AcuteCare Telemedicine Blog


Telehealth Legislation Continues to Evolve

Things are heating up in state and federal legislatures when it comes to advancing legislation that will help accelerate the spread of telehealth across America. The American Telemedicine Association (ATA) is working with congressional representatives to move forward on what is known as, “21st Century Cures”. The ATA is recommending that Congress take immediate action to improve coverage for telehealth services under Medicare payment innovations in a number of areas from fee-for-services to Accountable Care Organizations to bundled payment programs. The House and Energy Commerce Committee recently released a draft bill that will, in part, direct the Centers for Medicare and Medicaid Services (CMS) to implement a methodology for coverage of telehealth services.

Outside of Washington and all across the country, State legislatures are making telemedicine a priority issue for 2015. Ten states; Arizona, Arkansas, Connecticut, Montana, New Hampshire, New Mexico, Oklahoma, Virginia, West Virginia and Wyoming have introduced legislation that will impact how their state licensing boards enforce established clinical practice standards. In Arkansas, Connecticut, Indiana, New Jersey, Rhode Island, and Washington law makers are considering legislation that will require telehealth parity under private insurance.

In the state of Florida the battle to find acceptable legislative action to help increase access to health care in their rural communities is on-going. A bipartisan group of House and Senate leaders are confident they will reach agreement this year on how to boost the use of telemedicine in their state. “It’s abundantly important that we get it done and get it done right,” House Health Care Appropriations Chairman Matt Hudson, R-Naples, said during a news conference at the state Capitol in Tallahassee. As with several other states, law makers continue to struggle to pass legislation that satisfies legislators’ and healthcare industry concerns for the safety of patients and maintain the fiduciary responsibility of state government.

Lawmakers during the past few years have filed telemedicine bills that would allow for the use of modern telecommunication technology in the delivery of healthcare but the Florida House and Senate have not been able to reach an agreement. This year legislative leaders are expressing confidence that they can resolve their differences on regulatory issues. One of the points of disagreement in Florida and other states is the issue of individual state licensing and whether out-of-state physicians should be allowed to provide telemedical care to patients in their state. The current requirement and process of requiring a physician to be licensed in each state where treatment is rendered continues to be a significant stumbling block to the unabridged expansion of the practice of telehealth across state boundaries.

If the year 2015 is to become the predicted tipping point for expanding the benefits of technology driven medical care, state legislatures in Florida, and other states around the country, will need to do more than just debate and negotiate over the future of regulations that were relevant to times past.



Restrictive Rules On Use Of Telemedicine – Is It To Protect Or To Preserve?

The Tennessee Board of Medical Examiners (TBME) recently issued proposed changes to regulations governing the delivery of medical care through telemedicine technology. Patients in that state who seek care through telemedicine may soon be faced with new, complicated and restrictive regulations. Proponents argue the new rules are necessary to ensure that every patient in Tennessee has a primary care physician.

One of the most controversial rules mandates that patients have a face-to-face visit with a primary care doctor prior to receiving telemedical treatment. In addition, the new rule requires the patient to receive an in-person appointment with a physician annually or on the fourth consecutive time the patient receives care. Vaughn Frigon, chief medical officer for TennCare, the state’s Medicaid program, explains, “We want every patient in the state to say, ‘I have a primary care doctor,’ and that their initial access is through the primary care provider.”

In a time when general practice or specialized care physicians are in short supply, particularly in a state with large rural communities whose residents often do not have access to much needed healthcare, it is difficult for telemedicine advocates to understand how such restrictive regulations will provide rural Tennesseans with better or easier access to either general or specialized healthcare. It is as if the residents of geographically challenged rural areas had the opportunity to utilize a new state-of-the-art super highway to deliver better, less expensive life sustaining benefits offered by the outside world, only to have new restrictions levied to frustrate its use.

Applying the TBME logic to this scenario would mandate that anyone using the new improved highway would first be required to take the old path, slowly winding through the mountains on the old, more dangerous narrow roads so as to ensure the traveler has the opportunity to have the appreciation for the longer travel time and the abundance of beautiful scenery. To be certain that no one misses the experience, once each year, or every fourth trip, each traveler must repeat the more difficult journey.

This analogy may be over-simplified due to the fact that face-to-face medical care is important and will always have an important role in the delivery of quality patient care, but the comparison emphasizes that telemedicine is not a different or a lesser valued form of healthcare, only a different, and in most cases, less expensive and efficient means of delivering healthcare that improves access and availability to patients in rural and outlying communities.

Meaningful regulation across all industries is necessary to ensure the safety and protection of all people and communities. But excessive, though well-meaning, regulations often counter the promises of new technology to improve our lives. Expanding access to efficient, quality healthcare to all people is a worthy goal.



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.



Advancing the Benefits of Telehealth and Telemedicine

Dr. Teresa Myers, a family practice physician in Copley, Ohio, describes what she can see on her computer screen during a telehealth conference. “You know what HD television looks like. You can actually see the pimples on the actors’ faces,” she says. “I had a patient who was able to shine her iPhone flashlight to the back of her throat. I could see the exudates [pus-like fluid]. If you see that, you can be pretty sure.” A few more questions, as well as having the patient take her temperature and feel and describe her lymph nodes, and Myers felt confident diagnosing strep throat and prescribing an antibiotic.  The consultation started less than five minutes after the patient logged in, cost $49 and lasted 10 minutes. The patient never left home, learned a few things about examining her own body and, two days later, said she felt much better when Myers followed up.

The rural health care workforce is stretched to its limits in most states. Despite programs operated by state, federal and local governments aimed at recruiting and retaining primary care professionals to these areas, the need outpaces the supply in many communities. Also, many of the current primary care physicians are nearing retirement and the numbers to replace them are insufficient.

For many states with large rural populations, telehealth has emerged as a cost-effective alternative to traditional face-to-face consultations or examinations between provider and patient. Telehealth is the use of technology to deliver health care, health information or health education at a distance. Real time telehealth communications allows the patient and physician to connect and interact through video conferencing, telephone or video health monitoring device.  Store and forward telehealth refers to the transmission of data, images, sound and video from one care giver to another.

Forty-two states currently provide some form of Medicaid reimbursement for telehealth services and 17 states require private insurance companies to cover telehealth services. While individual states appear to be well out in front of the federal government on supporting telehealth innovation, the federal government is finally moving to catch-up with the recent introduction of “The Telehealth Enhancement Act of 2013 (H.R. 3306).”  The bill promises to strengthen Medicare and enhance Medicaid through expanded telemedicine coverage and calls for the adoption of payment innovations to include telehealth and to make other incremental improvements to existing telehealth coverage. Another Congressional bill, “TELE-MED Act of 2013” (H.R. 3077) would permit certain Medicare providers in a state to provide telemedicine services to Medicare beneficiaries in a different state.

The convergence of medical advances, health information technology, and a nationwide broadband network are transforming the delivery of health care by bringing the health care provider and patient together in a virtual world, especially those in disadvantaged areas. Telemedicine has the potential to improve health care access and quality to patients in urban and rural America alike, but a variety of barriers, such as reimbursement and licensing issues, continue to stand in the way of more aggressive, widespread adoption.

The recent progress by state and federal governing bodies to recognize the significant advantages of increased telehealth services for all Americans with the introduction of new and meaningful legislation to address and remove established barriers to expansion, is encouraging to those in the health care community whose fundamental goal is to provide the best quality medical care to their patients no matter where they live.



CMS Expanding Telemedicine Coverage

The Centers for Medicare and Medicaid Services have proposed rules that would provide telemedicine services to nearly 1 million new Medicare beneficiaries.  CMS proposes to increase the number of beneficiaries eligible for telemedicine by modifying their urban/rural definitions and proposes several new reimbursable telemedicine services.

The first change would extend reimbursable telehealth services to “originating sites” serving nearly one million rural beneficiaries living in large metropolitan areas. Currently, Medicare uses a strict county-based classification to enforce its rural-only rule for telemedicine coverage. The new rule would create a more precise urban/rural distinction based on geographically smaller census tracts.

The second proposed change would increase coverage for transitional care management services under Current Procedural Terminology (CPT) codes 99495 and 99496, involving post-discharge communication with a patient and/or caregiver. Reimbursement of these services will help healthcare providers deliver improved in-home care to at-risk beneficiaries and significantly reduce needless hospital readmissions.

Jonathan Linkous, Chief Executive Officer of the American Telemedicine Association cautiously supports the change and in a statement said, “This is one small step in the right direction.  For 15 years the federal government has placed strict restraints on the use of telehealth while employers, private payers, states and many other nations have moved boldly forward, improving the quality and reducing the cost of care. It is time to unleash the power of modern technology and allow Medicare beneficiaries, regardless of whether they live in a rural area, underserved inner-city, in a clinic or at home to be eligible to receive the benefits of telehealth.”

The proposal is currently open for comment and ATA encourages all telemedicine advocates to express their support.  The American Telemedicine Association is the leading international resource and advocate promoting the use of advanced remote medical technologies. ATA and its diverse membership work to fully integrate telemedicine into healthcare systems to improve quality, equity and affordability of healthcare throughout the world.



Not Yet Out of the Woods

As most Americans celebrated the New Year, our elected representatives met in Washington to approve legislation narrowly avoiding the ‘fiscal cliff.’ As part of its extensive provisions, the new legislation saved Medicare providers from an impending 2% payment reduction that would have gone into effect on January 1 and postponed spending cuts to Medicare, but only for two months. Within the terms of the agreement, negotiations on ways to cut spending are expected to resume after this period, meaning hospitals are still facing the risk of cuts triggered by uncertainty and further harm if the reduction does eventually takes effect.

While overall Medicare spending may not be affected now, hospitals are still face a long-term decrease in payments. The compromise legislation includes the “doc fix,” which negates a 26.5% decrease in Medicare payments to physicians, with hospitals bearing the brunt of financing it. The tally will come to about $15 billion over 10 years, or roughly half the total cost of the one-year fix. On top of those made by the passage of major healthcare reform in 2010, the new cuts include decreases in payout from both projected Medicare payment increases for inpatient or overnight stays and Medicaid disproportionate share payments, as well as reducing risk-adjusted payments to Medicare Advantage plans.

The kind of last-minute action taken by Congress is a reminder of the severe need to address the provider payment formula for Medicare reimbursement with a long-term solution. Short-term fixes ultimately result in a reduction of important healthcare services detrimental to both patient and provider. Until a solution is reached, hospitals simply cannot afford to cover the difference.