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.

Moving Our Eggs Out Of One Basket

According to Gary Capistrant, ATA’s resident expert on all things related to health policy, at least 73 million Americans, almost one quarter of the population, are now covered under some form of managed care. Such plans eschew the fee-for-service approach in favor of a fixed sum to provide health services with flexibility in what and how such services are provided. Importantly, federal restrictions on the use of telemedicine don’t apply to such managed care plans.

Managed care comes in many flavors. Medicare Advantage is offered mostly as a private managed care insurance plan and covers about 25 percent of all Medicare patients. About two thirds of state-run Medicaid patients are now enrolled in Medicaid managed care programs. Health reform, leading to 32 million more Medicaid enrollees will skyrocket that number in the next five years. On the private side, employer and private plans are all shifting away from traditional fee for service models and embracing various forms of bundling payments, incentives for cost reduction and coordination of care.

How important is this? Cigna, a traditional fee-for-service insurer is spending $3.8 billion to buy HealthSpring, which has 340,000 customers in its Medicare Advantage program in 11 states. Private insurers around the nation are rushing to turn their portfolio of covered lived from fee-for-service to managed care and, to further control costs, are becoming owners and managers of their own medical facilities and health services. It will be interesting to see if this leads to such dilemmas as United Health doctors pressing for privileges at a hospital owned by Aetna.

The rush toward alternative payment models is already shifting decision-making on services from the payer to the provider. To prepare, we need to shift traditional lobbying for a new CPT code or national payment policy toward efforts to convince health systems and even local providers on the benefits of using telemedicine.

Telemedicine Patents and Trademarks

Over the last three months, several ATA members have been contacted by lawyers representing a third party that was recently awarded a business-process patent regarding the use of telemedicine by the U.S. Patent and Trademark Office. The patent reportedly covers a physician simultaneously evaluating two or more remotely-located patients using a video-conferencing system. The following information is being provided because of the current member interest in this subject.

Patents for telemedicine are not uncommon and will likely grow as the industry matures. Typically, letters sent out regarding a patent claim reference the claim, suggest that the recipient may be in violation of the patent, and some offer to issue a license for the recipient’s continued use of the product or process. There is usually a fee or royalty associated with the license.

Patents are issued by the government in exchange for public disclosure of the underlying invention in order to protect the original inventor’s rights. In many cases, a patent is entirely legitimate and involves an appropriate claim of infringement. In other cases, questions have been raised about the validity and applicability of the patent.

When dealing with patents and trademark “cease and desist” or infringement letters, you may want to seek a legal opinion to determine the legitimacy and applicability of the patent. For instance, the patent may be invalid because it was issued for a product or process that had been in existence for many years prior to the claim (known as “prior art”). There are also cases of “patent trolling,” where an individual or group seeks to gain financial benefit from a patent with no intention to use it. You will want to consult with legal counsel as to how to respond to such demands.

More information on patents is available on the following websites

Copyright vs. Trademark vs. Patent
http://www.lawmart.com/searches/difference.htm

General information concerning patents
http://en.wikipedia.org/wiki/Patent
http://www.uspto.gov/patents/resources/general_info_concerning_patents.jsp

Patent Trolls
http://en.wikipedia.org/wiki/Patent_troll

Reed Franklin - a Colleague and a Friend

I am truly sorry to report that Reed Franklin, ATA's former Director of Public Policy, passed away earlier this week. He died of natural causes at his home in Arlington, Virginia.

Reed was an important part of ATA while on our staff from 2007 to 2009. His professionalism and quality of leadership raised the visibility of this organization within the nation's capitol. He was well known among Washington health-policy insiders and used his connections, his knowledge of the political process and expertise in government affairs to move our agenda forward. As a result, telemedicine gained significant support in Congress and among federal agencies.

In 2009 Reed decided to move over to the American Health Care Association (AHCA) where he served as the Director of Government Relations. However, he often returned to visit ATA. Demonstrating how Washington is often filled with insiders, his successor at ATA, Gary Capistrant, had also worked for AHCA earlier in his career.

More important to me, Reed was a friend. The son of a minister from rural Virginia, he stayed true to his roots, often telling about how he grew up as part of a community just like that featured on the Waltons television show. His good nature and his integrity came from these roots. A wine connoisseur, Reed served as our resident expert in such matters. His dry humor and mischevious smile added a spark to every staff gathering.

Ironically, Reed and I were planning to sneak away from our jobs this very afternoon to catch a Washington Nationals baseball game. I am glad to have known him.

White House Announcements, Regulations and Telemedicine

We are getting on the fast track.

President Obama recently announced a series of decisions to streamline the federal bureaucracy by eliminating hundreds of regulatory requirements across two dozen agencies, the changes could save $10 billion over five years. Included in the announcement was the May 5, 2011 decision to eliminate duplicative credentialing and privileging for telemedicine. CMS estimates that this will result in roughly $13.6 million in net savings.

The Administration and Congress are also considering a number of other regulatory changes related to telehealth that will further reduce costs and expand the availability and quality of care. Some of these were generated internally inside the Administration, others came as suggestions from ATA. Here are several examples:

• The President has personally declared that he wants to a policy that allows patients to have face to face video chats with their doctor.


• The Federal Communications Commission is streamlining a bureaucratically-clogged program to greatly expand rural health care networks.


• The Administration and Congress are looking at ways to eliminate red tape and allow patients to access doctors and specialists in other states without having to go through the delays, complications and costs of getting duplicate state medical licenses.


• CMS is considering changing regulations to allow Accountable Care Organizations to provide telemedicine services, reducing their costs and improving care.

Stay tuned...

Patents and Telemedicine

I have been writing about how telemedicine is finally going mainstream. That is good news. However, sometimes when you get to be popular you also get noticed by, well, others.

One area I worry about is Patent Trolling. According to Wikipedia, the term Patent Troll “is a pejorative term used for a person or company that enforces its patents against one or more alleged infringers in a manner considered (by the party using the term) unduly aggressive or opportunistic, often with no intention to manufacture or market the patented invention.” http://en.wikipedia.org/wiki/Patent_troll.

I provide this information because, over the past fifty years, telemedicine has grown enough to become a potential target of firms that have somehow gained a patent and seek to enforce it by sending out large numbers of certified letters demanding a license. As a technology-based industry, there are many patents that have been filed about various aspects of telemedicine. My advice to vendors and providers alike is to be always vigilent.

Of course, I am not pointing fingers at anyone. However, a few of you may be nodding your heads right now...

Six Misperceptions

Healthcare is a $2 trillion market in the United States and growing at a fast pace. For entrepreneurs, that figure is so alluring it is impossible to ignore. Companies, institutions and individuals from everywhere are looking to see how to get a piece of the healthcare market. It’s the gold rush of the 21st century and health technology is where a lot of companies are staking a claim. And now the attention is turning to telemedicine. The variety of new entrants is vast: vendors selling devices or software; sellers of remote health services; consultants and individuals simply wanting to get into the telemedicine job market. Every week there is a new conference, a newsletter or journal and even a new association targeting some aspect of telemedicine.

Based on the feedback from new entrepreneurs coming through the ATA offices it is apparent that there are a number of misperceptions about the telemedicine market. Here are six of them, learned over the past 18 years.

1. It’s not the technology, it’s the service. Dial up phones were a great invention. So was the VCR. They are both gone but telecommunications services and watching movies are bigger than ever. New and amazing devices and applications are coming on the market every day. But devices are tools that allow services to be provided at a distance. The focus, the purpose and the finances are on the service.


2. Despite what you hear, Medicare reimbursement is not the Holy Grail for telemedicine. It’s important, but… Medicare fee-for-service covers about 36 million Americans, 12 percent of the total U.S. population. 88 percent of Americans are covered elsewhere and 81 percent of healthcare spending comes from other sources. There are no federal restrictions on using telemedicine for billions of health dollars spent on managed care, bundled services and on alternative plans by private payers.


3. Healthcare institutions and physicians are partners, not the enemy. Transforming does not require replacing. So many new entrepreneurs in telemedicine start out with a negative, competitive attitude to traditional healthcare. We have not reached the point when someone with heart disease is going to trust their care to a computer alone. The role of doctors and hospitals is changing but they will continue to be the backbone of medicine.


4. Device regulation is not bad – it’s good; in fact it could rapidly accelerate adoption. FDA rules for wired and wireless telemedicine devices and their certification by an official government agency is a stamp of approval, providing reassurance for cautious buyers.


5. A great idea is born every minute but few of them are successful. I have heard of hundreds of stories about how a new technology, application or remote health service results in lower rates of hospitalization, improves compliance, etc. only to see it disappear a year later. Marketing, partnerships, revenue pathways and knowledge of healthcare business practices are essential, for starters.


6. Consumers don’t buy healthcare themselves. For fifty years the percent of spending on healthcare by consumers has dropped (not including insurance or co-pays). It is now about ten percent. Consumers are getting much more knowledgeable and engaged in selecting among available procedures and treatments but they don’t pay directly for healthcare products and services. The only exceptions are one-time beauty treatments and fitness fads.

I will no longer say “turning the corner” when it comes to telemedicine

For years we talked about reaching the point when telemedicine services became self-sustaining outside of temporary grants, going from promise to reality. We have long passed the point of telemedicine being a new application. After eighteen years the corner is turned and I promise to put that phrase away. This is what I mean about the reality of telemedicine:

• There are areas where remote health services have made a measurable difference in healthcare. At least half of the 5,000 U.S. hospitals are using teleradiology or other forms of remote imaging and the leading firm in this space, Virtual Radiologic, provided over 7 million reads last year. The Ontario Telehealth Network manages over 100,000 live physician-patient video consults a year for a variety of specialty and primary care services. The MedTrix Group provides 10-12 thousand video-based pediatric consults per month for the largest HMO plan in the Israel. The U.S. Veterans Administration is using remote health monitoring for 55,000 veterans.
• Revenue generated from telemedicine has resulted in profits for independent service providers and is a self-sustaining business within some healthcare delivery systems. For example, Epocrates, an online and mhealth drug interaction application is used by 1.3 million health professionals including 45% of U.S. physicians and reported a first quarter profit for 2011 of $3.7 million.
• Medical systems are integrating remote health care into the normal delivery of care. A recent survey of Washington, DC hospitals found that every hospital in the metropolitan area was using one or more telemedicine application as part of their normal delivery of health care for area residents. For example, to reduce time to catheterization , EKGs are transmitted from the ambulance to cardiologist’s cell phones at the George Washington University Hospital prior to arrival at the emergency room.

I tire of talk about needing to "prove the case." The argument that telemedicine is too new and needs more research falls away when looking at a list of a few other medical innovations that emerged around the same time or later than telemedicine (1960s-70s) and are now fully in use and reimbursed by most payer organizations including Medicare:
• Arthroscopic surgery
• CAT Scans
• Cochlear implant surgery
• Controlled drug delivery technology
• Deep-brain electrical stimulation
• Implantable cardioverter defibrillator (ICD)
• Laser surgery on human corneas
• Magnetic resonance imaging
• Permanent artificial heart implants
• Soft contact lenses

American States Lag European Nations in Licensure Portability

Allowing physicians the right of free circulation as providers of medical services within the 25-nation European Union is part of a founding EU principle for freedom of circulation of goods, persons and services. The EU lays out minimum training requirements for general practice and specialist physicians and provides for mutual recognition of physicians’ qualifications. It also enforces measures to ensure that the licensing provisions of individual Member states permit the free movement of doctors both to establish themselves and to practice their profession in all Member states. This is currently covered under the EU directive 2005/36/EC.

The 25 independent countries in Europe long ago figured it out. But the fifty states in America are still struggling with how to allow physicians to practice, and citizens to access healthcare across state boundaries. With the help of the Federation of State Medical Boards we are looking to put together a patchwork solution, but that still may be years away.

Shame on us.

On Snooze Alarms

A clever and well worn trick to resist change and protect the status quo by funding and regulating organizations is the use of demonstration or pilot projects. When faced with a constituency pressing for change, the official response is often to thank the group making the request and suggest that a demonstration project be established along with an evaluation of the outcomes. The decision whether to move forward is then postponed until after the final evaluation is completed. Such ideas may provide important resources for academic centers and researchers but are also commonly used to put off a decision.

All too often, the result of such studies are that more research is needed.

For ten years I was a proud government employee here in Washington, DC, and one of my favorite humorists at the time was the late James Boren, founder of the International Association of Professional Bureaucrats (INATAPROBU). The purpose of this tongue-in-cheek organization, according to Boren, was to "optimize the status quo by fostering adjustive adherence to procedural abstractions and rhetorical clearances.” It also promoted “feasibility studies, reviews, surveys of plans, surveys of feasibility studies and surveys of reviews.” The advice he gave us working in government was: “When in danger ponder. When in trouble delegate. And when in doubt mumble.”

It was funny because, for many of us, it used to hit so close to home.

Such “snooze alarm policies” have been effectively used for fifteen years as a way of resisting the use of telemedicine. Decisions on full reimbursement for almost every form of telemedicine have not occurred because “we just need more data” or that the research was not adequately designed or didn’t have a large enough sample size and a proper control group. Listening to such talk, one could come away wondering if telemedicine is just another far-out experimental idea.

Interesting. Especially when a search on Google Scholar for the terms “telemedicine” OR “telehealth” results in 98,000 references. Adding the term “outcome,” results in 28,500 references. Even PubMed lists almost 13,000 studies on the subject. Some of these date back over two decades.

No one in telemedicine is asking for blanket endorsement of each and every telemedicine application. Undoubtedly there are valid and important questions that need to be asked and answered about certain applications. However, there are also many areas in telemedicine that have been well researched, studied and proven to be useful for expanding access, improving care AND reducing costs.

Drastic health reform and innovations are needed in almost every country and by every insurer and employer. Donald Berwick, Administrator of the Centers for Medicare and Medicaid Management said “There has never been a better time to be an innovator in health care.”

We don’t need another snooze alarm; we need to wake-up and embrace the opportunities now before us.

A New Proposal for Telecommunications Support & Rethinking "Home Telehealth"

In December 2009 ATA provided comments to the Federal Communications Commission regarding a proposed national plan for broadband. The proposed plan called for broadband deployment to focus on rural communities. For healthcare, the thinking was to focus on access to rural health institutions and to the homes of rural residents. However, the use of wire as the primary technology for providing telecommunications access has been surpassed by the use of wireless and almost a quarter of all Americans rely entirely on wireless phones for their telephone service. The tether to "place" has been broken. That is why ATA suggested that “instead of home-based telemedicine, a more appropriate term is remote person-based care or personal telehealth.” We recommended that the broadband plan should be changed to include “a national goal of 100% coverage of broadband wireless services.” In conversations with FCC staff we encouraged the plan to shift from coverage of rural communities to coverage of people, regardless of their location.

So I am encouraged by an announcement today by President Obama of a new national broadband goal of 98% wireless broadband coverage for all Americans. As part of this, the FCC’s issued a Notice of Proposed Rulemaking (available at http://hraunfoss.fcc.gov/edocs_public/attachmatch/FCC-11-13A1.pdf) to restructure its universal service program to provide greater support for wireless broadband.


This shift in thinking also challenges ATA and our members with the use of the term “home telehealth.” Such a phrase implies maintaining equipment only in the home and limiting remote monitoring to wireline services. In fact, the surge in mobile health applications and the use of wireless technology for all types of remote monitoring devices suggests a new paradigm for chronic care services. I would also caution against entirely shifting to the term “mHealth” as that, too, focuses on a technology and not the service.

We need to come up with a new term to better describe the use of telemedicine to support the needs of patients outside of traditional institutions. I am open to suggestions.