AcuteCare Telemedicine Blog


Solving the Physician Shortage: Should it be Left to an Act of Congress?

Since 1997, the number of physicians entering the workforce each year has essentially been capped, while the demand for everything from hip replacements to treatments for diabetes to angioplasties has soared with our growing and aging population. Now, the Obama administrations newly proposed budget seeks to spend an additional $5.23 billion over the next decade to manufacture new physicians. While this sounds like a lot of money, given the magnitude of the doctor shortage issue, it won’t be nearly enough to solve the shortage problem on its own merits. The proposal is designed to swell the ranks of primary care doctors, those family physicians, general internists, and pediatricians that constitute the healthcare workforce that is predicted to experience the greatest shortage of all the medical disciplines.

But primary care is not the only medical care discipline that is facing future short falls.  According to a study by the American Academy of Neurology (AAN), by 2025 the demand for neurologists will far outnumber the supply, creating a 19 percent disparity in the number of doctors needed to adequately care for all patients. Those who suffer with neurodegenerative diseases like multiple sclerosis (MS), Parkinson’s, and Alzheimer’s will have to wait longer to see a specialist.

“The doctor shortage is worse than most people think,” says Steven Berk, M.D., dean of the School of Medicine at Texas Tech University. “The population is getting older, so there’s a greater need for physicians. At the same time, physicians are getting older, too, and they’re retiring earlier,” Berk says. And graying doctors, nearly half the nation’s 830,000 physicians are over age 50, are seeing fewer patients than they did four years ago.

The flow of doctors entering the market each year is determined by the number of U.S. residency positions, chiefly in teaching hospitals. Those positions are funded primarily by the program that oversees Medicare and Medicaid. In 1997, the federal government essentially froze spending on residency slots, limiting the number to around 100,000 over three-to-four years, and in turn freezing the number of newly licensed physicians available for hire each year to around 26,000. Over the past 17 years, a few hospitals have established new residency programs for primary care doctors, raising the number to around 27,000, or a less than 4% increase. Meanwhile, the U.S. population has risen by 50 million, or almost 20%. The American Association of Medical Colleges estimates that the U.S. will face a shortage of 46,000 primary care doctors by 2020, equivalent to one-quarter of everyone practicing in that category today.

The Affordable Care Act promises to magnify the problem but does attempt to address some of the issues to help stem its effect on the shortage by allocating an additional $1.5 billion in funding for the National Health Services Corps, which provides support to health care professionals in exchange for their service in areas with a more prevalent shortage. The law also puts more money toward training in hopes of increasing the primary care workforce and it offers more graduate positions for primary care doctors and more scholarships. It even offers a 10% bonus to primary care doctors who agree to see Medicare patients through 2015.

But many in the medical care industry do not see the solution reserved for government legislation alone. “Keep in mind the Affordable Care Act didn’t create this crisis,” said Dr. Reid Blackwelder, president of the American Academy of Family Physicians. “We’ve got an aging population that needs more care and a growing population.”

Many believe that new technologies will extend the reach of medicine in ways that will ameliorate the shortage problem. Health care professionals can serve more people by using telemedicine technologies to examine, treat and monitor patients remotely as well as providing patients increased access to advanced stroke care. These technologies are already keeping patients out of hospitals and doctors’ offices and providing improved recovery results. Creative new ways medicine is delivered, such as the use of “medical homes” and “accountable-care organizations” to better coordinate patient care, are also expected to improve efficiency and keep patients out of the hospital. Telemedicine enhances productivity and outreach while cutting costs, it improves diagnosis and care management in remote areas, and it reduces unnecessary care. The technology also strengthens partnerships between community based hospitals and advanced regional care centers.

“I understand there is a sense of worry, and change can be scary, but our present system is broken,” Dr. Blackwelder said. “We pay twice as much for our health in this country and have worse outcomes than other countries. Looking to government to fix a problem often harbors complexity, inefficiencies and long-term implementation of solutions. Dr. Blackwelder’s opinion reflects that of many other medical industry professionals, “We will have to start coming up with creative solutions to this problem, ones that won’t have to wait for an act from Congress.”



Why the VA is a Leader in Advancing Telemedicine

Initially used to reach those who live in rural areas, telemedicine is quickly expanding its reach into every area and genre of medical care delivery.

Interestingly, when the history of telemedicine is written, significant credit for hastening the advancement of telemedicine will go to a government health care agency that is not always credited with innovation and exemplary delivery of patient care and service.  The Department of Veterans Affairs (VA) is successfully deploying telemedicine on a large scale. In fiscal 2013, more than 600,000 veterans accessed VA care using telemedicine programs, for a total of more than 1.7 million episodes of care. The reach of VA’s telehealth services is growing at 22 percent a year. The agency is currently in the midst of a pilot program that allows veterans to enter vital information into an online tool that is accessible via mobile phones, tablets or desktop PCs to help their caregivers manage chronic conditions. The VA is launching another service that allows larger, better-resourced hospitals to connect with smaller facilities to provide remote support for intensive care.

“The VA did not get into telemedicine out of an inherent interest in technology”, said Dr. Adam Darkins, who leads national telehealth programs at the agency. Rather, VA officials wanted to help aging veterans with chronic disease live independently, for clinical and financial reasons. Although the VA has a network of 152 hospitals and more than 1,100 other caregiving facilities, it still faced the problem of having to cover a lot of territory in terms of reaching veterans. Additionally, officials found that 45 percent of those requiring treatment resided in counties classified as rural by the U.S. Census Bureau.

One big reason the Administration has been able to lead in the expansion of telehealth is attributed to its network of physicians who are able to treat veterans throughout the system without regard to state licensing rules, an advantage that private medical industry practitioners do not enjoy. The growing telemedicine industry is still working toward standardization and interoperability but the biggest impediments to the rapid expansion of telehealth remains state licensing and regulations that restrict treatment by out-of-state doctors.

Congress is beginning to take necessary legislative action to resolve many of the issues that are slowing telemedicine advancement in the private sector. The Telehealth Modernization Act, a companion bill backed by Reps. Bill Johnson (R-Ohio) and Doris Matsui (D-Calif.), would create a single, federal standard for telemedicine for use in national health care programs. And the Telehealth Enhancement Act from Reps. Gregg Harper (R-Miss.) and Peter Welch (D-Vt.) would expand reimbursement for telemedicine services under Medicare and Medicaid. It would also amend the Communications Act to support health care providers under the universal service requirement.

It’s not clear if any of those bills will pass, but the bipartisan focus on expanding telemedicine on that powerful committee indicates an interest in establishing some federal rules to make the patchwork of state laws more manageable for providers and insurance carriers. The VA has certainly provided an example of leadership as legislators clear the way for advancing the use of telecommunication technology in delivery medical care.



Can We All to Come Together in the Interest of Progress?

According to a recently published report, telehealth is about to experience explosive growth. RNCOS Business Consultancy Services has just released a report predicting 18.5 percent annual growth in telehealth worldwide through 2018.  It is predicted that the U.S. will outpace the rest of the world with its share of the telehealth market expected to grow to $1.9 billion in 2018 from $240 million today, an annual growth rate of 56 percent. This projected explosive growth has gained the attention of the federal bureaucracy. In 2013, two bipartisan bills were introduced in Congress, designed to encourage telehealth expansion and growth:

  • HR 3077, the TELE-MED Act, would permit certain Medicare providers licensed in a state to provide telehealth services to Medicare beneficiaries in a different state.
  • HR 3750, the Telehealth Modernization Act, would promote the provision of telehealth by establishing a federal standard for telehealth, and inducing all states to adhere to the regulations.

The Health IT Now Coalition is pointing out that neither bill imposes a huge burden of federal control and that these two bills do not interfere with state sovereignty over the licensing of medical and allied health professionals. Traditional state licensing laws did not envision a physician in one state treating a patient in another state and the oversight and lack of inter-state licensing of physicians and other health professionals has long been an obstacle to TeleHealth rapid adoption.  Many in the medical community are concerned that Congressional overreach would have unintended consequences in situations that are better dealt with by individual states. Decentralized control at the state level ensures less likelihood of an inflexible and quickly dated regulatory regime, which often happens when Congress takes the lead.

The Federation of State Medical Boards has promised that it is very close to agreeing on language for an interstate compact for physician licensing, which has already been achieved for nurses. A compact is a constitutionally approved method for states to make treaty-like commitments to each other. It is a very appropriate tool to accommodate mutual recognition of professional licensing for the purpose of inter-state telehealth.

It is very encouraging that both advocates and governmental representatives are endorsing an approach that will allow providers, patients, and entrepreneurs to develop and adopt telehealth with minimal political interference.  It is all too common for politicians and their formidable federal and state machinery to reach out to “help” advance a promising, revolutionary movement only to over indulge the regulatory rule-making which ends up hindering real or untethered progress.

Technology promises to change much in the delivery of medical care in the coming years. Let’s hope that all parties to the process of change continue to work together to advance a common mission of providing improved quality and increased availability of affordable medical care to all Americans.



FDA, mHealth Regulations are on the Horizon

A battle is beginning to build between various stakeholders and investors in new medical mobile applications over the timing of the release of long-anticipated Federal Drug Administration (FDA) regulation of the medical app industry. A group of 100 organizations including medical trade associations and electronic health record product companies wrote to federal regulators recently, urging the need for slowing the course on mHealth regulation, particularly until a mandated federal workgroup finishes working on a report to guide Congress on the issue.

Brad Thompson, attorney for the mHealth Regulatory Coalition, the group working to prepare the report for Congress, submitted a letter to regulators the same week urging the release of mobile app regulations as soon as possible. Thompson, a member of the workgroup says he’s “pretty familiar with what that group is doing, and I don’t see publishing the FDA guidance as frustrating at all.”

Mobile app developers need regulations now in order to know if their product needs FDA approval. Without it, they could be breaking a federal statute

if they go to market before the regulation is released and may find that they will be undersold by competitors who do not seek FDA approval.

The dollar amount of investments awaiting federal guidance is significant and the risk is even greater.  The uncertainty over the guidelines which will ultimately determine whether some medical application need FDA approval before going to market is palpable for stakeholders who are reserving large amounts of capital pending the news.  As is often the case with governmental regulations, knowing is far better than not knowing in the eyes of many investors.

Medical applications for use with mobile devices are a very promising niche for those who are marketing medical services through telemedicine.  Mobile applications promises to expand and ease accessibility to chronic disease patients who currently are underserved, particularly when it comes to highly specialized medical care.

FDA officials have indicated that they are moving toward an October 2013 release of regulations.



VETS Act Expands Veterans Access to Care

A bi-partisan bill, introduced by Representatives Charles Rangel (D-NY) and Glenn Thompson (R-PA) and cosponsored by 21 Members of Congress, would permit U.S. Department of Veterans Affairs health professionals to treat veterans nationwide with a single state license. The bill, known as the VETS Act, builds on the unanimous congressional enactment of the 2011 STEP Act (Servicemembers’ Telemedicine and E-Health Portability Act,) which provides a similar provision for healthcare providers in the U.S. Department of Defense. A similar licensing rule for patients and providers of Medicare, Medicaid and other major federal health programs was included in a comprehensive telemedicine bill submitted by Rep. Mike Thompson (D-CA) in December 2012.

These bills are a simple way, while preserving the states’ role to license, to address shortages of medical specialists, to improve patient access to the best qualified physicians, and to accommodate mobile Americans and multi-state health plans,” said Jonathan Linkous, Chief Executive Officer of the American Telemedicine Association.  Currently, most providers who practice interstate telemedicine must be licensed both where the patient and provider are physically located. In some states, medical boards are even imposing stricter licensing requirements for telehealth providers than they do for in-person care, such as requiring a prior face-to-face examination for each and every case.

The Veterans Administration is consolidating many medical specialties in regional facilities that are often located a considerable distance from veteran patients who need regular treatments for injuries suffered in the defense of the country.  In some cases these patients need to travel into another state to receive specialized care, resulting in significant inconvenience and expense to VA beneficiaries.  The ability to treat these patients across state lines by use of telemedicine technology promises considerable benefits to patients and the VA care providers.

For the Veterans Administration who is currently experiencing a backlog of more than 500,000 requests for benefits, removing or lowering regulatory barriers will surely enhance the accessibility of care for patients living in areas remote from VA treatment centers while generating operational efficiencies for the VA.



Medicare Recipients to Lose Telemedicine Services Benefits

Even though the availability of telemedicine has proven its value by lowering costs, increasing access and improving treatment and remote monitoring for chronic diseases, thousands of Medicare beneficiaries will soon lose access to telemedical services simply because of where they live, or more accurately stated, how government statistics identify where a patient lives.

Medicare patients from Hawaii to Puerto Rico to Minnesota will be redefined as living in “metropolitan” areas, precluding them from receiving Medicare coverage for video conferencing and other telehealth activities, even though 80% of beneficiaries live in urban counties such as those cut from the list.

“Congress has long overlooked the need for telemedicine services for residents of urban counties, despite the fact that they often suffer similar problems accessing healthcare.  Now, because of a statistical quirk, even more people will lose coverage of these services, reducing access and care,” said Jonathan Linkous, CEO of the American Telemedicine Association.

Originally, telemedicine technology demonstrated its most obvious benefits to rural communities, where specialized and chronic medical services and treatments were often not readily available without significant cost and inconvenience to patients.  However, the same cost/availability benefits have proven to be just as effective in urban areas and when chronic illness and extended, after hospital, care is encountered.

A study provided by the Commonwealth Fund shows that telehealth consultations are effective in reducing the amount of time patients spend in the hospital for care of chronic illnesses.  By examining data from large telehealth programs run by the Department of Veterans Affairs (VA), Partners HealthCare in Boston, and Centura Health, based in Colorado, researchers found that home monitoring programs can cut costs and raise patient satisfaction up to 85%.  Under the new guidelines, Medicare coverage will not be available for telemedicine visits to beneficiaries living in metropolitan areas–where over 80% of recipients live, resulting in cost reductions for the Medicare program.  Correcting this oversight will require an act of Congress, another incident of bureaucratic, regulatory interference with beneficial advancements in the delivery of healthcare to patients all around the country.

Given the increased involvement of government in the total delivery of health care in the coming years, this lack of insight does not bode well for reducing costs and improving availability to those who are most in need of the best in healthcare services.



The Dollars and Sense of Telemedicine

With the anticipated “break out” of telemedicine services looming on the horizon, an important and significant obstacle still remains to be cleared away if wide-spread expansion and acceptance of medical treatment and services is to be realized.  As with the growth of any new industry it raises the question of who is going to provide the investment capital and who is ultimately going to pay for the services necessary to sustain the budding industry?

Even with the obvious benefits that telemedical services promises to bring to the traditional health care delivery model, change to the well-established and traditional minded payers of medical services continues to be a major detriment to the crack of the starter’s pistol that will unleash the race to expansion.  Currently there are five primary sources of funding for the $2.8 trillion healthcare markets in the United States, according to Jon Linkous, American Telemedicine Association (ATA) CEO.

Hospital and Healthcare Systems now permits providers the flexibility to pay for telemedicine services wherever warranted, over 100 million Americans are now covered and the number is growing rapidly.  This source remains the most fit of providers readily eager to set the pace.

Private and public employee insurers in the U.S. are expanding coverage of telemedicine but only 16 states currently mandate private insurance coverage.  This important source of funding continues to lag well behind the pace and is not likely to contribute seriously to a break-out soon.

Federal Medicare payments are currently approved for imaging and live consultations to patients in rural areas and Congress is expected to take up expansion of the payments in the coming year, but this is Congress an agency not known for leading or setting any records for implementing change.

State Medicaid coverage is available in 44 states at some level of reimbursement and three more states are considering full support in 2013.  In April, legislators in Arizona passed a law prohibiting insurers from denying payment for medical services solely because they are provided through telemedicine. The law is limited to providing payments in 13 specific rural areas and only for telemedicine treatment for seven specific conditions. The laws implementation was delayed until the end of 2014 to satisfy insurance industry concerns.  Such tentative, piecemeal advances’ provides little hope for a surge in Telemedical services being paid for by Medicaid provider’s in Arizona.  Apparently, as with justice, the wheels of bureaucratic change move slowly.

Direct federal healthcare agencies, such as the U.S. Veterans Administration, Department of Defense, Indian Health Service, federal and state and local corrections departments are active providers of remote health care.  This is rapidly expanding and increasingly relies on partnerships with non-governmental health providers.

Investment capital remains a concern for providers looking to aggressively enter the telemedical marketplace. While the mystery of how the new technology will generate returns on investment begin to fade in investors and venture capitalist minds, infrastructure funding sources are limited and somewhat timid in this hesitant economic environment.

The benefits of telemedicine to improve the access and quality of patient care is obvious, and makes perfect sense to providers, practitioners and patients alike, but the dollars portion of the “dollars and sense equation” is proving to be a more persistent challenge to expansion and sustainable growth of this new industry.