State boards' policy for telemedicine may present roadblocks

The 10 physicians who practice telestroke medicine and teleneurology in the Mayo Clinic's Phoenix telemedicine hub either have medical licenses or are working toward obtaining them in four states besides Arizona. The law doesn't require it. But Mayo has decided that's the best way to go for its program.

Many more doctors soon may have to apply for medical licenses in other states as their medical organizations move into the rapidly growing field of telemedicine. That may become somewhat easier because the Federation of State Medical Boards is working on an interstate compact to streamline the process for obtaining multiple state licenses.

At its annual meeting in April, member state boards will vote on adopting the federation's proposed telemedicine policy codifying standards and principles for state boards and legislatures in developing their own policies and regulations. The federation proposal includes two key principles.

One is that whether a physician and patient have a digital or a face-to-face encounter, there should be no differences in the standards of care. The other is that “the practice of medicine occurs where the patient is located at the time telemedicine technologies are used,” the proposal states.

Requiring doctors to be licensed in every state where their telemedicine patients are located is not being received well by some telemedicine players. It would involve significant costs, said Jonathan Linkous, CEO of the American Telemedicine Association, which opposes telemedicine-specific interstate licensing requirements. Between 22% and 25% of U.S. doctors currently hold multiple state licenses. The costs associated with procuring multiple licenses may total up to $300 million a year, and that will increase as more doctors begin to provide telemedicine services in other states, he said.

Dr. Bart Demaerschalk, director of telestroke and teleneurology at the Mayo Clinic in Phoenix, argued that the federation policy could hamper rather than facilitate telehealth expansion. While he said he appreciated the federation's principles of putting patient welfare first, adhering to the highest standards of care, protecting patients' privacy and securely storing their information, he disagrees with the multistate licensing requirement. The need to obtain multiple state licenses has slowed the growth of Mayo's program, he said. It currently has physicians in Phoenix, Rochester, Minn., and Jacksonville, Fla., providing 3,000 neurology consults a year for a network of 36 hospitals across 10 states.

Continued regulatory barriers to telemedicine could lead to higher costs and poorer outcomes for patients, Demaerschalk cautioned. A recent Mayo Clinic study in the American Journal of Managed Care found that compared with a patient in a rural community hospital, patients in a telestroke network incurred costs that were $1,436 lower.

In addition, a recent study, by RAND Corp. researchers published in Health Affairs examined virtual visits provided by Dallas-based Teladoc. It concluded that using Teladoc instead of the emergency department or a visit to the doctor's office “could generate large savings for health plans.” Teladoc matches patients with physicians who are licensed in their state.

The three biggest obstacles to telemedicine are state licensing and hospital credentialing, reimbursement issues, and the cost of technology, Demaerschalk said.

Reimbursement for telehealth services is another major concern. According to the National Conference of State Legislatures, 43 states and the District of Columbia provide some form of Medicaid reimbursement for primary-care telehealth services, while 19 states and the District of Columbia now require private plans to reimburse providers for telehealth primary-care services.

Teladoc CEO Jason Gorevic said his company has “gone from obscurity to mainstream” in five years. Consultants now include telemedicine as “a core strategy” that they present to their employer clients when developing a cost-effective health benefits package, he said.

Follow Andis Robeznieks on Twitter: @MHARobeznieks