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Maine: Requiring Private Insurers to Reimburse for Telemedicine

In January 2010, Maine joined 11 other states in requiring private insurers to reimburse services provided via telemedicine. The new Maine law defines telemedicine as "the use of interactive audio, video, or other electronic media" for "diagnosis, consultation or treatment," excluding e-mail and telephone communication. It specifies that an insurance carrier must cover services that would be reimbursed if they were provided in person, and that patient cost-sharing for telemedicine services cannot be higher than it would be for the same service in person.

Maine's Medicaid program, MaineCare, has covered telemedicine services delivered via interactive video sessions for over a decade, but as of 2008 only one of four major insurers in the state had a policy for reimbursement of some telemedicine services. There are varying perspectives within the state on the role of telemedicine and how this change might affect its use and patients' access to care.

"The focus of this effort was really expanding the accessibility of care. Because Maine is so rural and the distances involved in getting to care can be so great, there are often significant challenges in accessing many different types of providers," said Representative Anne Perry, sponsor of the bill and a nurse practitioner. Indeed, past state efforts to expand rural health services have highlighted telehealth reimbursement as a barrier to its broader adoption, according to Michael Edwards, Ph.D., a project evaluator with the Regional Medical Center at Lubec and its division Maine Telemedicine Services. "It will take a few years to see whether private insurance coverage increases utilization," he said.

Charles Dwyer, director of Maine's Office of Rural Health and Primary Care, said Maine looked at the experience of other states in developing its approach. "The issue of reimbursement needed to be addressed, and we 'leapfrogged' by looking at other states with similar mandates," he said. "It was a welcome surprise to see such strong support for the bill."

Maine hospitals, some of which already have telemedicine programs, strongly supported the new law. Insurers opposed the change, arguing that evidence on the effectiveness of telemedicine and the need to expand its use in Maine was not sufficient to justify reimbursement requirements. The Maine Telehealth Advisory Committee, which Dwyer coordinates, will be studying the effects of the new law on utilization of telemedicine.

Also, Maine will be closely monitoring other states' coverage of home "telehealth" services, which its Medicaid program currently does not cover. This would include, for example, home blood pressure or glucose monitoring equipment with a telecommunications connection to a provider, which would enable diabetic patients to transmit information needed for care management to a remote location. Maine will "need to look both nationally and locally at emerging evidence showing decreases in hospital and emergency room use with in-home telehealth calls, especially for congestive heart failure and diabetes," said Perry. "Moving forward, especially given budget issues, we must focus on how to be more effective and cost-effective with services, and reduce the use of high-cost services as much as possible."

Though telemedicine is often considered to be most useful in increasing access to specialty care, it can also be useful in expanding access to primary care. "We're very rural, and as the primary care situation just gets worse across the nation, in terms of retirements and where medical students are going, the need for strategies such as telemedicine to address it will continue to grow," said Dwyer.

MaineCare's existing coverage of telemedicine services was part of the discussion of the new policy, but it did not drive the change. Use of telemedicine in MaineCare has been limited to date. According to MaineCare Medical Director Roderick Prior, M.D., early experience in the provider community suggests that certain factors are critical to making telemedicine work: a committed technology vendor to set up the infrastructure and make it user-friendly for providers and practices on both the "sending" and "receiving" ends, and providers who are committed to building telemedicine into their practices. "If these conditions are not met, interest may wane—in the past, providers have found that they were less productive via telehealth than face to face, which was a barrier," he said.

Improvements in telemedicine technology, coupled with providers' expanding information technology capacity, may encourage broader use of telemedicine for both primary and specialty care as states move forward with technology infrastructure investments.

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