Is Healthcare Delivery Finally Back-to-the-Future?

The Telemedicine Revolution is Here

Year after year of big promises, telemedicine is finally living up to its potential!!

Being driven by faster internet connections, ubiquitous smartphones and ever-changing insurance standards, more health and dental providers are turning to electronic communications to do their jobs—and it’s upending the delivery of the health care system.

Doctor and dentists are linking up with patients by phone, email and webcam. They’re also consulting with each other electronically—often making split-second decisions on heart attacks and strokes. Meanwhile, patients are using devices to relay their blood pressure, heart rate and other vital signs to doctors so that they can manage chronic conditions at home.

Telemedicine also allows for better care in those rural locations where medical expertise is hard to come by.

At least ten times each and every day, Doctors Without Borders relays questions about tough cases from its physicians in Niger, South Sudan and elsewhere within its network of over 280 experts around the world, and back again via the internet.

In the many rural communities across the country, shifts of doctors and nurses work around the clock in “virtual care centers”… “hospital without beds” providing remote support for intensive-care units, emergency rooms and other programs in smaller hospitals from North Carolina to Oklahoma. Many of them without a 24/7 on-site physician.

Critical-care doctors sit at oversize video monitors, continually collecting data on far-flung ICU patients and watching for signs of imminent trouble. If a patient needs attention, physicians can zoom in via two-way camera—close enough to read the tiny print on an IV bag.

In the past eighteen months, ICUs monitored by specialists have seen a 35% decrease in patients’ average length of stay and 30% fewer deaths than anticipated. That translates to 1,000 people who were expected to die who got to go home instead.

As a measure of how rapidly telemedicine is spreading, consider: More than 15 million Americans received some kind of medical care remotely last year, according to the American Telemedicine Association, a trade group, which expects those numbers to grow by 30% this year.

This is not to say that telemedicine has found its way into all corners of medicine. A recent survey of 500 tech-savvy consumers had found that 39% hadn’t heard of telemedicine, and of those who haven’t used it, 42% said they preferred in-person doctor visits. In a poll of 1,500 family physicians, only 15% had used it in their practices—but 90% said they would provided they were appropriately reimbursed.

What’s more, for all the rapid growth, significant questions and challenges remain. Rules defining and regulating telemedicine differ widely from state to state and are constantly evolving. Physicians groups are issuing different guidelines about what care they consider appropriate to deliver in what forum.

Some critics also question whether the quality of care is keeping up with the rapid expansion of telemedicine. There’s also the question of what services physicians should be paid for: Insurance coverage varies from plan to plan, larger federal plans cover only a narrow range of services.

Telemedicine’s future depends on how—and whether—regulators, providers, payers and patients can address these challenges:

Are patients trading quality for convenience?

The fastest-growing services in telemedicine connect consumers with clinicians they’ve never met for one-time phone, video or email visits—on-demand, 24/7. In the case of a dentist treating obstructive sleep apnea and looking to meet requirements of a “face-to-face” physician visit, telemedicine eliminates the need for the patient to make a trip to the physicians office and, from a cost perspective, the telemedicine consult costs around $45, compared with approximately $100 at a doctor’s office.

Many health plans and employers have rushed to offer the services and promote them as a convenient way for plan members to get medical care without leaving home or work. Nearly three-quarters of large employers will offer virtual doctor visits as a benefit to employees in 2017, up from 48% this year.

Web platforms such as Teladoc, Doctor on Demand and American Well are expected to host some 1.2 million such virtual doctor visits this year, up 20% from last year, according to the American Telemedicine Association.

But, there is always the concern that such services may be sacrificing quality for convenience. Consulting a random doctor patients will never meet, they say, further fragments the health-care system, and even minor issues such as upper respiratory infections can’t be thoroughly evaluated by a doctor who can’t listen to your heart, culture your throat or feel your swollen glands.

In the May 2016 JAMA Dermatology, researchers posing as patients with skin problems sought help from 16 telemedicine sites—with unsettling results. In 62 encounters, fewer than one-third disclosed clinicians’ credential or let patients choose; only 32% discussed potential side effects of prescribed medications. Several sites misdiagnosed serious conditions, largely because they failed to ask basic follow-up questions.

The American Telemedicine Association and other organizations have started accreditation programs to identify top-quality telemedicine sites; the association also tells consumers to be wary of sites that sell products.

The American Medical Association has already began approving new ethical guidelines for telemedicine, calling for participating doctors to recognize the limitations of such services and ensuring that they have sufficient information to make clinical recommendations.

Who pays for the services

While employers and health plans have been eager to cover virtual urgent-care visits, insurers have been far less willing to pay for telemedicine when doctors use phone, email or video to consult with existing patients about continuing issues.

Thus far, 32 states have passed “parity” laws requiring private insurers to reimburse doctors for services delivered remotely if the same service would be covered in person, though not necessarily at the same rate or frequency. Medicare lags further behind. The federal health plan for the elderly covers a small number of telemedicine services—only for beneficiaries in rural areas and only when the services are received in a hospital, doctor’s office or clinic.

Bills to expand Medicare coverage of telemedicine have bipartisan support in Congress. Opponents worry that such expansion would be costly for taxpayers, but proponents say it would save money in the long run—as much as $2 billion over 10 years.

Doctor-to-doctor consultations are also seldom covered by insurers. Health systems such as Mercy, the Mayo Clinic and the Cleveland Clinic that provide oversight and expertise on strokes, intensive-care units and other specialty care to networks of smaller hospitals typically charge those facilities a monthly fee, which generally cannot be charged to patients.

These arrangements enable small hospitals to provide top-flight care to patients on-scene and to suggest that they partner with world-class health-care systems. And it’s less expensive than hiring their own specialists…a win-win…win!!!!

With the 2016 election behind us, the future of ACA is uncertain and the likelihood of HMO becoming more prevalent, hospitals are likely to invest in telemedicine systems to move away from fee-for-service payments and prepare for managed-care-type contracts that give them a set fee to provide care for patients and allow them to keep any savings they achieve.

Is the state-by-state regulatory system outdated?

Historically, regulation of medicine has been left to individual states. But, more and more, the 50 states set of fees, licensing fees and even definitions of “medical practice” makes less sense in the era of telemedicine and is hampering its growth.

Currently, doctors must have a valid license in the state where the patient is located to provide medical care, which means virtual-visit companies can match users only with locally licensed clinicians. It also presents administrative hassles for world-class medical centers that attract patients from across the country.

At the Mayo Clinic, doctors who treat out-of-state patients regularly follow-up with them via phone, email or web chats when they return home, but they can only discuss the conditions they treated in person. If the patient wants to talk about a new problem, the doctor has to be licensed in that state to discuss it. If not, the patient should talk to his primary-care physician about it.

To date, 21 states have joined a compact that will allow a doctor licensed in one member state to quickly obtain a license in another. While this move is welcoming to some, some telemedicine proponents would prefer states to automatically honor one another’s licenses, as they do with drivers’ licenses.

But states aren’t likely to surrender control of medical practice any time in the near future, and most are considering new regulations. So far, in 2016, more than 200 telemedicine-related bills have been introduced in 42 states, many regarding what services Medicaid will cover and whether payers should reimburse for remote patient monitoring as well as store-and-forward technologies (where patients and doctors send records, images and notes at different times) in addition to real-time phone or video interactions.

What counts as practicing medicine?

The exploding volume of health information on the internet is raising new questions about what constitutes the practice of medicine. Some web-based businesses enable consumers to consult doctors overseas, who don’t have U.S. medical licenses, but post fine-print disclaimers that they are providing information and not medical advice.

Are such services “practicing medicine” without a license? The exact definition varies from state to state, and state medical boards generally don’t investigate unless a patient files a formal complaint. Even then, boards have jurisdiction only over individual doctors licensed in their state, not companies, or physicians overseas.

How will this change competition?

Telemedicine is shaking up traditional relationships between providers and payers and fueling the rise of medical “megabrands” whose experts are increasingly competing for patients in each other’s backyards.

Insurers such as Anthem and UnitedHealth Group are offering their own direct-to-consumer virtual doctor-visit services, rather than simply paying for plan members to use those from web-based vendors. Major health systems are making their physicians available for virtual follow-ups and chronic-disease management, as well as urgent-care visits, to new and existing patients.

Endeavor Health is working with our medical doctor clients to create a “Clinic in the Cloud” that would allow rural and incapacitated patients across the country to access physicians without going to an actual office . This will open up a world of relationships across a spectrum of health-care providers that we haven’t seen to date!


If your practice or health organization sees telemedicine in your future #weshouldtalk