U.S. Senators Joni Ernst (R-IA) and Mazie Hirono (D-HI), led eight co-sponsors, in introducing the bipartisan Veterans E-Health & Telemedicine Support Act of 2015 (VETS Act), legislation to improve health care access for disabled or rural veterans by expanding telehealth services provided by the Department of Veterans Affairs (VA).
As defined by the Department of Health and Human Services telehealth is, “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.”
Under current law, the VA may only waive the state license requirement for telehealth services if both the patient and physician are located in a federally owned facility. In addition, the VA may only perform at-home telehealth care when the patient and physician are located in the same state. These barriers are a deterrent for disabled or rural veterans who are seeking treatment from a physician in another state, in some cases forcing veterans to travel great lengths to a federal facility before receiving telehealth services by camera or phone.
The VETS Act would address these deficiencies by allowing qualified VA health professionals to operate across state lines and conduct telehealth services, including mental health care treatment, for veterans from the comfort and privacy of their own homes.
Telehealth is one of the VA’s major transformational initiatives, and the number of veterans utilizing telehealth services continues to climb. In fact, VA telehealth care grew by 18 percent among veterans in Fiscal Year 2014 and in turn more than 12 percent of veterans received elements of their care through telehealth services. According to the VA, 88 percent of veterans who utilized the VA’s telehealth services were satisfied with the care they received. Telehealth services are effective and affordable as veterans save on average $2,000 per year in health care related costs, including travel to a VA medical facility.
“The bipartisan Veterans E-Health & Telemedicine Support Act moves us one step closer to achieving more affordable, patient-centered health care that our veterans deserve by embracing telehealth services to offer physician care and health treatment beyond the walls of a VA facility,” said Senator Ernst. “Telehealth care is an innovative and important means to meet the wide-ranging needs of veterans in Iowa and nationwide, including the invisible struggles of mental health care.”
“Our nation has a moral obligation to provide the best care for all veterans,” said Senator Hirono. “This legislation would eliminate the added burden of traveling long distances, or even to different states, in order to see a doctor. The VETS Act will build on a VA telemedicine program that is proven to work and removes barriers to accessing care particularly for veterans in rural areas like Hawaii’s Neighbor Islands.”
Additional cosponsors to the bipartisan VETS Act include: Senators Kelly Ayotte (R-NH), John Boozman (R-AR), John Cornyn (R-TX), Chuck Grassley (R-IA), Mike Rounds (R-SD), Jeff Sessions (R-AL), Thom Tillis (R-NC), and Tom Udall (D-NM).
The VETS Act is widely endorsed by the Veterans of Foreign Wars, Paralyzed Veterans of America, the American Legion, Concerned Veterans for America, and the American Telemedicine Association.
The companion bill in the U.S. House of Representatives was introduced by Congressmen Charles Rangel (D-NY) and Glen Thompson (R-PA).
Click here to read the full text of the VETS Act.
- Allows VA health professionals to practice telemedicine across state lines if they are qualified and practice within the scope of their authorized federal duties.
- Ensures the VA and Congress provide oversight of the VA’s telehealth program by requiring the VA to measure program effectiveness.
Benefits of VA Telehealth Services in Fiscal Year 2014:
- Provided veterans telehealth care from more than 150 VA Medical Centers and over 750 Community Based Outpatient Clinics.
- More than 12 percent of veterans received elements of their care through telehealth services.
- More than 717,000 veterans participated in over 2.1 million telehealth care interactions.
- 45 percent of veterans who used telehealth services lived in rural areas.
- Reduced hospital bed days of care by 54 percent.
- Reduced hospital admissions by 32 percent.
- VA telehealth care grew by 18 percent among veterans in Fiscal Year 2014.
- Patient satisfaction for clinical video telehealth averaged 94 percent.
- Patient satisfaction for overall home telehealth services averaged 88 percent.
- Home telehealth services save veterans on average $2,000 per year.
Section 106(c): Telehealth
Medicare currently reimburses physicians for certain services provided at certain sites through live video conferencing for eligible Medicare beneficiaries. 42 U.S.C. § 1395m(m). MACRA requires the Government Accountability Office (GAO) to draft two reports to be submitted to Congress within two years of MACRA’s enactment; the first report will pertain to the Medicare telehealth program, and the second will focus on remote patient monitoring technology and services. The first report on the Medicare telehealth program will evaluate circumstances that help or inhibit the use of telehealth under Medicare and the possible effects of an expansion of telehealth on payment and delivery systems under Medicare and Medicaid. The second report will examine incentives for adopting patient monitoring technology and services by private health insurance, as well as barriers for adopting this technology by Medicare. This report will also look at which patients and circumstances may receive the greatest benefit from this technology. Many health care practitioners believe that the time for government studies of telehealth has long passed and legislative action is needed now to expand beneficiary access, particularly in rural areas.
After watching the two-hour hearing on Advancing Telehealth through Connectivity convened by Senator Roger Wicker (R-Miss), one has to be impressed by both the expert witnesses and the Senate Subcommittee on Communications, Technology, Innovation, and the Internet. The full hearing can be heard at http://1.usa.gov/1QpNu6Y.
- Kristi Henderson, Chief Telehealth and Innovation Officer, University of Mississippi Medical Center
– Mr. Jonathan D. Linkous, Chief Executive Officer, American Telemedicine Association
– Dr. M. Chris Gibbons, Distinguished Scholar in Residence, Connect2HealthFCC Task Force, Federal Communications Commission
– Mr. Todd Rytting, Chief Technology Officer, Panasonic Corporation of North America
- Broadband is vital and is the major way to provide telemedicine and its dissemination has languished because of regulatory issues and funding.
- The FCC needs to re-engage, streamline regulation and act by enhancing Broadband availability.
- Even metropolitan areas such as in NYC have Wi-Fi issues in high-rise buildings with poor and elderly citizens.
- CMS needs to remove the barrier of paying only for non-MSA populations. Reimbursement was raised several times and many agreed this was a major barrier to address.
- Two Senators explored whether telemedicine could have an impact on mental health and drug abuse. The witnesses answered in the affirmative.
- Some of the Senators were reassured by the witnesses that HIPAA and other patient privacy issues could be protected during telemedicine encounters.
- The committee members very well understood quality and affordable healthcare delivery through telemedicine. Some of these Senators have very robust eHealth centers within their home states.
- Mr. Linkous, ATA CEO, said states could help with medical licensure reciprocity as a way to solve the century old problem of interstate practice. He added the federal government could help by supporting these state initiatives.
- The issue of the need to have another agency oversee all the current agencies that participate in telehealth was raised. Again, Mr. Linkous felt that a high level coordinating committee might be the best answer.
- Finally, the really good news was that all the members of this bipartisan subcommittee appear to be very enthusiastic supporters of telemedicine.
State medical licensure for telemedicine is discussed in the April issue of Telemedicine and eHealth, by Drs. Hunter, Weinstein, and Krupinski. One of the authors in fact sat on the Arizona state medical board so a unique perspective is presented.
While progress is forthcoming for state reciprocity through an Interstate Compact initiated by the Federation of State Medical Boards (FSMB), licensure process may be slightly easier but the costs for licensing will remain.
Here are some key points:
- Article X of the U.S. Constitution states that individual states have the authority to insure health, safety, and welfare for their citizens. This explains why there is no universal medical license in the United States.
- There is tremendous variability among the states as far as requirements. See Rogove et. al. in this same journal
- The major exception to state requirements is through the federal government, which allows physicians to possess only one state license to practice at medical facilities such as the VA system.
- One of the biggest barriers to reciprocity is having a history of a malpractice suit. This will result in a major and lengthy investigation, often resulting in approval for most physicians.
- Interstate Compacts will not change the state’s existing medical practice act.
- The practice of medicine is defined in the state in which the patient is present and not the state where the physician resides.
- The significant challenges include:
- When is the physician-patient relationship established? Some states are now creating chaos by requiring the relationship must begin with a fact-to-face encounter.
- Assuring patient privacy.
- Limiting physician prescribing to certain classes and types of medication.
A process that has been in existence for 100 years is up for a remake to help enter the twenty first century. We have reached a cautious but optimistic time for pushing telemedicine towards reaching its important position in healthcare delivery.
For the study, researchers sent a 30-question survey to health professionals across the U.S. who process medical licensure applications (Rogove, C3O Telemedicine study, 2/11).
More than half of respondents said they process more than 100 applications annually (C3O Telemedicine release, 2/25). Of those:
- 54% said the application process takes longer than 12 hours; and
- 17% said the process takes four hours to nine hours (FierceHealthIT, 2/26).
After the application process is complete, the amount of time it took to acquire licenses varied among states. For example, it took one to three months to obtain licenses in Indiana, Arizona and Virginia, while it took at least 10 months in California, Illinois and Texas (C3O Telemedicine release, 2/25).
Just 8.3% if respondents said all states were “reasonable in processing the applications,” according to the study.
The authors concluded that state medical license portability “continues … to remain elusive for a solution that will allow for the exponential and timely growth of telemedicine.”
They added, “If there were ever a time for the mission of state medical licensure boards to rally in support of shaping the future of health care delivery by finding a solution for removing a most significant barrier to telemedicine, the time is now” (FierceHealthIT, 2/26).
According to Jonathan Linkous of ATA in todays Inside ATA:
“It’s only February, but telehealth is clearly a priority to state lawmakers. One hundred telemedicine-related bills have been introduced to define telehealth and telemedicine, redefine licensed provider practice standards, remove artificial barriers or improve coverage and payment options. Some bills seek to improve the telemedicine policy landscape while others risk to severely limit health providers’ clinical decision making and patient choice. ATA members are monitoring state activity using the ATA legislative and regulatory trackers, and seizing the opportunity to educate lawmakers about the clinical application of telemedicine and the unintended consequences of over regulation. Join the ATA State Policy webinar this Thursday, Feb. 26, at 1 p.m. EST, to hear about legislative proposals and possibilities for engagement.”
According to Christopher Cheney of HealthMedai Leaders: “Since the model Compact legislation was finalized by state medical board representatives and released to the states for their consideration at the end of 2014, it has been introduced in 12 state legislatures and endorsed by 26 state medical and osteopathic boards. We expect both counts to continue to grow,” Humayun Chaudhry, DO, president and CEO of theFederation of State Medical Boards, said last week.
So far, the draft has been introduced at statehouses in Iowa, Maryland, Minnesota, Montana, Nebraska, Oklahoma, South Dakota, Texas, Utah, Vermont, West Virginia and Wyoming. The FSMB is tracking the legislation’s progress on the organization’s website.
The Compact also has the support of the American Medical Association, the Council of Medical Specialty Societies, the Society of Hospital Medicine, and many other national and state provider, hospital, and specialty organizations. Consumer and patient advocacy organizations like the South Dakota AARP chapter have also been very supportive of the Compact and its potential for improving access to care.”
Critics of the Compact
The FSMB has lashed out at critics of the Compact, among them Independent Physicians for Patient Independence (IP4PI) and the Association of American Physicians and Surgeons (AAPS). In a letter to the US Senate dated Jan. 26, AAPS called the Compact “little more than a pretext for transferring state sovereignty to out-of-state, private, wealthy organizations” and called for “an investigation of the FSMB to “[evaluate] the very reason for their existence on top of state licensure boards and specialty boards.”
Critical Mass of States Needed to Launch Compact
Several states will have to enact laws codifying the model legislation before the Compact can seat commissioners and launch.
“The model Compact sets a minimum of at least seven states to enact the legislation in order to enable functionality and the creation of an interstate commission. The commission would be charged with the administrative functions of the Compact and be led exclusively by members of participating state medical boards,” Chaudhry says.
Just fast tracked on Telemedicine and eHealth’s website is an important survey of professional license companies that deal with over 1,000 applicants a year to practice telemedicine in multiple states. Dr. Herb Rogove and co-authors sent surveys to participants who have experience with telemedicine as well as on site practices in multiple states throughout the continental United States and its territories. Here are the key elements of this article:
- Fifty four percent of the respondents felt it was a prolonged process because of variable requirements and deficiencies within the medical board office.
- Difficulties were centered around failure to respond to questions, lack of cooperation, inability to use FCVS, lack of a uniform process and consistency across all medical boards.
- Lost documentation occurred and 79% had to resubmit documents.
- The most reasonable states (reasonable defined as responsive, cooperative, willingness to expedite, and knowledge) were identified as Oregon, Wyoming, Pennsylvania, and Montana.
- The respondents felt the most difficult states to deal with were: California, Texas, Arkansas, and Massachusetts.
- The shortest time to obtain a medical licenses was felt by respondents to be Indiana, Arizona, and Virginia.
- The longest time to obtain a medical license was thought to be California, Illinois, and Texas.
- Variability of requirements, which is set by each state, was considered to be a major issue.
- Reciprocity for all states was a major suggestion by those who were surveyed.
This survey illustrated that medical license portability continues to be a major and time consuming barrier for expanding telemedicine’s rapid deployment to areas in need of physicians. Despite the recent compact by the Federation of State Medical Boards, the process may be streamlined but lacks the major impact of full reciprocity of all states.
John Brumbach reports: This year the Washington State Legislature is considering legislation that would ensure Telemedicine services are reimbursable for those enrolled in commercial, managed care and public employee benefit plans. Telemedicine, which consists of health care services provided via interactive video and video technology, has built strong bipartisan support in Olympia because of the potential to increase access to more diverse services in rural and other under served areas. These services include telepsychiatry, telepain management, teleradiology and many other specialties not commonly available in all areas. In addition, a study showed that covering telemedicine could save Medicaid $37 million in reduced primary and follow-up care costs. Despite this support, previous efforts have failed to make it through the legislature to the Governor’s desk.
The last effort to pass legislation began in 2013 and received strong support in the House, but died twice in the Senate during the 2013 and 2014 sessions, where there was no corresponding companion bill.
Reasons for telemedicine’s failure in the Senate appeared to center around concerns from health plans around a lack of flexibility for reimbursement levels, as well as social conservatives regarding the potential to ease access to chemical abortions.
Health plans have fully embraced this version of the bill, while it remains to be seen whether or not social conservative concerns will be addressed, or if those concerns will be enough to halt the progress of the bill.
HB 1403 is scheduled to be voted out of the House Health Care & Wellness committee on February 3rd.