Thursday, January 24, 2013

    by Jonathan Linkous

    After 40-plus years of development, telemedicine has finally come of age. Whether you call it telehealth, mHealth or remote monitoring, the deployment of telemedicine is galloping. No longer relegated to a demonstration grants or experimental research, mainstream medicine has joined up with Silicon Valley, private payers and consumer groups to make use of telecommunications technology to transform the delivery of care. Consider these facts:

    • More than five million Americans had their medical images read remotely last year;
    • Approximately 10% of all the intensive care unit beds in the U.S. use telemedicine;
    • , there are more than 13,000 consumer health applications for the iPhone;
    • One million Americans benefit from remote cardiac monitoring for implantable devices or for checking on a suspected cardiac arrhythmia; and
    • The American Telemedicine Association estimates that more than 10 million Americans have directly benefited from some sort of telemedicine service this past year, probably double from just three years ago.

    The growth has been a long time coming. In the past, many compared the health care industry’s slow adoption of telehealth with other sectors that have rapidly adopted telecommunications technology, such as banking, entertainment and publishing.

    There are many reasons for the delay, but a leading problem is the red tape and top-down regulatory reticence demonstrated by various government agencies. Since ATA was launched in 1993, the leading barriers to the deployment of telemedicine in the U.S. have almost all involved government policy: reimbursement by Medicare and Medicaid, state-based standards of care and professional licensing, device regulation and telecommunications policy, just to name a few. To date, government has been telehealth’s lagging partner.

    So will things be any different in 2013? YES. Here are two reasons why.

    First, desperation breeds innovation. The triple whammy of rising costs, provider shortages and increasing demand for health care is forcing policymakers to finally consider alternatives that were never on the table before. With the cost of healthcare at $2.7 trillion and rising, the fiscal crisis is forcing even the worst Luddites in health and government to look seriously at new alternatives. Telemedicine is one of those “new ideas” whose time has come.

    Second, in 2013, advocates for telemedicine will no longer be alone in campaigning for change.  Five new groups of allies have recently emerged:

    1. State Legislators — This past month, three organizations of elected state lawmakers passed resolutions pledging their support for legislation to expand state Medicaid coverage of telemedicine next year: the National Organization of Black Elected Legislative Women, the National Hispanic Caucus of State Legislators and the National Black Caucus of State Legislators. ATA has been working on model legislation with all three groups.
    2. Patient Groups — This year, an array of patient groups will be advocating for public policy changes benefiting telemedicine through national symposia, testimony on state and national levels and co-sponsored activities. Partners include organizations such as the Parkinson’s Action Network and the National Heart and Stroke Association.
    3. Medical Societies — In December 2012, the American Psychiatric Association joined with ATA to ask CMS to address a problem with coding rules that would impede the use of telemedicine for mental health. Similar modest but meaningful activities are underway with a dozen other specialty societies.
    4. Private Payers — Last year, UnitedHealth and ATA worked together to overcome a potentially harmful proposal to telemedicine that came before the American Medical Association’s House of Delegates. In addition, as of 2013, online video visits will become a covered benefit by WellPoint and other private insurers.
    5. Health System CEOs — Leaders of health systems are relying on telemedicine to link new partners and deploy new networks as they seek expanded referrals and market share. Private practices are being bought up, specialty services are being outsourced and new institutional partnerships are being forged. The move toward Accountable Care Organizations and bundled payments has accelerated this trend.

    So what should we expect in 2013?  Here are a few prognostications.

    State governments will be a hotbed of health care policy overall, and especially so for telemedicine. It is too early to reference specific states, but here is a roundup of key issues.

    • Sixteen states have already adopted legislation requiring all private payers in the state to reimburse for telemedicine for services that would be reimbursed if they were provided in person. With the support of the groups of state legislatures pledging change, expect several more states to be added this year.
    • Expanded Medicaid coverage of telemedicine is sure to be the subject of legislative proposals in several states. Currently, 14 states provide some coverage for telemonitoring and seven for video-based home care. Of course, all states cover remote image examinations. Look for expanded coverage for several areas including telemonitoring, store and forward services, telemental health and telehealth in urban areas.
    • Many state Medical Boards are looking at regulating telemedicine services. Experiences to date have been mixed, with several boards moving backward and threatening existing remote health services with new rules. ATA is encouraging members to provide demonstrations and educational sessions for the members and staff of their state medical boards in an effort to improve understanding.

    The Federal government will likely take some steps in the right direction for telemedicine in 2013, even if only incrementally.

    • Rep. Mike Thompson (D-Calif.) has introduced legislation () that proposes major changes in state-based physician licensure, as well as expanded coverage in all federally sponsored insurance programs, marking the first legislative proposal for such change. While Thompson’s Telehealth Promotion Act was introduced in the past Congress, the ideas within this proposal serve as the starting point for negotiations with the new Congress in 2013.
    • At the end of 2011, the was approved, allowing credentialed health care professionals in the Department of Defense to work across state borders without having to obtain a new state license. Look for proposals in 2013 to expand this provision to other federal programs.
    • FDA soon will be promulgating revised final regulations governing mobile health devices. The agency already has approved about 75 mobile health applications. Look for lots more.
    • The Federal Communications Commission revising the rural health program. The new regulations streamline the application process and open the way for actually spending the $400 million originally allocated for the program. However, the new discount rate may have a devastating effect on some current awardees.
    • Finally, as other provisions of the Affordable Care Act kick in, CMS will again be front and center. Rules affecting accountable care organizations, meaningful use, medical homes and patient-centered care are only a few of the many areas that will be under discussion within the agency.

    So 2013 will be chock-full of activity. It is a year for federal and state governments to play catch up with the rest of the health and technology sectors by either supporting the use of telemedicine or at least by ceasing to be a roadblock in its pathway to the future.


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