Friday's decision by the Texas Medical Board to limit the practice of telemedicine runs counter to the direction being taken in most states, which are seeking to expand the use of such services to increase healthcare access and reduce costs. Many observers predict the Texas rule will have little effect on the growth of telemedicine in the rest of the country.
The Texas board, with the support of the Texas Medical Association, voted to finalize rules effective in June requiring Texas physicians to have an in-person visit with a patient before they can provide healthcare services through telecommunication technologies.
The Texas Medical Association, in a letter to the board, said safeguards were needed “to protect patients and ensure telemedicine complements the efforts of local healthcare providers.”
But critics say the new rule will hurt healthcare access for patients in a state that already has the country's highest uninsured rate and many rural areas with provider shortages. “We feel like it's going to be really negative for consumers,” said Krista Drobac, executive director of the Alliance for Connected Care, a Washington, D.C.-based lobbying group for the growing telehealth industry. “At some point there's going to be a realization that we're limiting access, and hopefully things change then.”
Teladoc also attacked the rule. “Unfortunately, the Texas Medical Board's decision to adopt a new rule takes away Texans' access to a safe, affordable and convenient healthcare option that many have depended upon for more than a decade,” the company said in a written statement. “As Texas' population booms, healthcare expenses climb, and the shortage of primary-care physicians grows, telehealth is a solution for patients dealing with common, non-emergency issues. This rule change only serves to intensify these problems without providing any benefit to Texans.”
Under the new rule, Texas physicians could use telemedicine when treating patients for the first time if the patient is already at a medical setting, such as a hospital or clinic, and another healthcare provider is with them to assist. Behavioral healthcare providers are exempt from the restrictions. The restrictions focus on defining how the relationship between provider and patient is established. The board rule says such a relationship cannot be established through “email, electronic text, or chat or telephonic evaluation of or consultation with a patient.”
The state's rule appears to diverge from guidance issued last year by the Federation of State Medical Boards, which defined the beginning of a doctor-patient relationship as “when an individual with a health-related matter seeks assistance from a physician who may provide assistance.”
The federation defined an established relationship as one where “the physician agrees to undertake diagnosis and treatment of the patient, and the patient agrees to be treated, whether or not there has been an encounter in person between the physician (or other appropriately supervised healthcare practitioner) and patient.”
In 2011, the Texas board threatened to discipline doctors working for Dallas-based telemedicine firm Teladoc for prescribing drugs to patients they had not seen in person. Teladoc sued, and won a temporary injunction while the board went through a rulemaking process. This latest vote follows an emergency rule issued by the board in January that required physicians to see a patient for an in-person visit before prescribing drugs.
Drobac said the Texas board's decision would have little impact on how other states regulate telemedicine. There is no indication other states are looking to adopt similar limits. “The direction that the federal government and most other states are going is the opposite of Texas,” she said.
The Texas board's rule was backed by the Texas Medical Association, which said it would help toward ensuring patient safety. “The Texas Medical Association applauds the Texas Medical Board for adopting rules to clarify and strengthen the standard of care for physicians using telemedicine to care for patients,” TMA President Dr. Austin King said in a written statement. “TMA appreciates the board's clarification that a face-to-face visit—either in person or via telemedicine—is required to establish a patient-physician relationship, while expanding the locations where telemedicine services may be used and carving out certain exceptions for mental healthcare services.”
But at a public hearing on the rule last Thursday, Bill Hammond, CEO of the Texas Association of Business, said the restrictions would “drive a stake through the heart” of telemedicine in Texas at the same time as many businesses are searching for ways to provide affordable healthcare to their workers. “This proposal is bad for business, bad for healthcare, bad for consumers.”
Meanwhile, a number of states are joining the Federation of State Medical Board's interstate compact for streamlining the process for doctors to obtain medical licenses in multiple states, with the goal of removing a barrier to the growth of telemedicine. The streamlined process would help facilitate the practice of telemedicine because states involved follow the policy that the practice of medicine occurs where the patient is located and not where the doctor is based. The compact will help deal with redundant licensing requirements by creating one place where physicians need to submit basic information such as education credentials.
The telemedicine industry is experiencing explosive growth. An August 2014 Deloitte study predicted 75 million virtual visits in North America in 2014 and as many as 300 million visits a year. Thirty-seven percent of employers planned to offer their workers telemedicine consultations in 2015, and another 34% planned to do so by 2017, according to a 2014 Towers Watson survey.