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August 2013

The Evolution of Telehealth
By Susan Chapman
For The Record
Vol. 25 No. 11 P. 22

At a time when all of health care is seemingly in transition, nowhere may the change be greater than in this “remote” field.

Telehealth, the delivery of care, consultation, and information using communication technology, is becoming a more widely accepted practice across the United States, affording health care access to patients who reside in rural areas or who otherwise cannot be seen in person by a provider.

“Medicare narrowly defines what qualifies as telehealth,” says René Y. Quashie, senior counsel in the health care and life sciences practice for the law firm Epstein Becker Green. “The interaction must take place in real time. Information can’t be transmitted and then reviewed at a later time by a health care professional. However, a tool like Skype, for example, enables a patient to be seen in real time and may be used by health care professionals to provide reimbursable care under Medicare assuming other requirements are met.”

Reimbursement Concerns
While the area of reimbursement for telehealth is evolving and not yet well established, providers can receive compensation for some services through private insurers, Medicare, and Medicaid federal and state partnerships. According to Quashie, the Medicare telehealth benefit is not optimal. “From fiscal year 2011, just a little over $6 million was spent on telehealth, and that’s just a drop in the bucket,” he says. “If you don’t live in the most rural areas of the country, under Medicare, you’re likely not eligible. You have to be a patient who presents in a county that is not included in a metropolitan statistical area or in a federally designated rural health professional shortage area.”

Beyond those two criteria, patients can be treated via only certain sites. “If patients meet the first two requirements, then they have to present at one of eight sites, such as a hospital or a rural health clinic,” Quashie explains. “Then patients must be treated by a specific provider, such as a nurse practitioner or a clinical psychologist, for instance. Only certain codes are then covered, generally behavioral services because the government believes telehealth is a good fit in that area. These requirements severely limit Medicare payouts.”

Medicaid offers more flexibility than Medicare, but there is no uniformity in how Medicaid covers telehealth services. “At last check, a little over 40 states provide some reimbursement for telehealth services, and some states are more expansive in their coverage,” Quashie says. “California is probably the most expansive. Other states are more restrictive. In this way, Medicaid is all over the board. The good news, though, is that at least 80% of states in the nation provide some coverage for telehealth.”

In April, Montana and Arizona became the 18th and 19th states, respectively, to enact legislation to mandate private health insurance coverage for telehealth. “The new Arizona telemedicine parity legislation demands that insurance payers reimburse for trauma; burn; cardiology; infectious diseases; mental health; neurologic diseases, including stroke; and dermatology telehealth consultations conducted for patients in rural regions the same as they would for face-to-face care,” says neurologist Bart Demaerschalk, MD, director of Arizona’s Mayo Clinic Telestroke and Teleneurology program and a pioneer in the telehealth field. “Five years ago, we had little to no ability to seek reimbursement from government and nongovernment payers. The only way we could develop telehealth was by introducing a model in which hospitals would pay a subscription. Now, as more states embrace telehealth, particularly to benefit underserved communities, the reimbursement landscape is clearly changing.”

Despite the advances, there remain reimbursement hurdles to clear. “We’re hearing a lot of operational issues associated with these new statutes,” Quashie says. “While they require coverage, they don’t require insurers to pay at the same level. Many practitioners and facilities are having issues being properly paid when they submit claims for telehealth services, mainly because many insurer systems aren’t adequately equipped to accept telehealth codes. So these new laws are great news, but there are a lot of operational issues that must also be addressed to ensure payment.”

Quashie notes that some insurers are more progressive than others when it comes to telehealth reimbursement. Many insurers are testing delivery models, and some big insurers are beginning to realize that telehealth actually could be cost-effective and provide physicians with another way to monitor patients on a daily basis. “Clinical delivery programs allow better monitoring of patients, more touchpoints, and better communication,” he says. “Because of this, over the last five years, we’re seeing much more progressive coverage of telehealth overall.”

Roy Schoenberg, MD, MPH, president and CEO of American Well Systems, notes that some private insurers have begun to cover telehealth ahead of state laws requiring them to do so. “Wellpoint came out publicly and said, ‘Irrespective of state mandates, we’re going to cover it. Our patients need it; we are going to pay physicians to care for our patients via telehealth and collect only a copay,’” he says. “And this is being followed by other payers in varying degrees. The bottom line is that we’re seeing the majority of private insurance companies covering telehealth. The state mandates are moving toward the same place but from another direction: Private insurers have to cover telehealth because residents lack available health care, whether geographically or due to a physician shortage. Additionally, there has been a flurry of federal legislation to make telehealth part of health care delivery, and Medicare is now reassessing how it will compensate providers.”

Risk Assessment and Malpractice Issues
Schoenberg believes one of the biggest challenges facing telehealth is clarity on the scope of health care services it can safely deliver. “We already use telehealth to bring timely care to patients with simple issues like bronchitis, rash, and urinary tract infections, but think of patients who are homebound with chronic illnesses, patients in bed after surgery, cancer patients, and even patients who avoid or delay needed care because their insurance carries high deductibles,” he says. “Telehealth enlists modern technology to bring health care to them. It clearly isn’t the right way to handle a car accident or a heart attack, but when used responsibly, it can do wonders all over the map of care delivery.”

Demaerschalk says one of the best ways to mitigate telehealth’s associated risks is to address them as new relationships develop. “Opportunities to examine and mitigate risks associated with a health care practice should be addressed at the beginning, when one first interacts with a new client—referring hospital, provider, and patient,” he says. “Even though telehealth contact is virtual, it should be conceptualized in the same way that we address face-to-face interactions. Providers need to have the appropriate credentialing, privileging, and licensing to assess and treat patients and should conduct themselves in the same way that they would at bedside. The consultation must be documented, and there must be contractual relationships between the hospital or clinic and provider, including a payment contract. All those things we sometimes take for granted in the face-to-face world, we must examine more closely in a telehealth relationship.”

Demaerschalk adds that patients must fully understand the telehealth process and its associated risks and limitations, and sign all consent forms in advance of the consultation.

In stroke, his specialty, Demaerschalk says there has been a paucity of telehealth malpractice claims, in part, perhaps, because the technology can help rapidly assess and treat emergency cases. “There haven’t been as many telehealth malpractice claims as neurologists feared,” he says. “In fact, there is a recent trend of malpractice claims increasing in community hospitals that have elected not to participate in a telehealth network for stroke. In some instances, patients and patients’ families have launched actions against those facilities because they provided neither direct nor virtual neurological care for emergency cases. Community hospitals electing not to engage in regional telestroke systems of care, when one exists, have become increasingly medico-legally vulnerable.”

The Expansion of Remote Treatment
The telehealth field is dynamic, and physicians and researchers are investigating ways for it to provide even broader benefits. One such researcher is Bert Vargas, MD, a neurologist at the Mayo Clinic in Phoenix who is exploring new uses for telehealth consultations and interacting with a broader scope of patients. An expert in the study of concussions, Vargas leads a research team that recently launched a study on the efficiency of telehealth in diagnosing concussions in football players from the sidelines. In the study, a remote neurologist uses a portable or robotic unit to conduct neurological exams on players who have suffered a possible head injury.

“At the high school level, many times there is no physician or team trainer to evaluate possible concussions at the time they occur,” Vargas says. “Often, it’s up to the coaches, referees, or parents to evaluate the situation resulting in countless players at the high school and middle school levels who fall through the cracks and don’t get treated properly. The unfortunate reality is that kids at that age are more susceptible to concussion, and this vulnerable population is at risk of not receiving the proper care.”

According to Vargas, telemedicine units are used as part of the general neurology consults for concussion in rural Arizona. These devices, some of which are robotic, have video monitors and high-tech cameras that can be controlled remotely to allow a physician to interact with and assess a patient.

“Right now, many of the units we use are fixed. What we’re currently developing is a means by which we can place a mobile robotic unit on the sidelines of collegiate sporting events,” Vargas explains. “At the time of injury, we are hoping to be able to move the robot directly to the player, observe the player, and do our own assessments as necessary along with the team physician or trainer who is on the sideline performing a face-to-face assessment. When an injured player needs to be evaluated in a quiet, more secluded area, he or she is usually taken to the training room. A robotic unit would allow us to follow this player to the training room and allow us to perform our evaluation.”

Because the units are mobile, they will be able to travel with the teams. As far as who decides a course of action, Vargas says it remains status quo. “We have been able to maintain the standard of care by allowing the team physicians and trainers to have the final say as to whether or not the player can return to the game,” he says. “We hope there is a high level of agreement between those assessing the player face-to-face and those working remotely.”

Vargas goes on to explain that what he and his fellow researchers hope to understand is whether they can accurately and safely make a remote concussion diagnosis and recommend when a player is safe to return to the field. “No one has yet been able to determine telehealth’s safety for return-to-play issues,” he says. “Our question is, using telehealth, can we identify when someone is normal, as opposed to when someone is not normal. Once we have more of a body of experience, then we want to be able to extend this course of treatment to those rural high schools that lack the technology and health care personnel.

The Industry’s Future
Schoenberg believes there are several interesting trends developing within telehealth. “The impetus for telehealth has generally revolved around costs rather than access. The key driving principle was to be more fiscally responsible,” he says. “Along with that came the newer opportunity to make patients’ lives easier. For patients with congestive heart failure or behavioral health issues, for instance, making it to an office visit isn’t easy. Telehealth benefits those patients and the system that cares for them—a rare win-win.

“So now we need to expand this from novelty to a scalable infrastructure,” he continues. “Much more fundamentally, we need a brokerage system that can get a patient in front of an available physician in real time virtually, regardless of the patient’s and physician’s respective locations.”

One way to do so is to make telehealth part of accountable care organizations (ACOs). “In this new insurance model, care providers are financially accountable for the outcomes of their patient panels,” Schoenberg says. “Where patients could benefit from frequent follow-up, providers can engage telehealth to be much closer to those patients. Providers, their office staff, even their after-hour covering partners can conveniently be available at their discretion and their patients can use their smartphones, tablets, or Web browsers to carry out those follow-ups. Lastly, since telehealth systems naturally connect with medical records, eligibility systems, payment processing, electronic prescriptions, and the like, they ironically allow everyone to spend more face time together. It’s a brave new world of health care delivery.”

Schoenberg cautions that managing patient expectations is key. “Telehealth doesn’t ‘retail’ physicians,” he says. “A patient cannot swipe a credit card and expect the physician to prescribe their medication of choice. In telehealth, like in-person visits, patients are acquiring physicians’ time and attention, not the outcome of that encounter. Under no circumstances is a physician pressured to diagnose and/or prescribe and their remuneration should never be tied to it.”

Experts agree that it’s important to create a consensus around telehealth, deciding what it can and cannot do. The upcoming years are expected to be the most interesting and productive for telehealth technology and legislation in the past two decades. “There is going to be a lot more activity in the states over the next three years, and it’s being driven by many outside forces,” Quashie says. “A lot of health groups are interested in minority health, and many minority legislators view telehealth as a way to help reduce health disparities in minority communities. We’re seeing a great deal of pressure being brought to bear in state legislatures, which could bring a transformation across the industry.”

Schoenberg adds, “We’re also seeing telehealth being embraced at the infrastructure level. In terms of companies that produce medical devices and practice management systems, many of these companies are taking steps to introduce telehealth technology into their offerings. It makes sense and is an incredibly important recognition of how invaluable telehealth is for the health care industry. It reverses the ancient paradigm that required patients to run around to seek the care they need. For the first time, with the help of technology, health care comes home. This technology stands to redraw the map of an entire industry.”

— Susan Chapman is a Los Angeles-based writer and author.