Consulting with a doctor through video conferencing isn’t new – the practice has been around for years. But while the technology has steadily improved and social acceptance of online communication has grown, experts have identified four policy issues that continue to plague widespread adoption of telehealth in the U.S.
Cross-state licensing for doctors is one of those challenges. State medical boards require a doctor practicing medicine to have a license in each state in which he or she has appointments with patients. The same requirement applies for telehealth visits.
It’s a huge problem, particularly for providers in border states, said Ed Bostick, executive director of the Colorado Telehealth Network. He explained that many times physician referral patterns include offices outside state geographical delineations. For example, referrals from Colorado doctors may include physicians in Utah, New Mexico or other locations outside state lines. That can complicate things if a doctor is willing to do a virtual appointment with a patient.
“If a physician is offering services via telemedicine, they have to have licenses in both states in order to practice that,” Bostick said. “To me, that’s a barrier for being able to deliver health care when they need to.”
Gary Capistrant, senior director of public policy for the American Telemedicine Association, agreed that licensure was one of the major barriers to telehealth. He thinks license reciprocity would go a long way toward solving the problem, and pointed out the success nurses have had with a 24-state compact that recognizes all nursing licenses issued in each member state.
Capistrant also said telehealth would flourish if state medical boards adopted the same recognition standards given to drivers' licenses.
“Every state you drive in recognizes the issuing state that gave you a license,” he said. “That ought to be the case for health professionals. We ought not to be hindered by a [medical license] process set up more than 100 years ago.”
In addition to licensure issues, reimbursing doctors for providing telehealth services is also a major sticking point. Depending on what state, insurance company, provider and treatment plans that are involved, telemedicine services may not be allowed.
Capistrant noted that Medicare doesn’t cover telemedicine services in metropolitan areas or for remote monitoring of people with chronic conditions. So even if a doctor and patient believe a telehealth consultation would work best in a particular situation, older citizens who rely on Medicare to pay for treatment wouldn’t be able to receive telemedicine services.
Federal legislation was introduced last year to allow certain Medicare health providers in one state to conduct telemedicine services to Medicare beneficiaries in another state. Sponsored by Rep. Devin Nunes, R-Calif., H.R. 3077, the TELE-MED Act of 2013, was referred to both by the House Ways and Means Committee and the House Energy and Commerce Committee in September. It has since been sent to the House Commerce Subcommittee on Health, where it currently resides.
Medicaid, however, does not have the same restrictions Medicare does, so that has helped push telehealth practices along somewhat, according to Capistrant. But he added that the crux of the problem is that insurance companies follow a traditional model of waiting for a claim to come in before figuring out whether they want to pay it based on the service provided.
And if telehealth is permitted and claims for services are ultimately paid, reimbursement levels for providers may not always be consistent, which is a disincentive for doctors to do telehealth, Bostick said.
Broadband & Payment Models
Looking ahead, Bostick was very concerned with the need for adequate broadband connectivity, particularly in rural or underserved areas. He called broadband rollout one of the most important keys to telehealth expansion in the future.
In addition, Capistrant and Bostick both agreed that the “fee for service” model that is in place for health care needs to change. As other types of care philosophies expand, such as the use of medical homes – where patients' needs are addressed depending on what’s best for them at a particular time – Capistrant thinks telehealth can become another tool providers can use when it makes sense.
“It’s very similar to banking when you have a check you want to deposit,” Capistrant said. “The last thing you think about is going in person to the bank and doing it face-to-face with a teller. And so there’s a lot of health care that doesn’t need to be done face-to-face on bank hours.”