[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
TELEMEDICINE: A PRESCRIPTION FOR SMALL MEDICAL PRACTICES?
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HEARING
before the
SUBCOMMITTEE ON HEALTH AND TECHNOLOGY
OF THE
COMMITTEE ON SMALL BUSINESS
UNITED STATES
HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
HEARING HELD
JULY 31, 2014
__________
[GRAPHIC] [TIFF OMITTED]
Small Business Committee Document Number 113-080
Available via the GPO Website: www.fdsys.gov
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HOUSE COMMITTEE ON SMALL BUSINESS
SAM GRAVES, Missouri, Chairman
STEVE CHABOT, Ohio
STEVE KING, Iowa
MIKE COFFMAN, Colorado
BLAINE LUETKEMEYER, Missouri
MICK MULVANEY, South Carolina
SCOTT TIPTON, Colorado
JAIME HERRERA BEUTLER, Washington
RICHARD HANNA, New York
TIM HUELSKAMP, Kansas
DAVID SCHWEIKERT, Arizona
KERRY BENTIVOLIO, Michigan
CHRIS COLLINS, New York
TOM RICE, South Carolina
NYDIA VELAZQUEZ, New York, Ranking Member
KURT SCHRADER, Oregon
YVETTE CLARKE, New York
JUDY CHU, California
JANICE HAHN, California
DONALD PAYNE, JR., New Jersey
GRACE MENG, New York
BRAD SCHNEIDER, Illinois
RON BARBER, Arizona
ANN McLANE KUSTER, New Hampshire
PATRICK MURPHY, Florida
Lori Salley, Staff Director
Paul Sass Deputy Staff Director
Barry Pineles, Chief Counsel
Michael Day, Minority Staff Director
C O N T E N T S
OPENING STATEMENTS
Page
Hon. Chris Collins............................................... 1
Hon. Janice Hahn................................................. 2
WITNESSES
Karen S. Rheuban, M.D., Senior Associate Dean for CME and
External Affairs Director, University of Virginia Center for
Telehealth, University of Virginia, Charlottesville, VA........ 3
Megan McHugh, Ph.D., Research Assistant Professor, Dirctor,
Program in Healthcare Policy and Implementation, Center for
Healthcare Studies, Institute for Public Health and Medicine &
Department of Emergency Medicine, Northwestern University,
Feinberg School of Medicine, Chicago, IL....................... 5
Maggie Basgall, Community Development Specialist, Nex-Tech,
Lenora, KS, testifying on behalf of NTCA - The Rural Broadband
Association.................................................... 7
Brenda J. Dintiman, M.D., FAAD, Fair Oaks Skin Care Center,
Fairfax, VA, testifying on behalf of the American Academy of
Dermatology.................................................... 9
APPENDIX
Prepared Statements:
Karen S. Rheuban, M.D., Senior Associate Dean for CME and
External Affairs Director, University of Virginia Center
for Telehealth, University of Virginia, Charlottesville, VA 19
Megan McHugh, Ph.D., Research Assistant Professor, Director,
Program in Healthcare Policy and Implementation, Center for
Healthcare Studies, Institute for Public Health and
Medicine & Department of Emergency Medicine, Northwestern
University, Feinberg School of Medicine, Chicago, IL....... 36
Maggie Basgall, Community Development Specialist, Nex-Tech,
Lenora, KS, testifying on behalf of NTCA - The Rural
Broadband Association...................................... 43
Brenda J. Dintiman, M.D., FAAD, Fair Oaks Skin Care Center,
Fairfax, VA, testifying on behalf of the American Academy
of Dermatology............................................. 51
Questions for the Record:
None.
Answers for the Record:
None.
Additional Material for the Record:
Parkinson's Action Network................................... 55
TELEMEDICINE: A PRESCRIPTION FOR SMALL MEDICAL PRACTICES
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THURSDAY, JULY 31, 2014
House of Representatives,
Committee on Small Business,
Subcommittee on Health and Technology,
Washington, DC.
The Subcommittee met, pursuant to call, at 10:09 a.m., in
Room 2360, Rayburn House Office Building, Hon. Chris Collins
[chairman of the Subcommittee] presiding.
Present: Representatives Collins, Coffman, Luetkemeyer, and
Hahn.
Chairman Collins. Well, good morning everyone. This hearing
will come to order. I want to welcome our witnesses and thank
you all for being here.
Small businesses as all of us know are innovators, and
particularly now in health care. Small companies are
transforming medical care with new products, new services and
cutting-edge technology. And small medical practices are
changing as well. They are helping us connect and serve a more
mobile population.
Telemedicine refers to patient medical care where the
provider and patient are separated by distance. Although the
adoption of telemedicine has been slow, it is increasing, and
recently, several medical organizations adopted model policies
for its appropriate use.
This technology offers the promise of connecting small
physician practices with patients, other medical providers,
hospitals in areas that are medically underserved.
Today, some small practices are finding it difficult to
stay afloat due to the burdens of complying with the health
care law and the cost of operating a small practice.
Telemedicine may provide opportunities for these practices to
broaden their reach and offer more accessible care to more
patients, serve a larger geographic area, or consult with
distant medical colleagues.
Some have suggested that small practices can be the hub
that connects a patient's health care team. But small practices
can encounter numerous barriers to telemedicine. The cost of
technology, broadband availability, licensing requirements and
reimbursement rules from private insurers, as well as Medicare
and Medicaid, may limit or delay the adoption of telemedicine.
Today this subcommittee will examine a topic that touches
both health and technology, the use of telemedicine and its
possibilities for small medical practices. We look forward to
hearing from our distinguished panel of witnesses about this
exciting convergence of medicine and technology.
I would now like to yield to Ranking Member Hahn for her
opening remarks.
Ms. Hahn. Where are the women? Oh, they are all here. I
usually always say that with the witnesses, but this is a good
crop of witnesses.
Thank you, Mr. Chairman.
Welcome to the witnesses, I look forward to hearing from
you. And as the chairman said, the coming expansion of
telemedicine has the potential to increase access to health
care to underserved communities, both in our inner cities and
rural areas and keep Americans across the country healthy and
independent.
Today's hearing offers us an opportunity to examine ways in
which we can increase the use of telemedicine, especially among
small medical practices.
We know that if implemented correctly, small practices may
be able to cut costs, connect with patients that would be
otherwise out of reach and improve patient care. Enabling
doctors to better communicate with their patients has been
shown to dramatically decrease hospital readmission rates and
give patients peace of mind.
Enabling health care providers to communicate with each
other would mean expanded access to the latest treatments and
the best possible care available. Unfortunately, questions
surrounding reimbursement, licensing, liability and the cost of
technology have prevented many small practices from adopting
telemedicine services.
The technology we need is ready. However, our Nation's
health care system is not. In the coming years, we as a country
will have to address how telehealth care is reimbursed. How and
where doctors are able to practice remotely and how to handle
sensitive patient information.
None of these questions have easy answers, and I appreciate
every one of our witnesses for joining us today in hopes of
shining some light on these and other issues. I look forward to
hearing from all of you and from my colleagues.
Colleagues, where are they? They are not here.
As the telemedicine expansion continues, I hope we can work
together so that doctors can provide patients with the very
best care possible.
I yield back.
Chairman Collins. Thank you.
Before we start, there will be votes coming up at some
point, we'll see where we are in the hearing. And worst case,
we will adjourn and then come back and finish. It is also our
last day in session for 5 weeks. So there is a lot going on,
and we will play this by ear.
If committee members have an opening statement prepared, I
will ask that they submit those for the record. Also, we have
some timing lights, you'll see them start out as green, turn
yellow, and turn red. We certainly have some latitude with
those, but it is just a guide for your 5 minutes.
Our first witness today is Dr. Karen Rheuban. Dr. Rheuban
is senior associate dean for continuing medical education and
external affairs director for the University of Virginia's
Center for Telehealth in Charlottesville, Virginia.
Dr. Rheuban is past president of the American Telemedicine
Association, very appropriate for today's hearing.
Welcome Dr. Rheuban, you have 5 minutes for your testimony.
STATEMENTS OF KAREN S. RHEUBAN, M.D., SENIOR ASSOCIATE DEAN FOR
CME AND EXTERNAL AFFAIRS DIRECTOR, UNIVERSITY OF VIRGINIA
CENTER FOR TELEHEALTH, UNIVERSITY OF VIRGINIA, CHARLOTTESVILLE,
VA; MEGAN MCHUGH, PH.D., RESEARCH ASSISTANT PROFESSOR,
DIRECTOR, PROGRAM IN HEALTHCARE POLICY AND IMPLEMENTATION,
CENTER FOR HEALTHCARE STUDIES, INSTITUTE FOR PUBLIC HEALTH AND
MEDICINE & DEPARTMENT OF EMERGENCY MEDICINE, NORTHWESTERN
UNIVERSITY, FEINBERG SCHOOL OF MEDICINE, CHICAGO, IL; MAGGIE
BASGALL, COMMUNITY DEVELOPMENT SPECIALIST, NEX-TECH, LENORA,
KS, TESTIFYING ON BEHALF OF NTCA, THE RURAL BROADBAND
ASSOCIATION; AND BRENDA J. DINTIMAN, M.D., FAAD, FAIR OAKS SKIN
CARE CENTER, FAIRFAX, VA, TESTIFYING ON BEHALF OF THE AMERICAN
ACADEMY OF DERMATOLOGY
STATEMENT OF KAREN S. RHEUBAN, M.D.
Dr. Rheuban. Chairman Collins, Ranking Member Hahn,
committee members, thank you for your invitation to testify
regarding the opportunities and challenges faced by health care
providers seeking to incorporate telehealth into everyday
practice.
I am the director of the Center for Telehealth at the
University of Virginia and a practicing pediatric cardiologist.
At our center, we connect patients at 128 different sites
across the Commonwealth of Virginia for access to specialty
care. Telemedicine or connected care is not a new specialty, a
new procedure or a new clinical service but rather technology
designed to enable the provision of health care services at a
distance, whether it is down the road, or across the State, or
across the country.
Twenty-first century telemedicine services can be provided
live by a high-definition video conferencing, supported by
peripheral devices or asynchronously using storing forward
technology or using remote patient monitoring tools keeping
patients healthy at home.
Telemedicine improves patient triage, reduces the burden of
travel for care, enhances timely access to care and saves
lives. A few examples: Telemedicine helps us to treat acute
stroke victims in critical access hospitals when every second
counts. It allows us to manage high-risk pregnant women in
their home communities, reducing premature deliveries.
Through telemedicine, we provide sorely needed mental
health services. We screen patients for diabetic retinopathy,
the number one cause of blindness in working adults. We monitor
heart failure patients after discharge from the hospital to
keep them healthier at home and in the workforce.
Regardless of the delivery system and, in particular, as we
migrate from volume-based to value-based systems of care,
telehealth supports patient engagement and self management. As
supported by extensive evidence, telemedicine improves clinical
outcomes and also lowers the cost of care.
It is widely accepted that our Nation faces a shortage of
physicians and other health professionals, expected to worsen
with our aging population, higher rates of chronic illness and
greater numbers of covered individuals. The use of telemedicine
maximizes provider efficiency, but again most importantly, it
is good for patients.
Despite our country's multibillion dollar investment in
telemedicine, broadband expansion, and health information
technologies, efforts to promulgate continued integration of
telemedicine, unfortunately, still remains stifled by 20th
century Federal and State barriers to more widespread adoption.
Opportunities for small practices to adopt telehealth are
extensive, depending on the credentials of the provider and the
model they might wish to deploy. Primary care and specialty
care providers can connect to their patients or to one another
through video conferencing. They may offer clinical services
through store and forward technologies, serve on panels for
telemedicine services companies, and utilize remote patient
monitoring in the home to manage their patients with chronic
illness.
Regardless of the model chosen, it is imperative that
interested practitioners take into consideration all relevant
Federal and State policies and specialty society best
practices. Significant challenges still impact telehealth
practice, such as originating sight restrictions on
reimbursement by Medicare and varying degrees of reimbursement
by State Medicaid programs and private payers.
Last year, sadly, Medicare reimbursed less than $12 million
nationwide for telemedicine related services. A patient's or
provider's zip code should not determine eligibility for
telemedicine care when, on the other hand, our Medicare and
Medicare programs spend many hundreds of millions of dollars
annually on transportation costs. As an example, last year our
UVA program saved patients more than 4.8 million miles of
driving for access to care. It keeps patients local in their
community.
Equally challenging are variable state board regulations
that have led to continued uncertainty for practitioners,
confusion about credentialing and privileging regulations, lack
of licensure portability, which is a deterrent to interstate
practice. Anti-kickback laws, HIPAA privacy and security
regulations, evolving technology platforms, device
interoperability and health information exchange are all
important issues to be considered, as is the cost of sufficient
bandwidth.
In conclusion, telehealth is a valuable tool to address the
significant challenges of access to high quality care to
mitigate workforce shortages, improve population health and
lower the cost of care. There are many opportunities for small
practices to integrate telehealth into everyday practice.
However, even for large health care systems such as our
own, managing and navigating the complex legal and regulatory
environment which impacts telehealth can be very challenging.
It is imperative that we create and implement policies that
foster certainty, high quality, secure and sustainable
solutions that empower patients, and providers, and payers to
adopt 21st century models of care. Thank you.
Chairman Collins. Thank you Dr. Rheuban.
I would now like to yield Ranking Member Hahn for the
introduction of our next witness.
Ms. Hahn. Thank you.
I am pleased to introduce Dr. Megan McHugh, research
assistant, professor, and director of health policy and
implementation at the Institute for Public Health and Medicine
Center for Health Care Studies at Northwestern University,
Feinberg School of Medicine.
Dr. McHugh's research focuses on Federal health policy and
advocacy and has been awarded support by prestigious
institutions like the Robert Wood Johnson Foundation, CMS, CDC
and the Kaiser Family Foundation.
She holds a masters from the College of William and Mary
and a Ph.D. in public policy from the George Washington
University.
Welcome Dr. McHugh.
STATEMENT OF MEGAN MCHUGH, PH.D.
Ms. McHugh. Thank you, Chairman Collins, Ranking Member
Hahn and members of the subcommittee.
I'm honored to have been invited to testify today. My name
is Megan McHugh, and I am a research assistant professor at
Northwestern University. And my research and teaching focuses
on Federal health policy and the impact of policy changes on
health care costs, quality and access. And the opinions that I
am going to share today are my own and not of the university
First, I would like to make three points: First, by
adopting telemedicine services, small physician practices may
be better prepared to participate and succeed in new models of
care. The traditional fee-for-service payment system which pays
providers for each visit, procedure or test is an obstacle to
achieving the triple aim of better health care, better health
and lower cost.
In an effort to move away from the fee-for-service model,
the Center for Medicare and Medicaid Innovation which was
created by the Affordable Care Act is supporting the
development of new payment and delivery models, which reward
providers for delivering high quality, low-cost care.
Telemedicine has played an important role in these value-
based purchasing programs. For example, under the bundled
payment demonstration providers have the flexibility and the
financial incentive to care for patients using the best means
possible at a lowest cost. And since some data suggests that
telemedicine offers comparable care quality at a lower cost
than traditional in-person visits, providing care via
telemedicine is a natural choice.
Given the momentum towards value-based purchasing, small
physician practices would be well served by exploring whether
and how telemedicine may help them provide high-quality care at
a lower cost.
My second point is that reimbursement and state licensing
policies serve as barriers to the adoption of telemedicine by
small physician practices. Medicare generally limits payment
for telemedicine services to interactive audio and video
telecommunications with realtime conversations where the
original sites are located in a rural area.
As a result, telemedicine accounts for a very small portion
of Medicare services, as we just heard. However, through the
rulemaking process, CMS has been gradually expanding
reimbursement for telemedicine. For example, just this year CMS
changed the geographic criteria for originating sites, which
will expand reimbursable telemedicine services to more rural
Medicare beneficiaries.
Although research on the impact of telemedicine on cost,
quality and access is very promising, the evidence, I believe,
is not conclusive. And as a result, I believe that the gradual
expansion of telemedicine coverage under Medicare is a sensible
course of action and one that will produce a slow but steady
increase in the number of small practices that effectively and
efficiently use telemedicine.
And a good first start, in my opinion, would be to extend
coverage for telemedicine to all value-based purchasing
programs, like patient-centered medical homes and accountable
care organizations.
With regard to licensure, some State medical boards require
telemedicine providers practicing across State lines to have a
valid license in the State where the patient is located. And
providers who want to practice across State lines must obtain
an additional State license, which can be administratively
burdensome.
This burden may by greater for small practices, which are
less likely to have support staff who can help them navigate
this process. My personal opinion is that the current medical
licensure system is inadequate to address the growing practice
of telemedicine. And there are several alternative models that
could be considered, though each of them might raise some
political and potentially legal challenges.
Then, third, any policy that expands the use of
telemedicine should be carefully monitored. The academic
literature on the impact of telemedicine is voluminous and
still growing, and overall, the evidence suggests that
telemedicine can improve access to care as well as the value of
care.
However, evidence of the impact of telemedicine is not
entirely consistent. Some studies have shown no positive
benefits to telemedicine. Clearly, there's a need for continued
research in this area, but there's another issue concerning
research that I believe needs to be addressed and that is that
many studies of the effectiveness of telemedicine have been
conducted within hospitals or large physician practices. So, as
a result, our understanding of the impact of telemedicine among
small physician practices is much more limited.
In conclusion, telemedicine is an important tool for small
practices as payers transition away from the fee-for-service
model. State and Federal policymakers have the ability to
facilitate the adoption of telemedicine through policies
related to reimbursement and licensing, but expansion should be
coupled with oversight to monitor impact.
Again, I'd like to thank you for allowing me to appear
before you today and share my opinions, and I would be happy to
answer my questions that you might have.
Chairman Collins. Thank you very much, Dr. McHugh.
Our next witness is Maggie Basgall.
Maggie is the community relations representative for Nex-
Tech in Lenora, Kansas. Recently, Ms. Basgall was involved in a
telemedicine pilot project, collaborating with local hospitals
and clinics regarding their broadband needs. She is testifying
on the behalf of the NTCA, the Rural Broadband Association.
Welcome, and you have 5 minutes.
STATEMENT OF MAGGIE BASGALL
Mr. Basgall. Great. Good morning and thank you for having
me. Chairman Collins, Ranking Member Hahn and members of the
subcommittee, I am honored to be here today on behalf of the
NTCA, the Rural Broadband Association, to discuss the use of
telemedicine and its possibilities for small medical practices
from the perspective of Nex-Tech.
Nex-Tech serves over 2,200 broadband customers and has over
2,300 voice access lines spread across a 9,300 square mile area
in rural northwest and central Kansas. We serve 11 hospitals
and 14 clinics among several other small physician practices.
I worked as a community development specialist for Nex-Tech
for the past 4 years. I have a passion for rural communities,
because I lived in rural Kansas for most of my life. Most of
the my time with Nex-Tech is spent working with our
communities, particularly our anchor institutions, such as
health care providers.
Nex-Tech recently focused a pilot project on telemedicine
in efforts to promote a greater adoption of advanced
telemedicine capabilities. We spent time meeting with each
hospital and several of the clinics in the small physician
practices in our footprint.
Collaborating with these health care providers was very
enlightening as we learned of the rather large barriers they
are faced with in looking at adopting telemedicine. Hospitals
and clinics are undergoing large changes stemming from the
Affordable Care Act and other regulatory changes. Several are
still in the process of converting to electronic health care
records and looking into new financial challenges. Others share
that much of their time and efforts have to be focused toward
doctor recruitment, insurance barriers, and other pertinent
issues.
That being said, however, they are all aware of the
importance of broadband and how their access to affordable,
reliable connections is significant. We have noticed an
increase in subscribed bandwidth for our health care
facilities, even in just the last couple of years.
We have several hospitals with 50 megabyte per second
connections and higher. Many are currently using it for
everyday activities, such as offsite backup, checking insurance
eligibility, sending and receiving digitalized files,
conducting research, et cetera.
Most of these hospitals are engaging in some forms of
telemedicine, generally consisting of consultations from
patient to mental health care provider or screen-to-screen
trainings and Webinars. There are more uses that our hospitals
and clinics could delve into.
So many of our customers live in areas that are literally
hours and hours from the nearest specialist or major hospital.
Telemedicine has been but could be even more so of the
lifesaver for those in our area.
Even with health care staff time and efforts directed to
it, there are other factors that come into play as well. As
we've talked about, there is a lack of health insurance
reimbursement for care through telemedicine and a lot of
questions regarding physician licensure.
In visiting with hospitals, there is also a lack of
resources showcasing tangible applications or even overall
guidance that hospitals can utilize to get a sense of the
efficiencies that can be added.
There are programs available that these hospitals, clinics,
and physician practices can look toward for funding, but so
often these programs are overwhelming and can be difficult to
navigate through.
We do have fascinating ideas and programs that are
developing at a regional hospital in our footprint, Hays
Medical Center. They are currently preparing to deploy robots
to four pilot locations that can effectively transport a doctor
stationed at a hospital to a remote area.
There the patient can interact with the doctor through the
robot with the use of plug-ins equipped to conduct diagnostic
testing. Possibilities such as these are endless, but seeing
these through fruition can be another story.
Unfortunately, due to a lot of these barriers mentioned, we
haven't been able to move forward with our telemedicine pilot
project we began in 2012. Not only are our area health care
facilities facing these types of barriers, but Nex-Tech is as
well. Telemedicine cannot be implemented without an underlying
robust wired network. Unfortunately, Nex-Tech has been faced
with a number of regulatory uncertainties stemming from the
Federal Communication Commission's high-cost fund reforms.
Due to the high expense of delivering quality communication
networks in rural areas, rural providers need predictable
universal service support. However, in 2011, the FCC made
changes from what was available to the Quantile Regression
Analysis, QRA, which has created great uncertainty in the rural
telecom arena.
While the FCC has now eliminated the QRA, we have reverted
back to the previous methodology, a new Connect America Plan
for rural telecommunications providers still has not been
developed.
In summary, we at Nex-Tech are just absolutely thrilled to
be able to collaborate with our area hospitals clinics and
physician practices on current and future ideas and projects in
telemedicine arena. However, we must be able to continue to
deliver the services that hospitals are currently subscribed to
and be ready for the influx of those who continue to need more
bandwidth as they grow and technology advances.
Rural America will not realize the promise of telemedicine,
however, without a broadband USF that offers carriers the
regulatory certainty needed to make network investments and an
insurance industry that lacks telemedicine coverage.
Guidance is also needed for health care facilities to take
advantage of all that telemedicine offers. We look forward to
working with Congress and the appropriate agencies to ensure
these programs work as efficiently and effectively as possible.
Thank you.
Chairman Collins. Thank you very much.
Our final witness is Dr. Brenda Dintiman. She is a
physician with Fair Oaks Skin Care Center in Fairfax, Virginia.
Dr. Dintiman is a board certified dermatologist who has
practiced for over 16 years. She is testifying on behalf of the
American Academy of Dermatology.
Thank you very much.
STATEMENT OF BRENDA J. DINTIMAN, M.D., FAAD
Dr. Dintiman. Chairman Collins and Ranking Member Hahn, as
a fellow of the American Academy of Dermatology Association,
which represents more than 13,000 dermatologists nationwide,
and a past president of the Medical Society of Northern
Virginia, I commend you for holding a hearing on how
telemedicine can further the efficiency, quality and access to
health care.
I am here today to discuss barriers of implementing
telemedicine as a modality of care. Specifically, lack of
reimbursement and cumbersome credentialing posed the greatest
challenges. Although some reimbursement exists, it is not
consistent across payers or across States to allow for proper
patient access. Telemedicine is an innovative, rapidly evolving
method of care delivery. The Academy supports the appropriate
use of telemedicine as a means of improving access to the
expertise of board-certified dermatologists to provide high
quality, high value care.
As a physician who runs a small dermatology practice in
Northern Virginia, I currently use DermUtopia for the provision
of telemedicine. This is a HIPAA compliant, mobile phone, and
Web-based application. Through this application, I am able to
evaluate, triage and treat both my patients and patients who do
not have a primary dermatologist.
We are aiming to go treat Medicaid patients through
DermUtopia. However, there have been delays in ability to
solidify funding, despite the fact that Medicaid has been
improved for reimbursement for telehost services in Virginia.
I have faced several barriers to most effectively providing
care via telemedicine. While I face these barriers as a
physician, it is ultimately the patients, often the most
economically vulnerable, that are the most directly affected.
The largest barrier, as noted, is reimbursement for telehealth
services. Without reimbursement, providers and patients are
unlikely to utilize telehealth.
The benefits of such reimbursement would be widespread,
telederm can save a patient time missed from work, travel time
and, in the correct clinical context, allow for timely
diagnosis and treatment when face-to-face care is unavailable
or inaccessible.
While telederm has traditionally been used to increase
access to the remote or underserved areas, it indeed has great
potential for serving a variety of patients for dermatological
needs. For instance, insured patients in urban areas may face
similar access delays or issues as those in geographically
remote areas and therefore benefit from teledermatology.
I have seen firsthand a number of patients that could have
had the consultation done virtually and prevented an onerous
trip to the office or to an urgent care or emergency room. An
89-year old woman who lives alone at home, with no family in
the area, and who would need to be brought to the doctor via
wheelchair and transport vehicle, may be more easily evaluated
via telemedicine.
A nursing home patient with dementia who requires a nurse
aide, and transportation, and coordination costs from the
nursing home to evaluate a leg ulcer or an early infection
could be effectively evaluated via teledermatology. A 2-year
old with severe eczema, an infection, who cannot get in to see
a dermatologist due to lack of access to a Medicaid
dermatologist and inability for the parents to transport them
during work hours, across the city, two bus rides, away could
be easily evaluated and monitored via teledermatology.
Overall, telemedicine provides a modality of care which can
expand patient access to medical specialists, such as
dermatologists. But barriers to implementation remain. Most
notably issues of proper credentialing and reimbursement exist
to varying degrees across States. These barriers impact
providers but ultimately can hinder patient access to care.
I as well as the academy appreciate the subcommittee's
continued leadership on this issue. And look forward to working
with you to ensure that patients can benefit from high quality,
timely and cost-efficient care for telemedicine. Thank you.
Chairman Collins. Thank you very much.
I want to thank all of our witnesses.
So far, we haven't had votes called. So, at this point, I
would like to yield to Mr. Luetkemeyer for his 5 minutes of
questioning.
Mr. Luetkemeyer.
Mr. Luetkemeyer. Thank you, Mr. Chairman.
Ms. Dintiman, thank you for your testimony. I was kind of--
as we go through the process here of talking about
telemedicine, I'm kind of curious, you're involved in the
practice every day. How many more patients can you see? In
other words, how much more benefit can it be when you have the
ability to do telemedicine here? I realize every case is
different, but I mean just----
Dr. Dintiman. Well, I think, as she said, these studies
have not been done, but we're anxious to do them, pilots and to
see what the benefits could be. Personally, I think I could see
5 to 10 more patients a day.
Mr. Luetkemeyer. Very good.
Dr. Dintiman. And that's with the effectiveness of
evaluating them through the applications, through the computer,
through the details that are provided, because teledermatology
is a unique specialty that allows the pictorial view of the
disease.
Mr. Luetkemeyer. How do you minimize or mitigate the
liability situation that you have as a doctor when you diagnose
someone and someone else takes that diagnosis and then
administers the care? How do you mitigate that? Are you
concerned about it at all?
Dr. Dintiman. Of course, our concerns are to protect the
physician and protect the patient, ultimately. It is
interesting a lot of care is already provided via the phone,
with very little details, and with sometimes misinformation
communicated through a phone. Whereas, with the use of video or
stored forward technology, you're getting so many more details
and so much more important information that allows you to you
make a very important triage or suggestion to advise the
patient to come in, advise the patient to go to the ER. I think
that, in many ways, it protects the physician to have
telemedicine as part of their practice.
Mr. Luetkemeyer. Excellent.
Ms. Basgall, you went at length with regards to the
broadband problem that is very prevalent in a lot of rural
parts of our country. And you know, to me this is probably the
biggest problem I would see other than, perhaps, reimbursement
with regards to telemedicine from the standpoint of the benefit
it could be to the rural areas. Yet, with the barrier of the
lack of broadband, in some areas, it would seem that would be a
huge hurdle.
I know I live in the rural part of Missouri, and I am
barely within a broadband area myself. And so I know there are
a lot of areas within my own district that do not have
broadband. So can you speak to that a little bit about the
concerns, how you are working with providers, maybe some
hurdles and some things that perhaps we can help you with to be
able to enhance that?
Mr. Basgall. Sure. Well, Nex-Tech is actually sitting in a
very good position as far the broadband that we are table to
offer our customers because of some past RUS loans, because of
the broadband stimulus grant and loans that we were able to
get. We were able to build out fiber optics and also WiMAX, a
wireless technology, to reach several of our customers that are
out in a rural area, who otherwise had dialup service.
So I feel like we are sitting in a pretty good position,
where we can continue to work with those. You are always going
to have customers who aren't in line of sight of a tower and
are down in a draw or have trees surrounding them, and you just
continue to work with them and say, what else can we do? Can
you look for a unique solution for that? Can you put up a pole
or put whatever might be able to work for them?
As far as other companies in other areas, I know that it is
a large issue, and I think a lot of maybe investments that
would have otherwise been made at this time haven't been due to
the regulatory uncertainty. I believe in the written testimony
we have some statistics where it talks about the number of RUS
loan applicants that were during the first 3 years of the
program versus the past 3 and how those have dropped
tremendously just because people aren't certain of--it has to
be feasible in order to make it work. And when it is uncertain,
it is difficult to make that happen.
Mr. Luetkemeyer. Thank you.
Dr. McHugh, you talked about licensing across State lines
is a problem. And I am sure when you practice across the States
you have to have a license, so when you practice telemedicine
across State lines, it is a whole new world there of licensing.
Can you talk about the problems and what kind of solutions you
may have?
Ms. McHugh. Sure. This is a bit of a challenge, especially
where State medical boards have made decisions to limit
practice to physicians who are located in the same State as the
patients. It really limits competition, and it limits the
ability for the patients to seek care outside of the State
lines.
There are several different approaches that could be used
to address this problem anywhere from Federal approaches, where
the Federal Government decides that we're going to have sort of
a national leadership in term of licensing of telemedicine
providers, to keeping this a State responsibility and having
States come together through some sort of interstate agreement,
where one State will recognize licensure in another State.
Mr. Luetkemeyer. Is there a movement along that line?
Ms. McHugh. There has been some advocacy along that line,
but there has not been not been a whole lot of groundswell of
support. I don't believe that many States have signed on to
that yet.
Mr. Luetkemeyer. I see I am over my time.
Thank you, Mr. Chairman.
Chairman Collins. Thank you, Mr. Luetkemeyer.
I yield to Ranking Member Hahn for her questions.
Ms. Hahn. Thank you, Mr. Chairman.
I really appreciate all of your testimony. I learned a lot
listening to each and every one of you. Some of my questions
were already asked by Representative Luetkemeyer, but I was
thinking along the same lines.
One of the things that comes to my mind is patient privacy.
And I was going to direct this to Dr. Rheuban, but any of you
might want to answer that. There has been a high profile case
lately of a doctor who was found secretly videotaping one of
his patients in the exam room, and I think that just sort of
sends fear through--I know women particularly.
What would be your take on who should design the protocols
for processing, sending patient information? And can or should
the Federal Government be involved in helping to regulate
telemedicine to ensure patient privacy?
Dr. Rheuban. That is an excellent question. And certainly,
all HIPAA privacy and security regulations apply to
telemedicine providers as well. So I don't know that we
necessarily need to regulate even more. The American
Telemedicine Association has developed practice guidelines and
standards. And I believe they should be sufficient, but it is a
matter of training; working with industry, working with a
provider community, working with the Federation of State
Medical Boards so that everyone understands where we are
currently; and then educating providers themselves about the
appropriate use of telemedicine.
Ms. Hahn. Does anyone else have any comments on that?
Dr. Dintiman. Yes. I think that if you go to the ATA
meeting, the American Telemedicine Meeting, you see that HIPAA
compliance and security is of utmost importance. The technology
is there. The enthusiasm of the scientists that come to these
meetings is there.
I think that what we may not realize is already a lot of
information is communicated in non-HIPAA compliant ways. And so
we need to actually channel the physicians and the health care
providers to use these various secure systems that have been
developed, because I think ultimately that is risk for the
patient, but it can be overcome.
Ms. Hahn. Now, Dr. Dintiman, you talked a little bit about
how it could work in the world of dermatology. And you also
mentioned possibly a patient in a nursing home with
Alzheimer's. I was wondering how the rest of the doctors could
comment on, what do you see as good cases for telemedicine? And
are there ones that, of course, would not ever able to be
accommodated by telemedicine? I just would like to hear a few
more, what are the actual cases you think that would be served
well by this?
Ms. McHugh. Well, I will just jump in and say that when you
think about the functionality and the capabilities of
telemedicine, you know, they cover such a broad range of
functions, you know. You can have a consultation. You can
diagnose. You can do remote monitoring. You can even have
physician mentoring.
And so when you think broadly about the scope that
telemedicine covers, it is really hard to imagine a specialty
that couldn't be aided by telemedicine. I mean, you can even
think about things beyond traditional specialties. So, for
example, I teach a graduate health policy course, and one of my
students is an emergency physician who wrote a terrific paper
on the use of telemedicine for EMS, Emergency Medical Services.
You can imagine an ambulance even going out into the field and
getting really expert advice about whether to transport a
patient and where to transport a patient.
Dr. Rheuban. I don't think you even need to imagine it,
because it is already here. So, in our program, we are
providing services in more than 45 different subspecialties of
health care. We do rely on our clinicians as to their comfort
level of providing the service. We have protocols in place that
have been developed with the providers to be sure we are doing
the right thing for the right patient at the right time.
American Telemedicine Association has many dozens of special
interest groups that work with the specialty societies. If you
want some use case scenarios, high-risk obstetrics
telemedicine, cancer services. We do screening for diabetic
retinopathy, acute stroke care. In my own speciality of
pediatric cardiology, I can use a electronic stethoscope and
read an ultrasound in the nursery where there is a baby that
may have low blood oxygen. It is pretty much, as Dr. McHugh
said, diverse across our specialties.
Ms. Hahn. Thank you. I know my time is up, but I will say I
read something which none of you have actually touched on was
the doctor-to-doctor use of this. And I was reading an example
of a doctor who had, alone at night, kind of dealing with a
case, no one was around, and the opportunities of sending to
another doctor these kinds of video or pictures and having a
consultation with another physician.
Thank you very much.
Chairman Collins. Yes, thank you.
I would like to now yield to Mr. Coffman for 5 minutes.
Mr. Coffman. Thank you, Mr. Chairman.
I thank you all for coming here to testify on telemedicine.
And obviously, my hope and I think the hope of many members of
Congress is what can we do to reduces cost and expand access to
health care.
So I am wondering if you all could elaborate on I think
three things: Number one, to what extent have we--what are the
frontiers for telemedicine in terms of, what can we still
exploit in terms of opening access, lowering costs? And then,
the second part, what are the impediments to do that? Are they
cultural within the provider community, or are they regulatory
in nature? And then I think the third would be just an idea in
terms of what it could mean to our health care system if we
could advance telemedicine further in terms of opening up
access and reducing cost.
Dr. Rheuban, why don't we start with you, please?
Dr. Rheuban. Thank you.
I think the frontiers are the delivery of care in the
nontraditional environment, so in the workplace potentially,
when people are traveling, many--in the home. We have a lot of
cost savings data actually that are available. And as an
example, in our own program, I mentioned the high-risk
obstetrics telemedicine program. We have reduced preterm
delivery and reduced days in our NICU by 39 percent. That is a
huge cost saver for State Medicaid program and for the payer
community.
In stroke, if you can provide timely access to a stroke
neurologist and appropriate use of clot-busting medication,
that saves huge disability, saves lives, and saves--nursing
home care. Nursing homes are a wonderful place because the
challenge of transporting patients, the cost of the Medicare
program.
Remote patient monitoring in the home. We have done about
650 patients we supported after discharge from the hospital,
and we have reduced readmission by 50 percent in those patients
who would have bounced back. So those, again, cost savings. So
the frontier is being broader in terms of our look-see and how
we can do it and eliminating some of the regulatory barriers
that have limited providers from utilizing these opportunities.
Mr. Coffman. Okay. Thank you.
Ms. McHugh. Mr. Coffman, you had asked whether the barriers
are more public policy related versus cultural. I would argue
that they are both. There is certainly a lot that policymakers
can do to expand the use of telemedicine, but I think that
cultural barriers are an important one that we haven't really
touched on yet. Work and quality improvement has shown for
decades that changing physician behavior is very, very
difficult. But one thing that is very much in your purview is
to change reimbursement policies. As I mentioned, my personal
opinion is that expanding telehealth coverage value-based
purchasing programs would be a natural and next step for that,
because under value-based purchasing programs, physicians and
hospitals are incentivized to provide high-quality care at the
lowest cost. In some cases, we know that providers don't have
the flexibility to use telemedicine under these programs, even
though it could be a very useful tool to improve the value of
care delivered.
Mr. Coffman. Ms. Basgall.
Mr. Basgall. Yes. I would also like to touch on those same
lines. The frontier in our rural area seems to just be let's
get this started, let's move past just the face-to-face
consultations they are currently having with--most of it is
focused on the mental health side. We have a shortage, I think,
of mental health psychologists, psychiatrists in our area. So a
lot of times the hospitals are using kind of an ITV sort of set
up for those means. So I think we just need to get past that.
But I think one of the--like you mentioned, cultural, one
of biggest barriers is we have an aging population, and that is
both doctors and patients. So doctor recruitment will be
interesting as they are trying get some younger doctors in to
focus on, maybe they will have a want or a desire to bring in
some of this technology. And then also helping our customers
understand broadband and bring that into their lives a little
bit more so.
Mr. Coffman. Dr. Dintiman?
Dr. Dintiman. I would like to focus on the cost saving
aspect of telemedicine. I really think that if we look at our
rehab centers and nursing home, how we could bring the care to
the patient, instead of bringing the patient to an office or an
emergency room without knowing where they need to be. For
example, if we bring the care to the patient, we can evaluate a
leg ulcer or an early infection more quickly and get the care
implemented so they do not end up a patient that is
hospitalized.
Secondly, I think one of our biggest patient populations is
our obese and diabetic population that can be monitored through
teleophthalmology. They can be monitored through
teledermatology. They have leg ulcers that are, again, big cost
to the health care system as well as the other complications of
diabetes. So I feel that we can see this in many specialties
that we bring the care to the patient, and the system will save
money.
Mr. Coffman. Well, thank you all for your testimony today
and for working in this frontier I think that has such promise
in terms of opening up access and lowering costs and hopefully
maintaining, if not improving, quality.
Madam Chairman, I yield back--Mr. Chairman.
Ms. Hahn. I like Madam Chairman.
Chairman Collins. Thank you very much.
Well, we have timed this fairly well. They have called
votes, but we still have some time. I would like to ask a few
questions to close this out.
On the reimbursement issue, I mean, we talked a lot about
Medicare and Medicaid. Dr. McHugh, what about the private
insurers? Start with the basic question: Do they make the
decision themselves whether they reimburse because you have one
insurance company in an area saying, we will reimburse our
doctors for telemedicine, and yet another private insurance
company saying no, or is this a statewide issue?
Ms. McHugh. So insurers do make the decision themselves.
However, they have to follow State laws regarding mandated
benefits. So some States have laws saying that insurers who
offer coverage in their State must offer that particular
benefit.
Chairman Collins. So you could have, though, a cutting-edge
company saying, we're going do it.
Ms. McHugh. Uh-huh.
Chairman Collins. So if the insurance company can do it, a
State might mandate it, but in the case of, I think, there are
20 States, as I understand it, that have a reimbursement
policy, but that leaves 30 States without one. So, in those
States, a private insurer could decide it is good business for
them.
Ms. McHugh. Absolutely. We see many insurers being swayed
by the evidence and going far beyond offering coverage for the
services that are mandated. They realize it makes good business
sense.
Chairman Collins. So, Ms. Basgell, some rural areas, and
certainly mine--I have a very rural area. We have 25,000 to
50,000 households that don't have broadband coverage, and part
of that gets back to the definition of what is an underserved
area or not. Have you seen any cases where somebody could have
a small, office setting, or clinic setting, in a rural area
that has broadband, so a patient could actually drive 5 miles
there and connect at that point to a physician that is 50 miles
away, almost like a call center? Have you seen anything like
that?
Mr. Basgall. You know, the most that we have seen as far as
that goes is on the mental health side. And again, I think it
goes back to some the closest psychologists are, you know, an
hour and a half, 2 hours away. In my area, I think a lot of
people are used to driving, and it is maybe not as bothersome
to them to go to see their doctor physically, rather than
online.
I do think it also goes back to it the aging population and
what their comfort level is. I think that there are a lot that
are just more comfortable being there physically, but as we
have a younger population coming back to our area, I think that
that is starting right now. We are seeing a trend where some
younger people are moving back to their hometowns. I think if
that continues, I think that that comfort level will rise, and
maybe we will see more of that in the foreseeable future.
Chairman Collins. We have college kids that may be seeing,
for various reasons, a mental health professional at home. They
developed a relationship with that person. They go off to
college. Maybe they are back and forth. It would appear that
would be a very appropriate use. You can't just say to a
college student in another State, because of licensing
procedures, you have to start a new relationship. Would anyone
like to comment on that?
Dr. Rheuban. That is absolutely a perfect use case and
example of why the lack of licensure portability can be a
challenge. That provider that is caring for that student would
have to have a license to practice medicine in that State.
Now the Federation of State Medical Boards is moving
forward with an interstate compact to try to expedite the
licensure process, but it is still going to be time consuming.
And we look to seeing how quickly and how expedited this
process will be. Your example is a perfect example about why we
need some broader vision in that regard.
Chairman Collins. Would any of you like to comment?
Dr. McHugh, is that a proper role, perhaps, for the Federal
Government? I think some of us would say we defer to the 10th
Amendment and States' rights. I, for one, am very reluctant to
ever step in with a Federal policy or support of Federal policy
that tramples on States rights. But you know, we seem to be in
this telemedicine quandary of 20 States have reimbursement
policies; 30 States don't. The licensing issue was brought to
bear recently with a football physician who was treating his
team in another State, and a player sued him. That brought that
to the forefront. Is this one where perhaps some Federal
statutes could give some limited coverage?
Ms. McHugh. I think so. Certainly the Federal Government
coming in and taking over this responsibility does introduce
some issues with federalism. However, as a consumer and a
parent, I want high quality care. And whether it is the Federal
Government who shows leadership or State governments who show
leadership, if States aren't going to act, I would like to see
the Federal Government act.
Dr. Rheuban. I would like to point out there are 50
different State Medicaid programs with all different
regulations as well. And that is a major challenge for our
patients, especially as we see more insured patients under the
Medicaid program. So I would certainly be supportive of greater
oversight when it comes to medicaid programs and telemedicine
as well.
Chairman Collins. It almost seems like you could have some
exceptions for existing patient relationships to avoid that. I
am from western New York. A lot of our older population goes
south for 3 months to Florida. There is another case; they have
the relationship. It is not a New York doctor poaching in the
Florida area for clients, but rather an existing client
relationship, much like the college student and so forth.
Do you ever think you could see something where there would
be protections and/or licensing granted to existing patient-
doctor relations different than a new patient? Is that even a
possibility?
Dr. Dintiman. I think that that is very doable and
especially to--some of the States have a specific telemedicine
license. It doesn't give you full access, but you do have the
ability to treat patients across lines.
And I just wanted to remind us that there are many States
that have--there is a huge shortage of pediatric specialties,
such as pediatric rheumatology and endocrinology. There are
whole States that don't have one pediatric rheumatologist. I
think those people should have the ability to have a
telemedicine consult, even if there is not an existing
relationship.
Chairman Collins. I think our time has come to an end. I
have other questions, but I think what we have seen here is
common sense. We would like to think that common sense should
carry the day. And technology has now moved to us a place we
can better serve an aging population or a rural population
where we know there is going to be a shortage of doctors. There
is already a shortage of specialties. There are many mental
health professionals that are doing concierge medicine; they
don't even take insurance. I know in the dermatology
profession, especially, you can wait 18 months to get--they
call it an annual skin check, but they should now call it an
18-month skin check. So I think common sense says we need to
move it forward. If a doctor doesn't get paid, they are not
going to be participate, so reimbursement. The licensure
issues. No one wants to be put in a position of not complying
with the laws relative to their license or, in some cases,
their own liability insurance policies.
So what our purpose was today, and I think we accomplished
it, was to start a discussion. I think this is only the second
hearing in Congress on telemedicine. It is messy with State
laws. It is messy with Medicare and Medicaid and different
practices and existing relationships and so forth. But if we
don't start the discussion at some point--and we are seeing a
hodgepodge of things move forward State by State.
So, again, your testimony was quite timely. We appreciate
all of your comments and hope that this discussion is helpful
to those of us who just want to move forward in a common sense
direction.
I ask unanimous consent of members that we have 5
legislative days to submit statements and supporting materials
for the record.
And with no objection, that is so ordered.
The hearing is now adjourned.
[Whereupon, at 11:02 a.m., the subcommittee was adjourned.]
A P P E N D I X
Testimony before the Committee on Small Business
Subcommittee on Health and Technology
July 31, 2014
Karen S. Rheuban MD
Professor of Pediatrics
Director, University of Virginia Center for Telehealth
P.O. Box 800711
University of Virginia Health System
Charlottesville, Virginia, USA 22908
[email protected]
434-924-2481 (phone)
434-982-1415 (fax)
Chairman Collins, Ranking Member Hahn, members of the
Subcommittee on Health and Technology, thank you for the
invitation to provide testimony regarding the opportunities and
challenges for small medical practices seeking to incorporate
telehealth into everyday practice. My name is Dr. Karen
Rheuban, and I direct the Center for Telehealth at the
University of Virginia. I am the Principal Investigator of the
federally funded Mid Atlantic Telehealth Resource Center, a
past president of the American Telemedicine Association and
Board Chair of the Virginia Telehealth Network. I also have the
privilege of serving as Board Chair of the Virginia Department
of Medical Assistance Services (Medicaid). Although the focus
of my testimony relates to opportunities for and barriers to
the use of telehealth at the provider level, it is also
important to note there are parallel implications for small
business development in sectors such as telemedicine services
companies and technology innovation.
``Telemedicine'' is defined as the practice of medicine
using electronic communications, information technology or
other means between a provider in one location, and a patient
in another location. Generally, telemedicine is not an audio-
only telephone conversation, e-mail/instant messaging
conversation, or fax. Telemedicine is not a new specialty, a
new procedure or a new clinical service but rather, technology
designed to enable the provision of healthcare services at a
distance. 21st Century telemedicine services can be provided
live, via high definition interactive videoconferencing
supported by peripheral devices, or provided asynchronously,
using store and forward technologies, or through the use of
remote patient monitoring tools.
Telemedicine has been demonstrated to mitigate many of our
nation's significant challenges including disparities in access
to care, healthcare workforce shortages, and geographic mal-
distribution of providers. Telemedicine improves patient
triage, clinical outcomes, reduces the burden of travel for
care, and fosters more timely access to care. Telemedicine
tools support patient engagement and self-management where
appropriate, and, as supported by extensive evidence published
in the peer-reviewed literature, improves clinical outcomes,
and lowers the cost of care \1\,\2\.
---------------------------------------------------------------------------
\1\ Lustig, Tracy A. The role of telehealth in an evolving health
care environment: workshop summary. National Academics Press, 2012.
\2\ Schwamm, Lee H., Heinrich J. Audebert, Pierre Amarenco, Neale
R. Chumbler, Michael R. Frankel, Mary G. George, Philip B. Gorelick et
al. ``Recommendations for the Implementation of Telemedicine Within
Stroke Systems of Care A Policy Statement From the American Heart
Association.'' Stroke 40, no. 7 (2009): 2635-2660.
Vetted by and in collaboration with the relevant specialty
societies, the American Telemedicine Association has developed
and published practice guidelines designed to ensure best
---------------------------------------------------------------------------
practices in telemedicine that ensure high quality care.
Examples of telehealth supported care include:
Remote diagnosis of stroke with timely use
of thrombolytic (clot busting) agents to reduce
morbidity and mortality, improve patient outcomes, and
lower overall costs of care;
Delivery of telemedicine supported
obstetrical services to women at high risk for
complicated pregnancies ultimately resulting in
improved clinical outcomes, lessened infant mortality
rates, reduced days in neonatal intensive care and
lower costs of care;
Regular ophthalmologic screening of patients
with diabetes for retinopathy, the number one cause of
blindness in working adults;
Better management of chronic illness such as
heart failure, diabetes, hypertension, chronic
obstructive pulmonary disease;
Improved access to cancer screening tools,
collaborative diagnosis through virtual tumor boards
and even remote access to clinical trials;
Access to mental health services for
children and adults to include emergency psychiatry
services;
Telemedicine supports an integrated systems approach
focused on disease prevention, enhanced wellness, chronic
disease management, decision support, improved efficiency,
quality and patient safety.\3\
---------------------------------------------------------------------------
\3\ Kvedar, Joseph, Molly Joel Coye, and Wendy Everett. ``Connected
health: A review of technologies and strategies to improve patient care
with telemedicine and telehealth.'' Health Affairs 33, no. 2 (2014):
194-199.
Opportunities for small practices to adopt telehealth
relate to the model they wish to deploy and the credentials of
the provider. Primary care providers can serve as ``originating
sites'' so as to connect their patients to specialists, they
may offer direct-to-consumer services for their own patients,
they may choose to serve on panels for telemedicine services
companies offering direct-to-consumer services for their own
patients or others, and/or they may engage in remote patient
monitoring services for chronic disease management for their
patients. Specialty care providers may serve as consulting
``distant site'' providers to provide consultative services and
follow up visits either through their offices or at the
hospital. Specialists may also serve as ``originating sites''
to connect to other providers. They may offer services live
using videoconferencing technologies or through store and
forward applications. Specialty care providers may choose to
serve on panels of consultants for telemedicine services
companies, offer direct-to-consumer services for their patients
or for payers and telemedicine services companies, and
participate in remote patient monitoring models. Regardless of
the model chosen, is imperative that willing providers take
into consideration all relevant federal, state, specialty
society policies and best practices that impact telehealth
---------------------------------------------------------------------------
practice.
A) Rural healthcare:
Although rural communities face the same basic challenges
in access, quality and costs as their urban counterparts, they
do so at far greater rates, attributable to a host of factors.
``Core health care services'' as defined by the Institute of
Medicine as primary care, emergency medical services, long term
care, mental health and substance abuse services, oral health
and other services are considerably less accessible in rural
communities.\4\ Where local specialty care services are not
available, particularly in rural and underserved regions and
health professional shortage areas, telemedicine offers timely
access to care and spares patients the burden of long distance
travel for access to that care.
---------------------------------------------------------------------------
\4\ Institute of Medicine, Committee on the Future of Rural Health
Care. ``Quality through collaboration: The future of rural heath
care.'' (2014).
Rural communities lack sufficient patient volumes to
support specialty and subspecialty practices. Primary care
providers are often overwhelmed with complex patients with
acute and chronic illness. Telehealth technologies offer ready
access to critical services when rural providers partner with
---------------------------------------------------------------------------
tertiary and quaternary care facilities.
Attracting health professionals to rural communities
remains a daunting task and retaining those health
professionals to practice in rural communities is all the more
difficult. Rural healthcare providers generally work longer
hours, see more patients and have grater on-call demands
because of lack of cross coverage opportunities. Strategies to
recruit and retain clinicians to practice in rural and frontier
communities must include applications that enhance the
management of patients with acute and chronic illness, and
reduce the chronic sense of isolation experienced by those
practitioners by affording enhanced connectivity to colleagues,
and educational opportunities.
Telehealth should be viewed as integral to rural
development. More than 90% of patients seen through our UVA
telemedicine program remain within their community healthcare
environment, resulting in a reduction of unnecessary transfers,
and thereby contributes to the economic viability of community
hospitals.
B) Urban healthcare
Although the challenges of unfavorable geography and
distance tend to be uniquely rural, socioeconomic issues,
health disparities, and other serious barriers to access to
quality healthcare are equally compelling in urban areas.
Poverty, unhealthy behaviors and adverse health status
indicators are as prevalent in the shadow of our finest urban
academic health centers as they are in rural communities.
Isolated, vulnerable urban patients also suffer from high rates
of chronic illness, and for whom a bus ride across town can be
as challenging as is a long ride for rural patient.
C) Workforce
It is widely accepted that our nation faces a shortage of
physicians and other health professionals which is anticipated
to worsen with our aging population, higher rates of chronic
illness, and greater numbers of covered individuals seeking
care following the implementation of the Affordable Care Act.
The Association of American Medical Colleges (AAMC) in a recent
communication with the Committee on Veterans Affairs reported
an estimated shortage of 46,000 primary care physicians and
45,000 specialists by 2020.\5\ The incorporation of telehealth
technologies into integrated systems of care offers tools with
great potential to address some of the challenges of access,
specialty shortages, and changing patient needs both in the
rural and urban setting.
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\5\ https://www.aamc.org/download/385178/data/
aamclettertocongressionalconfereesonveteranaffairslegislation.pdf
The aging of our population has already created increased
demand for specialty healthcare services to address both acute
and chronic disease in the elderly. Such a demand, in the face
of anticipated provider shortages, requires a fundamental shift
from the model of physician centered care to one focused on
patient centered care using interdisciplinary teams, evidence
based medicine, the use of informatics in decision support and
telehealth technologies when specialty care services are not
locally available. Home telehealth and remote monitoring in the
arena of chronic disease management improves care and prevents
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hospital readmissions.
To facilitate this paradigm shift, it is imperative that we
train a broad spectrum of health professionals to deliver 21st
Century healthcare facilitated by telehealth technologies.
D) Example: The University of Virginia Center for
Telehealth
The UVA Telemedicine program serves as an example of both
traditional and innovative applications in telehealth. Our
Center for Telehealth was established initially as the Office
of Telemedicine in 1996. Since the establishment of our
program, we have developed collaborations and agreements
connecting the UVA Health System with 128 sites across the
Commonwealth using high definition video-teleconferencing,
store and forward technologies, remote patient monitoring and
mobile health applications to improve access to healthcare
services for the citizens of the Commonwealth. We connect with
hospitals, clinics, health centers, community service boards,
medical practices, correctional facilities, skilled nursing
facilities and emergency medical services. Our telemedicine
program has reduced the burden of travel for Virginians by more
than 9 million miles, saved lives and fostered innovative
models of care delivery and workforce development. We have
launched a care coordination and remote patient monitoring
program designed to reduce hospital readmissions, and to manage
chronic disease in the community setting. UVA telemedicine
supported clinical care spans the continuum from prenatal
services, to acute care consultations and follow up visits, to
chronic disease management and palliative care. We have
leveraged these efforts to also expand broadband communications
services in rural regions of the Commonwealth.
The UVA Telemedicine program has received funding from
HRSA, USDA, the Department of Commerce, and the Rural
Healthcare Support Mechanism of the Federal Communications
Commission. We have worked with our colleagues at the Centers
for Medicare and Medicaid Services, and with the Institute of
Medicine to help advance the implementation of policies that
allow for innovation, sustainability and high quality patient
care. In 2010, the Center was awarded a federal grant to serve
as the Mid Atlantic Telehealth Resource Center (MATRC) to
provide technical assistance to providers, healthcare systems,
state governments and other entities in eight states and the
District of Columbia.
The Center for Telehealth has also worked closely with all
relevant agencies of the Commonwealth of Virginia to help build
our telemedicine network, to pilot innovative applications, and
to ensure sustainability through sound state public policy
collaborations that integrate telehealth into mainstream
healthcare in the Commonwealth. These efforts led to broad
reimbursement by Virginia Medicaid in 2003 and in 2010, a
legislative mandate for parity third party payment.
Our Center for Telehealth tracks a host of metrics to
include process metrics for emergency care (time from consult
request to completion of encounter), process metrics for non-
emergency services which are compared to traditional face to
face services, clinical outcomes metrics, hospital readmissions
rate, miles of travel avoided, comparisons to national
benchmarked telemedicine programs, patient satisfaction, and
other organizational metrics.
Examples of UVA telemedicine clinical outcomes metrics
include:
a) High-risk obstetrics telemedicine in which we
compared traditional face to face care with care
provided via telemedicine to 374 high risk pregnant
women. We have documented a reduction in NICU hospital
days for the infants born to these patients by 39%
compared to control patients, reduced patient no-shows
by 62% and reduced patient travel by these pregnant
women by 162,000 miles.\6\
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\6\Veith, Sharon T et al, ``Perinatologists and Advanced Practice
Nurses Collaborate to Provide High Risk Prenatal Care in Rural Virginia
Communities.'' In Association of Women's Health, Obstetric and Neonatal
Nurses (June 14-18), 2014). AWHONN, 2014.
b) In partnership with BroadAxe Care Coordination,
remote patient monitoring tools have been deployed to
prevent hospital readmission and have been an effective
tool for patients with heart failure, acute myocardial
infarction, chronic obstructive pulmonary disease, and
pneumonia, reducing all cause 30 day readmissions by
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45%.
c) Store and forward ophthalmologic screening for
retinopathy, the number one cause of blindness in
working adults has been provided to underserved adults
with diabetes. Over two years, 1736 screens have been
performed, with 802 abnormal patients identified (46%)
as being at risk for blindeness.
d) Remote patient monitoring tools have been used to
reduce the burden of diabetes in the community setting.
All clinical metrics tracked (Hgb A1c, fasting blood
sugar and blood pressure) have had impressive
reductions in the range of 9-10%.
e) More than 2000 patients have participated in the
video-based interactive patient education programs of
our diabetes community network.
E) Issues for consideration:
Despite the federal government and private industry's
multi-billion dollar investment in telemedicine, broadband
expansion and health information technologies, disappointingly,
efforts to promulgate continued integration of telemedicine
remain stifled by 20th Century federal and state barriers to
more widespread adoption. If challenging to large healthcare
systems such as ours, it follows naturally that despite great
promise, these obstacles create significant challenges for
small medical practices seeking to use telehealth tools. Larger
systems can draw upon the expertise of contract attorneys,
information technology specialists, a robust billing staff,
electronic medical records and picture archiving and
communications services, credentialing and privileging staff,
and other support systems to help facilitate telehealth
integration.
Currently, 26 different federal agencies report engagement
in telehealth, be it through research or other grant funding
opportunities, the establishment of broadband communications
networks, clinical service delivery, device development and
regulation, and other interests. The Fed-Tel working group
efforts to coordinate telehealth policy has made some progress,
however, there still remains a serious lack of coordination of
practical policies across these agencies in part because of
statutory barriers.\7\
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\7\ Doarn, Charles R., Sherilyn Pruitt, Jessica Jacobs, Yael
Harris, David M. Bott, William Riley, Christopher Lamer, and Anthony L.
Oliver. ``Federal Efforts to Define and Advance Telehealth--A Work in
Progress.'' TElemedicine and e-Health 20, no. 5 (2014): 409-418.
As an example: mal-aligned federal definitions of rural
have resulted in federal grant support for telemedicine
technology and broadband connectivity deployed to certain
clinics and hospitals eligible for funding according to those
agency definitions of rural, but sustainability is thwarted by
statutory barriers that deny Medicare reimbursement because of
a more limited Medicare definition of rural and other
originating site restrictions. Inconsistent state policies and
regulations create additional barriers for otherwise willing
providers seeking to integrate telehealth into care delivery
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models.
1) Reimbursement
a) Medicare:
Payment coverage restrictions remain a major impediment to
the broader adoption of telehealth by providers. Congress, in
1997, through the Balanced Budget Amendment, and in 2000,
though the Benefits Improvement and Protection Act (BIPA),
authorized the Center for Medicare and Medicaid Services (CMS)
to reimburse for telehealth services provided to rural Medicare
beneficiaries across a broad range of CPT codes and services.
However, the current Medicare telehealth provisions in the
Social Security Act 1834(m), enacted in 2000, have not kept
pace with advancements in technology, and more than a decade of
best practices and outcomes research. In the Act, Congress,
directed CMS to study and report opportunities to expand
coverage within two years. Fourteen years later, no such report
has been produced.\8\
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\8\ Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act (BIPA) section 223(d).
The Affordable Care Act did not expand eligible originating
sites in the traditional Medicare program in part because of
adverse scoring by the Congressional Budget Office that failed
to take into account services provided in lieu of face to face
care, and Medicare savings accrued by patient monitoring
programs. Pilot programs have been launched through the Center
for Medicare and Medicaid Innovation that include remote
patient monitoring. The regulations for Accountable Care
Organizations still require the patient originating site to
conform to the regulations set forth in Section 1834(m) without
flexibility to include providers serving patients living in
metropolitan communities across the nation including patients
in nursing homes.\9\ These statutory barriers placed on
telehealth programs are borne out by the meager reimbursements
reported by CMS for telemedicine services. In 2013, CMS
reported fewer than $12 million dollars in reimbursements for
``allowable charges'' NATIONWIDE which include distant site and
originating site fees. (Attachment A: CTEL). Although physician
offices and community based clinics are ideal originating sites
for telemedicine encounters, the current Medicare originating
site payment ($24.63) is insufficient to cover the costs of
establishing and maintaining a telemedicine services. In its
2014 physician payment schedule, CMS expanded its operating
definition of rural from non-metro counties only to also
include those regions defined as rural by the Office of Rural
Health Policy.
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\9\ Grabowski, David C., and A. James O'Malley. ``Use of
telemedicine can reduce hospitalizations of nursing home residents and
generate savings for medicare.'' Health Affairs 33, no. 2 (2014): 244-
250.
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b) Medicaid:
Currently 47 state Medicaid programs provide some form of
reimbursement for the delivery of telehealth facilitated care
to Medicaid beneficiaries. However, there is no consistency in
telehealth coverage across the Medicaid programs, despite clear
needs of patients served by our Medicaid programs and in the
face of coverage expansion post implementation of the
Affordable Care Act. Most Medicaid programs pay for
transportation of patients and yet, in many states, there are
still considerable limitations on coverage for telehealth
services. In 2013, Virginia Medicaid expended $70 million
dollars on non-emergency transport of Medicaid
beneficiaries.\10\ A consistent federal-state approach to
Medicaid payment for telehealth services would provide cost-
savings both in operations costs (transportation) and more
importantly, in access to care and models of care delivery.
Virginia Medicaid has taken many positive steps integrating
telehealth for its beneficiaries, and since 2003, has provided
telehealth coverage for urban and rural beneficiaries. Virginia
Medicaid covers live-interactive video based consultations and
follow-up care for all Medicaid enrollees. Our Medicaid program
has begun to cover certain store-forward services by Medicaid
providers, and has integrated remote patient monitoring for our
(urban and rural) dual enrollees, the most vulnerable and
costly patients we serve, though our newly launched pilot with
CMS ``Commonwealth Coordinated Care''. Virginia Medicaid has
also expanded the list of eligible providers and services
beyond the eligible providers in Medicare. Medicaid coverage
decisions requested by providers are analyzed based on clinical
need, technical viability of the service, models supported by
other payers, support of professional organizations,
establishment of protocols, costs, and risk of fraud and abuse.
In 2013, Virginia Medicaid reported reimbursements of $570,000
for more than 10,000 telemedicine claims in the fee for service
and managed care programs.\11\
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\10\ Communication with Hazelton, A., Virginia Department of
Medical Assistance Services, July 2014.
\11\ Communication: Nelson, J, Virginia Department of Medical
Assistance Services, July 2014.
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c) Private pay:
Twenty-one states plus the District of Columbia require
that private insurance cover telehealth services. These states
are: Arizona, California, Colorado, Georgia, Hawaii, Kentucky,
Louisiana, Maine, Maryland, Michigan, Mississippi, Missouri,
Montana, New Hampshire, New Mexico, Oklahoma, Oregon,
Tennessee, Texas, Vermont, Virginia, and the District of
Columbia. Some of the commercial payers support payment for
telemedicine services even in the absence of a state mandate.
Others have developed or adopted direct-to-consumer models as
either a benefit to members, or an additional payment option.
d) Other models:
A number of telemedicine services companies have developed
models to provide contractual services to hospitals,
correctional facilities and other entities, by recruiting
individual physician providers and contractually fully managing
the interface between physician, hospital and patient
(examples: Specialists on Call, Insight Telepsychiatry).
Other companies contract with payers or directly with patients
in direct to consumer model (examples: Teladoc, American
Well, MD Live) and offer services via video-based encounters
and telephone services to the home, workplace or travel
locations. The Federation of State Medical Boards \12\ and the
American Medical Association \13\ have issued recent policy
documents and guiding principles to ensure patient safety,
quality of care, privacy of patient information, protecting the
patient-physician relationship while promoting improved care
coordination and communication with medical homes.
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\12\ http://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/
FSMB--Policy.pdf.
\13\ REPORT 7 OF THE COUNCIL ON MEDICAL SERVICE (A-14) Coverage of
and Payment for Telemedicine, June, 2014.
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2. Boards of Medicine policies:
Inconsistent board regulations across the states and
territories have led to continued confusion for practitioners.
Some state boards have adopted positions of opposition to the
mainstream adoption of telehealth requiring an in-person visit
prior to any subsequent telehealth encounters. We applaud the
Federation of State Medical Boards, for its April, 2014 Report
Appropriate Regulation of Telemedicine (SMART) Workgroup
report. This report, ``Model Policy for the Appropriate Use of
Telemedicine Technologies in the Practice of Medicine''
establishes a framework and common language for adoption by the
states.\12\ As stated by the FSMB, ``this new policy document
provides guidance to state medical boards for regulating the
use of telemedicine technologies in the practice of medicine
and educates licensees as to the appropriate standards of care
in the delivery of medical services directly to patients via
telemedicine technologies. It is the intent of the SMART
Workgroup to offer a model policy for use by state medical
boards in order to remove regulatory barriers to widespread
appropriate adoption of telemedicine technologies for
delivering care while ensuring the public health and safety.''
Notably, this working group provided guidance to the Boards of
Medicine that an initial telemedicine encounter (live
interactive video based or store and forward) can indeed
establish a bona-fide doctor patient relationship so long as
the encounter conforms to current standards of practice.
Indeed, our experience and that of others supports that
concept. Timely access to care is a key driver of telemedicine
programs....as an example, it is highly unlikely that any acute
stroke victim might pre-emptively have scheduled an in person
visit with a stroke neurologist prior to suffering his/her
first stroke. We rely upon our clinicians and their respective
specialty societies to determine the wisdom and need for an
initial in-person visit when developing our telehealth
protocols.
The SMART Working group also established additional
guidelines for the Boards that address informed consent,
privacy and security of patient records, patient choice,
prescribing, licensure, continuity of care and access to
emergency care. In particular, the FSMB model policy clearly
states that prescribing as a result of a telemedicine encounter
should follow all current standards of practice in terms of
indications, appropriateness and safety considerations.
3. Credentialing and Privileging
Credentialing and privileging are important elements of
telehealth practice so as to ensure patient safety, quality and
that appropriate services are provided by the appropriately
credentialed provider. Telehealth has been incorporated into
the Joint Commission standards beginning in 2000 and in their
revised standards of 2004. In 2011, after extensive
deliberations with telehealth providers, CMS published much
welcomed new regulations in its hospital Conditions of
Participation standards to address credentialing and
privileging to include proxy arrangements so as to further
facilitate the delivery of telemedicine services across the
nation.\14\ Despite this progress, there remain delays in the
credentialing and privileging processes, and confusion amongst
practitioners and hospitals regarding roles and
responsibilities to include the requisite sharing of quality
data.
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\14\ http://www.ofr.gov/OFRUpload/OFRData/2011-
10875--PI.pdf.
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4. Licensure
State medical licensure is a slow, costly and cumbersome
process for providers who wish to offer services through
telemedicine to patients physically located in other states.
The process of securing multiple licenses is time consuming at
its best, with requirements for extensive primary source
verification, an application and fee for licensure in the
states in which the provider might wish to evaluate and treat
patients. So as to ensure the ability of the Boards to respond
to complaints and enforce actions against providers, in
response to requests for licensure portability, in April, 2014,
the Federation of State Medical Boards (FSMB) developed an
expedited licensure process. As compared to true licensure
portability, as has been applied in the Nurse Compacts and as
proposed in legislative proposals, this new process still risks
being time consuming and costly to providers. Nonetheless, the
FSMB expedited licensure proposal is an improvement over
current licensure policy.
5. Stark and Anti-kickback laws
Providers and healthcare systems must be aware of the
implications of the Stark and Anti-kickback laws when
considering models for acquisition of telehealth equipment and
technology. As reported on the CMS website, ``the Anti-Kickback
Statute (42 U.S.C. Section 1320a-7b(b) makes it a criminal
offense to knowingly and willfully offer, pay, solicit, or
receive any remuneration to induce or reward referrals of items
or services reimbursable by a Federal health care program.\15\
Where remuneration is paid, received, offered, or solicited
purposefully to induce or reward referrals of items or services
payable by a Federal health care program, the Anti-Kickback
Statute is violated.
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\15\ https://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNProducts/downloads/
Fraud--and--Abuse.pdf
The Physician Self-Referral Law (Stark Law) (42 U.S.C.
Section 1395nn) prohibits a physician from making a referral
for certain designated health services to an entity in which
the physician (or an immediate member of his or her family) has
an ownership/investment interest or with which he or she has a
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compensation arrangement, unless an exception applies.''
Both these statutes must be considered as important risks
for telemedicine providers or entities who ``purchase, lease,
order, or arrange for or recommend the purchasing, leasing, or
ordering of any good, facility, service, or item for which
payment may be made in whole or in part under a federal health
care program......Health care providers must take utmost
precaution and care in developing processes and procedures to
implement telemedicine programs to avoid liability under the
Stark and Anti-Kickback statutes.''.\16\
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\16\ Ali, S. http://ctel.org/wp-content/uploads/2011/12/CTeL-The-
Practice-of-Telemedicine-The-Impact-of-Stark-and-Anti-Kickback.pdf
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6. Broadband availability:
The Rural Healthcare Program of the Federal Communications
Commission's Universal Service Fund was established following
the passage of the Telecommunications Act of 1996. This program
has been extraordinarily useful in expanding broadband services
for eligible entities located in rural areas by providing
discounts for ongoing connectivity that compare to those rates
available to urban providers. Unfortunately as compared to the
e-Rate, High Cost, and Low Income programs, the Rural
Healthcare Programs have not fully met their Commission defined
funding cap because of onerous, complex application processes,
and statutory exclusions to eligibility that do not always
align with health disparities. In the Telecommunications
Program, as an example, for profit hospitals, initially
considered ineligible entities, may receive funding support for
connectivity to the Emergency Department but other connections
within that hospital are not eligible, even if that hospital is
the sole provider in a rural county.\17\
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\17\ FCC Report and Order, Order on Reconsideration and further
Notice of Proposed Rule Making, Federal Register: January 22, 2004
Volume 69, Number 14
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Other ineligible entities include emergency medical
services providers and skilled nursing facilities. For-profit
clinics and solo practices are not eligible for support. Good
faith efforts by the FCC to expand within their statutory
authority, has led to somewhat broader use of the
Telecommunications Program. The FCC Pilot Program and the
Health Care Connect Fund, allows, through consortia,
collaborations that may include urban providers. Chapter 10,
Healthcare, of the National Broadband Plan, outlined important
steps to integrate broadband communications services into
sustainable models of healthcare delivery.\18\
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\18\ Thomes, Cynthia, ``The National Broadband Plan: Connecting
America. Administered by the Federal Communications Commission, 445
12th Street SW, Washington, DC 20554. Retrieved October 15, 2010, from
http://www.broadband.gov.'' (2011): 435-436.
Despite significant outreach efforts, through 2012,
utilization of the fund still remains less than 30% of the
funding cap established by the Commission after passage of the
Telecommunications Act of 1996. Total funding commitments
reported on the Rural Healthcare website through June 2012 were
$114,123,355 of which $47,723,468.67 were allocated to
providers in Alaska.\19\
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\19\ http://www.usac.org/rhc/tools/news/default.aspx?pgm=telecom
The cumbersome and time consuming application process and
confusing regulations surrounding the rural healthcare programs
remain a disincentive for participation by individual providers
and small practices even if they otherwise meet the eligibility
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requirements set forth in the Act.
7. Patient Privacy and Disclosure
Providers must ensure that any telemedicine collaboration
conform fully to the regulations of the Health Insurance
Portability and Accountability Act (HIPAA). As with in-person
healthcare, providers have a duty to maintain confidentiality
and security of patient data. Where a technical staff is
included in the healthcare team at both originating and distant
sites, and with the additional components of technologies and
communications service providers, it is imperative that
providers pay special attention and adhere to both the privacy
and security elements of the HIPAA regulations. The HIPAA
Omnibus Rule requires that providers and their healthcare
associates have in place a Business Associate Agreement (BAA)
when interactions include protected health information.
Business associates include entities that create, receive,
maintain, or transmit protected health information to perform
certain functions on behalf of a covered entity. They also
include subcontractors of the business associate delegated a
function, activity, or service in a capacity other than as a
member of the business associate's workforce. HIPAA also
requires the covered entity be able to conduct audit trails to
ascertain the presence of breaches which is not readily
available with certain video based applications. As an example,
in 2011, Skype issued the following statement:
``Skype is not a business associate subject to HIPAA, nor
have we entered into any contractual arrangements with covered
entities to create HIPAA-compliant privacy and security
obligations. Instead, Skype is merely a conduit for
transporting information, much like the electronic equivalent
of the US Postal Service or a private courier. Skype does not
use or access the protected health information (PHI)
transmitted using our software. However, Skype has implemented
a variety of physical, technical and administrative safeguards
(including encryption techniques) aimed at protecting the
confidentiality and security of the PHI that may be transmitted
using Skype's calling and video calling products.''\20\
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\20\ Skype Statement: onlinetherapyinstitute.com/2011/03/
videoconferencing-secure-encrypted-hipaa-compliant/
Many practitioners are unaware of the complex nuances of
these regulations as they relate to telemedicine and do not
have in place the legal infrastructure to assist them in
managing the additional regulations that govern telehealth
practice.\21\
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\21\ http://caltrc.org/wp-content/uploads/2014/01/HIPAA-for-TRCs-
2014.pdf
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8. Informed consent
Informed consent is a requisite element of all healthcare
encounters. Telehealth practice adds additional layers of
disclosure, to include authentication of the identity and
location of the patient and provider, provider credentials, and
delivery systems utilized during the encounter. In addition,
providers must have in place an emergency plan should the
clinical situation warrant a higher level of care, and a plan
for care in the event of technology failure and all should be
disclosed to the patient as a component of the consent.
The FSMB Model Policy makes the following recommendations
regarding Informed Consent.\12\
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\12\ FSMB
``Appropriate informed consent should, as a baseline,
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include the following terms:
Identification of the patient, the physician and
the physician's credentials;
Types of transmissions permitted using
telemedicine technologies (e.g. prescription refills,
appointment scheduling, patient education, etc.);
The patient agrees that the physician determines
whether or not the condition being diagnosed and/or treated is
appropriate for a telemedicine encounter;
Details on security measures taken with the use of
telemedicine technologies, such as encrypting data, password
protected screen savers and data files, or utilizing other
reliable authentication techniques, as well as potential risks
to privacy notwithstanding such measures;
Hold harmless clause for information lost due to
technical failures; and
Requirement for express patient consent to forward
patient-identifiable information to a third party.''
9. Standards and Practice Guidelines:
The American Telemedicine Association and its >2500 member
supported Special Interest Groups, Committees and Discussion
groups have developed standards to address technical
applications, and clinical practice guidelines, many of which
have been endorsed by specialty societies.\22\
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\22\ Krupinski, Elizabeth A., and Jordana Bernard. ``Standards and
Guidelines in Telemedicine and Telehealth.'' In Healthcare, vol. 2, no.
1, pp. 74-93. Multidisciplinary Digital Publishing Institute, 2014.
These standards and practice guidelines extend beyond the
practice guidelines that currently exist for traditional
healthcare. The development of standards and guidelines,
addressing both interoperability (such as HL 7, DICOM, or
H.320, 323, 324, compression standards for videoconferencing)
and specialty specific applications (such as teleophthalmology
or telepathology), will increase functionality related to and
acceptance of advanced technologies applied to healthcare. The
Special Interest Groups of the American Telemedicine
Association have worked collaboratively with the clinical
specialty societies to develop practice guidelines in
telehealth that conform to accepted standards of care. These
guidelines are developed after careful review of the evidence,
and in consultation with the specialty societies. Examples
include teleophthalmology, teledermatology, telemental health,
tele-ICU, home telehealth, telerehabilitation, and
telepathology. Practice guidelines and standards guide
providers and payers in models of best practice, informed by
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the evidence.
10. Provider education, technical support and training
Training programs in telehealth are important additional
elements of health professional education and include the
appropriate use of telehealth technologies, board regulations,
relevant standards and guidelines, interprofessional models of
practice enhanced by telehealth, and specific training to
operate and troubleshoot videoteleconferencing equipment,
devices and patient monitoring tools. The American Telemedicine
Association offers certification for certain for-credit
programs, and others have developed hybrid on-line and hands on
training. With HRSA funding, and in partnership with the
Virginia Health Workforce Development Authority we have trained
300 health professionals across the disciplines to become
certified telehealth presenters, and/or coordinators to keep
pace with the demand for such trainees. Telehealth should be
incorporated into every medical and nursing school curriculum,
with subsequent experiences during graduate medical education
so as to prepare our physicians and nurses on the appropriate
use of telehealth in everyday practice.
11. The evidence:
In 2013, the American Telemedicine Association reported
``Over 40 years of research has yielded a wealth of data about
the cost effectiveness and efficacy of many telemedicine
applications.''\23\
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\23\ http://www.americantelemed.org/docs/default-source/policy/
examples-of-research-outcomes---telemedicine's-impact-on-healthcare-
cost-and-quality.pdf
More than 20,000 citations in the peer reviewed literature
address outcomes across the specialties, including pediatric
cardiology, high risk pregnancies, congestive health failure,
asthma, chronic obstructive pulmonary disease, cancer,
telepathology, teleradiology, diabetes care, dermatology and
wound care, to name just a few. The overwhelming evidence is
that telemedicine and remote patient monitoring compares
favorably with in person care, and in many cases, is associated
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with better outcomes.
a. Home telehealth
Home telehealth is defined as the use of synchronous or
asynchronous telecommunications technologies by a home
care provider to link patients to out-of-home sources
of medical care, education, or other services. These
services may incorporate interactive home telehealth
technologies using POTS (plain old telephone service)
or broadband telecommunications technologies. Home
telehealth programs generally include monitoring
devices such as pulse oximetry, blood pressure, EKG,
blood sugar, weight, temperature, and passive
monitoring of motion. It has been reported by the Food
and Drug Administration, which regulates medical
devices, that home care systems represent the fastest
growing segment of the medical device industry.
Home telehealth can be utilized by traditional home health
agencies, for the delivery of hospice care, or for case
management by providers, clinics or hospitals to facilitate
chronic disease management for patients. Home telehealth
programs reduce readmission rates, visits to the emergency
room, physician visits, and impart significant cost savings.
The federal government supports major initiatives for aging in
place such as PACE, but does not cover the technologies that
will keep people healthy, and independent in their own homes.
The Veteran's Administration has published data to
demonstrate that the VA Care Coordination and Home Telehealth
program reduces hospital admissions by 19% and hospital days by
25% for patients with chronic disease.\24\
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\24\ Darkins, Adam, Patricia Ryan, Rita Kobb, Linda Foster, Ellen
Edmonson, Bonnie Wakefield, and Anne E. Lancaster. ``Care coordination/
home telehealth: the systematic implementation of health informatics,
home telehealth, and disease management to support the care of veteran
patients with chronic conditions.'' Telemedicine and e-Health 14, no.
10 (2008): 1118-1126.
Integration of home telehealth into rural models of
healthcare is a particularly efficient cost-effective choice
when one considers the distances traveled by home health staff
in rural areas. Factoring in the time spent traveling to the
home, significant cost savings accrues with the use of these
technologies. Dimmock et al report the cost savings associated
with the supplementation of regular in home visits by home
telehealth visits at approximately $50/visit.\25\
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\25\ Dimmock, S et al, A case study of benefits and potential
savings in rural home telemedicine, Home Healthcare Nurse, 2000: 18 (2)
124-135.
A recent analysis of the evidence for telemedicine
interventions to include remote patient monitoring has
identified significant cost-savings and improved outcomes when
applied to the management of chronic illness.\26\ These
findings are consistent with our earlier referenced UVA Center
for Telehealth experience.
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\26\ Bashshur, Rashid L., et al. ``The Empirical Foundations of
Telemedicine Interventions for Chronic Disease Management.''
Telemedicine and e-Health (2014).
---------------------------------------------------------------------------
12. Acceptance of advanced technologies
Patient acceptance of and satisfaction with the use of
telehealth technologies for consultation and ongoing acute and
chronic care has been remarkably positive, attributable in part
to the obvious benefit of timely access to locally unavailable
specialty healthcare that spares patients the burden and
expense of travel to remote tertiary and quarternary healthcare
facilities. Indeed, we have collected data in many of our
programs that demonstrates the telehealth ``no-show'' rate is
considerably lower than the in-person clinic ``no shoe rate.\6\
---------------------------------------------------------------------------
\6\ Veith, Sharon T et al
Provider acceptance of advanced technologies and telehealth
tools has been equally gratifying for patient consultation,
patient education, distance learning opportunities, and for
---------------------------------------------------------------------------
collaborations in remote patient monitoring.
Conclusion:
Telehealth is an essential tool to address the significant
challenges of access to high quality care for both acute and
chronic disease management, to mitigate workforce shortages,
improve population health and lower cost of care. There are
many opportunities for small practices to integrate telehealth
models into every-day practice. However, even for large
healthcare systems, managing and navigating the complex legal
and regulatory environment which impacts the practice of
healthcare using telehealth tools can be challenging. For small
group practices and solo practitioners, telehealth holds great
promise, but the administration and regulatory challenges can
be overwhelming. Thus it is imperative that we create and
promulgate policies that foster certainty, transparency, high
quality, secure and sustainable solutions that empower
patients, providers and payers to adopt 21st Century models of
care.
[GRAPHIC] [TIFF OMITTED] 1
Telemedicine and Small Physician Practices
Testimony presented before the House Committee on Small
Business,
Subcommittee on Health and Technology
July 31, 2014
Megan McHugh, PhD
Research Assistant Professor
Director, Program in Health Policy and Implementation
Center for Healthcare Studies, Institute for Public Health
and
Medicine &
Department of Emergency Medicine
Northwestern University
Feinberg School of Medicine
Thank you Chairman Collins, Ranking Member Hahn, and
members of the Subcommittee. I am honored to have been invited
to testify before you today on this important policy topic. My
name is Megan McHugh, and I am a research assistant professor
at Northwestern University, Feinberg School of Medicine. My
research and teaching focus on federal health policy and the
impact of policy changes on health care cost, quality, and
access. The opinions that I will share today are my own, and
not the University's.
My testimony is organized around three points:
1. By adopting telemedicine services, small physician
practices may be better prepared to participate and
succeed in new payment and delivery models, such as
bundled payment.
2. Reimbursement and state licensing policies serve
as barriers to the adoption of telemedicine by small
practices.
3. Any policy that expands the use of telemedicine
should be carefully monitored. While there is promising
evidence about the value of telemedicine, the evidence
is not conclusive (or easily accessible to physicians
in small practices).
Telemedicine and New Payment and Delivery Models
There is widespread agreement that the traditional fee-for-
service system, which pays providers for each visit, procedure,
or test, is an obstacle to achieving the triple aim of better
health care, better health, and lower cost.\1\,\2\ Researchers,
health care advisory groups, and policy makers have called for
public and private payers to move away from the fee-for-service
system toward reimbursement models that reward providers for
the quality of care delivered, cost consciousness, and patient
satisfaction.\3\-\5\ As a result of these calls, the way in
which physicians and hospitals are paid is beginning to change.
For example, the Centers for Medicare and Medicaid Innovation
(CMMI), created under the Affordable Care Act, launched a
bundled payment initiative in which providers receive a fixed,
negotiated fee covering a set of treatment services for an
episode of care (e.g., hip replacement, stroke). Providers are
also required to report quality data. The single, set payment
per episode encourages providers to manage costs and integrate
care, and the reporting requirements promote accountability for
care quality.\6\ Similarly, the CMMI is supporting new models
at the state level. The State of Oregon received a grant to
reorganize its delivery system into coordinated care
organizations (CCOs). CCOs are networks of different types of
providers that have agreed to work together to manage the care
of Medicaid enrollees financed by a single per-patient budget.
Telemedicine has an important place in these value-based
purchasing models. Reimbursement is not contingent upon in-
person services; instead, providers have the flexibility and
the financial incentive to care for patients using the best
means possible at the lowest cost. Several studies have shown
that telemedicine costs less than in-person visits, and may
reduce utilization of high-cost services. One study found that
the availability of telemedicine videoconferencing after hours
in nursing homes reduced hospital readmissions and led to
approximately $150,000 in Medicare savings per nursing home
each year.\7\ Additionally, a primary care electronic
consultation system that allowed iterative communication
between a referring physician and specialist resulted in 20%
fewer specialty referrals.\8\
Given the momentum towards value-based purchasing, small
physician practices and hospitals would be well-served by
exploring whether and how telemedicine could be used to support
high-quality care at a reduced cost.
Challenges to the Adoption of Telemedicine by Small
Practices
While there are several barriers to the adoption of
telemedicine by small physician practices, the two that are
arguably the most important and policy relevant are
reimbursement and licensing.
Reimbursement
Medicare generally limits payment for telemedicine services
to interactive audio and video telecommunications with real-
time conversations where the originating sites are located in a
rural area.\9\ As a result, telemedicine accounts for a very
small portion of Medicare services. Only 369 providers had 10
or more Medicare telehealth consultations in 2009, and in 2011,
Medicare payments for telemedicine totaled over $6
million.\10\,\11\ Medicare's rather cautious policies related
to reimbursement for telemedicine are magnified because private
insurers often look to the Medicare program when crafting their
own reimbursement policies.
However, through the rulemaking process, the Centers for
Medicare and Medicaid Services (CMS) has been gradually
expanding reimbursement for telemedicine. For example, CMS
changed to geographic criteria for originating sites for
calendar year 2014. Previously, payment for telemedicine
services was limited to rural areas that were not located in a
metropolitan statistical area (MSA). This year, payment for
telemedicine services is also available in rural census tracts
within MSAs, which will expand reimbursable telemedicine
services to nearly 1 million rural Medicare beneficiaries. CMS
also added coverage for complex chronic care services for
patients with multiple chronic conditions, as well as
transitional care management. Earlier this month, CMS proposed
to add annual wellness visits, psychoanalysis, psychotherapy,
and prolonged evaluation and management services to the list of
covered services.
Although research on the impact of telemedicine on cost,
quality, and access is promising, the evidence is not
conclusive. As a result, I believe the gradual expansion of
telemedicine coverage under Medicare is a sensible course of
action, and one that will produce a slow but steady increase in
the number of small practices that effectively and efficiently
use telemedicine.
Licensing
While state borders may be irrelevant to the delivery of
quality care via telemedicine, they do present an important
legal barrier. In most instances, physicians are limited to
practicing in states where they are licensed. Telemedicine
practice is regulated at the state level by state medical
boards, which are given authority by state legislatures. Some
state medical boards require telemedicine providers practicing
across state lines to have a valid state license in the state
where the patient is located.\12\ Those who support
requirements for physicians to be licensed in the same state as
their patients, including the American Medical Association,
argue that easing state licensure could compromise patient
safety. For example, state regulators may have no power to
conduct an investigation of an out-of-state provider if a
patient is harmed. Obtaining an additional state license to
practice telemedicine typically costs between $200 and $600 per
state, and the administrative and time burdens are substantial.
These burdens may be greater for small practices, which are
less likely to have support staff who can help navigate this
process.
My personal opinion is that the current medical licensure
system is inadequate to address the growing practice of
telemedicine. There are several alternative models that could
be considered, though each presents challenges. For example,
federal licensure and regulation would inevitably raise
federalism concerns as professional licensure has historically
been a state power. Another option is an interstate agreement
that would grant privileges in all participating states,
provided that the physician has a valid license in at least one
of the participating states. However, when this approach was
attempted by the nursing profession, only half the states
adopted the interstate agreement.\13\
Notably, decisions by state medical boards may come under
greater scrutiny with the Supreme Court scheduled to hear oral
arguments in the case of North Carolina State Board of Dental
Examiners v. FTC. The board, overseeing the practice of
dentistry, sent cease-and-desist letters to unlicensed
practitioners who removed stains from teeth. The Federal Trade
Commission accused the board of illegally excluding non-
dentists from the teeth-whitening market. While this conflict
involves a dental board, the outcome could have repercussions
for how states regulate medical practice. The court will
consider whether a regulatory board whose members have a
financial interest in the industry it is charged with
regulating can define practice to reduce competition.
Evidence on the Impact of Telemedicine
The academic literature on the impact of telemedicine is
voluminous and still growing. Overall, the evidence suggests
that telemedicine can improve access to care and the value of
care. Here are just two examples:
The Veterans Health Administration has a
national home telehealth monitoring program that
provides routine care, care management, and case
management services to veterans with chronic illness
through remote monitoring. Patient satisfaction levels
are high (greater than 85 percent), the program
facilitated independent living, and it reduced hospital
days by 40 percent.\14\,\15\
Using store-and-forward teledermatology
(where a referring physician uploads a patient history
and images of a skin lesion to a secure site for a
consulting dermatologist to review), dermatologists at
Kaiser Permanente in San Diego were able to handle 50
percent more cases compared to face-to-face visits.\15\
Other research has shown that teledermatology consults
are just as accurate as in-person consults. Store-and-
forward teledermatology consults reduce in-person
clinic appointments by 25 percent, and real-time
teledermatology consults reduce clinic appointments by
50 percent. Satisfaction among patients, referring
clinicians, and dermatologists is high.\16\
However, evidence of the impact of telemedicine is not
entirely consistent. For example, one study found that
physicians were more likely to prescribe antibiotics when the
visits occurred via telemedicine, suggesting that telemedicine
may result in a more conservative care plan, which could have
unintended consequences, such as antibiotic resistance.\17\ A
randomized controlled trial found that telemonitoring for frail
older adults did not reduce hospitalizations or emergency
department visits, and was associated with greater
mortality.\18\ In a recent compilation of systematic reviews on
telemedicine, twenty reviews concluded that telemedicine was
effective, 19 were less confident about the effectiveness of
telemedicine but noted its potential, and 22 concluded that its
effectiveness was limited or inconsistent.\19\
Clearly, there is a need for continued research in this
area. Additionally, there are two other issues concerning
research that should be addressed. First, many studies of the
effectiveness of telemedicine have been conducted within
hospitals or large physician practices affiliated with health
systems. As a result, our understanding of the impact of
telemedicine among small, independent practices is much more
limited. Second, information about the impact of telemedicine
is typically published in the academic literature, which is not
easily accessible to leaders of small practices. This limits
physicians' ability to make informed decisions about whether or
not to adopt telemedicine.
Despite the gaps and inconsistencies in the evidence, I
believe that telemedicine holds great potential to expand
access, improve care, and reduce cost. This past year, my
colleagues and I at Northwestern University designed a new
model for primary care in partnership with a private
foundation. Our model incorporates telemedicine, reflecting our
belief that telemedicine can not only improve the value of
health care, but also improve patient and provider
satisfaction, and potentially make the practice of primary care
more attractive to physicians. We are currently developing an
implementation plan for the adoption of this primary care model
by small physician practices.
Conclusion
In conclusion, telemedicine is an important tool for small
practices as payers transition away from the fee-for-service
model. State and federal policy makers have the ability to
facilitate the adoption of telemedicine through policies
related to reimbursement and licensing, but expansion should be
coupled with oversight to monitor impact.
Again, I would like to thank you for allowing me to appear
before you today and share my opinions on this topic. I would
be happy to take your questions.
[GRAPHIC] [TIFF OMITTED]
INTRODUCTION
Good morning, my name is Maggie Basgall and I serve as the
Community Development Specialist for Nex-Tech in Lenora, KS.
Thank you for inviting me to join the panel this morning--it's
an honor to testify on behalf of NTCA--The Rural Broadband
Association and its nearly 900 small, rural telecom provider
members who deliver high-speed broadband and other advanced
telecom services to rural America that form the essential
foundation of telemedicine and other innovative applications.
Among its 25,000 plus customers spread across 9,300 square
miles of rural northwest Kansas, Nex-Tech serve 11 hospitals,
14 health clinics, and numerous small physician practices. Ten
of those hospitals have already adopted telemedicine, and all
plan to use it more extensively in the future. Thanks to Nex-
Tech's ambitious broadband-capable network deployment efforts
through the years, many of these healthcare providers can
access up to 100 Mbps broadband. Depending on size, these
entities purchase a range of services from 20 Mbps to 100
Mbps--the same speed recommended by the Federal Communications
Commission's (FCC) 2010 National Broadband Plan (NBP) for
achieving full functionality of real-time diagnostic
imaging.\1\
---------------------------------------------------------------------------
\1\ Federal Communications Commission. National Broadband Plan:
Healthcare Broadband in America. 2004. Retrieved from www.broadband.gov
Broadband is proving to be a great equalizer for rural
America. This is especially true for health care needs in rural
areas, as high-speed broadband helps healthcare providers serve
patients more efficiently and effectively. One of Nex-Tech's
goals is to provide doctors with the resources to fully realize
what broadband capabilities generally and telemedicine more
specifically can offer patients, especially through technology
that helps overcome the distance between rural health centers
---------------------------------------------------------------------------
and patients.
To be clear upfront, broadband isn't only used and useful
for telemedicine. It has become essential to the very provision
of healthcare in any form or fashion, as doctors' offices,
clinics, and hospitals need broadband to: backup systems at
offsite data centers; connect with insurance companies to check
eligibility; offer electronic billing; conduct research; and
host educational webinars. Further, some hospitals provide IT
services to other facilities and thereby reduce hardware and
software costs.
But even with these many benefits for the provision of
healthcare generally, it is clear that broadband can play a
special role in rural areas by enabling greater telemedicine
functionality and helping residents overcome the challenges of
distance that make so many tasks more expensive and time
consuming. Telemedicine means a patient in need of an immediate
mental health consultation who lives hours from the nearest
facility can have an instant connection to their psychologist
through a telemedicine platform at their local hospital.
Another patient may need digital x-ray scans sent to a far-away
physician who can assess how their fracture is progressing.
These are only a few of examples of the telemedicine
possibilities that robust broadband enables.
To help promote greater adoption of advanced telemedicine
capabilities, Nex-Tech recently assembled a pilot project with
the goal of helping a large local hospital offer in-home
treatment for patients through telemedicine. We assembled a
team of technology and business experts to serve as advisers to
our customer, and we offered to cover some technology costs for
a couple of years to help get the project off the ground.
Unfortunately, we had to suspend the project because, due to
lack of health insurance reimbursement for care through in-home
telemedicine, our customer couldn't make the service work
financially over the long-term. The interest was there from all
parties, but reimbursement was essential to make it work
financially.
Healthcare professionals generally need three significant
barriers removed before they can adopt and implement
telemedicine: 1) robust broadband capability, 2) money for
hardware and software, and 3) staff who know how to use the
technology. Insurance reimbursement may present a major barrier
to in-home telemedicine, but availability and adoption of
technology present other obstacles, not only in rural Kansas
but in rural areas across the US.
While barriers to in-home telemedicine remain, healthcare
providers are still able to use numerous other existing and
innovative applications that help them provide better care to
patients. For example, thanks to robust, wired broadband that
enables high-speed Wi-Fi at the rural health clinics in our
service territory, soon hospitals will be able to deploy robots
that can effectively transport a doctor stationed at a hospital
to a far-away rural area. Patients who visit the clinic are
able to interact with the doctor through the robot, which is
equipped to conduct diagnostic testing. The same Wi-Fi is
helpful to doctors who travel to clinics and need to use their
mobile devices while on the premises to communicate with other
health care professionals.
Currently, licensing of doctors is handled at the state
level and, as such, oftentimes providers cannot serve patients
across state lines, which greatly limits the use and/or
implementation of virtual telemedicine visits. The TELE-MED Act
(H.R. 3077), introduced by Representatives Devin Nunes (R-CA)
and Frank Pallone (D-NJ), improves seniors' access to care by
permitting Medicare providers who are licensed to practice
physically in one state, to treat patients electronically
across state lines in any U.S. jurisdiction, without having to
obtain additional state licensing or authorization. The bill
builds upon recent congressional efforts that have expanded
virtual care for military personnel and veterans. I applaud the
efforts of Representative Nunes and Pallone for their
leadership on this matter. Government programs provide some
assistance. For example, the American Recovery and Reinvestment
Act sought to promote use of electronic health records (EHRs)
through Medicare and Medicaid and regional extension centers
such as the Kansas Foundation for Medical Care, which provides
ongoing technical assistance to practices. The NBP also
recognized the potential of telemedicine over four years ago
and recommended that the federal government further incentivize
and promote widespread adoption.\2\ This is accomplished in
part through the FCC's Universal Service Fund (USF) and the
rural telecom lending and grant portfolio of the USDA's Rural
Utilities Service (RUS). However, many rural health centers--
especially family practice physicians--still lack the resources
to fully use telemedicine capabilities.
---------------------------------------------------------------------------
\2\ Id.
USF can help fill telemedicine deployment and adoption gaps
through two of its four components. The USF High Cost fund
supports the actual rural networks that Nex-Tech and about
1,000 other small, rural telecom providers deploy all over the
country. These networks deliver the broadband data and other
traffic that make telemedicine possible; all of the efforts
we're discussing would not be possible in the absence of those
networks that high-cost USF support enables and sustains in the
first instance. The USF Rural Health Care (RHC) fund can
further help healthcare providers pay for services, thereby
stimulating adoption and use. Most hospitals and doctors'
offices operate on very tight budgets, such that telemedicine
often has to take a back seat to other vital priorities, such
as ensuring the facility is staffed with the best available
doctors, physician assistants, and nurses. USF can help bridge
this financial gap through RHC, which is available to non-
profit and public healthcare providers located in an FCC-
---------------------------------------------------------------------------
approved rural location.
Finally, Nex-Tech couldn't have delivered broadband to
rural western Kansas without the help of RUS's rural telecom
portfolio and the seasoned experts that staff the department.
Not only does RUS lend for broadband-capable plant in rural
territory, it also offers a telehealth program that helps
healthcare providers purchase the hardware necessary to use
telemedicine. The critical role that USF and RUS play in
telemedicine deployment and adoption are discussed further
below.
USDA RURAL UTILITIES SERVICE
RUS Role in Telemedicine and Rural Telecom Deployment
USDA's Rural Utilities Service's Distance Learning &
Telemedicine (DLT) Grant Program helps healthcare providers
adopt telemedicine through grants for capital assets such as
computer hardware and software, audio and video equipment, and
other network components. Traditionally, approximately 40% of
program funds support telemedicine. Eligible entities include
corporations, partnerships, and state or local units of
government providing education and medical care via
telecommunications. With funds for telemedicine in short supply
at so many doctors' offices, clinics and hospitals. DLT has
played a key role in establishing hundreds of telemedicine
systems in rural areas across the U.S. USDA Community
Facilities Loans and Grants are also available to help rural
towns construct healthcare facilities and purchase equipment.
RUS also plays a crucial role in rural broadband deployment
through its telecom loan portfolio that finances network
upgrades and deployments in rural areas. RUS has been lending
for broadband-capable plant since the early 1990s. RUS lending
and Universal Service Fund (USF) support are inextricably
linked at 99.2% of RUS Telecommunications Infrastructure
borrowers receive High-Cost USF support. The presence of high-
cost recovery is crucial to the RUS telecom and broadband loan
calculus. RUS programs have helped rural providers deploy
modern networks in many rural areas where the market would
otherwise not support investment. Reliable access to capital
helps rural carriers meet the broadband needs of rural
consumers at affordable rates.
Nex-Tech began providing broadband in Western Kansas in
1998 with the help of RUS financing. The company later acquired
10 exchanges from another carrier and then used an RUS loan to
build fiber tot he premise (FTTP) on those communities. This
type of financing is not readily available from the private
sector due to the challenges of operating in rural areas and
the long-term payback in doing do, and this RUS financing comes
in the form of loans that must be paid back with interest,
creating a win/win situation for taxpayers and the rural
broadband consumers who need the technology now.
Unfortunately, the success, momentum, and economic
deployment achieved from the RUS's telecommunication programs
were put at risk as a result of the regulatory uncertainty
arising out of USF reforms that are discussed in greater detail
below. It will be all the more important to continue providing
RUS with the resources it needs to lend to the rural telecom
industry as demand for financing will inevitably increase when
reforms are improved and regulatory certainty is restored. Once
again, telemedicine efforts will be for naught if robust
broadband-capable networks aren't there in rural areas to
support those efforts or if the broadband services offered on
those networks are not affordable and upgraded over time.
THE USF HIGH COST FUND AND RURAL HEALTH CARE PROGRAM
USF Rural Health Care Program
The High Cost and Rural Health Care components of USF have
a symbiotic relationship--the High Cost Fund supports the rural
networks that carry telehealth and other data all over the
world, and the Rural Health Care Fund can help healthcare
providers purchase telecom services so they can send and
receive data over the network. Both components are essential to
telemedicine adoption.
The RHC is available to non-profit and public healthcare
providers located in an FCC-approved rural location. Within
RHC, the Telecommunications Program provides discounts for
telecommunications services and, as of last month, broadband.
Funding for broadband is now available through the new
Healthcare Connect Fund (HCF). HCF provides a 65 percent
discount on eligible expenses related to broadband connectivity
to rural health care providers. Finally, the new HCF is also
serving participants in what was formerly known as RHC's Pilot
Program, which provided funding for construction or
implementation of state and regional broadband networks.
Hundreds of health care providers are participating in the
program through 50 active projects.
Pilot Program participants include The University of Kansas
City for Telemedicine & Telehealth (KUCTT), whose telehealth
network has over 100 sites throughout the state--including Nex-
Tech customer Hays Medical Center. KUCTT uses the network to
conduct clinical consultations and host educational events.
The FCC's High Cost Fund Reforms
As I have noted earlier, telemedicine simply cannot be
implemented without an underlying robust, wired broadband
network. Though demand for faster broadband is expected to
increase dramatically in the near future, RUS received only 29
broadband loan program applications for rural network loans in
fiscal years 2011-2013, compared to 130 in the first three full
years of the program.\3\ Why would an experienced lender such
as RUS want for customers when demand for networks is high?
Look no further than the state of rural telecom cost recovery
mechanisms.
---------------------------------------------------------------------------
\3\ U.S. Government Accountability Office, (2014).
Telecommunications: USDA Should Evaluate the Performance of the Rural
Broadband Loan Program. (GAO Publication No. GAO-14-471). Retrieved
from http://www.gao.gov/assets/670/663578.pdf
For example, the FCC's 2011 ``Quantile Regression
Analysis'' (or ``QRA'') model to cap USF support for small
carriers created rampant uncertainty in the rural telecom
marketplace. In short, the QRA model took data from the
investments and operations of hundreds of small carriers in the
United States from two years in the past and then, on the basis
of over a dozen different variables, ran those costs through a
formula that created new caps each year to govern each
carrier's USF support. This was an unsustainable approach to
universal service that ran directly contrary to the
congressional mandate that USF be predictable; the errors in
capturing actual costs used and useful in providing universal
service also meant the QRA model did not satisfy the
---------------------------------------------------------------------------
congressional mandate that USF be sufficient.
Despite the fact that the FCC ultimately eliminated the
troubling QRA caps after a few years, the question of what
comes next creates its own lingering regulatory uncertainty.
Updates to legacy USF support rules are still very much-needed.
For example, in rural areas served by smaller companies such as
Nex-Tech, FCC rules still require customers to purchase
landline voice service in order for their line to receive USF
support. The customer is effectively denied the option of
cutting the landline-voice cord and purchasing only broadband.
Such outdated rules that undermine consumer freedom and inhibit
technological evolution present an obstacle to the technology
transition that consumers and industry are making and the FCC
is working to expedite and facilitate in other contexts.
Universal Service support should not be tied to a limited
service, but available instead to advanced networks that
provide consumers with access to a variety of essential, high-
quality services from which each consumer may choose.
Nearly three years after a ``Transformation'' order, small,
rate-of-return providers still await an updated cost recovery
mechanism that will provide sufficient and predictable support
for the simple act of responding to consumer demand for better
broadband. Meanwhile, the Connect America Fund set up for
larger companies in that 2011 order is in year four of
development--a good indication that, if this is how long it
takes to create and implement such changes, greater emphasis
should be placed on creating a similar fund for smaller
carriers as soon as possible. The FCC should move forward
immediately to adopt and implement a carefully tailored update
of USF that will provide sufficient and predictable support for
broadband-capable networks in areas served by smaller rural
carriers. Over 130 members of Congress--including Chairman
Graves and other Small Business Committee leaders--along with
dozens of organizations that serve rural America encouraged the
FCC to act through a series of letters earlier this year.\4\
---------------------------------------------------------------------------
\4\ See US House letter led by Representative Gardner and US Senate
letter led by Senators Thune and Klobuchar, both sent to FCC Chairman
Wheeler on May 6, 2014. See also rural organizations letter sent to
Chairman Wheeler on March 5, 2014.
The broadband revolution presents major opportunities for
small businesses to innovate and grow, but the business (or
entrepreneur with an idea) must have broadband access to take
full advantage. Markets will ensure many consumers realize the
full benefits of innovation at the lowest possible prices, but
in rural areas there are often no such markets to speak of.
Though small, rural providers have been leaders in broadband
investment even under the current statutory and regulatory
regime, further law and policy changes will be necessary to
ensure high cost rural areas both become and remain served even
as providers also edge broadband out into unserved areas. We
cannot hope to realize the full benefits of broadband for the
provision of healthcare generally, and telemedicine more
specifically in rural areas, if outdated rules deny support for
broadband-capable network investments or the threat of adverse
changes to these USF rules create uncertainty in making the
decisions to undertake such long-term investments. Sufficient
and predictable USF support that provides recovery for both the
initial costs of installing a rural broadband network and the
ongoing costs of operating and upgrading the network over time
must be seen as a prerequisite to any successful efforts in
---------------------------------------------------------------------------
telemedicine.
CONCLUSION
Telemedicine already offers health care providers numerous
ways to better serve patients, and many more exciting
innovations are on the horizon. The desire for advanced
telemedicine already exists, but now we must supply--and then
sustain--the robust broadband capability, funding, and
education to spur increased adoption of the services across the
country.
Nex-Tech and its counterparts in the rural telecom industry
are thrilled to play a key role in this process by delivering
the networks that carry the data, and we look forward to
greater collaboration with the healthcare industry to work
through any barriers to adoption.
Rural America will not realize the promise of telemedicine
without a broadband-oriented USF that offers carriers the
regulatory certainty needed to make network investments.
Support through the USF Rural Health Care Fund and RUS Distance
Learning and Telemedicine Grant Program for doctors and nurses
who need to purchase hardware, software, and telecom services
will continue to be helpful in the advancement of telemedicine.
We look forward to working with Congress and the appropriate
agencies to ensure these programs work as efficiently and
effectively as possible.
[GRAPHIC] [TIFF OMITTED]
U.S. House Small Business Committee
Subcommittee on Health and Technology
Hearing on
``Telemedicine: A Prescription for Small Medical
Practices''
July 31, 2014
Chairman Collins and Ranking Member Hahn, as a fellow of
the American Academy of Dermatology Association (Academy),
which represents more than 13,000 dermatologists nationwide,
and a past president of the Medical Society of Northern
Virginia, I commend you for holding a hearing on how new
technologies and advances in telemedicine can further
efficiency, quality, and access to health care. We applaud you
for raising awareness of this care delivery model and look
forward to working with you to ensure that our patients can
benefit from advances in telemedicine, while also receiving
high-quality, timely, cost-efficient care.
I am here today to discuss barriers of implementing
telemedicine as a modality of care. Specifically, lack of
reimbursement and cumbersome credentialing pose the greatest
challenges. Although some reimbursement exists, it is not
consistent across payers or across states to allow for proper
patient access. To place this issue in context however I would
like to first discuss who I am and who I am here on behalf of.
The Academy is a leader in supporting the expansion of
telemedicine, while ensuring quality of care is delivered. As
dermatology is a visual specialty, it lends itself well to
telemedicine in various patient scenarios.
Telemedicine is an innovative, rapidly evolving method of
care delivery. The Academy supports the appropriate use of
telemedicine as a means of improving access to the expertise of
Board certified dermatologists to provide high-quality, high-
value care. Teledermatology services are valuable means of
improving patient care to underserved patients with limited
access to speciality care, as a triage tool to determine which
cases need to be seen in person most urgently, or as a platform
to deliver care to those who are unable to receive the benefits
of face-to-face dermatology visits. As the field of
telemedicine continues to grow, there is significant potential
to improve access to care coordination and communication
between other specialities and dermatology.
While teledermatology is a viable option to deliver high-
quality care to patients in some circumstances, the Academy
supports the preservation of a patient's choice to have access
to in-person dermatology services. Teledermatology providers
choose between or combine two fundamentally different care
delivery platforms (Store-and-Forward vs. Live Interactive),
each of which have strengths and weaknesses. Live interactive
teledermatology takes advantage of videoconferencing as its
core technology. Participants are separated by distance, but
interact in real time. Store-and-forward teledermatology refers
to a method of providing asynchronous consultations to
referring providers or patients. A dermatologic history and a
set of images are collected at the point of care and
transmitted for review by the dermatologist. In turn, the
dermatologist provides a consultative report back to the
referring provider or patient at the point of care.
As a provider who runs a small dermatology practice in
Northern Virginia, I currently utilize DermUtopia for the
provision of telemedicine. This is a HIPAA compliant, mobile
phone and web-based application. Through this application, I am
able to evaluate and treat both my patients and those who do
not have a primary dermatologist. We are also currently in
discussions with the safety-net and federally qualified health
clinics in the area, and hope to use this store-and-forward
application to provide care for their patients in the near
future.
Some of these clinics will refer patients that they see
through Project Access of Northern Virginia, a program of the
Medical Society of Northern Virginia Foundation that provides
specialty medical care to low-income, uninsured safety-net
patients who reside in Northern Virginia. Additionally, we are
aiming to treat Medicaid patients through DermUtopia. However,
there have been delays in an ability to solidify funding,
despite the fact that Medicaid has approved reimbursement for
telehealth services.
I have faced several barriers to most effectively providing
care via telemedicine. While I face these barriers as a
physician, it is ultimately the patients--often the most
economically vulnerable--that are the most directly affected.
The largest barrier as noted is reimbursement for telehealth
services. Without assured reimbursement, providers and patients
are unlikely to utilize telehealth. While Virginia law
addresses coverage for telehealth services, this does not
guarantee access with all private insurance and many states do
not have similar policies. Provider knowledge and use of
teledermatology is often limited in these areas. Congress can
help set the stage for larger-scale reimbursement by, for
example, enabling Medicare to reimburse for telemedicine
services.
Appropriate reimbursement for these physician services
could be implemented in a variety of contexts. The Academy
believes that retaining state-based licensure is the best way
to preserve accountability and protect patients. However, we do
favor changes, such as the Compact proposed by the Federation
of State Medical Boards, which would make it easier for doctors
to be licensed in multiple states. Support for studies of
existing health systems that could show the impact of
teledermatology on access, quality and cost of care in
healthcare ecosystems would be beneficial. This would be
pivotal in assessing the value of telemedicine and a great step
in the goal of removing reimbursement as the biggest hindrance
to the proliferation of telemedicine.
The benefits of such reimbursement would be widespread.
Teledermatology can save a patient time missed from work,
travel time, and, in the correct clinical context, allows for
timely diagnosis and treatment when face-to-face care is
unavailable or inaccessible. While teledermatology has been
traditionally used to increase access in remote or underserved
areas, it indeed has great potential for serving a great
variety of patients with dermatology care issues. For instance,
insured patients in urban areas may face similar access delays
or issues as those in geographically remote areas, and
therefore benefit from teledermatology.
I have seen first-hand a number of patients that could have
had the consultation done virtually and prevented an onerous
trip to the office, or to urgent care. For example, included
are specific patients who could have a teledermatology
consultation and receive treatment at their home or facility.
An 89 year old woman who lives alone at home, with no family in
the area, and who would need to be brought to the doctor via
wheelchair and transport vehicle, may be more easily evaluated
via telemedicine. A nursing home patient with dementia, who
requires a nursing aid and transportation and coordination
costs from the nursing home to evaluate multiple growths, could
be evaluated via teledermatology. Finally, a 2 year old with
severe eczema and infections who cannot get in to see a
dermatologist due to lack of access to a Medicaid dermatologist
and inability for parents to transport her during their work
hours across the city, two bus rides away, could be evaluated
and/or monitored via teledermatology.
Many large health systems, including the Veterans Affairs
(VA) and Kaiser Permanente, are reimbursed for their services
and use telemedicine with great benefit. These programs help to
improve access to dermatologic consultations within their
integrated health system and reduce the turnaround time from
referral to diagnosis. Additionally, a recent study by
researchers at the University of Pennsylvania looked at
individuals who were in the hospital who needed a doctor's
assessment for a skin problem. All of the participants had an
in-person consultation with a doctor, and the researchers also
sent photos of their skin conditions to two independent
dermatologists remotely. They discovered a 90% agreement for
recommendations to be seen in person and a 95% agreement in
recommendations for biopsy between the in-person and remote
doctors. Finally, emergency setting studies have shown a high
patient acceptance rate of teledermatology and that it can
provide rapid and accurate diagnostic and treatment advice from
a dermatologist. This is especially vital in the cases of
commonly misdiagnosed dermatologic conditions.
Overall, telemedicine provides a modality of care which can
expand access to medical specialists, such as dermatologists,
but barriers to implementation remain. Most notably issues of
proper credentialing and reimbursement exist to varying degrees
across states. These barriers impact providers but ultimately
can hinder patient access to care. I, as well as the Academy,
appreciate the subcommittee's continued leadership on this
issue, and look forward to working with your office to ensure
that patients can benefit from high-quality, timely, cost-
efficient care via telemedicine.
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article.aspx?articleid=1829638
\1\http://www.medscape.com/viewarticle/455635
\1\http://ncbi.nlm.nih.gov/pubmed/21995470
\1\http://archderm.jamanetwork.com/
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