Telemedicine has been praised as a cost-effective approach, enabling physicians to monitor their patients’ medical conditions and consult with specialists in a way that overcomes time and distance.
But despite a half-century of technological advances, the ready availability of interactive devices such as smartphones and the full-throated encouragement of the Obama administration, advocates say telemedicine has failed to reach its full potential, due largely to policies that make it difficult to practice, and pay for, such care.
“The technology has opened up this huge opportunity, this game-changer,” said Allison Wils, director of health policy for the ERISA Industry Committee, a trade association that advocates on health-care issues for large, multistate employers. “The problem is that there are still varying levels of comfort with it across the states.”
Some states require that patients be accompanied by a health professional during telemedicine sessions. Hawaii, Indiana and Ohio limit Medicaid coverage to patients who live a minimum distance from their providers. (In Indiana, for example, the standard is 20 miles.) Another significant hurdle is that each state licenses the doctors who practice within its borders, so a doctor licensed in one state cannot see a patient digitally in another state without getting a license there.
Because of those barriers, patients who are elderly, infirm, isolated or busy may be denied full access to health care, said Latoya Thomas, director of state health policy at the American Telemedicine Association (ATA).
States that have been slower to embrace telemedicine, including Arkansas, Rhode Island and Texas, are merely being prudent, waiting to be assured that the approach does not diminish the quality of care that patients receive, say some physician regulatory boards. “There is a concern that whatever is put in place not be dangerous,” said Lisa Robin, chief advocacy officer for the Federation of State Medical Boards, which represents the state agencies that license and discipline doctors.
Those pushing for a less restrictive approach say telemedicine is not an inferior method but a vehicle for extending quality health care to more places. And, they argue, some policies curbing telemedicine have been motivated by fear of competition among more-traditional practitioners.
“In some states, the issue comes down to protecting their doctors from outside competition,” Thomas said. “Their doctors with brick-and-mortar practices assume that someone who uses telemedicine is trying to take away patients.”
Telemedicine’s origins date to the early days of the U.S. space program, when NASA scientists developed technology that enabled doctors to monitor astronauts in space. Thanks to rapid advances in technology, telemedicine developed quickly, principally to link physicians to remote populations in such places as Alaska and Arizona’s Tohono O’odham Indian reservation, which borders Mexico west of Tucson.
Telemedicine also spread from rural to urban areas. Doctors now monitor or communicate with patients from afar on everything from routine preventive care to chronic disease management and psychiatric conditions. Primary care doctors and their patients consult with specialists and diagnosticians who might otherwise be beyond their geographic reach.
The approach received a major boost from the American Recovery and Reinvestment Act of 2009 and the Affordable Care Act of 2010, both of which increased federal spending on health information technology and telemedicine. President Obama has often extolled its potential to increase access to quality health care while cutting costs. Nearly 13 million Americans use telemedicine, according to Gary Capistrant, senior director of policy at the ATA.
As the use of telemedicine became more common in the 2000s, more state legislatures and regulatory boards adopted telemedicine policies. (The Center for Connected Health Policy has compiled a state-by-state list.)
Twenty-nine states require private insurers to pay for telemedicine at the same rate as in-person services, according to the ATA.
In addition, Medicaid programs in 48 states and the District offer at least some coverage for telemedicine. (Connecticut and Rhode Island are the only states that largely refuse to pay for telemedicine in their Medicaid programs.) About half of state Medicaid programs require that a patient be in a medical facility during telemedicine encounters rather than at home.
Many states have also adopted laws and policies concerning how physicians practice telemedicine. Some require that a health professional be physically present with a patient during a telemedicine session. Most require patients to sign special consent forms.
Some states require in-person follow-ups. Texas is locked in a federal lawsuit with Teladoc, a service that digitally links patients and doctors, over the state’s requirement that physicians either meet with patients in person before moving to a digital relationship or have other providers physically present with patients when treating them remotely for the first time. Arkansas has a similar law.
Russell Thomas, a former member of the Texas Medical Board and the Federation of State Medical Boards, uses videoconferencing to provide primary care to at-risk students at a high school 300 miles away from his family practice in Eagle Lake, Tex. He also consults with cardiologists and dermatologists in Houston for his patients.
Doctors should first meet with patients before moving to a digital relationship, he said. “I can’t imagine that I can provide the best care to my patients if I never laid eyes on them, if I never physically assessed them.”
The ATA says that telemedicine should be governed by the same rules that apply to traditional care. “Our belief is that if you license a health-care provider, you expect them to uphold the standard of care — whatever tools they are using,” the ATA’s Thomas said. In other words, each physician who practices telemedicine should determine whether a remote session suffices or a face-to-face visit is necessary.
States that put additional requirements on telemedicine, she said, are depriving people of access to medical care. “It’s a delivery model that may not be familiar to everyone, but where it is available, it should be used fully.”
This article was produced by Stateline, an initiative of the Pew Charitable Trusts.