Despite the excitement surrounding the potential of telemedicine and the technology being available, several barriers are holding it back.
When Mia Finkelston, a family practice physician in Leonardtown, Md., first opened her small-town physician practice, things started off well.
"I was taking care of patients that I'd see in the grocery store. My patients were my friends' parents. It was that sort of thing. It was very tight-knit and within the community," Finkelston says.
Yet, like many other physicians in today's healthcare landscape, financial constraints forced Finkelston and her partner to sell to a larger practice. The practice implored them to see a higher volume of patients. In turn, having to see a higher volume of patients shoved aside the ones from her community, with whom she had built a rapport. Those patients told her it was harder to get an appointment with her and began to see other providers.
That's when the idea of telemedicine came into her head. She said she wanted to see the people from her community who couldn't get an appointment with her after hours, via a telemedicine application. Unfortunately she says, "No one in my town was interested in it. I think being a small town, it was too new."
The idea, however, came back to her when American Well, a Boston-based provider of telemedicine software, came calling.
After a few conversations, she accepted a position in Online Care Group, an American Well-affiliated online medical practice that uses the telemedicine technology to care for patients. While she wasn't burned out from running a practice, Finkelston says telemedicine gave her flexible hours that made it a huge draw over practicing face to face. At first, she tried to practice via telemedicine and maintain a brick-and-mortar practice. Eventually, she went all in on telemedicine.
"I quickly realized [telemedicine] isn't going anywhere. It's going to get better and better. It gave me a lot of energy … so I made the jump to full time telemedicine," she recalls.
Finkelston's excitement over the promise of telemedicine is not an anomaly in medicine. A recent survey by the American Academy of Family Physicians and the Robert Graham Center, a nonprofit organization focused on population health, found that nearly nine in 10 family physicians say they would use telemedicine as a tool to treat their patients if they were compensated for it. Moreover, Miranda Moore, economic and health services researcher at the Robert Graham Center, says that majority of respondents, whether they used telemedicine or not, agreed it had the potential to improve physician access and continuity of care.
Like Finkelston, Peter Antall, a pediatrician based in Westlake Village, Calif., and chief medical officer of Online Care Group, was excited with what telemedicine could offer in terms of flexibility when it first came up as a potential career path for him. Not just for doctors, but for patients as well.
"For those parents who have a very sick child, imagine the impact on their work life when they have to bring their children in all the time. Imagine a patient with a chronic condition who has to make judgment calls on taking time off from work to see the doctor vs. just sucking it up. When integrated properly, telemedicine offers another access point for these patients," says Antall, who also left private practice for telemedicine four years ago.
John Jesser, President of LiveHealth Online, which is health insurer Anthem's telemedicine software solution, notes that in an era where it can take weeks to schedule a face-to-face appointment with a doctor, instantaneous care is a crowd pleaser. Concurring with that belief is physician Joseph Kvedar, vice president of Boston-based Partners HealthCare Connected Health, who says telemedicine is among a wave of mobile health (mHealth) technologies that will push healthcare from volume to value.
"Healthcare is trying to move primary care from the old fashioned Marcus Welby-type practice to a team-based sport. When you have teams of care providers working together, these remote monitoring tools can become integrated into the process," he says.
HOLDING IT BACK
Potential is, of course, the big word. Telemedicine is still in the potential phase. The AAFP and Robert Graham survey indicated that 85 percent of family medicine respondents had not used telemedicine in the last 12 months and of the small percentage of those who had, most had only used it one to five times. Moore says that physicians at the small practice level were the least likely to use telemedicine. These practices do not have access to the same kind of resources as larger practices and have less money to invest in technology, she says.
Standing in most physicians' way is lack of reimbursement, or as Kvedar says, "We all respond to monetary incentives." Insurers, like Anthem Health, have been more open to paying all doctors for telemedicine. Jesser says that in 2012, Anthem came out in favor of reimbursing for responsible, HIPAA-secure telemedicine because it "made good clinical sense to pay for these types of visits."
Still, CMS is the bellwether for all other insurers and as it goes, they go. Currently, CMS only reimburses telemedicine encounters in rural areas, at federally-qualified health centers, and through value-based programs.
Nadia de la Houssaya, a partner with Jones Walker's Business & Commercial Litigation Practice Group in Lafayette, La., says there is a proposed bill in Congress that would reimburse doctors in all regions who use telemedicine encounters for the monitoring of patients with chronic conditions. There is another proposed bill that's designed to strengthen federally-sponsored programs, such as accountable care organizations, that support the use of telemedicine. However, both are still in proposal stage and long shots to becoming law.
While more than half of U.S. states have telemedicine parity laws in place, requiring insurers to cover telemedicine to the same extent as in-person services, these do not address scope of coverage, de la Houssaya says. "If the policy isn't that great, the chances of telemedicine being covered aren't that great," she says.
Another barrier to telemedicine has to do with licensure. According to de la Houssaya, if providers want to give care to a patient located in a different state, they have to be licensed in that state. Getting licensed in another state, she says, is a costly, time-sensitive procedure. She notes that an interstate licensing compact, signed by 11 states currently, could change the game on this front, making it so physicians could practice across state lines.
Along with the price of getting licensed across state borders, the overall cost of telemedicine solutions can be an obstacle for practices. While there is the cost of implementing and maintaining a solution, Jesser argues that by using telemedicine, they increase the scope of their practice without a lot of overhead.
Kvedar also says an attitude shift from practitioners will have to happen before telemedicine is more widespread. "People in healthcare from nurses to doctors to just about every healthcare professional, are trained to believe that they, or at least their [face-to-face] reflexes, can only get things done if they are in the same room as the patient. They'll say, 'I need to examine patient and look them in eye,'" he says.
ADVICE AND LOOKING AHEAD
Even the most ardent supporters of telemedicine say it's not designed to replace face-to-face care, but rather act as a complementary service. "I think [primary-care physicians] need to not think of it as competition. It should be a medical team. How can we collectively take care of the patient?" says Finkelston. Jesser says telemedicine could be useful in a multi-physician practice, where one or two doctors who have an interest in technology would be willing to try it out.
For physicians who are interested in dabbling in telemedicine, Kvedar says they should start with these seven words of advice: "Find out if you can get paid." He says reach out to local payers to see if there is planned or current reimbursement. Also, Finkelston says if there are lingering doubts, physicians should try it on their own. "Be a secret shopper. See what it's about. Try it out as a patient," she says.
She also says practices should start looking to their patients for guidance. "Start polling your patients. On exit interviews, have them fill out a quick survey asking if they'd be interested in telemedicine services. If you get more than 50 percent, it's definitely in your interest to train a few of your doctors in telemedicine," says Finkelston.
Many say the widespread usage of telemedicine is a matter of "not if, but when," as de la Houssaya says. Consumer demand will drive the market, Jesser says, but the idea is still in its infancy. In that sense, a recent survey from TechnologyAdvice, a consumer-focused research firm, indicates that telemedicine indeed has a ways to go. Only 35 percent of consumers polled by TechnologyAdvice would choose a virtual visit over a face-to-face one.
Antall, Kvedar, and other telemedicine advocates say the trickle-down effect, where this becomes more widespread and a consumer expectation, will begin in 2016. "I think 2016 will be a gradual shift. There won't be a dramatic tipping point because everything is moving in the right direction. The [different factors pushing adoption of telemedicine] take time. The reimbursement patterns and team-based care elements are falling into place. It's sort of like a soup you need to stir and heat up," says Kvedar.
Gabriel Pernais the managing editor for Physicians Practice. He can be reached at firstname.lastname@example.org.
This article was originally published in the March 2016 issue of Physicians Practice.