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.
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 into the benefits, such as earlier diagnosis and less travel from rural areas to urban medical centers, among others, similar to the rural program. But these benefits will be weighed against some potential drawbacks, including an unmet need for consulting with specialists which may be fulfilled once telemedicine potentially enables more consultations. "We expect it to increase," England said. "But the question is how much. So we're looking at potential savings offset by increased use."
Private insurers would also be affected, as they may be billed for increased consulting with telemedicine. "They pay for consultants now, but they may pay differently," said Bob Achermann, executive director of the California Radiological Society. "It could open up more access to specialists that they don't pay for now."
PRACTICE ACROSS BOUNDARIES
While telemedicine improves health care by providing better access to specialists, it also raises issues of cross-state practice. Physicians are currently licensed by the states, which set standards and handle most disciplinary action. About half the states currently have exemptions from licensing in
the patient's state for physician consultations, and telemedicine is likely included.
But because telemedicine challenges state borders by allowing a physician to see a patient without physically being in the patient's state, states are beginning to explore solutions to a geographic-based licensing system.
Congress briefly considered legislation earlier this year to exempt some telemedicine practice from state licensing, but the effort fell to arguments that the measure lessens state medical board regulatory authority.
Some states are moving on the licensing issue, and there are at least two approaches being taken on the issue. One approach is to require a physician to be fully licensed in any state where patients are located. A doctor using telecommunications to see a patient located in another state would need to be fully licensed in both states. Kansas adopted a regulation in 1994 requiring licensing for out-of-state consulting. This approach was taken by South Dakota in legislation last year, and California was considering similar laws this summer.
The Federation of State Medical Boards created a model act for state legislatures to pass with the intention of creating a common registration program for telemedicine. Dale Austin, a vice president of the Federation, characterized the model legislation as being a "middle way" between full and no licensure. "It seeks to simplify the process, and not be burdensome," he said, while continuing to allow states to regulate the profession.
The model act, which has yet to be adopted by a legislature, would have physicians -- already licensed in a state who want to practice telemedicine in another -- submit some basic information on themselves along with a small fee. A check would be done with the state issuing the physician's full license to ensure good standing. A database kept by the federation with actions taken against physicians can also be checked by a state processing an application.
There is some dissent from the federation's research, however. Some critics, including the California Radiological Society, argue that physicians should hold a full license with a state they are practicing in, even for telemedicine. Because licensing requirements vary from state to state, the argument goes, a physician licensed in a relatively weak licensing state could get a permit to practice telemedicine in a state where physicians must meet more stringent requirements to practice. Achermann, of the California Radiological Society, said that a better approach may be to have physicians "compete on the same standards."
KEEP THE PROMISE?
The growth of telemedicine over the past few years has outpaced the policies and rules of health care, and governments are trying to catch up. While technology continues to develop, answers to questions raised by telemedicine applications are slowly being formed. At this early stage, it's hard to know beyond intuition how well telemedicine works and how it is best utilized.
"It's hard to make assumptions," Achermann said. "The opportunity is great, especially in rural areas. But we just don't know."
As telemedicine is
tested as a method
to expand health
care access,
questions are
being raised
about how useful
it can be and
how to deal
with cross-state
medical licenses.
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