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.
The Texas Medical Board on Friday, April 10th finally decided to severely restrict the practice of telemedicine. In a majority vote with one dissent, the Board upheld the previous decision that requires an established physical encounter prior to a telemedicine visit. Now text, email, chat, or telephone are considered inadequate for the establishment of a physician-patient relationship.
Who is on the Board? It appears the membership is diversified and accomplished in their respective professions. There are currently 19 members, 12 of which are physicians. The remaining members are three business executives, one real estate banker, one biochemist, and three attorneys.
What does this mean for telemedicine?
- A significant departure from where the rest of the country (and world) is going.
- The board’s presumption that telemedicine is not a regulated and safe healthcare delivery system.
- Challenges the medical literature, which establishes telemedicine as a highly acceptable and safe means to deliver healthcare.
- The presumption that the only specialty that has a shortage is psychiatry since mental health is the one true exception for the use of telemedicine.
What does this mean for Texans?
- Texas is the second largest state with 24.7% of its population in small towns and rural areas. That accounts for over 6 million people, which is the size of the state of Tennessee (2010 census).
- As a result of the new regulations, access to healthcare for over 6 million of these Texans is limited to traveling long distances to seek care.
- Because the level of poverty is high in these areas, not only the cost of travel but the cost of care in an ED versus the less expensive telemedicine consult is an added burden on an already stressful life.
- Finally, the citizens of Texas had no say in this decision. The freedom of choice has been significantly curtailed.
Texas has made a decision based upon 19 Texans. It appears the only way that telemedicine is acceptable by the board is in a clinic or hospital setting, which requires a qualified healthcare provider to “assist” in the consultation. If this means only a physician, then again a major barrier exists.
Despite how one analyzes the decision, it would be safe to say that everyone in the telemedicine community supports patient safety and quality of care as the principle of why telemedicine is an important and integral part of our healthcare delivery system. Support for strong regulation is essential and must be part of every states mandate, but the restriction of the practice of telemedicine without thoughtful deliberation deprives Texans of accessible and affordable medical care.
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.
Telemedicine can have a significant impact upon the existing racial disparity of healthcare access through home monitoring of hypertensive patients. It is a well know fact that hypertension and hypertensive heart disease is predominant among the African-American population, especially males. It is also known that access to care for all communities has been less than optimal.
In a recent review in Curr Hypertens Rep there was evidence of better compliance, very good acceptance by patients, and a lower utilization of high cost facilities such as the emergency department. The review also concludes that it is not only hypertension but also chronic heart disease including CHF and Diabetes that also benefit from close patient monitoring. While the review has demonstrated some excellent outcomes, the authors are the first to admit more studies are needed.
The study begins the discussion where patients with hypertension now have access to healthcare professionals who can monitor and advise patients in a convenient and cost-effective model that is all inclusive. When healthcare economists continue to look for value, this solution is simple, easy to implement, and can result in millions of dollars in saving annually.
A telepediatric cardiac critical care program dealing with children with congenital cardiac problems has shown a significant decrease in length of stay for both the ICU and hospital. This prepublication abstract is at Telemedicine and eHealth.
This unique study whereby UPMC (Pittsburgh) partnered with the Cardiovascular Foundation of Columbia was able to provide post-operative critical care to pediatric patients in the ICU. These children required surgery as they had significant congenital cardiovascular diseases.
While there was no difference in mortality, a good sign that care was the same, the TeleICU component was able to reduce length of stay. In the ICU the LOS went from 17 to 10 days. For the hospital, the LOS went from 28 to 22 days. This is important as the telemedicine patients had a higher acuity.
How does stroke telemedicine response times in giving tPA measure against an on site stroke team? In an online release of a stroke study from the Mayo Clinic, the Journal Telemedicine and eHealth published a study of 196 patients from 2009-2012 who either received standard on site care versus care provided by a vascular neurologist (VN) via robotic telemedicine. The time from stroke alert activation to receiving tPA or door-to-needle time(D-T-N time) was 8.6 minutes longer in the robotic telemedicine group. In the subgroup of acute ischemic strokes the mean time from activation to treatment was 18 minutes longer in the robotic group. There was no difference in safety outcomes which was defined as compliance with standard protocols and hemorrhage.
Another very important observation to note is that the robotic telemedicine patients had a higher severity and that this patient group received a higher percentage of tPA compared to the standard group.
The conclusion was that in hospitals that do not have an onsite program, then robotic telemedicine is an extremely attractive alternative. It is fair to say it is not only response time to give the medication but also the rate of utilizing this life saving therapeutic intervention.
According to estimates by ATA, the number of ICU patients in the U.S. that are remotely monitored for at least a portion of the day will reach 550,000 this year. This represents roughly 11 percent of all ICU patients in the U.S. The estimates were reached in consultation with leading providers and vendors involved in providing tele-ICU services. The use of telemedicine for intensive care involves highly skilled specialists including intensivists and critical care nurses that allow clinicians in one center to remotely monitor, consult, and care for ICU patients in multiple distant satellite centers. Estimates of the growth of these remote medical services range from 10 to 25 percent per year. The rapid increase in the use of telemedicine for critically ill patients is a result of a number of factors including shortages in specialty providers, increases in the number of ICU patients (due to the aging of population) and better acceptance of telemedicine by established health systems. Such use has been documented to improve efficiencies, clinical outcomes and financial results. The widespread use of tele-ICU services has had a significant and lasting impact on the way healthcare is delivered. This is a leading indicator that ATA’s vision, that telemedicine will be fully integrated into healthcare systems to improve quality, access, equity and affordability of healthcare throughout the world, is starting to be realized. Last year, ATA adopted Practice Guidelines for Tele-ICU Operations which have since been endorsed by several medical specialty societies. They are available for free on the ATA website.
Perceptions of tele-ICU users are not well studied. Thus, we undertook a study focused on assessing staff acceptance at multiple hospitals that had implemented a tele-ICU system.
Materials and Methods: We designed a survey instrument and held interviews that gathered perceptions on multiple facets of tele-ICU use and administered it to clinical and administrative staff at 28 hospitals that had implemented a tele-ICU system.
- Respondents were generally positive about all facets of the service.
- Analyses found no significant differences in comparisons between critical access and larger hospitals or between clinical and administrative/managerial respondents.
- Respondents at hospitals averaging more tele-ICU use and that had implemented it longer were significantly (p<0.05) more positive in their responses on multiple survey items than other respondents.
Conclusions: Tele-ICU was particularly valued when critical access hospitals retained critical care patients. Tele-ICU can aid rural hospitals, but multiple delivery models are warranted to meet disparate needs.