ATA Policy Summit: Telemedicine Policy Topics Ripped from the Headlines

The program for the ATA Federal Telemedicine Policy Summit (June 27-28 in Washington, DC) is designed to give you insider perspective on the big policy issues facing remote healthcare. 

We all know what these policy hot topics are—they’re splayed throughout the industry press on a daily basis. In a sense, the program for the Policy Summit is ripped from the headlines.  If it’s in the telehealth news, we’re talking about it at the Summit.  

Our speakers, all leading figures in federal telehealth policy, will help you make sense of the news, providing valuable, operational insight in how these issues are creating new opportunities and challenges for you and your organization.   

Here are just a few examples:

Telemedicine More Prevalent in Urban, Wealthy Populace, Census Data Shows
(FierceGovernmentIT, June 12, 2013)
Using telemedicine to better reach underserved patient populations is an ongoing challenge. The alignment of government resources, including the funding of personnel, networks, resource centers and safety net providers is critical for achieving healthcare equity. The ATA Federal Telemedicine Policy Summit includes a presentation by the head of the HRSA, the federal agency charged with funding much of the infrastructure of telehealth.

Mary Wakefield, PhD, RNAdministrator, Health Resources and Services Administration, U.S. Department of Health and Human ServicesDr. Wakefield will speak Thursday, June 27, 2:45pm – 3:15pm

FDA, Facing Cybersecurity Threats, Tightens Medical-Device Standards 
(Washington Post, June 13, 2013)
The ATA Federal Policy Summit includes two presentations focused on the increasingly important topic of cybersecurity and device regulation. Speakers will outline best practices for health data security as well as the future of regulating consumer devices that are used for healthcare functions.

Gavin W. O’BrienProject Manager for the National Cybersecurity Center of ExcellenceNational Institutes of Standards and Technology Mr. O’Brien speaks Thursday, June 27, 3:45pm – 4:15pm 

Jeffrey Shuren, MD, JDDirector of the Center for Devices and Radiological HealthU.S. Food and Drug Administration Dr. Shuren speaks Friday, June 28, 10:45am – 11:15am 

For Ailing Vets in Rural Areas, Telemedicine Can Be the Cure 
(National Public Radio, May 28, 2013)
Veterans Affairs is the largest single healthcare provider in the United States and an innovator in using telemedicine to serve a large, disparate patient population. The ATA Federal Telemedicine Policy Summit features one of the chief architects of the VA telehealth programs. 

Adam Darkins, MD, MPHM, FRCSChief Consultant for Telehealth ServicesVeteran’s Health AdministrationDr. Darkins speaks Friday, June 28, 10:15am – 10:45am

Licensing Woes Make Inter-State Telemedicine a Headache 
(EHR Intelligence, June 6, 2013)
America’s state-based licensing system limits providers’ scope of practice and restricts patient access to the best care.  The ATA Federal Telemedicine Policy Summit explores solutions to this issue with a presentation by a leading Congressional voice for licensure reform—and the lead author of both the 2011 STEP Act and 2013 VETS Act.

U.S. Congressman, Glenn Thompson Pennsylvania, 5th DistrictU.S. House of RepresentativesRepresentative Thompson speaks Thursday, June 27, 4:30pm – 5:00pm

Of course, this is just a small sample of the speakers who will speak at the Forum. Our list of presenters is truly phenomenonal, with several Congressmen, an FCC Commissioner, the HRSA Adminsitrator and more leading health policy experts.  For a full list of confirmed speakers, please visit http://www.americantelemed.org/summit.

A Great Month for Telemedicine

Two major developments this week point out the rapidly evolving market in telemedicine both between medical centers and out to consumers.

 

For the first time, the American Heart and Stroke Association issued new guidelines for early stroke treatment endorsing the use of telemedicine.  The guidelines support the development of regional networks of stroke centers, acute stroke-ready hospitals and community hospitals.  The guidelines are published in the American Heart Association’s journal Stroke.  This is an important and timely development and another sign that leading disease and patient groups are taking up the call for more widespread use of telemedicine.  Legislation sponsored by Rep. Mike Thompson (D-CA) calls for Medicare reimbursement of telestroke services.

 

Also for the first time a major U.S. insurer is paying for online visits with a physician.  Wellpoint, a major private insurer in the U.S. is starting to pay physicians for video visits with patients in or outside their practices.  The company operates through a number of subsidiaries throughout the United States and covers over 60 million individuals.  The program starts out in California and Ohio early this year and will expand to other states later.  Covered patients can go to a web site to view doctors’ biographies and credentials and pay co-fees and submit claims based on their plans. The site is located at www.livehealthonline.com.

 

I Wish We Could Just Talk About Design

In a recent column in the New York Times Ray Bilton wrote about his experience at the Consumer Electronic Show (CES) and the changed emphasis of the products on display away from technical specifications to design elements.  He states: “I don’t care about the technology inside the technology anymore. It just works — for the most part — and therefore consumers no longer need to think about it.”

 

I also attended CES and was struck with the growing number of over-the-counter consumer health devices but was struck with how many of them were sleek and catchy but had virtually no real usefullness for personal or clinical healthcare.  Wearing a band around your wrist that flashes your pulse count is not what I would think is a health aid.  But at least it was really good looking and didn't need a long user guide to understand it.

 

We are just starting to see the same evolution for telemedicine.  Large telehealth programs and private, remote medical service providers are just starting to move away from needing a full engineering staff to operate their interactive networks.  It’s not as easy as dialing a phone yet - but we are getting close.

 

The growing number of health providers using such consumer-friendly technologies as Skype and FaceTime for consultations have been unfortunately restrained by legal fears of violating privacy laws.  I’m not giving any application the all clear but - just for the record - HIPAA does not certify products.  There is no such thing as a device being “not HIPAA compliant.”  Technical, consultant and lawyer-fed hyperbole about such issues are becoming one of the biggest impediments to expanding healthcare.

I long for the day when we talk only about sleek designs and friendly provider and patient interfaces for real telemedicine devices and not just pixels, privacy and transmission speeds.

Fiscal Cliff Fun Facts – What happens if we take the jump?

As we go into this holiday season the U.S. “fiscal cliff” has taken center stage inside the Washington, DC beltway.  Pundits, lobbyists and bureaucrats are gathered together around late night fires eating roasted marshmallows and sharing horror stories about what will happen come January 1st.  Each one is trying to top the other with tales of the dreaded effects of the cliff.  Many are so worried that they have even forgotten to place blame, the most popular game in this town.

 

The fiscal cliff is composed of an assortment of automatic tax increases and spending cuts that will occur if no alternatives are approved.  Here’s the fun part – this is all self-imposed, a result from years of deferring action to balance spending and revenue.  It’s like the end of “Thelma and Louise” where all the politicians have climbed into a convertible and zoomed toward the edge.  But here’s the problem – we’re stuck in the trunk!

 

No solution is perfect.  Most of the alternatives are focused on the short-term.  For example, the cliff would cut Medicare hospital related payments by 2 percent, but suggested alternatives could cut even more.

 

So what happens if the government “goes over the cliff?”   Here is a quick summary of what will happen.  One might even call this the, ahem, cliff notes (sorry):

 

NO IMPACT - Social Security, Medicaid, federal pay (including military pay and pensions), and veterans' benefits, are exempt from any spending cuts.  These are the third rail of politics and no elected official wants to go there.

 

CUTS - Spending for defense and non-defense programs would be reduced through “budget sequestration,” automatic spending cuts.  The cuts would be about $110 billion per year, split evenly between defense ($55 billion) and non-defense ($55 billion) spending.  This is out of a total of $1.3 trillion in total projected spending, so don’t expect Uncle Sam to be setting up a lemonade stand.

 

But the cuts would not be uniform as certain defense and non-defense programs will still need to increase.  If no action is taken, some programs would certainly take a big hit and it will not be pretty.  In the health care world, one part of the “cliff” is an automatic 27% cut January 1 in Medicare fees for physicians and other practitioners.  This annual ritual requires Congress to step in each year to avoid the cut for one more year - the notorious “doc fix.”  The cost to avoid this pay cut for 2013 is $25 billion – money that has to come from somewhere else.  Also, other programs, such as extended unemployment benefits, would immediately cease.

 

TAXES - The biggest change, if we go over the cliff, would be increased taxes.  From fiscal year 2012 to 2013, federal tax revenue is expected to increase $399 billion, almost 20 percent.  This includes an increase in Social Security payroll taxes and an end of the Bush tax cuts and alternative minimum income tax.

 

TELEMEDICINE - The immediate impact on telemedicine is uncertain but will likely be minor.  Medicaid won’t be touched and we will probably see little immediate change in Medicare, but we may be seeing cuts in grant programs that could be hard for some telemedicine networks. 

 

Despite the myriad budgetary problems of the government over the past few years, we have seen a doubling in the use of telemedicine.  Going over the “cliff” or adopting other drastic budget decisions next year may force health officials to adopt even more efficient ways to deliver health services and reduce the horror stories of spiraling costs.

 

The savings attributed to telemedicine and the efficient solution it provides to the growing shortages of health professionals is one of the tools needed for these trying times.  While eating their roasted marshmallows, let's hope they see the light.

Regulation or Roadblock?

Telemedicine is a tool that has been used to improve and extend healthcare for well over two decades.  In 2012, ten million Americans will have benefitted from such remote health services as teleradiology, teleICU and remote vital sign monitoring.  Technologies such as video conferencing, the Internet, mobile phones and machine-to-machine applications are all being used to deliver health services.

Rules and laws governing the practice of medicine are needed in order to protect patients and ensure the quality of care.  Telemedicine should not be exempt from such rules.  But neither should it be singled out as a separate practice.

Regulating agencies including state medical boards, the Food and Drug Administration and accrediting bodies need to constantly review and update the standards of care that are placed on medicine.  Our knowledge, the practice, and the tools used in healthcare constantly evolve and new lessons are being learned.  This changes the baseline of best practices.  For example, the history of medicine, from the use of stethoscopes to the deployment of video services has proven that we can no longer equate mere physical proximity to the patient with higher quality health care.

Interestingly, telemedicine often employs clinically superior tools than those normally used by physicians for in-person care such as electronic stethoscopes or digital otoscopes.  Clinical decision support systems, once considered electronic voodoo, are commonly used in every hospital and even mandated by the federal government as part of meaningful use.

Certainly there are some basic issues that need to be reassessed in light of rapidly changing medical evidence, new technologies and delivery innovations.  However, placing radically tougher requirements and significantly higher standards of care for the use of telemedicine will not necessarily ensure the quality of healthcare or protect patient’s lives.  In fact, such new regulations, often developed out of ignorance and fear, create serious roadblocks in the pathway to health reform.

(c) American Telemedicine Association

Telemedicine wins big in first round of innovation awards

Telemedicine initiatives were a significant feature of the first round of projects announced by the Centers for Medicare and Medicaid Innovation (CMMI).

Established by the Affordable Care Act, CMMI has been appropriated $10 billion over ten years to fund initiatives that foster health care transformation.  The CMMI Health Care Innovation Awards provide grants to support the most compelling new ideas to deliver better health, improved care and lower costs to people enrolled in Medicare, Medicaid and Children's Health Insurance Program.
The leadership of the Center has been eager to include telemedicine as a priority since its inception.  In response to an early request from the Center, ATA provided an analysis of some of the leading areas for the Center to fund. 
The first round of Innovation Awards were just announced.  Out of the total of 26 approved projects, 7 went to projects involving telemedicine for a total of $46 million in funding. The projects using telemedicine are projected to yield a combined 3-year savings of $76 million.

A description of the approved projects involving telemedicine is available here: www.americantelemed.org/files/public/policy/CMMI_Projects_Telemedicine.pdf.

Unfortunate Hits on HIT

The latest issue of Health Affairs (http://content.healthaffairs.org/content/31/3.toc) has brought into question two tenets behind HIT: reducing the number of medical tests and increasing quality based on increased electronic health information.

One article titled: "Computer Access to Test Results Doesn’t Reduce Imaging" finds that allowing doctors easier access to medical imaging tests “was associated with a 40-70 percent greater likelihood of an imaging test being ordered.” The easier it is for a doctor to quickly see the test results, the more likely the person is to order such tests. Arguments have been made to counter the study since it used four year old data and did not take fully into account the role of customized systems that have full electronic records in place and greater incentives for the doctor to stick with previous lab tests and images. But the size of the study involving almost 1,200 physicians divided between those using such computer access and others that do not and the clear distinction in the results between the two groups will prove vexing.

The second article, titled: "Hospital Compare Site Has Little Effect on Death Rates, Study Finds" looks at the CMS program to publically compare hospital performance data. The effort assumes that, once consumers can see and compare hospital performance data there would be pressure on underperforming hospitals to improve outcomes. After looking at claims data for hospitals between eight years, they found little differences in death rates due to heart attacks or pneumonia that could be attributable to publicizing hospital performance. While the report doesn't throw out the need for such information it clearly indicates that the expectations over such an effort are overblown.

These articles add another layer of criticism to earlier reports that electronic records systems actually allow hospitals to increase billings to insurers rather than just cut costs.

Since telemedicine services are based on the transmission of electronic data and images, the establishment of a comprehensive, interoperable and easily accessible electronic health information highway can greatly facilitate the use of remote healthcare. Implementation of electronic records has been slow but recently accelerated thanks to incentive payments CMS is providing to physicians and health systems. It will be interesting to see if these reports inhibit further adoption initiatives.

© 2012

The Cost of Licensure

Last week’s Congressional briefing on state medical licensure brought surprises. Even though I have been looking at this issue since ATA started (in 1993) I had no idea the extent of the concerns by providers and the amount of potential problems facing consumers. Nor was I aware of the actual financial cost of the current system. Based on a recent examination of state policies, physician licensing statistics and fee requirements, ATA conservatively estimates that over $250 million is spent annually for additional state license fees by physicians already licensed in their home state.

Of course, this varies from state to state. For example, of the 88,000 physicians licensed in New York, 20 percent reside outside of the state and, presumably also hold a license in the state in which they reside. In Wyoming, of the 3,000 licensed physicians 66 percent live outside the state. Some states license for two years, others charge an additional application fee. Some offer a reciprocal license but still charge a fee. All of this was taken into account in our estimate.

There are approximately 850,000 active physicians in the United States, regulated and licensed by 70 state-based medical and osteopathic boards. It is estimated by the Federation of State Medical Boards that currently 22 percent of U.S. doctors hold a license in more than one state, but this number is bound to increase as medicine, physicians and patients increasingly rely on mobile devices.

In the end, the cost of licensure is not just about finances. It includes the cost of patient safety related to uncoordinated practice rules, regulation and disciplinary activities of separate, independent authorities governing thousands of health professionals.

© 2012

Seven Market Trends

The telemedicine market is expansive, multifaceted and growing. I have selected seven topics for brief comments and predictions as we start 2012:

1. Shifting away from reimbursement and from CMS decision-making

It’s been the Holy Grail for telemedicine in America. But the rapid growth of managed care, Accountable Care Organizations and medical homes are changing the way telemedicine services are paid, away from the fee for service model. One quarter of all Americans, 73 million patients, are now covered under a managed care health insurance program. With such shifts the focus of decision-making is gradually turning to local and regional healthcare decision makers.

2. Telemedicine as a standard of care

Medical images, x-rays and the like, have been viewed in digital form for forty years. Teleradiology is now so common that many hospitals don’t use the term – outsourcing radiology, at least for after-hours, is just the way things are now done in healthcare. It has become so common that providing 24/7 services by a radiologist, relying on teleradiology where needed, may be the first part of telemedicine to become a true standard of care. Such standards are included in state, federal and Joint Commission requirements and serve a basis for court decisions on legal liability that hold hospitals accountable. It would not surprise me to see a legal suit decided on this basis, it has already been raised in a few cases.

3. Emergence of independent remote clinical enterprises

Outsourcing the interpretation of radiological images is now used by most hospitals in the U.S. Independent diagnostic testing facilities have been around since 1998. Now, a relatively new and related market is the use of private firms of medical specialists to provide remote clinical consultations. A series of vendors have sprung up to do just that for stroke care, mental health, hospitalist and intensivist services, and dermatology. Some may be considered competitors to hospital-based telemedicine programs serving smaller clinics while others may be contractors to the hospital. Look for mergers and expansions of such enterprises as the market starts to take off.

4. The rise of virtual medical centers

In October 2011, Mercy Hospitals announced that it would build a $90 million virtual care center near its headquarters in Chesterfield, MO. The specialists will be located at one site and serve patients in outlying centers across the four states in which Mercy operates: Missouri, Kansas, Arkansas and Oklahoma. On a smaller scale, intensivists at Inova Health System in Virginia are based out of a corporate office building and provide remote ICU services to 122 ICU beds throughout northern Virginia. Other health systems are looking closely at these developments and, if successful, will start on their own versions of virtual centers.

5. mHealth

mHealth is still a sizzling subject and is an important addition to the mix of technologies changing the way healthcare is delivered along with other innovations such as social networking, “Big Data” and personalized medicine. In June 2010 I wrote that we were at the top of the hype cycle for mHealth. I was premature. Wild promises, naivety about the way healthcare is paid for and delivered, and investors throwing money at some, well, “interesting” devices and services have continued. Mobile health apps are multiplying exponentially. No doubt there will be some upcoming market adjustments, but wireless technologies will continue to help redefine what we mean by telemedicine.

6. Programs vs. networks for multi-site telemedicine operations

Federal grants have helped to establish about 200 telemedicine programs linking multiple health centers throughout the country. Almost all have been based out of one large medical center, operating a hub-and-spoke program that allows the medical center to provide remote clinical and educational services to connected spokes. Such a design can expand a center’s competitive footprint and increase referrals. An alternative approach connecting multiple centers, clinics and offices based on a true network design is starting to gain favor. Such a network is typically financed by paid memberships from participating sites and grants rather than clinical services fees. Services can be delivered from any site on the network to any other site. An early model is the Arizona Telemedicine Program. The Ontario Telehealth Network is a classic model of his approach.

7. Multi-nationalization

Once confined largely to international charities to under developed nations and a few remote image-reading centers, telemedicine is poised to become a major source of international trade. Global investments in high-speed networks and emerging practice guidelines are providing the infrastructure. Issues such as licensure, payment mechanisms, trade protectionism and cultural biases are but a few of the barriers in the way. However, the potential revenue from such services could have a significant effect on worldwide trade balances.

© 2012 Jonathan D. Linkous

Standing at the Threshold of 2012

It’s been a great year. 2011 left many old timers in telemedicine enjoying the newfound enthusiasm about telemedicine, telehealth and all the other related expressions (mHealth, e-health, etc.) that describe this field. Bells were pealing. Hypers were hyping. Prognosticators were predicting. We were overwhelmed with an ocean of hullabaloo about the wonders of telecommunications technology and health care. We were awash with inventors, entrepreneurs, investors and captains of other industries leaping into the frenzy like groups of whirling dervishes all vying to profess the most superlative expectation. Truly it is wonderful to see.

Woo hoo!

Back on earth the day-to-day reality for telemedicine remains on delivering care, modifying clinical processes, changing public policy and, oh yes, making a profit. Nevertheless, I believe we stand in December 2011 at a significantly different place than last December. The change is not so much in the hype or even the numbers (although they are significant) but that we have witnessed a fundamental shift in the landscape, leaving this field poised for enormous change during the twelve to twenty four months ahead.

Special thanks is deserved to three groups that have made all of this possible. First, ATA’s Board of Directors reflects the dramatic shift in attention toward telemedicine with a unique mix of clinicians that provide health care through telemedicine joined by several captains of industry, private payers, government agencies and non-profit groups from the United States and other countries. Under the leadership of Dr. Bernard Harris the Board has provided guidance and unwavering support for ATA as we sail ahead. Second, my thanks to the hundreds of volunteer leaders and thousands of members of ATA whose enthusiasm, hard work and insights have contributed both to ATA’s success and the tremendous progress for telemedicine this year. Finally, the ATA staff, a small band of incredibly talented, dedicated and very hard working group of professionals. Few in the Association business can believe that a staff of only eleven full time employees manages all of ATA. Thanks to the use of a number of great contractors and innovative use of technology, the staff has been able to make ATA one of the fastest growing Associations in the country and an effective, widely recognized leader in health care throughout the world.

From the start, a key value of this Association has been to focus on transformation and not building castles. But it still amazes me that, from a small group of idealists and true believers that gathered together in 1993, ATA is on the verge of helping to transform the world of healthcare.