Over the past two years, telemedicine has emerged as a topic of interest among Members of Congress, CMS, state governments, and a host of trade and professional organizations. As a result, we have seen an increase in the number of Congressional hearings and bill introduced on the subject. We also have witnessed a growing debate about the appropriate regulation and compensations model for such services. As technology improves and we – as patients – become more accustomed to the delivery of services via technology as opposed to only through face-to-face interactions, the use and acceptance of telemedicine will increase, placing even greater pressure on policy-makers at all levels to establish a conducive regulatory and payment structure.
There are three major challenges to the widespread adoption of telemedicine. The first is the lack of a widely-accepted definition, the second is an antiquated regulatory structure that serves as an obstacle to physician deployment of appropriate and available technologies, and the third is fee-for-service.
Let’s address the definitional issue first. A quick internet search reveals just how complex this industry has become. We have telemedicine, telehealth, telecounseling, remote monitoring, health apps for our smartphones, fitbits, you get the picture – a multitude of platforms and products exists and more are emerging. According to the American Telemedicine Association, telemedicine is “the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status. Telemedicine includes a growing variety of applications and services using two-way video, email, smart phones, wireless tools, and other forms of telecommunications technology.” This is a nicely worded definition, but it is also broadly applicable to the small list of items I articulated previously. If we are going to get serious about benefit and payment design, we are going to need a cleaner definition of what we are providing and paying for.
For the purposes of starting a conversation, I want to go on record and move that, at some point very soon, we stop calling it telemedicine and instead choose a name that is more 21st Century. Telemedicine reminds me of dial-up internet, which doesn’t exactly scream “innovation.” We need a clean term that is free from historical biases.
The second issue is the regulatory structure that guides the practice of medicine and care delivery. Currently, physicians must obtain a medical license from the state or states in which they practice medicine and provide care. If they practice in other states, then they must be licensed in each of those states. There is great merit to a state-based licensing system and I would never suggest nor support a federal medical license. However, there is definitely room for improvement in the current system.
This summer the Federation of State Medical Boards (FSMB) approved the Interstate Medical Licensure Compact. According to the FSMB press release, “The interstate medical licensure compact model legislation creates a new process for faster licensing for physicians interested in practicing in multiple states and establishes the location of a patient as the jurisdiction for oversight and patient protections.”
The problem with this statement is despite being more efficient in process, the compact “establishes the location of a patient as the jurisdiction for oversight and patient protection.” I understand the need for administrative oversight, but this is 20th century thinking. With today’s technology, I could be anywhere in the world and have an appointment with my primary care physician. So long as I have a continuous relationship with my personal primary care physician, why does it matter where I am physically located? The answer to this question comes into focus later in the FSMB press statement when they state, “The compact is a dynamic system of expedited licensure over which the member states can maintain control through a coordinated legislative and administrative process.” The key words are “member states” and “maintain control.” Don’t be fooled, this is protectionism of a business model not protectionism of patients.
The use of telemedicine is complicated and the notion of such technology being used for diagnosis and treatment of patients who do not have an existing relationship with the physician or the physician practice they are interacting with via any technology is deeply concerning. We should not send patients to a “call center” to receive a diagnosis and prescription; this is wrong and bad medicine. However, if there is a continuous patient-physician relationship, then the physical location of either party shouldn’t inhibit the delivery of appropriate care. It is a patient-physician relationship – not a patient-physician-state licensing board relationship. I appreciate fully the role of state medical boards to ensure the competency of physicians and the safety of care they provide, but we must do this in the context of modern society – not the previous century.
I recognize that there are advocates who will challenge the “existing relationship” requirement as limiting access and I am inclined to agree with them. However, there is a strong body of literature that demonstrates the value of a “usual source of care” as a definitive factor in improved quality and lower cost. Due to this I think our goal, at least in primary care, should be for patients to have a relationship with a physician or physician practice.
The final challenge lies inside the fee-for-service system. Episode-based payment models complicate everything in our health care system because it places the focus on “who gets paid” versus “does the patient get the care they need, when they need it.” I appreciate that fee-for-service will continue to play a role in our health care system for the next 5 years, but let’s hope CMS and private insurers have the foresight to decouple it from as many physician services as possible including telemedicine.
Technology has changed the world, but it is still struggling to change health care delivery. The 114th Congress has the opportunity to be the incubator that produces meaningful policy changes to capture the benefits of technology for patients.
Shawn Martin is the Vice President, Practice Advancement & Advocacy, at the American Academy of Family Physicians