We are seeing a surge in online physician services; both in telemedicine (video consults with and without diagnostic tools) and in telehealth (education, assessments, intervention, consultation, supervision, and information sharing) solutions.¹
Some offerings are limited (niche markets), available only to individual states, insurance member groups or employees. Some are reaching out nationally, and some are targeting specific patient groups.
Early adopters focused on behavioral health, dermatology, prison health care management (Texas’ telemedicine system is second only to the U.S. government in a correctional setting)², and teleradiology. New adoption is moving to direct online access, post-acute care, care transition, patient monitoring, and specialty consults.
The Veteran’s Health Administration (VHA) has understandably been called a silent leader in telemedicine and telehealth. According to Case Studies in Telehealth Adoption (January 2013)³. The VHA, through its Care Coordination/Home Telehealth (CCHT) program, reports “more than 70,000 patients receiving telehealth-supported care management in 2012”.
VHA efforts are impressive. For the end of fiscal year 2010, the VHA reported an 85 percent increase in home telehealth services offered through CCHT, and reductions in bed days of care in excess of 40 percent on pre-enrollment figures for the
CCHT population receiving home telehealth.
According to the report, CCHT is now a routine service that uses home telehealth and disease management technologies in the remote care management of chronically ill patients at risk for long-term institutional care.
It would make sense than that online non-emergency care offerings are growing. Some services are creating state-wide physician groups; some are trying to grow a nation-wide physician base. The challenge is that telemedicine laws vary by state.
Many states require that an established physician/patient relationship exist (patient has previously been seen in office) and require full H&P records prior to consult, and many states do not allow online prescriptions unless patient is an existing patient. A few states allow physician/patient relationships to be established via telemedicine if a distant site medical presenter participates (e.g. RN, PA, or paramedic) is with patient and diagnostic tools are available.
There are state licensing barriers around the practice of medicine. Currently, physicians are required to have a medical license in each state where they provide care (or a special license or telemedicine license needs to be obtained).
Provider services are trying to find creative ways around these barriers. Offering telemedicine and telehealth to insured members makes sense; patients already have a physician and have usually been seen by that physician or physician group (any group physician can step in to cover member patients). Scalability on a national level is harder. Services need to create physician provider groups state-by-state to provide care.
Telemedicine/telehealth offerings to businesses and employees make sense. In these instances physicians or physician groups are being made available to employees for medical care in efforts to control costs. Employees have to select and first see a primary care provider (PCP). Providers are licensed to practice in the employee’s state and may offer visits to employer sites to establish history and physical relationships.
Once relationships are established most non-emergency care can be provided via telemedicine– or telehealth where questions are answered and consultations given. Access to physicians can reduce unnecessary trips to the ER. Americans made a total of 124 million visits to hospital emergency departments in 2008 (4). The percent of non-emergency visits to emergency rooms is between 10% (4) and 60% (5) depending on reporting source (national, state, or plan).
The issue of reimbursement is still the most challenging hurdle to physician participation, but along with reimbursement comes state licensing and credentialing oversight.
A recent study in the Telemedicine and e-Health (6) journal noted that physician licensing, physician credentialing, and reimbursement were the three regulatory and financial barriers to telemedicine. Telemedicine and telehealth services working with hospitals have to credential their physicians at every hospital they serve; that is a daunting task and can take months. While there are some universal standards, each hospital sets their own requirements. And physicians must be re-credentialed (CMS– at least every three years) based on individual hospital standards.
We will continue to see growth in telemedicine/telehealth offerings as these issues are addressed. Reimbursement remains a deterrent but progress is being made. Paritiy laws have been passed in a number of states.
To see the current “State” of Telehealth Reimbursement, visit: http://www.excaliburmed.com/teleradiology-telehealth-blog/bid/157958/Updated-Telehealth-Reimbursements-are-Growing-Is-your-state-on-the-list
=============
Sources
1 – Telemedicine Terms – Medicaid.gov (2013)
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html
2 – EMR, telemedicine saves Texas $1B (2011)
http://www.healthcareitnews.com/news/emr-telemedicine-saves-texas-1b
3 – Scaling Telehealth Programs: Lessons from Early Adopters (2013)
http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2013/Jan/1654_Broderick_telehealth_adoption_synthesis.pdf
4 – Nonurgent Use of Hospital Emergency Departments (2011)
http://hschange.org/CONTENT/1204/1204.pdf
5 – Tool address non-urgent ER use (2010 – BCBC in Virginia)
http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/tools-address-non-urgent-er-use
6 –Telemedicine and e-Health(2013)
http://www.liebertpub.com/tmj