The Promise of Telemedicine Runs Into Reality, IOM Panelists Say

The Promise of Telemedicine Runs Into Reality, IOM Panelists Say

By Jane Norman, CQ HealthBeat Associate Editor

An estimated 10 million patients in the United States are served by telemedicine each year, but expanding its reach further and making it an integral part of the health care system will remain a challenge without changes in reimbursement policies and state licensing, panelists said at an Institute of Medicine workshop Wednesday.

Yet plenty of ideas abound, such as using relatively inexpensive personal devices like tablets or cell phones for increased remote monitoring of patients’ chronic conditions, or teledentristy for conducting dental examinations, or even telesurgery using robots directed by a surgeon at a remote console.

The Supreme Court decision upholding the health care law was regarded as a plus for telemedicine because the law seeks to modernize the traditional medical system and increase innovation, including telemedicine pilot projects through the Centers for Medicare and Medicaid Services (CMS). Advocates, though, remain dissatisfied that telemedicine is barred by regulation from playing a major role in the operation of Medicare accountable care organizations.

Telemedicine, in which patients are treated by a provider at a remote site through the use of telecommunications technology, has been in use for decades in the United States. The idea dates back to 1879, when an article in the British journal Lancet discussed how to use the telephone to reduce unnecessary physician visits, said Thomas Nesbitt, a professor of medicine at the University of California, Davis.

Most often it’s used for patients in rural areas, and Nesbitt said that the biggest need is for treatment of people with costly chronic conditions. Traditionally such patients are treated in doctors’ offices when their conditions demand it, rather than in a structure that manages care using frequent patient contact and assessment, he said. The Department of Veterans Affairs health care system has developed a successful system to use telemedicine to treat veterans who live in remote areas and recently eliminated copayments for video health care.

Other common uses of telemedicine are to monitor diabetes or hypertension, perform radiological scans, read pathology slides and prescribe drugs.

The workshop, organized by the Health Resources and Services Administration (HRSA), was intended to look forward and determine what the Department of Health and Human Services should do next, what the special implications of telemedicine are for rural areas and what the evidence shows works in telemedicine.

Jonathan Linkous, CEO of the American Telemedicine Association, said that in its early days, telemedicine was based out of academic medical centers or the largest hospitals. That’s greatly expanded and telemedicine has been absorbed into the larger health care system, including doctor offices, he said.

But there remain “deadly barriers,” including money, regulations, hype and even success, Linkous said. Most Medicare reimbursements for telemedicine remain limited to rural areas rather than underserved urban areas out of fears that overuse or abuse might result, he said. Managed care, with the exception of the VA, does not make much use of telemedicine to control costs, he said. Some companies that see opportunity in telemedicine come into the market without sufficient knowledge or background.

Telemedicine faces problems in operating across state lines because doctors generally must obtain licenses in each state where they practice, despite practitioners who may practice in multiple states and providers that are forming nearly national systems. Linkous said some state regulators now are even requiring in-state consultations with doctors before patients can use telemedicine.

“I think that licensure is a big problem; we need to address that,” Linkous said.

Gary Capistrant, senior director of public policy for the telemedicine association, said people in remote states who need the services of specialists are hindered in their access to providers. The solution for some doctors is multiple state licenses. He said he met an ophthalmologist recently with 15 state licenses. But Capistrant said that “there is a huge price to that” and the system is doing more harm to patients than good. “We can’t even get some states to allow for a physician to talk to another [out of state] physician without being licensed in that other state,” he said.

Other states have adopted a telehealth license, but telemedicine should not be regarded as some subspecialty of medicine, Capistrant said.

CMS is funding the formation of accountable care organizations, but telemedicine faces problems because of numerous Medicare restrictions on how it can be used, Linkous said. Generally, the restrictions take the form of Medicare not reimbursing for telemedicine services for patients in metropolitan areas even if the area is underserved. Linkous said that even though CMS officials have talked up the use of telemedicine in ACOs, they have not waived the restrictions on its use as a central component of health care.

Linkous also said advocates of telemedicine can be “victims of our own hype” because they talk about studies showing telemedicine works, but not the ones that might show some attempts don’t work.

“There are areas in telemedicine that cost too much,” he said. “There are applications that might not work right. If we are going to get serious . . . we have to get serious about this and face these issues.”

Mary Wakefield, HRSA administrator, said she wants to encourage the discussion of telehealth’s role in the health care overhaul. “The importance of this will continue to grow, especially as more and more people in rural and isolated areas across the United States are able to seek a full complement of health care services,” she said.