American Telemedicine Association’s policy guys, Jonathan Linkous, CEO, and Gary Capistrant, senior director of public policy, are back with another monthly installment of This Month in Telemedicine.

They’re predicting an additional 30 to 40 million Americans will be added to Medicaid roles by next year, and there are now 20 states looking to expand Medicaid coverage to accommodate this surge. Better start preparing now, says Linkous. “I think next year we’re going to see a whole different world, in a few short months it’s happening so the time to gear up is now,” he says.

Funding Opportunity
The Center for Medicare and Medicaid Innovation has just launched another billion dollar funding opportunity. It’s looking for “big, bold projects,” particularly any that will be actionable on a multi-state level. Letters of intent are due by June 28, and the full applications are due August 15.

Austin Meeting Recap
Linkous and Capistrant also discussed the ATA’s recent meeting that was held at the beginning of May in Austin, Texas. During the meeting, the first of four best practices was released. They’re for state Medicaid programs, and the ATA has been working with special interest groups and refining the guidelines, and they should be available soon. They cover specialties such as telemental health, home telehealth and remote monitoring, school-based telehealth, and specialties like diabetic retinopathy.

The ATA also distributed a draft version of their state best practices guidelines, which is now being reviewed by special interest groups. Additionally, a new and expanded version of their toolkit is now available on the ATA website.

“We try and provide more information for you all to use,” says Capistrant. “But also to try and act as a clearing house and identify what the various states are doing so that all the other states can benefit from that without duplicating efforts or trying to draft something from scratch.”

Federal News
On the federal level, the ATA is very focused on dealing with getting Medicare coverage approved, and some opportunities for Medicaid as well. The bill sponsored by Senator Scott Thompson is working its way through the system, but because that bill is more of a big-picture attempt to solve and clarify telemedicine issues, the ATA felt the need for a bill that would deal with smaller-scale issues that could move quickly and be approved relatively easily. To that end, they’ve been working with Congressman Greg Harp, R-Mississippi, to assemble a package of incremental changes. “Hopefully, [it will be] easier to get support and budget estimates,” said Capistrant. They’re also hoping to be involved in physician payment reform.

As discussed during previous ATA webcasts, 104 counties lost Medicare coverage in February because of redesignation as metropolitan areas. The ATA is working on restoring coverage to the affected counties. The ATA is also working to remove some major barriers, like metropolitan area access, stroke diagnosis, and services for homebound patients that aren’t currently covered by Medicare. Homebound patients present a particularly strong argument, says Capistrant. “They’re not in the position to travel to a doctor’s office, so there’s a compelling clinical case for care in the home.”

Bipartisan Effort
There’s bipartisan interest in telemedicine, says Linkous, which is something the ATA has cultivated. “We’ve always made sure this is a bipartisan effort,” he says. “We’ve worked very hard to avoid any type of partisan positioning.” The ATA has had congress people of both stripes approach, and voice support for telemedicine.

In state action, Georgia and Alabama both have proposals from their respective medical boards under review. They’re improved versions of past proposals although still there are still issues: they don’t deal with the full range and diversity of telehealth uses and situations e.g. emergencies, and also interpretative services such as cardiology, radiology, etc. For example, in Georgia, telehealth ICU would require patients to I.D. every health practitioner who had previously served them, which is a burdensome task for all involved.

In the Alabama proposal, telehome care is exempt from rules if delivered by a licensed homecare health agency but community health centers and physician practices are excluded.

The pair also took issue with certain language in both proposals, identifying it as “anti-telehealth”; particularly requirements for prior physician-patient relationships, meaning the physician has to see patient in his or her office first. “That’s a code word for people who want to kill telemedicine,” says Linkous. ”It’s about protecting your market and protecting yourself from competition that telemedicine provides. And when you do that, there are 5.5 million Americans received teleradiology services and they’re gone, they don’t get it anymore because of the prior physician-patient relationship [requirement].”

April’s This Month in Telemedicine by the American Telemedicine Association, hosted as always by Jonathan Linkous, Chief Executive Officer, and Gary Capistrant, Senior Director of Public Policy discussed state and federal updates, collaborations, and quality assurance.

State Licensure Remains a Hot Topic
Gary Capistrant went over the basic situation of licensure, including a proposal that would let Medicare recipients to (virtually) cross state lines for care but would impose a requirement that the patient and doctor have a previous relationship, i.e. an initial consultation in person has to occur. While some states do allow that a legitimate patient-doctor relationship can be established via video, this proposal does not recognize that and could be a “step backward” for telemedicine, plus require states to enforce a prior relationship where they hadn’t done so before.

“In terms of our principles on licensure, we want to be regulated the same as in-person services, not held to a higher standard or a lower standard,” said Capistrant. The ATA has set up a petition. Also, some states are deciding that telemedicine needs regulating but are doing so by treating it as a separate health service, even though telemedicine was already active under the current medical regulations.

State Activity
Three states have enacted full parity with private insurance: Mississippi, plus Medicaid and state employee benefits; Montana, including parity with private; and New Mexico. Connecticut and Missouri passed parity bills in Senate, which are now moving to their respective Houses. New York recently introduced a parity bill, and Ohio will soon follow suit.

ATA is finalizing state best practices guidelines for home telemedicine and remote monitoring, and in the works: school-based care, telemental health, and more.

Federal Action
A workgroup was recently announced, a joint effort between the FDA, FCC, and Office of National Coordinator. A report is due in January 2014 examining the overlap of some issues that are overseen by the various agencies, including consumer health devices, electronic health records, and clinical decision support.

“It’s a little bit of a mess right now in terms of the regulation and one of the reasons they have this is group is because there’s a little bit of uncertainty amongst the different agencies over who’s taking the lead on what,” explains Linkous.

Quality Assurance
A big area of activity for ATA is quality assurance, which, although it’s flown under the radar somewhat, is getting plenty of attention now. ATA’s next board meeting will see the approval of the organization’s practice guidelines for online video-based telemental health. “A very important role for ATA is to weigh in and try to get some meaning and some semblance of order to what’s happening,” says Linkous.

ATA’s board has also approved the move towards ATA becoming an accrediting body with the end goal of becoming a reliable information source for consumers. They’re also involved with some trade associations to improve consumer awareness. Linkous: “It’s important that consumers know that if you’re not getting access to telemedicine, you could and you should and you need to ask your doctor about it.”

Next year, look for a cohesive effort by patient and consumer groups to expand telemedicine, including physician communications, consultations, lab results, etc., which should all be accessible online by patients.

The Q&A: A Selection of Questions Asked & Answered

Q: Define telemedicine, telemedicine, etc.

A: I think we should come up with a contest to see who can come up with the most names that relate to telmedicine. E-consults, e-health, telemedicine, telecare, e-care, telepractice, remote care. About 6 or 7 years ago we had a board meeting in Chicago and we talked about changing the name of the ATA. We talked about what we should change it to…we spent about 3 hours of the board meeting [discussing this] so at the end, we just threw our hands up in the air and left it as it is.

We define telemedicine very broadly as providing healthcare to patients or consumers using telecommunications.

Q: How can companies assist ATA in the process of getting legislation passed?

A: ATA has a Circle Membership and Industry Council and we have corporate members representing anything from large, multi-national, multi-billion dollar companies to a small ma and pa [businesses], but all of them have a stake in this. And if there’s a large corporation that has a Washington office with a staff of people who are full-time policy people, yes, please let them get in touch with us. We’d love to talk with them about what they do. Or if you’re an organization that has a consultant online who does work in Washington, or if you’re a small company in another state and you have an area representative…it’s important that you get very active…There’s always things to do at the state level.

Annual Meeting
ATA’s annual meeting will be held next week in Austin, Texas, from May 5 to 7. For a free exhibit hall pass, click here to register and enter  the code VIPcomp13.

This month’s telemedicine videocast from the American Telemedicine Association focused on a major change in the population tabulation that directly affects telemedicine reimbursement, as discussed by ATA’s CEO Jonathan Linkous and Gary Capistrant, senior director of public policy.

Federal Policy Changes & Activity
The hot topic was the re-designation of many counties from rural to metropolitan, which resulted in the loss of Medicare telehealth reimbursement. Due to a change to the Standard Metropolitan Statistical Areas, 97 counties newly designated as “urban” will lose reimbursement privileges because Medicare reimbursement for telehealth services is not available to populations in metropolitan areas. On the other hand, 28 counties will gain coverage because they are now designated rural.

While this is a setback for telemedicine and Linkous proposed two ways to deal with the situation: the first, to grandfather in counties that have been redefined as metropolitan; the second is to expand Medicare reimbursement for urban populations. “This really shows the need to do that,” said Linkous.

Also mentioned was the F.I.T.T bill (Fostering Independence Through Technology), which is sponsored by South Dakota Democratic Senator John Thune and Minnesota Democratic Senator Amy Klobuchar. The bill aims to establish a pilot program for home health agencies serving rural communities to use remote patient monitoring.

Capistrant and Linkous also discussed FDA regulations about medical devices, licensure and interstate health commerce, and the need to coordinate the various roles that the federal government plays in healthcare. Linkous points out the very real potential for backlogs—the FDA, Linkous says, has received 100 or so applications but can only process 20 a year.

“The good thing is there’s a lot of innovation in mobile health. The bad is it’s taking a long time to get through regulation, and, number two, you can’t get paid for it.” - Jonathan Linkous, CEO American Telemedicine Association

State Activity
They also discussed the ongoing issue of licensure, and the burden acquiring multiple state licenses places on telehealth providers. The Federation of State Medical Boards is proposing a form of state reciprocity but, Linkous points out, getting all the states on board could take a long time—a decade or more. He offered the example of the nursing compact, which was started 15 years ago and less than half the states have signed on to date. (The ATA has not endorsed any one approach).

Big Med Developments
Larger healthcare systems are seeing the potential business benefits of telehealth, and are looking to expand their footprint and brand by providing more services to a larger population. Linkous gave the example of the Mayo Clinic Care Network, an affiliation program. They have a goal of reaching 200 million patients by 2020, through both their own hospitals and the affiliation network by using “e-consults”, i.e. telemedicine. Cleveland Clinic also has an affiliate program. “It’s an interesting contest,” says Linkous, noting this is a business decision and cost-reduction tool. Mercy Healthcare is using telehealth for a broad range of services, including stroke, autism, and cardiac care, and they’ll soon be breaking ground for a virtual healthcare center which will house subspecialists and a teaching facility at their headquarters outside of St. Louis.

New Online Education
ATA will be launching an education service on their website with webinars, videocasts, and online courses, with many continuing medical education accredited. The organization is looking to develop a major educational center—online, of course—for telemedicine providers.

Annual Meeting
ATA’s annual meeting will be held in Austin, Texas, from May 5 to 7. For a free exhibit hall pass, click here to register and enter  the code VIPcomp13.

The next This Month in Telemedicine videocast is on April 23.

This Month in Telemedicine

Each month, the American Telemedicine Association broadcasts This Month in Telemedicine, a webcast discussing news and topics in the telemedicine field. February’s webcast featured ATA’s Jonathan Linkous, Chief Executive Officer, and Gary Capistrant, Senior Director of Public Policy, discussing the growth of telemedicine and policy issues.

A deluge of demand, a raft of pending legislation, and licensing challenges—these are a only a few of the issues facing telemedicine.

Activity:
Telemedicine is undergoing an “explosion of activity,” says Linkous. The ATA estimates 10 million patients in the U.S. and Canada are now using telemedicine (the majority for radiology). Two trends he’s seeing: the involvement of patient groups, who are showing interesting and researching how telemedicine could be employed by their members, and the growth of “big med” across the country.

The ATA is anticipating the demand will only grow—possibly reaching 50 million patients in the next couple of years. The question is whether providers, telemedicine networks, and vendors will be able to meet the growing need for telemedicine services. Linkous calls this, “A serious issue we need to focus on.”

New Developments:
“We’re moving away from the fee-for-service model,” says Linkous. “We’re moving to managed care, accountable care, medical homes.” This is good news for telemedicine, he says.

New developments in telemedicine include specialty service providers—a group that’s appeared in the past couple of years. To help track this growth, ATA created a new service provider forum of private companies that provide direct services to patients.

Also, a few major companies are offering online consultations, including American Well and TelaDoc. And insurance plans are also expressing interest in the potential of telemedicine. Several major plans now reimburse patients for online consultations, but only in a few states so far. Some are offering the service as an add-on to traditional care for an additional fee. However, while patients can get prescriptions online, they won’t for controlled substances, in compliance with federal law. “You will not see that done,” says Linkous.

Issues:
With health care reform becoming a reality, a large number of people are expected to be added to Medicaid, and states don’t know how they’re going to accommodate the increase in Medicaid demand. The ATA sees telemedicine as an answer to that problem.

A big issue with telemedicine is licensing. Each state has its own licensing board. About 22% of doctors have licenses in more than one state, and the ATA estimates this costs $300 million per annum, paid to states for 2nd, 3rd, and 4th licenses. They’re looking to the model established by the Department of Defense and approved by Congress last year—their doctors only need to be licensed in one state. Several states have proposals to follow the D.O.D.’s lead, but that’s a cause for consternation for the medical boards, who are looking at a major loss of income if this licensing model is actually established nationwide.

For health systems and private companies that are telemedicine focused, health care provider licensing is a subject they’re following closely. “There are concerns that an agreement requiring approval by each state could mean years of delay,” says Linkous.

California Congressman Mike Thomas introduced a bill (The Telehealth Promotion Act) with the aim of increasing federal acceptance of telemedicine, which would include Medicaid, the V.A. medical system, and other federal health programs. The licensing model proposed with this bill is one where health care providers need only be licensed in their own state, and the patient’s location would be deemed irrelevant.

Policy & Legislation:
“We’ve never had so many bills introduced at state level,” says Gary Capistrant. There are 13 states plus D.C. that have legislation pending to mandate private insurance coverage of telemedicine services (15 states already have this as law). 11 states are expanding Medicaid coverage to ensure parity with in-person health care. He suggested the Thompson Bill might be segmented to smooth the commitment process.

States:
As of March 1st, 2013, California, Texas, and Vermont are the only states that have legislation for both private and Medicaid coverage; 14 other states have a legislated mandate for private coverage, and only Pennsylvania and Nebraska have it for Medicaid. But 24 states have proposals on the table for either are both. You can see the full list here. To help track state telemedicine information and changes, the ATA has set up atawiki.org—click on Current Events, or type in a state in the search box for the latest info.

 

With the technology used in telepsychiatry becoming more reliable, inexpensive, and ubiquitous, there has been a corresponding increase in mental health professionals who are turning to remote treatments. In fact, psychiatry has been at the forefront of telemedicine use.

The general consensus thus far is that telepsychiatry is particularly useful for rural populations, children, the military, and those in institutions like prisons. In other words, telepsychiatry reaches people who otherwise wouldn’t have access to mental health services. (There is a severe shortage of child and adolescent psychiatrists). Telepsychiatry can also lessen some of the barriers often cited to obtaining mental health treatment, including cultural, shame, cost, and distance.

Many states, often in conjunction with state university medical and public health departments, have recently initiated telepsychiatry programs. The South Carolina Department of Mental Health established a program in 2007 to provide telepsychiatry in state hospital emergency departments. Also in 2007, University of Alabama’s College of Community of Health Sciences joined the Alabama Department of Mental Health (and others) to launch a telepsychiatry program, focusing on rural populations. New York State’s Office of Mental Health runs the New York Consultation and Telepsychiatry Program (NYCaT) aimed at children, and last fall West Virginia University’s WVU Healthcare received a government grant that will cover four years of telepsychiatry programs for an addiction treatment clinic. The Centers for American Indian and Alaska Native Health at the Colorado School of Public Health also run a telehealth program that includes mental health services.

That’s just a handful of examples, but they demonstrate the range of applications and growth of telepsychiatry. While the interest and investment is there, acceptance is by no means guaranteed. Here are five potential obstacles to telepsychiatry adoption.

Cost: States vary greatly in their definitions, approach, and regulation to telehealth (or telemedicine) according to a recent report from the Center for Connected Health Policy, State Telehealth Laws and Reimbursement Policies. While the majority of states reimburse telehealth through Medicaid; some do not, including Connecticut, Iowa, Massachusetts, New Hampshire, New Jersey, and Rhode Island, plus the District of Columbia. Amongst those that do reimburse, there is a wide range of what and who is reimbursed, and when.

Privacy: “Increased video-conferencing over public networks also creates the potential for unauthorized access to protected health information.” This is from a recent article in Current Psychiatry. The authors’ recommendations: use VPNs and encryption; train health professions in data storage and telemedicine ethics.

Legal: A provider must be licensed in every state they provide care. So a health care provider in one state that is conducting a telepsychiatry session with a client in another means they must be licensed in both states. There are 9 states, however, where the medical boards have instituted special telehealth certifications. As telemedicine becomes more common, look for this issue to become a hot topic.

Habits: Old habits die hard, and not every mental health care provider sees the value of telepsychiatry, or wants to invest the resources in training and adopting new modes of treatment. A study by the California HealthCare Foundation, which focused on telepsychiatry adoption in 7 emergency departments, found that in every case, there were initial problems getting support from involved parties, including doctors, nurses, and psychiatrists. From the study: “Some of the spoke sites felt that they had neither the time nor the energy to devote to telemedicine efforts.”

Lack of training or incorrect training: “Training is critical,” writes Mark Vanderwerf in his chapter Ten Critical Steps for a Successful Telemedicine Program. He recommends “layered” training, that is, training presented in progressive stages, and it should be formal to increase its perceived value. For the first level, he suggests course materials, a syllabus, registration, and testing, and even a certificate awarded to those who pass the course. The second layer includes on-site evaluations, and the third includes support and “refresher sessions.”