Telemedicine Is in Anesthesiologists’ Future
Telemedicine, in one form or another, is going to be part of most physician practices within the next decade. For many doctors, it will arrive sooner, if it is not already here. Five years ago, Dr. Girish Joshi wrote in the ASA Newsletter (Global Patient Perioperative Care through Clinical Pathways, ASA Newsletter. 2010; 74(8):10-12):
Telemedicine is a term used to describe health care provided by a practitioner at a remote location with the help of advanced technologies. Telemedicine is expected to play an increasingly important role in outpatient settings (e.g., home health care, remote patient monitoring, chronic disease management and rural health care) as well as in hospital settings (e.g., emergency department and ICU). Other applications of telemedicine include battlefield medicine, maritime medicine and aviation health care. Telemedicine provided in the critical care setting is commonly referred to as e-ICU. e-ICU has been proposed as a potential means of bringing the expertise of critical care specialists to hospitals with inadequate access to intensivists. … The practice of telemedicine may also be applicable to anesthesiology in which an anesthesiologist stationed in a room (within the operating area) could monitor multiple operating rooms. The telemedicine concept combined with automated anesthesia systems or closed-loop systems may further improve patient safety.
The tools and the practice of telemedicine (for which the word “telehealth” is used interchangeably) have without doubt advanced in the last few years and even since we broached the topic in our January 13, 2014 Alert. Among the most recent developments, Mercy Health in St. Louis, Missouri has just opened a $54 million Virtual Care Center from which 290 nurses and other clinicians monitor 2,431 patient beds in 34 hospitals across five states. Have clinical practice laws and regulations and payment policy kept up? Not to the extent advocated by the proponents of telemedicine.
Professional licensure portability and practice standards
Practicing across state lines raises issues in telemedicine as in other contexts. Most, if not all, states require that a physician be licensed in the state where the patient is located, a serious impediment to telemedicine across many geographic areas.
Physician licensure requirements and procedures vary considerably between state medical boards. At one extreme, the authorities require full, unrestricted state licensure without exception in order to provide medical care whether by telehealth or any other means. According to the American Telemedicine Association’s (ATA) State Telemedicine Gaps Analysis Physician Practice Standards & Licensure report, only four states are this limiting: Michigan, North and South Dakota and Pennsylvania. (The ATA is careful to note that their reports do not constitute legal advice, a caveat that we echo. For a full understanding of law and rules applicable in their individual states, readers should consult counsel.) Other states recognize exceptions to the state-licensure requirements that ATA broadly categorizes as:
- reciprocity for bordering states (D.C., Maryland, New York and Virginia),
- physician-to-physician (P2P) consultation exemptions (e.g., Massachusetts), and
- conditional/telemedicine licenses (Alabama, Louisiana, Minnesota, Nevada, New Mexico, Ohio, Oregon, Tennessee and Texas).
No state achieved a top score on licensure portability, meaning that “every state imposes a policy that makes practicing medicine across state lines difficult regardless of whether or not telemedicine is used.” Other indicators on which the ATA measured states’ acceptance of telemedicine include:
- requiring an in-person visit before, during or after telemedicine encounters,
- adopting practice standards with higher specifications for telemedicine than for face-to-face care,
- requiring a telepresenter or health care provider on the premises during a telemedicine encounter, and
- requiring informed consent (written, verbal or unspecified) before a telemedicine encounter.
Overall, twenty-two states averaged the highest “composite grade” suggesting a supportive policy landscape that accommodates telemedicine adoption and usage. Twenty-six states and D.C. were in the middle with room for improvement. Two states (Alabama and Texas) averaged the lowest composite score, indicating many barriers for telemedicine advancement.
This is an area that is changing very rapidly. In 2015, more than 100 bills relating to telemedicine have been introduced in 36 states. Only ten of these bills would expand licensure requirements to encompass telemedicine. Arkansas is one of states that adopted a very restrictive law this year, but in September, the Arkansas State Medical Board’s Telemedicine Advisory Committee indicated that it was drafting a rule to allow establishment of a physician-patient relationship through the use of real-time audiovisual communication rather than an in-person visit, evidently seeking a way around the new statute.
Payment for telemedicine services
Twenty-three states, as well as D.C., have adopted full parity statutes requiring that private insurers pay for telemedicine services at the same or comparable rates and terms as face-to-face services. This number has doubled in the last three years alone. Maine, New Hampshire, New Mexico, Tennessee and Virginia and D.C. are ranked as the most supportive jurisdictions. Arizona is unique in having enacted a partial parity law that mandates coverage and reimbursement, but limits coverage to a certain geographic area (e.g., rural) or a predefined list of health care services. Some states with parity laws were rated lower than others in the ATA’s State Telemedicine Gaps Analysis-Coverage & Reimbursement report because of restrictions on the type of technologies (e.g., audio-visual only), services and/or conditions covered.
Many insurers even in states that do not have parity laws are voluntarily increasing coverage of telemedicine. Blue Cross and Blue Shield plans have been leaders in the field. Aetna and Cigna also provide coverage. There are other private payers, however, that continue to deny payment for telemedicine services. Physicians seeking to change their managed care organizations’ policies are advised to “communicate to MCOs that telemedicine services are part of their customary and usual practice” with letters stating their “intention to use telemedicine in the normal course of business, including notification of future claim submittal, and encourag[ing] the private payer to ask questions and make comments.” They should also add “telemedicine” to the list of covered services identified in their provider agreements and add coverage for telemedicine services to the services and obligations section of those agreements. See Telemedicine Services: Steps for Providers Seeking Reimbursement, an e-alert from the Milwaukee law firm of Reinhart Boerner Van Deuren S.C.
Twenty-four states provide some coverage for telemedicine under their state employee health plans with 21 states extending coverage under their parity laws. Medicaid is even more of a hodge-podge, as reported by the ATA, with 48 state Medicaid agencies allowing some type of coverage for services provided via telemedicine. Requirements that the patient be located at a specific type of “originating site,” such as a hospital, a doctor’s office, a federally qualified health center or a health department facility, but not their home or place of work or school, hamper the full use of telemedicine’s potential in about half of the states. Most of the states in which Medicaid covers some telemedicine services also restrict the type of provider for whom payment will be made. Florida, Idaho, Iowa and Montana ranked the lowest with coverage for physicians only.
Medicare is lagging behind. The fee-for-service program has tightly limited payments to certain rural areas and certain services because of Congress’ concern that telemedicine might increase Medicare expenses, according to a Kaiser Health News article published on June 23, 2015 (Medicare Slow To Adopt Telemedicine Due To Cost Concerns). Thus Medicare only covers a short list of services provided via telemedicine (inpatient and office visits, some behavioral and substance abuse services, transitional care management, kidney disease and diabetes care training). The originating site, i.e., the location of the Medicare beneficiary, must be (a) a rural Health Professional Shortage Area (HPSA) located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract, or (b) a county outside of a MSA. The distant site practitioners can only be physicians, nurse practitioners, physician assistants, nurse midwives, clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists and social workers for non-medical services and registered dietitians or nutritionists. Finally, only the use of interactive audio and video telecommunications systems that permit real-time communication is covered. Asynchronous “store and forward” technology is permitted only in Federal telemedicine demonstration programs conducted in Alaska or Hawaii.
Although Medicare Advantage plans are beginning to offer telemedicine services, as are some Medicare accountable care organizations, fewer than one percent of Medicare beneficiaries have used the available videoconferencing technology.
Legislation has been introduced in Congress that would liberalize the rules on Medicare payment for telemedicine. The Tele-Med Act of 2015 (S. 1778/H.R. 3081), for one would allow beneficiaries to receive care from a U.S. health professional licensed by any state. The bill was referred to committee in July and is still awaiting action.
With or without Congressional action, however, telemedicine is a highly dynamic field and there is significant support for its expansion through favorable laws and regulations. Clinical applications in anesthesiology critical care and other medical specialties—and certainly primary care—will become increasingly important as value-based purchasing becomes the norm. Dr. Joshi noted five years ago that the tools of telemedicine could allow a single anesthesiologist stationed within the operating area to monitor multiple rooms. Since then, the development of software such as AlertWatch, which integrates various sources of medical data into a single dashboard view of the patient, has expanded the horizons for remote patient monitoring. In the preoperative area, pre-anesthesia assessments and consultations via telemedicine (e.g., TelePREOP) can permit the timely completion of patient evaluation and reduce the number of case cancellations on the day of surgery. Tele-technology will allow anesthesiologists to assume greater responsibilities for overseeing the post-discharge care of surgical patients. We hope that the legal and payment policy framework for these developments will advance quickly.