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Wednesday Mar 12, 2014

Barriers Impede Telemedicine's Potential

Editor's note: During the AAFP's Scientific Assembly in San Diego, a panel discussion on practice transformation generated far more questions than the panelists could answer in the time allotted. This is the fourth post in an occasional series that will attempt to address the issues members raised -- including payment for telemedicine -- during the panel.

We know that telemedicine, the use of technology to deliver care at a distance, has the potential to expand access to care in underserved areas, reduce ER visits and save patients time. Questions remain, however, about how we can best expand telemedicine's use in primary care.

Telemedicine already is used in subspecialty care, including dermatology and radiology. But in our current fee-for-service model, can telemedicine be integrated into primary care without significantly increasing health care costs?

Kimberly Becher, M.D., left, the resident member of the AAFP Board of Directors, accompanied me on a trip to Capitol Hill while I was a visiting scholar at the AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care. I interviewed more than a dozen representatives of federal government health agencies and congressional staff about telemedicine for my project.

I recently spent a month in Washington researching telemedicine and the barriers to its expansion as a visiting scholar at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. Participating in the Larry A. Green Visiting Scholars Program was an invaluable educational experience, and I acquired skills that will help me for the rest of my career. The Graham Center staff provided me with in-depth training on research, including how to plan a project from beginning to end, proposal writing, information and data gathering, manuscript writing and more.

The training actually started months in advance as I worked with Graham Center staff to define what my project would be so that I could hit the ground running when I arrived in Washington for one month of intense work.

I picked telemedicine as my topic, in part, because the Graham Center was already in the midst of a research project on the subject. Funded by a $200,000 grant from WellPoint, the project produced a literature review, a report from the meeting of an expert panel, and -- coming later this year -- a survey of AAFP members about our knowledge and use of telemedicine.

It is hoped that the member survey results and my manuscript will be published in peer-reviewed journals. The Academy also intends to share the report from the expert panel.

For my project, I interviewed 14 representatives from government health care agencies and congressional staff to gauge their understanding of telemedicine and to identify barriers to its expansion in primary care and what is required to move beyond those barriers.

Barriers, it turns out, are not in short supply. One of the biggest issues is payment because of the constrained rules that exist in the current payment systems. There are certainly ways that telemedicine can be integrated into care delivery now, but I hope with alternative payment models on the horizon -- where physicians are paid based on quality and value -- we will see more physicians use it to deliver care at a lower cost for their patients.

Reimbursement for telemedicine services vary widely by payer and state. Ten states require Medicaid coverage of telemedicine, and 43 states require Medicaid coverage for some telemedicine services. Eighteen states mandate private payer coverage for telemedicine, and 14 other states have legislation pending.

But telemedicine is complicated in many other ways. According to the American Telemedicine Association, more than half the state legislatures are considering bills related to telemedicine. One of the most prevalent issues is licensure.

In Florida, for example, the state medical association has said that it supports the expansion of telemedicine, but the association is lobbying against a bill that seeks to create statewide standards and establish reimbursement requirements for telemedicine. The association is fighting the bill, which also would create a system for registering out-of-state physicians, because it opposes the idea of physicians licensed in other states treating Florida patients via telemedicine.

That's a significant issue in Florida because of the annual migration of people who spend the winter months in the Sunshine State.

What's at stake? A nonpartisan, nonprofit public policy research institute released a report this month that said reducing costly interventions, such as ER visits, by as little as 1 percent could reduce the state's health care costs by $1 billion a year.

Among my interview subjects, there was broad recognition that telemedicine is an important issued related to access to care. But another barrier we must overcome is that many rural and underserved parts of country still don’t have access to broadband internet. That's important because although the "tele" in telemedicine might prompt people to imagine a physician on a telephone, there's much more to it. Telemedicine can involve video conferencing with a patient from his or her home, electronic monitoring of chronic conditions and so much more. The fact that telemedicine means different things to different people could be a barrier as well. There's no consensus on what the term actually means.

That's unfortunate because more than 50 percent of U.S. hospitals already are using telemedicine in some manner. Incorporating the use of this technology in care delivery is happening, and it will continue to expand, so we have to figure out how it fits in primary care.

A good step forward would be finding a way to expose medical students and family medicine residents to telemedicine. I'm a fourth-year medical student and have yet to experience it. Medical school and residency is where we get our feet wet, and the models we train in influence how we will practice later.

We have the technology and the ability to extend ourselves, improve access to care and save our patients time and money, but there are many questions left to answer. I hope that when the Graham Center's survey lands in your in-box later this year, you will take a few minutes to give us your thoughts on telemedicine. The more people who participate in this important survey, the more valuable our data will be.

Tate Hinkle is the student member of the AAFP Board of Directors.

Comments:

Actually, the main barrier for me is complying with HIPAA and privacy regulations which in my opinion stifle the practice of medicine immensely. I have a private cash-only "boutique" practice so payment is not a limitation for me. I would love to use Skype or Facetime with patients, but these are not HIPAA compliant technologies. I often have people traveling who have acute illnesses and want my advice. I recently had a woman in Myanmar who had no cell phone access but did have email and wifi access - she had gastrointestinal illness and it would have been great to Skype with her. I have a college student calling in by phone this afternoon to discuss recurrent bouts of abdominal pain - ? gallstones - her mom asked me if I could do Facetime with her but I had to apologize and say no - not HIPAA compliant. I think Facetime would help me out immensely in this situation. College freshman, I am thinking IBS, abdominal migraine, gastritis? Make sure to ask about regulatory burden and privacy as a barrier for telemedicine.

Posted by Chris Flores on March 12, 2014 at 03:42 PM CDT #

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.