Outdated laws and other obstacles have prevented providers from being able to use telemedicine to reach patients to its full potential, but with healthcare reform in full swing, those barriers are slowly disappearing.
This article appears in the May, 2014 issue of Medicine on the Net.
With more than 7 million people signing up for coverage under federal healthcare reform and millions more gaining coverage under Medicaid Expansion, providers now need to reach more rural patients than ever before. But providers and payers in many states are still struggling with outdated laws and other obstacles in their effort to reach patients in remote areas.
But experts say those barriers to care are slowly disappearing as more states pass laws to allow Medicaid to reimburse providers. That effort is also being helped by pilot programs launched by providers and insurers in an effort to improve care and generate savings by allowing rural residents to address health problems before they get worse.
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Investing in pilot programs
The Center for Connected Health helps promote the use of telemedicine in the U.S. and advance legislation that makes it easier for payers and providers to take part in programs. Those efforts hinge in large part on what the Centers for Medicare & Medicaid Services (CMS) decides to invest in.
"When it comes to being reimbursed for healthcare services, it starts with CMS," said Joseph C. Kvedar, MD, director of the Center for Connected Health. "Most telemedicine is in the pilot phase and not part of any regular reimbursable CPT codes."
One major barrier to creating new programs is lack of solid data that shows they can generate cost savings for government programs. That's one of the reasons CMS has been cautious about approving new plans. "CMS has been slow to create CPT codes for telemedicine services, which would facilitate providers being reimbursed, because a very clear connection between the service and it improving clinical outcomes is needed.
This can be tricky for telemedicine to improve, but CMS is still investing in pilots to determine just that. Once there is adoption by CMS, then adoption will occur with other payers."
Another problem at the federal level is the lack of a common language among different federal agencies on how telemedicine is defined. That has become more difficult as new areas of care such as remote patient monitoring enter the picture to create new categories of care.
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A new federal study titled Federal Efforts to Define and Advance Telehealth – A Work in Progress, looked at how different agencies define telehealth. It found that the CMS and National Coordinator of Health IT defined telehealth as "the use of telecommunications and IT to provide access to diagnosis, health assessment, information, and patient care." The Health Resources and Services Administration defined it as "the use of electronic information and telecommunications technology to support long-distance health."
The report noted that "while many definitions are similar, there are nuanced differences that reflect each organization's legislative intent and the population they serve." It added that "these definitions affect how telemedicine has been or is being applied across the healthcare landscape" and concluded that "a common nomenclature for defining telemedicine may benefit efforts to advance the use of this technology to address the changing nature of healthcare and new demands for services expected as a result of health reform."
Template for other states
Rather than waiting for CMS to establish policy for telemedicine, individual states are taking the initiative by adopting laws that make it easier to form telemedicine programs.
California is often used as a template for other states to follow. In 2011, state legislators approved the California Telehealth Advancement Act, which paved the way for telemedicine by defining remote consults in the same terms as face-to-face visits with physicians to make it easier for insurers to compensate participants.
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The Act also allowed the state to compensate providers who used telemedicine programs that employed store-and-forward technology. As a state with 36 million people and a large percentage of residents who live in rural areas, California had a greater need for telemedicine services than most states and acted accordingly.
"California payers and providers have been much quicker to embrace telemedicine in order to reach rural patients," said Margaret Laws, director of the Innovations for the Under-Served program at the California HealthCare Foundation. "And it's been at the forefront
in terms of adopting legislation that makes creating new telemedicine programs easier."
The state has more than a half-dozen telemedicine programs including pilot programs for dentistry, dermatology, and eye care. Other more ambitious pilots include a tele-ICU program established by John Muir Health and a pediatric ICU program being headed by the UC Davis Health System.
But even California is falling short in some areas.
"One thing California has not done yet is create policies that would allow for remote patient monitoring programs to reimbursed," said Mario Gutierrez, executive director for the Center for Connected Health Policy (CCHP). "With a few exceptions, just about every state is lagging in some areas."
State-by-state breakdown
To help providers keep up with what's happening in telemedicine across the U.S., the CCHP created the State Telehealth Laws and Reimbursement Policies,a section of its website that provides a comprehensive scan of telemedicine laws with a state-by-state breakdown.
"Some states have incorporated policies into law, while others have addressed issues such as definition, reimbursement policies, licensure requirements, and other important issues in their Medicaid Program Guidelines," Gutierrez said in his introduction to the latest report released in February 2014.
The report shows that 46 state Medicaid programs currently reimburse providers for some form of medicine using live video. Nine states offer Medicaid reimbursements for providers involved in telemedicine programs using store-and-forward technology.
And 11 states reimburse providers who use remote patient monitoring to care for patients after they're discharged from a hospital or rehab facility. Only two states—Alaska and Minnesota—currently reimburse providers through Medicaid for all three areas.
Bellwether for change
Gutierrez said that, in addition to CMS getting more involved, major providers are leading the way with programs designed to show that telemedicine can improve outcomes and save money.
Kaiser Permanente, which has 9.1 million health plan members and dozens of hospitals and medical centers in eight states, recently launched a program called HouseCalls. The program allows patients to conduct 20-minute physician visits from their homes and is available in Virginia, Maryland, and Washington, D.C.
Kaiser also has teledermatology programs operating in Colorado and California that allow primary care physicians to send high-resolution photos of moles and skin lesions to dermatologists by email, avoiding the need for many patients to schedule unnecessary visits.
"[Kaiser is] a bellwether for what's happening," said Gutierrez. "I think we're going to see more wellness-based systems like Kaiser's because they are value-based and save money in the long run."