Increasing patients' access to care at lower cost are two highly anticipated benefits of telemedicine. Advocates for expanding its use say that if handled properly, telemedicine can improve overall quality of care. But widespread adoption will require some significant changes in how physicians deliver and are paid for these services.
Hoping to speed the process along, several health organizations recently sent a letter to HHS Secretary Sylvia Burwell(www.connectwithcare.org) asking the agency to allow Medicare to pay for telemedicine consultations through eligible accountable care organizations (ACOs).
The HHS secretary has the authority to make changes to ACOs' acceptance of Medicare payments without congressional action, according to the Patient Protection and Affordable Care Act. Qualifying ACOs would have to be part of the Medicare Shared Savings Program.
"We're focused on the use of telemedicine and remote monitoring in lieu of an in-person visit," said Krista Drobac, executive director of the Alliance for Connected Care, which spearheaded the letter. "It reduces the number of inpatient visits, ER visits and urgent care. There's already evidence of it now. Telemedicine can save money, and there is no difference in the quality of care."
- Supporters of telemedicine anticipate that use of the technology can boost patients' access to care while lowering costs.
- The AAFP has weighed in on the issue in a letter sent to a House subcommittee that is drafting legislative language on the topic.
- Meanwhile, the Federation of State Medical Boards has issued new policy recommendations intended to guide telemedicine proponents in moving forward.
As telemedicine expands, said Drobac, the medical community needs to find ways to ensure that care is effective, physicians are fairly compensated and potential fraud is avoided. "We're trying to find that balance now," she told AAFP News.
Billing for telemedicine is a major obstacle to expanding its use. According to a recent survey(online.liebertpub.com) conducted by the peer-reviewed journal Telemedicine and e-Health, 55 percent of respondents said they do not bill for telemedicine services. The primary reason given for not doing so was that neither private insurers nor Medicaid pay for the services.
If telemedicine is to expand, a lot will depend on whether practices can afford to invest in the staff and technology required to take advantage of the new model.
"A lot of one-person practices may never see sufficient volume or report efficiency gains to support telemedicine encounters," said Ateev Mehrotra, M.D., a professor of health care policy and medicine at Harvard Medical School.
Currently, a family physician practice is eligible for a $25 facility fee from Medicare if a telemedicine consultation is arranged in the practice (the "originating site"). In a letter sent last week(5 page PDF) to House Committee on Energy and Commerce Health Subcommittee Chairman Joe Pitts, R-Pa., AAFP Board Chair Jeff Cain, M.D., of Denver, said the fee is not adequate to cover the fixed and variable costs associated with using the technology. The letter was written in response to a request for comment on draft legislative language the subcommittee is considering.
"The fees for telemedicine do need to be improved in order to push it forward in a fee-for-service environment," observed Steven Waldren, M.D., director of the AAFP's Alliance for eHealth Innovation.
Cain also urged the subcommittee to define telemedicine more broadly than does current law, which "generally limits 'telehealth services' to professional consultations, office visits and office psychiatry services, furnished via a telecommunications system." Whereas the statute specifically excludes telephones, fax machines and email systems from the definition, many family physicians provide care to patients via these methods and others as a matter of professional responsibility.
Furthermore, said the letter, as long as Medicare maintains a restrictive definition of an originating site, there is little incentive for family physicians to increase their patient volume through telemedicine. The current law defines an originating site as a recognized health care facility such as a physician's office or a health clinic, and it must be located either in a rural shortage area or lie outside a metropolitan district. The AAFP recommended that such restrictions be dropped in the proposed legislation.
"For family medicine, the restrictions on the originating site are the problem," said Waldren. "A patient's home can't be considered an originating site. The originating site definition is outdated and needs to be changed so that physicians can take care of patients where they are."
A number of demonstration projects are underway that seek to evaluate telemedicine's potential to increase access to care at a lower cost. In Arkansas, Blue Cross/Blue Shield began a pilot project earlier this year that pays the primary care facility or other originating site a $50 facility fee and a separate fee to the subspecialist.
Curtis Lowery, M.D., a professor at the University of Arkansas, Little Rock, is participating in the initiative and explained that the insurance companies initially wanted to pay one flat fee but were persuaded to make separate payments to the family physician and the subspecialist.
Lowery noted that a method to certify telemedicine sites and provide regular accountability for what meets effective care standards is needed. Certification should include the requirement that an individual be an existing patient of the physician before receiving a telemedicine consult, he said.
Overall, Lowery is concerned that use of telemedicine could skyrocket if no parameters are placed on its use.
"There's a fine line between profiting through overutilization and being paid enough to provide care for the patient," Lowery said. "All of this (concern about overutilization) goes away if we're not in a fee-for-service environment, but we're not out of that (environment) yet."
Lowery cautioned that if physicians abuse telemedicine, insurance companies will respond by refusing to pay for consults or paying the lowest possible fee. The fear is that utilization rates for telemedicine facilities could increase substantially without any measurable improvements in patient care.
"It's a real concern," said Lowery. "The insurance companies have been burned so many times, not on telemedicine but on other things. They can smell it."
Drobac pointed out that networks of neurologists are already on call exclusively via telemedicine to provide consults to ER physicians. Many rural and suburban hospitals contract with such networks, whose subspecialists might spend an entire day online offering telemedicine consults for stroke victims, for example.
"I am concerned that the greatest advantage of telemedicine is also its Achilles' heel," said Mehrotra. "It's so convenient that it's too convenient."
To prevent overutilization, Mehrotra suggested that Medicare and private insurers could limit the types of care for which they would pay or establish requirements stating that telemedicine could only be used in designated physician shortage areas.
The Federation of State Medical Boards (FSMB) recently adopted a revised policy on telemedicine(www.fsmb.org) that addresses scope of care and protocols for consulting with the patient. First and foremost, the physician should be licensed by or under the jurisdiction of the medical board of the state in which the patient is located, according to the policy.
In addition, before providing telemedicine services for a patient, the physician should establish a relationship with that patient, which can occur via technology. The policy advises that a physician should complete and document a thorough medical evaluation and collect the patient's clinical history before providing treatment or writing prescriptions, in person or online.
The FSMB policy also includes other guidelines for the use of telemedicine, such as requiring documentation that patient informed consent was obtained and ensuring the patient's medical record includes information about all electronic communications.