As technology advances at an ever-increasing rate in the 21st century, opportunities are opening up for healthcare professionals to expand their reach and treat more patients than ever before. With a growing market of mobile medical apps, it is possible for a physician to schedule an appointment, view a patient’s medical history, diagnose and treat an illness, remotely monitor the patient and conduct follow-ups all from a single convenient handheld device. Coupled with improved two-way video communication that can break down geographical barriers, there appears to be a vast potential for the growth of telemedicine over the next decade. However, there are still hurdles that need to be cleared before telehealth services can become as commonplace as traditional face-to-face visits. In particular, medical practitioners must navigate a confusing framework of state regulations that vary widely in matters of licensure and reimbursement. Practitioners must also exercise caution to protect themselves and their patients by maintaining HIPAA compliance and ensuring that their medical malpractice insurance covers telemedicine services.
There is very little doubt that a market exists for telemedicine services. The free medical resource website WebMD sees an average of more than 12 million visitors monthly, making it the most visited health-related website and one of the most visited websites overall in the United States. Many of these visitors are trying to diagnose and treat their own medical issues in an effort to save the money or time it would take to visit a primary care physician. Conversely, physicians and other practitioners spend a portion of their day in face-to-face visits with patients who have minor ailments that could be treated more quickly and efficiently through an online visit. A 2014 report published by Deloitte estimated that more than 100 million e-visits would be conducted globally that year, representing a 400 percent increase from 2012. The report went on to state that about half of the 600 million annual general practitioner visits in the United States and Canada could be solved by an e-visit instead(1).
Telemedicine can be broken down into four basic categories. Asynchronous communication, often referred to as “store and forward,” consists of transmissions that are not conducted in real time. An example of this would be a radiologist taking an x-ray and electronically transmitting it to a specialist in a different location. That is followed by synchronous communication, which involves real-time interactions such as video chats and telephone calls. Remote patient monitoring consists of the use of a device or devices to track a patient’s vital signs and activities. The final category is mobile medicine, which can include text messaging and the use of apps for smartphones or tablets.
Several telemedicine businesses have already been established in the U.S. in the past decade. Virtual provider services such as Zipnosis, Virtuwell and American Well offer patients the opportunity to log in and request a diagnosis whenever it fits their schedule. Depending on the service, patients either fill out a guided questionnaire or conduct a video visit to describe their symptoms and histories. The cases are then reviewed by a practitioner, and if no further physical examination is needed, the patient can receive a treatment plan and even have a prescription sent to his or her pharmacy. These services can cost as little as $25 for the consultation and in some cases can be partially covered by private insurance.
The benefits may also extend beyond convenience and cost. In a 2015 position paper, the American College of Physicians asserted that, “telemedicine can be an efficient, cost-effective alternative to traditional health care delivery that increases the patient’s overall quality of life and satisfaction with their health care”(2). The paper points to a 2006 study that determined there was a slightly higher level of improvement in diabetes mellitus patients over the age of 55 whose treatment included telemedicine case management than those who were treated under usual practices. The telemedicine group saw better glycemic control, blood pressure levels and cholesterol levels than their counterparts in the non-telemedicine group(3). Many other studies and case reviews have similarly concluded that there can be a measurable positive effect on patient outcome when telemedicine is a component of a patient’s treatment plan.
While telemedicine technology and implementation are becoming more common, policymakers are scrambling to catch up. One of the biggest obstacles for practitioners who wish to add telemedicine services is the fact that no two states govern telehealth in the same way. Licensing requirements and Medicaid reimbursements may vary widely from state to state, and understanding these limitations is a complex but necessary part of the process.
Some states have well-developed licensing guidelines for out-of-state telemedicine providers, while others have vague guidelines or none at all. Louisiana and Texas are among the states that issue telemedicine licenses to physicians from other states, with some restrictions. Kentucky and Mississippi grant exemptions to telemedicine providers if they are consulting with a physician licensed in their state (4). Maryland, New York, Virginia and the District of Columbia are currently the only places with reciprocity, allowing exemptions to all states that adjoin theirs. On the other hand, Michigan, North Dakota, Pennsylvania and South Dakota offer no exemptions whatsoever to telemedicine providers (5). Further restrictions exist regarding what practitioners are allowed to do when granted an exemption or license in another state. In Texas, for example, a practitioner who examines a patient online can only write a prescription for up to three days’ dosage unless there was a prior client-physician relationship established in person.
When it comes to receiving reimbursement for telemedicine services, the rules are almost equally as varied. Only 22 states plus the District of Columbia have active laws regulating private-payer insurance reimbursements for telehealth services. Federal Medicare regulations are somewhat strict as they apply to telemedicine. Medicare patients are only allowed access to telemedicine services if they live in a designated rural Health Professional Shortage Area (as determined by the Health Resources and Services Administration) or if they live in a rural census tract or a county outside of a Metropolitan Statistical Area (as determined by the U.S. Census Bureau).
Many states have adopted similar policies for their Medicaid programs, but all have variations. Medicaid reimbursement for telemedicine is determined by the policies in the state where the patient is located (the originating site), and many states restrict what types of locations can be used as originating sites. Twenty-five states allow a patient to receive telemedicine care in the home. Other states require a more professional setting such as a hospital, doctor’s office or some other type of medical center. Some states also require a licensed medical practitioner to assist at the originating site.
There are also regulations determining which forms of telemedicine a physician can be reimbursed for. Currently, 46 states and D.C. have policies to allow reimbursement for two-way video visits. Only 10 states offer reimbursement for store-and-forward services, and 13 offer reimbursement for remote patient monitoring. Alaska, Minnesota and Mississippi have the least restrictive policies and are currently the only states that reimburse for all three (4). These policies are broken down even further to restrict the specialties and treatments to which Medicaid patients have access. Because of the complexity of licensing and reimbursement policies, many physicians may choose to limit their telemedicine services to the state in which they practice or to a very limited number of states.
The safety and security of patients’ personal and medical information must also be taken into account, as practitioners must adhere to Meaningful Use and HIPAA regulations. For example, while Skype is currently one of the most widely used two-way video communication programs globally, it is not HIPAA compliant. HIPAA requires there to be a Business Associate Agreement (BAA) between a healthcare provider and the company responsible for telemedicine technology. The BAA has to guarantee that the technology meets all HIPAA requirements for security and data encryption, and providers must obtain informed patient consent prior to conducting any telemedicine services. Even though some popular general-use technologies may promise security, there are plenty of programs on the market developed specifically for medical practitioners that will meet or exceed HIPAA standards and can be tailored to a provider’s needs.
Since telemedicine is still an emerging field, not all insurance carriers are prepared to write coverage for this type of risk. Many non-traditional carriers may be more open to providing coverage than standard carriers, and the levels and types of services covered can vary. Depending on the carrier and the services the provider wants to offer, this could come with a higher insurance premium. Physicians who practice telemedicine in multiple states expose themselves to the chance of litigation in any state in which they practice, and they open themselves up to personal liability if they practice in a state where the damage caps exceed the per-claim coverage limits of their policy. For these reasons, it is extremely important for any physician to work with his or her broker to make sure they have the best coverage available before offering telemedicine services.
With rapid growth in just the last few years, telehealth appears to be the next frontier for the medical profession. Physicians who are ready to join the movement can find it beneficial on several levels, but until more uniform regulations and standards are put into place, they should proceed with caution.
- Lee P, Stewart D, Calugar-Pop C. Technology, Media & Telecommunications Predictions: 2014. New York: Deloitte; 2014. Web. 21. Sept. 2015 <deloitte.com/content/dam/Deloitte/global/Documents/Technology-Media-Telecommunications/gx-tmt-predictions-2014.pdf>
- Daniel, Hilary, BS, and Snyder Sulmasy, Lois, JD. “Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings: An American College of Physicians Position Paper.” Annals of Internal Medicine. N.p., 8 Sept. 2015. Web. 17 Sept. 2015. <http://annals.org/article.aspx?articleid=2434625>.
- Shea, Steven; Weinstock, Ruth S.; Starren, Justin; Teresi, Jeanne; Palmas, Walter; Field, Lesley; Morin, Philip; Goland, Robin; Izquierdo, Roberto E.; Wolff, Thomas L.; Ashraf, Mohammed; Hilliman, Charlyn; Silver, Stephanie; Meyer, Suzanne; Holmes, Douglas; Petkova, Eva; Capps, Linnea; and Lantigua, Rafael A. “A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus.” Journal of the American Medical Informatics Association 40th ser. 13.1 (2006): n. pag. The Oxford University Press. Web. 21 Sept. 2015. <http://jamia.oxfordjournals.org/content/13/1/40.abstract>.
- “State Telehealth Laws and Medicaid Program Policies A Comprehensive Scan of the 50 States and District of Columbia.” Center for Connected Health Policy. N.p., July 2015. Web. 17 Sept. 2015. <http://cchpca.org/sites/default/files/uploader/50%20STATE%20MEDICAID%20REPORT%20SEPT%202014.pdf>.
- Thomas, Latoya, and Capistrant, Gary. “State Telemedicine Gaps Analysis: Physician Practice Standards and Licensure.” American Telemedicine Association. N.p., May 2015. Web. 17 Sept. 2015. <http://www.americantelemed.org/docs/default-source/policy/50-state-telemedicine-gaps-analysis–physician-practice-standards-licensure.pdf?sfvrsn=14>.