One-on-one Web-based video chats and other electronic consultation between doctors and patients isn’t new — it’s been used throughout the U.S. in varying degrees for a few years now. But health-care reform, a ballooning and aging population and a shortage of available family physicians may be a perfect storm that could blow the doors open for telehealth to go mainstream.
As states’ health insurance exchanges — online marketplaces where citizens can compare and purchase insurance plans — begin to debut in advance of the 2014 deadline set forth by the Affordable Care Act (ACA), access to health-care providers should expand for many Americans. Obtaining insurance coverage soon may be easier, but the gap between the number of incoming patients and available primary care doctors is widening.
According to a 2006 report from the American Academy of Family Physicians, the U.S. will have a shortage of at least 39,000 family physicians by 2020 — a figure compiled before the passage of the ACA, which mandates that most Americans purchase health insurance.
Improved fiber-optic lines and faster broadband connectivity have allowed telehealth to supplement face-to-face care, which could help put a dent in the projected shortage of primary care physicians in the U.S.
With the convenience of telehealth, doctors can practice online before and after normal working hours, ultimately serving more people. Whether it’s retired doctors who would still like to practice, physicians who’ve stopped practicing due to family commitments, or doctors who simply want to expand the scope of their business, the technology can help increase the pool of available primary care physicians.
Some industry representatives view telehealth as distinct from telemedicine in that the latter pertains to multiple physicians using electronic communication methods to discuss topics or patients among themselves. Telemedicine has been used for decades.
Experts believe that telehealth may become an essential alternative in order to diagnose and prescribe treatment for common ailments.
Roy Schoenberg, a medical doctor and CEO of American Well Systems, a provider of telehealth technology, believes health-care consultation via the Internet has the potential to move the needle on health-care delivery. And that’s particularly true in light of the 30 million more consumers expected to impact the health-care system in 2014 due to the ACA’s insurance mandate.
“You are not only creating efficiency inside the health-care system, you have the potential of redistributing health care completely,” Schoenberg said. “You are rewriting the map of accessibility to health-care services using technology.”
Glen Stream, president of the American Academy of Family Physicians and a family physician in Spokane, Wash., agreed. He stopped short of calling telehealth a “substitute” for in-person interaction with a patient, but recognized the benefits technology can bring to a medical practice.
For example, Stream said a face-to-face visit likely isn’t necessary for patients he knows well and is familiar with their ongoing medical conditions. A phone call or short video conference could give him all the information he needs in order to make decisions on future treatment.
“The capability [of telehealth] can extend convenience to the patients but also could potentially expand the ability of the practice to take care of folks,” Stream said. “One of the areas where this could be especially helpful is in rural areas.”
Eric Brown, president and CEO of the California Telehealth Network, said telehealth is already bridging a service gap in California, particularly in underserved rural and urban areas that don’t have the physicians to meet the care demands of the patient population.
The California Telehealth Network works with stakeholders to establish broadband connectivity for communities so technology services can be used to improve the quality of health care. The organization has helped establish more than 350 telehealth sites in the state.
Challenges
Despite the benefits that online remote health care can provide, a number of hurdles still exist before telehealth becomes a widespread practice in the U.S. Licensure of doctors and reimbursement of telehealth services are two issues at the top of the list.Doctors practicing telehealth need to be compliant with the laws and regulations of the state in which the patient is located. A doctor in Virginia wouldn’t have a problem using telehealth for an in-state patient, but medical facilities near state borders could encounter some legal issues if a patient lives in North Carolina, West Virginia or Maryland.
According to Greg Billings, executive director of the Center for Telehealth and e-Health Law, 12 states currently have a special license that physicians can apply for, or a streamlined licensure process that will allow them to give direct care to patients in other states through telehealth.
Further, a doctor is required to establish a physician-patient relationship in order to prescribe medications. Only 12 states allow an electronic examination to meet the requirements of a face-to-face examination.
Billings said doctors practicing telehealth and prescribing to patients in the 38 states that don’t have an electronic examination law on the books, may be in violation of state law.
Brown added that the issue of practicing teleheath across state lines is a contentious subject among some of the California Telehealth Network’s members. Predictably in-state doctors would lose business from patients who choose another to get their medical care from doctors in another state.
“If you are California-licensed and credentialed doctor, you’re not really happy that all of a sudden providers [could] go out of the state to get their needs met,” Brown said. “I think it’s inevitable and I think the marketplace will ultimately prevail if it’s allowed to.”
On a national level, U.S. Sen. Tom Udall, D-N.M., is considering legislation to make it easier for doctors to practice telehealth. Government Health IT reported in February that the proposed legislation would streamline the portability of licensure across state lines. As of September, a bill had not been introduced.
When contacted by Government Technology, Jake McCook, Udall’s deputy press secretary, indicated that the senator’s staff still is working on the bill and that it would eventually be introduced.
Show Me the Money
Payment for telehealth services presents an additional roadblock to telehealth expansion. Only 15 states have legislation requiring health insurance providers to recognize claims for services rendered through telehealth.Michigan and Maryland are the two newest states to enact such a law. California passed a similar law in 2011.
Brown called the issue of reimbursement “the most formidable” of the obstacles preventing telehealth from taking root in the U.S. Billings agreed and explained that the reimbursement legislation some states are passing doesn’t require insurance companies to do anything new.
In the 15 states that have authorized reimbursement of telehealth services, if an insurance policy covers an in-person medical visit and the physician feels they can treat the policyholder using telehealth, then an insurance company can’t deny payment of that electronic visit.
“I think more and more states are going to do that,” Billings said. “Michigan cropped up organically, with a member of the [state] legislature grabbing onto it. We are taking a look at it as well — to make sure that all the other states are educated on this issue and can conceivably move forward on it.”
