Resistance from regulators, restrictive licensing rules that make it difficult for doctors to practice in multiple states, and even push-back from physicians themselves stand in the way of telemedicine. But nothing seems to be able to stop it.
Spawned by the Internet and fueled by consumer interest in self-monitoring and videocasting, telemedicine—a broad term that covers a range of services including virtual visits and remote monitoring—is growing, despite some stubborn obstacles.
In Austin, MN, employees of the local school system can step into a booth at work, shut the door, and consult a doctor via video. Inside, the booth, they can put on blood pressure cuffs and instantaneously send the results to the Mayo Clinic, 40 miles away.
In Ohio, Cleveland Clinic is offering $49 virtual visits to patients who have an Internet connection and a video-enabled device. And University of Iowa Health Care just launched a telemedicine program last month.
Providers and retailers are racing to enter the space. Walgreens now offers $49 video visits via an app and a website. And companies like NowClinic and American Well are popping up to compete with established providers like Mayo Clinic.
Joseph Kvedar, MD
Joseph Kvedar, MD, vice president of the Partners' Center for Connected Health in Boston, says that at two recent health industry meetings "every panel and every conversation had something on telemedicine and virtual visits."
Telemedicine is taking off, but there is resistance from regulators in at least one state, and stubborn questions about reimbursement and efficacy in general.
One telemedicine provider, TelaDoc, is engaged in an ongoing legal battle with the Texas Medical Board, which wants to restrict video visits to follow-up care or doctor-to-doctor consults. Essentially, patients would have to see a doctor face-to-face first before interacting via video. In May, a federal judge blocked enactment of the rule until after the case goes to trial.
But, earlier this month, doctors from Texas convinced the American Medical Association to table a proposal for telemedicine ethics guidelines. The plan would have allowed virtual visits without a face-to-face encounter.
Who Will Pay?
Another barrier, says Kvedar, is reimbursement. He notes that the Centers for Medicare & Medicaid Services published a new chronic care management code in January that will allow physicians to bill for consulting patients via video.
UnitedHealthcare, the country's largest commercial payer said last month that it will offer coverage for virtual doctor visits to 20 million beneficiaries by next year. Anthem offers its own version of telemedicine.
For hospitals, the approach requires a strong relationship with primary care physicians and a solid electronic health records system, Kvedar says.
Though the full value of remote monitoring remains unknown, "Patients love this stuff," Kvedar says. "Uniformly, you get high patient satisfaction scores when you offer these kinds of programs. They feel more connected, they feel more special and they feel like their doctors are really looking after them."
Matt Bernard, MD, a primary care physician and one of Mayo's primary care service line chairs, agrees. "So far, they love it," he says of the patients using the Health Connection kiosk program, which is just one element of Mayo's telemedicine program. "They love the convenience, they feel like they are getting good service and it's a time-saver."
As long as checks and balances are in place, doctors can deliver good care through telemedicine, he says. Like others, Bernard notes that reimbursement is an issue. "The constant tension is how we can afford to do this in the current reimbursement model."
Healthcare's Convenience Revolution
Bundled payment models, which are less procedure-specific, may improve access to telemedicine. But even supporters of this approach say the true benefits of virtual visits are not well established. Testifying before a Congressional committee last year, Harvard Medical School professor Ateev Mehrotra, MD, MPH, said more population-based quality studies, rather than studies specific to one type of care, are need to ensure the benefits of telemedicine.
He called for "more ongoing evaluation of telehealth and on what works and what doesn't work." Still, he defined the rise of telemedicine as part of the "convenience revolution in healthcare."
Karen Rheuban, MD, director or the Center for Telehealth at the University of Virginia calls telemedicine with its live, interactive, and video conferencing capabilities, a "transformational tool." For example, real-time video connections can improve the timely diagnosis of stroke, and the delivery of mental health services.
But she says that while there is data supporting many of the approaches to telemedicine, such as some patient monitoring tools, more research is needed in what she describes as "direct-to-consumer telemedicine. The evidence needs to be created and evaluated in terns of safety and efficacy."
In the meantime, hospitals and doctors are moving forward. Kvedar says that he sense a change in the attitude of hospitals administrators toward the advent of connected health has changed from "downright skepticism" to healthy skepticism.
"The tenor or the discussion is essentially, 'We know this is coming, we have to learn by doing, we'll figure out the details of how we are going to get paid and how it will work… 'If we don't start doing and stop talking, we're going to miss the boat."
"We need to meet the patients where they want to be met." he says. In terms of telemedicine: "We need to define it or someone else is going to define it for us. "