Telemedicine could become one of the great benefits of the Information Age. Using videoconferencing, a physician can examine a patient located at a different facility through telecommunications technology, or examine test results and X-ray film. It could provide better health care for rural and even urban patients, who would be able to access experts and specialists unavailable in their geographical area.

The private sector has been increasing its investment in telemedicine, and the new Telecommunications Act includes provisions intended to give health facilities, along with schools, breaks on telecommunications services.

While the technology for telemedicine is here and improving, health professionals are not sure how it will pan out beyond the current experimental stage. Before major strides are made in mainstreaming telemedicine, a number of issues will have to be resolved by both public and private bodies. These include, but are not limited to, what telemedicine's benefits are precisely, public and private insurance reimbursement for medical services, and cross-state licensing.

LOOKING FOR ANSWERS

The federal government has several programs to explore telemedicine and generate data. The Office of Rural Health Policy, part of the U.S. Health and Human Services Department, runs a grant program with 11 rural health networks to collect data. The network hubs and their spokes include

a wide variety of telecommunications technologies and facilities, including university and government hospitals.

The intention of the program, which is finishing its second year, is "to see if this is a good tool for rural health care," said Carole Mintzer, director of the Rural Telemedicine Grant Program. "With the variety of grantees, we can see what works and what doesn't."

There have been some lessons learned so far, but lessons will continue to be drawn for several years, as more facilities continue to experiment with telemedicine. When facilities reach the maximum of three years in the grant program, self-reliance of telemedicine programs will be another lesson from the program, Mintzer said.

COMPENSATION

A federal program to explore reimbursement questions is being prepared to begin this fall. The Health Care Financing Administration (HCFA), the U.S. Department of Health and Human Services arm that handles Medicaid and Medicare reimbursement for medical services, is preparing to launch a three-year field study on telemedicine reimbursement with 57 facilities in four states.

The HCFA (commonly pronounced heck-fa) currently reimburses for teleradiology consultations through Medicare. Physicians using teleradiology, which is essentially sending X-rays and other images through telecommunications lines, often consult with a specialist who may have more experience or an expertise in a certain subspecialty. The reimbursement is the same as if the consulted physician acquired the images through overnight mail or with telecommunications equipment.

But other potential applications of telemedicine, including pathology consultations, are caught in a gray area of federal reimbursement rules on Medicare. Medicaid reimbursement rules, meanwhile, are set by states within federal guidelines, and a dozen states currently cover some aspect of telemedicine through the program, which is mainly used by the uninsured.

"We are collecting information to see how physicians use this," said William England, telemedicine research and demonstration project officer at HCFA. "It's not limited to certain specialties." Once the three-year HCFA project ends, it will probably take another year to create new reimbursement rules with Medicare, he said.

The federal programs will likely provide data for public insurance and the private insurance industry as it begins to explore telemedicine. In some cases, private insurance is being prodded through legislation.

The California Legislature, which had a number of telemedicine bills pending this summer, debated one with a provision requiring private insurance companies to submit plans for telemedicine reimbursement by July 1997. The bill was still pending earlier this summer.

RAISE HEALTH CARE COSTS?

The HCFA demonstration project will also look