The Conundrum of Internet Prescribing

For several years ATA has been drawn into controversies surrounding the online prescribing of medications. Some issues in this area are clear but many others are murky and have become even more blurred with biased statements by groups on both sides with an obvious self interest.

Over the past few years, ATA worked with Senate and House staff and related regulatory agencies on limiting online access to controlled substances. The 2008 Ryan Haight Online Pharmacy Consumer Protection Act includes language to protect telemedicine programs from federal efforts to close down sites that illegally sell controlled substances. The Administration is now finalizing their final regulations regarding the Act and they should be made public soon.

ATA has also been asked to comment on recent court judgments against physicians convicted of prescribing in states where they did not hold a license. Other issues related to state licensing, who can prescribe, and the bases for making a prescription are but a few of the issues in question.

It’s complex. Lawyers, politicians, regulatory agencies, advocacy groups and many others have weighed in on parts of the controversy. In some areas, state laws vary and contradict each other as do laws in other countries.

Clearly, ATA cannot and should not attempt to clear up all of the issues surrounding internet prescribing. However, as telemedicine and telehealth grows and the use of telecommunications to provide health services expands, it is important to identify areas of interest to our members with recommended policy solutions. A white paper outlining some of the issues has been posted on the ATA website at http://www.americantelemed.org/i4a/pages/index.cfm?pageID=3335.

Telemedicine, Telehealth, Remote Monitoring and the Latest Congressional Health Reform Proposal

This week, the United States Senate Finance Committee announced its proposed health reform bill. This is the last of five proposals in Congress (two in the Senate, three in the House) to come forward. The proposals in the House are being combined into one bill and the same will probably happen in the Senate. Although it has already come under attack by many groups, the Finance Committee proposal, put forward by Sen. Max Baucus (D-MT), has been touted as having the best chance of actually going forward. So it’s important to take a look at the provisions and how they affect many of the areas of interest to ATA members.

The Finance Committee issued a document that describes the proposed bill in relatively plain language. It’s available at http://finance.senate.gov/sitepages/leg/LEG%202009/091609%20Americas_Healthy_Future_Act.pdf.

The comments and referenced page numbers here are based on this document.

Much of the bill takes a broad approach to health reform; financing, insurance options, etc., and it rarely gets into specifics on coverage issues. So it’s not surprising that the bill does not include the specific recommendations put forward by ATA. Nor does it include some telemedicine provisions that are included in the House bill, such as the establishment of a Telehealth Advisory Committee. But it does address many areas directly related to the use of telecommunications technology and health and opens the door for more specific provisions that might get added later.

• The bill calls on the federal Center for Medicare and Medicaid Services (CMS) and other parts of the Department of Health and Human Services (HHS) to compile data and launch pilot programs designed to reduce hospital readmissions. It is widely recognized that the use of remote patient monitoring is a safe and effective approach to reducing such readmissions. It gives the Secretary of HHS, working with a newly proposed Innovations Panel, the authority to include readmission rates as part of an incentive payment policy for health institutions. Language beginning on page 97 of the document addresses recommendations made by the Medicare Payment Advisory Committee (MedPAC) about readmissions. The bill calls for immediate data collection and enforcement actions related to this issue starting in 2012. As part of this approach, language on page 99 also calls for a new “Transitional Care” pilot program with an authorization of $500 million over three years. Remote monitoring is not specifically mentioned but the examples provided of appropriate services could lead one to conclude that remote monitoring is a logical approach.
• In setting up a new CMS Innovation Center (page 90) the bill directs the Center to test models of delivery that include the use of care-coordination for the chronically ill and the use of home telehealth technology. In each of the models to be evaluated, the bill calls on the Center to include “patient-based remote monitoring” as one of the approaches it tests in developing patient-centered delivery and payment models.
• Under Title II – Promoting Disease Prevention and Wellness, (page 69) the bill provides that Medicare beneficiaries would have access to a comprehensive health risk assessment by 2011. “The assessment could be provided through an interactive telephonic or web-based program or during an encounter with a health professional. The Secretary would also set standards for the electronic tools that could be used to deliver the assessment.”
• A Workforce Advisory Committee would be established (page 107) to address issues of provider shortages. The Committee is to develop a national strategy to address the issue. The language refers to the role of health information technology in addressing such needs.
• The bill endorses the use of a medical home (page 77) and includes references to using health technology to link services and the provision of service virtually.
• Demonstration Projects on Culture Change and use of Information Technology in Nursing Homes are proposed (page 183). The bill would require the Secretary to conduct two demonstration projects for nursing homes: (1) for the development of best practices for facilities involved in culture change; and (2) for the development of best practices in facilities for the use of information technology to improve resident care. The Secretary would be required to submit a report to Congress after completion of the demonstration projects. The report would evaluate the projects and make recommendations for legislation and administrative actions. The demonstration projects cannot exceed three years.

Much work remains and there are still opportunities to add or change certain provisions. Such provisions might be in the form of amendments to the bill in Committee, on the Floor of the Senate, in conference with the House or in report language that would accompany the Senate bill or the final joint bill. Also, language already in the consolidated House bill relating to telemedicine may be expanded and inserted in the Senate bill.

Stay tuned.

Telemedicine and Health Reform: a little progress, a lot of hope

Over the past few months you have heard a lot from ATA about the various machinations going on with national health reform. Starting out with high hopes we have witnessed the usual highs and lows of the legislative process. ATA has promoted a broad expansion of governmental support for telemedicine, only to have parts of it dashed by a few parties that refuse to consider what telemedicine can do for cost savings and improved quality of care. However, most of our problems are that telemedicine is lost under the shouting and publicity around the overall costs of health reform.

However, telemedicine has a lot of friends in high places.

Yesterday, the Federal Communications Commission held a workshop on healthcare and broadband. It amounted to a love fest for telemedicine. President Obama's Chief Technology Officer, Aneesh Chopra, gave a strong close. He stated: “We can’t move forward in advancing our nation’s health reform goals without the appropriate use of technology and telemedicine is a key component.” He went on to recount personal experiences and his perspectives on how critical telemedicine can be for the nation. Clearly, Chopra gets it.

In addition to Chopra, three important members of ATA were asked to speak at the meeting: ATA President Karen Rheuban, ATA President-Elect Dale Alverson and Chair of ATA’s Standards Committee Nina Antoniotti. All three gave outstanding presentations. Details of the meeting and a recorded version of the webcast are available at: http://www.americantelemed.org/i4a/pages/index.cfm?pageID=3337#updates