If Vice President Al Gore's parents get sick on their ranch in rural Tennessee, he would rather keep them at home than see them travel a long distance for a possible inpatient hospital stay.
That's what Gore told executives of Hays (Kan.) Medical Center in Washington earlier this month during a demonstration of the hospital's home health telemedicine project.
"The vice president said, `This is the kind of technology we need out in rural Tennessee,' " recounts Bob Cox, M.D., a pediatrician and medical director at Hays.
However, Cox says, the technology will never get to Tennessee unless Medicare starts paying for it.
To date, Medicare doesn't reimburse providers for home health telemedicine services, although Congress continues to bemoan the rising federal budget for home health spending.
The Congressional Budget Office projected Medicare home health spending will reach $18.2 billion in federal fiscal 1998, which ends Sept. 30. Before passage of the balanced-budget law last summer, the CBO projected home health spending would reach $21.1 billion in fiscal 1998.
Although home health telemedicine programs have the potential to save Medicare money, fewer than a dozen are operating in the U.S., and most are tied to universities, the U.S. Commerce Department estimates.
Hays has been active in telemedicine for the past decade. Three years ago, it launched a home health telemedicine program funded by the Commerce Department, which provided $300,000 in grants, and the Kansas Health Foundation, which gave it $30,000.
"Hays used a new approach to coordinate a project we felt was innovative in the home health area," says Shari Wyatt, program officer for the health area of the Commerce Department's Telecommunication and Information Infrastructure Assistance Program.
"We want to determine and show the health industry if it's effective," Wyatt says. "If it is effective and efficient, it could become reimbursable, and HCFA is looking at that."
HCFA, meanwhile, is in the process of establishing its own home health telemedicine pilot project, which over the next three years will evaluate Medicare reimbursement for such services. No details about the pilot project were available.
The Commerce Department says HCFA will be able to use data from the Hays project in its evaluation.
The Hays project has demonstrated marked savings. Its average telemedicine home health visit costs $35, while its average in-home visit costs $90.
"The big cost difference is in the travel time," Cox says. "Our county has about 26,000 people; but our service area has four times that, and it's spread across 18 counties."
Hays' service area includes more than 100,000 people. The nearest hospital of similar size is 100 or more miles away.
"In rural areas like ours, a nurse can make a number of visits via telemedicine rather than having to travel from home to home," Cox says.
Home health telemedicine visits constitute 1,640, or 11%, of Hays' 15,000 annual home health visits.
"With traditional face-to-face home health, we have seven or eight RNs, three LPNs and three aides," says Kathy Rupp, the registered nurse who handles most of Hays' telemedicine home health visits.
The cost of setting up standard home health telemedicine equipment in a patient's home is $800 to $900, or about the cost of an oxygen tank. The standard equipment includes a camera, a 13-inch color television equipped with a phone, an automatic blood pressure monitor and a tympanic thermometer.
Last fall, Hays reduced its home health telemedicine costs when it expanded the program to serve communities outside its service area, including Rawlins County, which is 150 miles northwest.
To cut costs during the expansion, Hays switched from telemedicine through the local cable television network lines to the "plain-old telephone system." The cable company charges averaged about $900 a month, or about 2 cents per minute. By comparison, phone charges average $35 a month.
"The transmission over the cable television network provided us with a better picture, but we were limited geographically," Cox says.
Home health telemedicine allows providers to see more patients in a shorter amount of time and to check on them more frequently without numerous in-person visits. For example, a forgetful patient can be reminded to take his or her medicine via a phone call rather than a visit.
Telemedicine also has the potential to keep home health patients out of the emergency room and even the nursing home, Rupp says.
"We have kept patients out of the emergency room, and that could cost a few hundred dollars (for an ER visit)," Rupp says. "Some patients forget to eat. We can see that they are eating and that there is food in their homes. We have kept people at home and out of the nursing home."