1. To Infinity and Beyond: Policies to Expand Telemedicine Services
Marc G. Kaprow, D.O., FACOI  AOA Health Policy Fellow 2015
Generously sponsored by the Florida Osteopathic Medical Association
Introduction
Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status.1 Medicare does not acknowledge telemedicine as a distinct service, but rather as a way of providing an already defined service.2
Telemedicine has the potential to increase access to care, especially in currently underserved areas, but its adoption faces many barriers.
Background
Impact on Access and Quality
A 2003 Veterans Administration (VA) study evaluated the cost effectiveness and quality of care rendered by telemedicine.3 Over 4 years the VA enrolled 30,000 veterans and achieved a costs savings of 19% in hospitalizations.
A University of California Davis study on seriously ill or injured pediatric emergency patients in rural settings found that patients in the telemedicine arm had significantly better quality scores than the patients who had telephone-only consults or no consults.4
Barriers to Telemedicine
Impact on quality of care
Licensure (state vs. national)
Reimbursement
Impact on liability
Practitioner scope of practice
Quality
Critics cite the lack of physical contact between providers and patients as a detriment. The concern for eroding the relationship between patient and physician is not unfounded. A study concluded that even terminally ill patients value physical examinations and contact by their doctors.5
Licensure
Due to the CMS rule to license providers in the state where the patient is located, providers may need to secure and maintain multiple licenses. Lack of license portability hinders providers from being more widely available. In 2014 Florida failed to pass a bill that would have let a provider licensed in any state perform telemedicine services in Florida.6 The Federation of State Medical Boards has received a Health Resources and Services Administration grant to administer a licensure compact to streamline the process while preserving state-based licensure. 7 Both the American Osteopathic Association and the American Medical Association oppose national licensure.
Medicare currently reimburses telemedicine services for rural or underserved patients. CMS expanded the scope of these settings with a rule.8 Remote services use the same billing code as face-to-face services. State telemedicine laws may mandate payment parity for some or all of these services. Currently 26 states mandate payment parity, up from 22 in January 2015.
Liability
The potential for liability may be contributing to slower adoption. The use of telemedicine in hospitals for consultation allows physicians anywhere in the world to see patients in any other part of the world. Questions have been raised regarding the liability of the consultant, the local practitioner, and the facility. This becomes more complicated when the telemedicine consultant is not licensed in the state where the patient is located. The local practitioner might be able to be held accountable for the advice and actions of a subspecialist. Other concerns include confusion about informed consent, ;which might expose the local practitioner or facility to greater liability.9
Practitioner Scope of Practice
In 2015 Florida failed to pass a bill that would have permitted 27 types of healthcare practitioners, including chiropractic physicians and acupuncturists, to perform telemedicine encounters.10 Some resistance to telemedicine is based on concerns for scope of practice. Not all specialties will be able to provide services via telemedicine.
Recommendations
Federal Level
Establish universal reimbursement and standards for telemedicine services paid for by Medicare and Medicaid because universal reimbursement is essential to incentivizing practitioners to invest in and utilize telemedicine, driving improved access.
Key policy issues to avoid at the federal level should include licensure and establishment of a federal standard for duty of care.
State Level
Establish a standard for scope of practice; considerations may include licensure (either unrestricted or limited scope), certification, and specific education requirements as well as limits on services that may be performed via a telemedicine encounter (e.g. prescribing controlled substances, recommendations for medical marijuana, management of certain high risk/hands-on procedures such as obstetrical services).
Requirements around malpractice liability should include the use of informed consent to mitigate liability to the local physician, and specific medical record requirements, including guidance about recording.
Expedite licensure for qualified practitioners.
References
American Telemedicine Association. What is Telemedicine? Accessed January 2015.
Centers for Medicare and Medicaid Services. Telemedicine. . Accessed January 2015.
Darkins A, Ryan P, Kobb R, et al. Care Coordination/Home Telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemedicine Journal and e-Health. December 2008;14(10):
Heath B, Salerno R, Hopkins A, Hertzig J, Caputo M. Pediatric critical care telemedicine in rural underserved emergency departments. Pediatric Critical Care Medicine. September 2009;10(5):
Hunt DP. Do patients with advanced cancer value the physical examination? Cancer. June 2014;120(14):
Florida Senate Bill 1646 (2014)
Federation of State Medical Boards. Federal grant to support state medical boards in developing infrastructure for interstate medical licensure compact. July 17, Accessed August 2015.
Center for Medicare and Medicaid Services. Policy and payment changes to the Medicare physician fee schedule for October 31, Available at: Accessed June 2015.
Rowthorn V. Legal impediments to the practice of telemedicine. Accessed August 2015.
Florida Senate Bill 478 (2015).