Telemedicine's Explosive Growth Rate Belies its Penetration

Telemedicine has grown tremendously in the past five years in some rural areas. Yet barriers remain, and only a fraction of the population has access.

"Soccer is America's sport of the future," so that old joke goes, "and it always will be."

I am reminded that of that chestnut every four years as I follow the World Cup misfortunes of the U.S. men's team, and whenever the subject turns to telemedicine.

For so many years we've been talking about the potential of telemedicine, how it can improve population health and access and contain costs, particularly in rural America. Still, we've yet to achieve the sort of widespread utilization and population health benefits that many advocates have envisioned.

For example, a new study in JAMA examined claims data and found that telemedicine visits among Medicare beneficiaries increased by 28% each year from 2004 to 2013, and that 107,000 telemedicine visits were provided in 2013.

More than 40,000 rural Medicare beneficiaries received one telemedicine visit that year, with a mean of 2.6 visits each. That's pretty impressive growth.

Still, 107,000 telemedicine visits represent a fraction of 1% of the nation's 55 million or so Medicare beneficiaries.

There is a human face behind each of those 107,000 visits in 2013. The study found that the most likely users of telemedicine services were disabled beneficiaries with mental illness who were generally sicker and poorer than the average Medicare beneficiary.

Related: Forcing the Conversation on Behavioral Health

It also found that that the "vast majority" of these visits were for behavioral health services. The numbers aren't overwhelming, but for many of these vulnerable people telemedicine is a lifeline.

In tribal communities, such as the Fort Peck Indian Reservation in Montana, "initial internal reviews and anecdotal evidence suggest that the physical distance [of psychiatric consultations by videoconference] helps patients open up about difficult experiences more quickly than if they received therapy in-person, potentially speeding up treatment progress," according to the Billings Gazette.

Is the Glass Half Empty?  Or Half Full?

JAMA study lead researcher Ateev Mehrotra, MD, an internist, pediatrician, and associate professor of Medicine and Health Policy at Harvard Medical School, takes the half-empty/half-full approach to telemedicine.

"The glass half full perspective is that after all these years of conversation and interest in telemedicine, we see very steady and fast growth in the number of telemedicine visits that are provided for Medicare beneficiaries, despite all the restrictions and complaints about how the Medicare rules are outdated." Mehrotra says.

"The fact that there have been more than 100,000 of these telemedicine visits provided in the Medicare population is a big number if you compare it to things like bypass operations and other things in the Medicare population. From that perspective it is relatively big numbers."

"The glass half empty aspect is pretty much the opposite. Less than 1% of the Medicare population rural beneficiaries are being affected," he says.

"Yes, it is growing fast but it hasn't had a big population-level effect. It does take a while for things to take off and the numbers might be even higher in 2014 and 2015."

Mehrotra says some of the blame goes to Medicare for its conservative approach to expanding telemedicine. The Centers for Medicare & Medicaid Services limits payments for telemedicine care to patients living in rural areas who receive a live-video visit at a clinic or other facility.

"The reimbursement to the provider of a telemedicine visit is the same as an in-person visit, and on top of that there is a small additional fee that is given to the hosting site," he says. "The concern is that it is very limited in terms of who can get a telemedicine visit. The debate is often about why we are limiting this only to rural beneficiaries."

At the state level, the response has been uneven, with turf wars erupting over licensing requirements, regulation, efficacy, and scope of practice.

Even with that foot-dragging, progress creeps forward. More than half of the 50 states have passed parity laws mandating that telemedicine visits be reimbursed as the same level as in-person visits.

"Telemedicine is very geographically varied," Mehrotra says.

Barriers to Telemedicine Expansion

"In some states there are very high rates of usage, and in other states there are very few telemedicine visits. The question is why isn't it growing even faster? I don't know the answer to that question."

He says some explanations include the "crazy reimbursement structure" for telemedicine. "This plan may be covering it, and this plan may not," Mehrotra says. "So, as a physician, it is hard to go all in on telemedicine because you're not sure."

There are also issues around the quality of the technology. "In many of these rural communities they may not have the level of high-speed internet necessary to support a video teleconference," Mehrotra says.

Another reason is the ambivalence of physicians. Mehrotra says many physicians aren't sold on the efficacy of telemedicine, and that even when they support it, they may not have time to put it into practice.

"There is not a huge pool of doctors who are willing to do this," Mehrotra says.

"The average doctor it is not sitting in the office with lots of extra time on their hands to expand their business with telemedicine. Providers are busy enough, so when you already have a demand for in-person visits in your office you may not see a huge call for telemedicine visits in another county or state."

That has led to speculation that a growing number of physicians will dedicate themselves to telemedicine, rather than dedicating one or two days a week to remote care.

"I don't even know what the word would be. 'Telemedicinist?'" Mehrotra says.

"You are seeing a number of companies that are focused only on telemedicine care. They feel that the skill set necessary to provide telemedicine visits is different, and that you have to be fully committed to it as opposed to doing it here and there on the side like a hobby."

Of course, there's another huge problem with telemedicine. Nobody knows if it works. Anecdotal evidence suggests that it does, it passes the common sense test, and some smaller clinical tests have shown that telemedicine is just as effective as in-person visits in treating or monitoring conditions such as depression and diabetes.  

However, there is no evidence that telemedicine has improved the health of rural Medicare beneficiaries, in large part because there aren't enough rural Medicare beneficiaries using it. "The whole point is not that we are replacing in-person visits but that we are providing a complement for those rural beneficiaries who can't get in to see a provider," Mehrotra says. "We don't know if that has led to an improvement in health."

Despite all the stutter steps, Mehrotra has big hopes for telemedicine.

"When we think about telehealth to improve care, it doesn't always have to be a video visit. It could be text or email, or you answer a series of questions and do an e-visit," he says.

"It is a broad umbrella for telehealth and there is a lot of potential to improve access and improve the quality of care that we provide in rural communities and everywhere else in the nation. We are still figuring this out."