The telemedicine is usually termed as beneficial by the healthcare industry, but the idea has yet to be completely accepted and integrated within the healthcare programs of government. 2 recent government publications released this past summer support the telemedicine expansion within public health programs, pointing out the advantages of telemedicine from both service and cost perspectives, but also noting the issues to such expansion.
The U.S. Department of Health & Human Services (HHS) released, at Congress’ request, a report in the month of August on their progress and attempts in the telemedicine arena, known as the Report to Congress – E-health and Telemedicine. The report describes hurdles HHS believes are primary impediments to the progress of telemedicine. The Centers for Medicare & Medicaid Services (CMS) released a proposed rule for yearly updates to the Medicare Physician Fee Schedule (MPFS) (81 FR 46161, July 15, 2016) one month earlier. Issues and challenges are mentioned within MPFS by CMS’ decision not to expand the Medicare telemedicine benefit to few services for reasons regarded to existing policy and legislation, which require being changed to facilitate the growth requested by stakeholders.
Instead of the issues and challenges, the MPFS and, more plainly, the HHS report convey certain degree of promise for telemedicine expansion by explaining the commitment of government to it. However, the complete scope of integration that stakeholders expect for may be distant; the government is moving towards that direction.
Ina accordance to the definition of American Telemedicine Association defines “the use of medical information exchanged from 1 site to another through electronic communications to improve a patient’s clinical health status.” The word originally was understood to mean communication between 2 providers. The word “Telehealth” is mostly used interchangeably with “Telemedicine”, as are mobile health (m-health) and electronic health (e-health); although, telehealth commonly refers not just to telemedicine, but also to patient/provider communication and electronic health management/data collection.
The m-health is commonly termed as a subset of telehealth and, more particularly, as the use of apps created to support well-being. E-health is broader, as it encompasses entire kinds of digital information tools, like electronic health records (EHRs).
Pros of Telemedicine
The HHS report motivates and supports the position that the telemedicine delivery model increases access to care, quality of care, and healthcare results. A very usual instance of who benefits using telemedicine is sufferers in rural areas without convenient access to primary care. Less critical problems not dealt proactively might increase in severity and suddenly establish into acute conditions necessitating hospital admissions for these remote patients. These sufferers can get care at their local community hospital from a specialist through telemedicine, or perhaps in their home from a primary care physician. Videoconferencing serves earlier interventions and diagnoses, which might prevent the progression of the condition. Not just are the quality of care and results improved, but patient satisfaction is also enhanced.
The HHS report also mentions the advantages of telemedicine for the chronically ill and the “particular promise” held for chronic disease management contrary to an agency’s findings that there is not sufficient evidence to assess the overall cost-saving potential of telehealth. Particularly noted is that telemedicine might cut down on the frequent clinical visits that this population mostly needs and “avert expensive emergency room visits and hospital stays.”
In recent quality-improvement measures, the anticipation of government of telehealth’s cost-saving potential is reflected. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) involves incentives for physicians’ better performance and coordination of care, and recommends telemedicine as a way to acquire these performance aims. The commentary of government in each of these issuances involved rationale anticipating not just the potential for better quality and/or patient satisfaction, but for cost savings, as well.
However particularly calling out chronic care management as ripe for the use of telemedicine, the MPFS neither adds it to the scope of the Medicare benefit nor mentions it as a telemedicine service CMS declines to cover. It would not be shocking to observe the inclusion of chronic care management services as a reimbursable telemedicine service in the fee schedule of subsequent year.
Issues Remain, but It is Getting Improved
For expanding telemedicine, serious barriers exist and important actions are needed to overcome the hurdles. HHS discusses what it considers are areas of concern in the report.
Payment and Reimbursement: Medicare restricts telemedicine reimbursement deployed on the location of the patient and provider and the kind of distant site facility. The facility’s payment often falls short even if a service meets these requirements.
An estimated 61% of all healthcare providers (and of those, 50% of hospitals) use some form of telemedicine, in accordance to HHS report. Over $9 billion in revenue was generated by Telemedicine industry in the year of 2013, but Medicare spent just $14 million in the year of 2015, or .01% of its total spending. While the 2017 MPFS does consider and propose an expanded list of reimbursable telemedicine services — particularly end-stage renal disease-related services, advanced care consultations, and chronic care consultations for seriously ill — it also excludes several stakeholder-advocated services, like emergency medicine consultations, observation services, psychological testing and physical/occupational/speech therapy. In accordance to CMS, it excludes these services due to the deficiency of evidence that they generate similar benefits as in-person services, and because the service providers (i.e., therapists) are not authorized by the Medicare statute governing telemedicine.
Moreover, Medicare Advantage plans are allowed to give telemedicine reimbursement beyond that offered by Medicare fee for service, but just 3 plans does so. Among commercial payers and state Medicaid programs, variability also exists; 48 state Medicaid programs provide some benefit and, on the commercial side, thirty-two states have telemedicine parity laws that need private payers to reimburse telemedicine consultations at the similar rate as in-person consultations.
Licensure: Patients are offered with easier access to healthcare across borders by the telemedicine, but the same can’t be said for providers. 80% of states impose hurdles in the form of licensures, in accordance to HHS. However, state licensing boards might view this measure as a minor administrative obstacle necessary for the safety and health of their citizens, healthcare providers might consider it an important burden and not worth their time.
Another workaround for the licensure barrier is the Interstate Medical Licensure Compact (Compact). The Compact is model legislation drafted by the Federation of State Medical Boards (FSMB) created to streamline the licensure procedure and permit physicians to more easily practice in several jurisdictions while remaining under authority of their home state’s medical board. To date, just 26 states have launched the Compact and just seventeen have enacted it, in accordance to the FSMB. This season of summer, FSMB declared a $250,000 grant from the Health Resources & Services Administration (HRSA) to support and fund state medical and osteopathic boards as they execute the Compact. This might increase the number of states adopting the legislation. Telemedicine also motivates expansion of the Nurse Licensure Compacts and assists to get other latest multi-state licensure compacts off the ground, like those for physical therapist and mental health providers.
Hospital Credentialing and Privileging: In reaction to confusion among hospital parties to telemedicine service arrangements, The Joint Commission (TJC) and CMS have totally clarified that the hospital at which the sufferer is situated has the ultimate credentialing authority over treating/consulting physicians (virtually or otherwise). The HHS report recommends, although, there is somewhat of a turf-war among specialists regarding who they’ll permit to have a say over their scope of practice. The HHS report doesn’t give further description on the subject, so it is not clear either this is a current and/or key challenge, or just a consideration within telemedicine arrangements.
However, specialists and other physicians did have understandable gripes about multi-faceted credentialing procedures, TJC and CMS have relieved that uncertainty by permitting delegated credentialing. The federal credentialing procedure has been eased, but parties to telemedicine arrangements must be aware of state level credentialing procedure requirements.
Internet Connectivity or Signal Strength: The last challenge mentioned in the HHS report was the most practical and the one everyone can relate to: signal strength. Internet connectivity might be taken for granted in the vast majority of the country, but HHS reminds us that rural areas — the very places that benefit most from telemedicine — yet experience hurdles to access, either because the infrastructure doesn’t support it or because people can’t afford the service. In accordance to Federal Communications Commission (FCC) report, 53% of rural Americans don’t have “benchmark service” (25 Mbps/3 Mbps). Access problems are even more prevalent on Native American reservations. Outreach programs targeted at making better access and subsidizing related costs, like those sponsored by the FCC and Department of Agriculture, might assist to deal the problem.
Ongoing Government Telemedicine Attempts
Present activities have been summarized by HHS report, involving grants and investments, by federal agencies into the research and expansion of telemedicine services within government programs and service offerings, and particularly note the advantages of telemedicine by the Department of Veterans Affairs. An Agency for Healthcare Research and Quality (AHRQ) cost benefit analysis discovered that, almost universally, patients are happy with the result of their telemedicine visit. The AHRQ overview highlighted telemedicine’s distinct promise in 4 particular places: behavioral health, dermatology, chronic disease management, and physical rehabilitation, as well as the potential for better access or care in teleradiology, burn care, and surgery support. The MPFS doesn’t involve physical or occupational therapy in the scope of the Medicare telemedicine benefit, although. Physical rehabilitation can’t be included in the Medicare benefit without legislative action.
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