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Telehealth Advocates Remain Optimistic After Recent Setbacks

By Kerry Young, CQ Roll Call

June 12, 2015 -- Advocates for telehealth services say they are optimistic about expansion in the field even after recent setbacks, including decisions that may hamper the more widespread use of medicine delivered over computer or phone by the Medicare program.

This week, leaders at the American Medical Association (AMA) sent a report on telemedicine ethics back to an internal council for further consideration. There were concerns raised by radiologists, a group that's been at the forefront in this field, and some spillover from a fight between the Texas Medical Board and Teladoc Inc., a firm that connects doctors and patients through the Internet and phone. The two are at odds about a state requirement that seeks to have at least one initial in-person contact with a health professional.

Last week, Medicare officials rebuffed requests to expand use of telemedicine in the highly watched accountable care organization, or ACO, program. And bids to expand use of telemedicine through the House Energy and Commerce's 21rst Century Cures bill have so far fallen short.

But Krista Drobac, executive director of the Alliance for Connected Care, said she is pleased that discussion of federal payments for telemedicine has expanded beyond the currently approved uses in Medicare, that often serve people who live in areas where health care can be scarce.

"It takes a while," Drobac said. "We are just pleased that policymakers are looking at this as more than a rural issue."

Among the developments that people advocating for telehealth see as a positive sign is the requirement in the recent Medicare payment overhaul (PL 114-10) for a Government Accountability Office (GAO) report on telehealth. The law directs GAO to study how the private health insurance industry is using remote patient monitoring and financial incentives for telemedicine, and examine the barriers to the adoption of such services in Medicare. The results of the work could make lawmakers more willing to expand Medicare's use of telehealth, said Alice B. Borrelli, director of global health and education policy for Intel Corp.

"We have had some setbacks, but there is so much interest in finding a solution," Borrelli said.

The field of telemedicine is growing rapidly in the private sector, with potential annual savings for companies of $6 billion, according to an analysis released last year by the actuarial firm Towers Watson. About 37 percent of employers surveyed said that by 2015 they expect to offer their employees telemedicine consultations as an alternative to emergency room or physician office visits. 

And federal health officials see promise in this approach.

Officials at the Centers for Medicare and Medicaid Services intend to allow more access to telehealth in an advanced version of its ACO program, known as the Next Generation initiative.

Groups supporting telehealth have not given up on getting provisions into the Cures bill and also are continuing to press for legislation to widen its use. Among the bills supported by the American Telemedicine Association is one (S 1465) from Sen. Mark Kirk, R-Ill., that would expand the use of health services provided at a distance for people recovering from strokes.

State officials also are working to define how best telemedicine can be used, an exercise that can lead to disputes with professionals in the field. The Texas Medical Board is seeking to require that a health professional be in attendance for at least the initial contact between patients and physicians. Patients should be at a location where there is sufficient medical staff and diagnostic equipment for an exam, a spokesman for the board said.

Contesting that rule is New York-based Teladoc Inc., which connects people to physicians via mobile devices, the internet, video and phone. It handled 300,000 interactions last year.

The challenge from Teladoc marks the third lawsuit filed in Texas courts against the state's medical board, according to a regulatory filing. These disputes center on the Texas board's bids to define the terms of the relationship between doctor and patient in ways that would limit Teladoc's physicians from prescribing medicines, according to the filing.  The company announced on May 29 that a federal court had issued an injunction regarding the April rule adopted by the Texas Medical Board. The ruling blocks enforcement of the revised rule until after a trial to determine whether it violates the law. Teladoc said the decision marks the sixth occasion in the four years that the courts have sided with Teladoc against the state medical board.

"Not only is telehealth the wave of the future, but Texas physicians have been treating patients without a prior in-person visit for decades," said Jason Gorevic, chief executive officer of Teladoc, in a statement, adding that other states have been more welcoming on telehealth.

The AMA could revisit the question of telemedicine as early as November. Arlo Weltge, the emergency room doctor who spoke for the Texas physicians at the June AMA meeting, agrees that there is promise in the expanded use of telemedicine. But the draft that was slated for consideration this week didn't address some of the downsides of telehealth or make clear the standards that are needed to practice medicine safely at a distance, Weltge said in a recent interview.

Doctors need a good baseline reading on patients' physical condition, he said. This doesn't necessarily require a meeting with the doctor. A patient could visit a center where a physician's assistant or another trained medical worker could check blood pressure and assess health risks, including signs of kidney damage that can raise risks for complications with some prescription drugs, according to Weltge.

"There needs to be a face-to-face some interaction," Weltge said in an interview with CQ HealthBeat. "One of the most important parts [in the practice of medicine] is taking a history."

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