Telehealth, which has been around for four decades, lives in regulatory limbo, despite being one of the more promising technologies for improving patient outcomes and lowering costs.
But this could be a breakout year for medicine at a distance if the federal government finally removes some longstanding legal, financial and regulatory impediments.
High on the list is bringing state physician licensing requirements—currently controlled by 50 state medical licensing boards—into the 21st century.
Telehealth comes in many forms. Traditionally, it involves a physician engaging in a care encounter with a patient at a remote location either by telephone or video hookup. Medicare reimburses providers at its regular rates for those activities, but only for the one-fifth of the U.S. population living in rural areas.
But over the past decade, telehealth has expanded to include remote readings of radiologic images, midnight intensive-care unit consultations and telephone outreach services by accountable care organizations and medical homes to manage people with chronic conditions. Hospitals have become major users of telehealth services, even when they aren't reimbursed.
And therein lies the rub. Telehealth is a disruptive technology that displaces traditional practice patterns and will substantially reduce some physicians' incomes, especially if they practice in isolation or small groups and remain disconnected from larger healthcare systems. A patient in an ICU who is being monitored with cameras and computerized charts by a remote physician doesn't require a local physician to come in at 3 a.m. to see how he's doing.
Other than the Veterans Affairs department, the federal government has been slow to embrace telehealth. The CMS still doesn't reimburse for the service in metropolitan areas.
It also doesn't reimburse at the same rates when services are delivered by a telehealth firm. Last week, the House Energy & Commerce Committee headed by Rep. Fred Upton (R-Mich.) finished drafting a bill that would pay telehealth firms the same rates as other Medicare providers, as long as the service substitutes for an in-person visit, reduces readmissions or enables the substitution of lower-cost services such as home health.
To protect the public purse, the legislation gives the CMS the right to refuse payment if it determines it would increase overall Medicare costs. Clearly, the bill's drafters are trying to answer concerns that telehealth providers are nothing more than the latest group looking for new ways to jump on the Medicare fee-for-service bandwagon.
Private insurers haven't had that experience in the 22 states and the District of Columbia that already require payment parity for telehealth services. Anthem, one of the nation's largest insurers, sits on the board of the Alliance for Connected Care, a telehealth lobbying group.
So do CVS Health and Walgreen Co., which see telehealth as a way to extend their medicine management programs.
But to practice telehealth across state lines, a physician or other licensed professional needs a license in the state where the patient resides. Telehealth firms have to get multiple licenses costing thousands of dollars for every physician they employ. Some states have imposed restrictive rules on telehealth practices, such as requiring that any patient receiving the service must have had prior physical contact with the physician at least once.
Bipartisan legislation introduced in the last Congress would have cut through that Gordian knot by allowing physicians to practice telemedicine as long as they were licensed in any state. Its backers likened it to reciprocity among the states on drivers' licenses.
Both that bill and the payment parity bill could get attached to the next physician payment fix, which comes due at the end of March.
Sensing the tide is running against them, the Federation of State Medical Boards, supported by the American Medical Association, has proposed a voluntary national compact on joint licensing for the states. Individual physicians could make one application for multiple state licenses—as long as the state was in the national compact, they paid each state's licensing fee and met each state's specific requirements.
This is states' rights on steroids. It will encourage local medical societies to set up more roadblocks to telehealth deployment. Many states won't join. The FSMB's approach will only keep telehealth on hold.
