the use of telehealth services.
Adler-Milstein, et al., examined telehealth adoption rates among U.S. hospitals and found wide variation across states based on licensure requirements and payment for services. Wilson, et al., reported that payment for evaluation and management telehealth services were 30% lower than for face-to-face services. They concluded that payment differentials created lower incentives for physicians and providers to invest in telehealth technologies that don’t reduce cost even if they do increase access.
Similar conclusions were reported in several more articles and studies on telehealth. It has great potential to improve access due to the significant convenience factor, but widespread adoption has significantly trailed expectations. Patients, physicians and providers require additional education on how to access, use and value telehealth services. Similarly, state laws that incentivize the use of telehealth services vary greatly in different states across the nation.
In Texas, for example, the new telemedicine law established that a telemedicine visit must be held to the same standards of care as an in-person visit, under the regulatory eye of the Texas Medical Board. Texas was the last state to pass a telemedicine statute and set out regulations for its use in direct-to-patient or patient-initiated visits. The key stumbling block to acceptance in Texas was the requirement of an established relationship with the patient before medical advice could be given or a prescription written.
Surveys show wide public acceptance of telemedicine, and proponents believe that as the younger, tech-savvy, convenience-driven generation seeks medical care, telemedicine will be high on their list compared to the baby boomers’ preference for in-office, face-to-face visits with their physician.
The American Telemedicine Association developed practice guidelines and standards for telemedicine and is advocating their adoption into state rules. And, for good reason, because adhering to the guidelines could reduce the physician’s liability exposure.
Most physicians believe that telemedicine is necessary to provide convenient access for their patients. However, they caution that strong referral networks need to be in place, telemedicine encounter records need to be transmitted to the patients’ primary care physician, serious illnesses must be detected or diagnosed timely, and finally, they must be paid appropriately for the services rendered.
It's estimated that telehealth is an $18 Billion industry with significant growth projected. Telemedicine has become an especially established option with specialty consultations for follow-up care, and increasingly for monitoring patients with chronic conditions, in both rural and urban areas. To be safe and effective for patients, telemedicine needs to adhere to a few core principles:
Licensure: The practice of medicine occurs where the patient is receiving treatment, not where the physician is located.
Adherence to established standards of care: The standard of care for telemedicine is the same as for in-person care.
Payment: A medically necessary and covered service should be paid for regardless of how it is provided.
Even under the new Texas law, payment remains a stumbling block, as the health plans argue that telemedicine is a service rather than a mode of delivering a service that is already covered. The counter-argument is this: A covered service provided to an enrolled patient by a contracted physician should be paid for – so long as the physician is licensed in Texas and the physician has access to and utilizes the relevant clinical data necessary to make a diagnosis in accordance with accepted standards of care.
Telehealth will accelerate once lawmakers and legislators address these issues ¾ together with physician and patient education on how and when to access telehealth services.
We write about physician trends and the changing healthcare landscape. Gary Price, MD, is the current president of the Physicians Foundation, and a practicing plastic surgeon.