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Rheumatology Practice Management August 2016 Vol 4 No 4 - Employers’ Perspective
Rita M. Marcoux, RPh, MBA
F. Randy Vogenberg, RPh, PhD

The term telehealth is used interchangeably with telemedicine by some organizations. However, telemedicine is typically associated with the delivery of traditional clinical diagnosis and monitoring by using some form of medical technology, whereas telehealth has a much broader definition that comprises education, disease awareness, and wellness, in addition to the use of technology to connect physicians to patients.

As defined by the US Health Resources & Services Administration, telehealth is “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.”1

The Federation of State Medical Boards defines telemedicine as “the practice of medicine using electronic communication, information technology or other means of interaction between a licensee in one location and a patient in another location with or without an intervening healthcare provider.”2

Telehealth is becoming a mainstream part of primary care delivery in the United States, but is still evolving for some specialties. In 2013, more than 50% of hospital systems used some form of telehealth, and that number may have reached 65% by the end of 2015.3

Telehealth Growth, Scope, and Care Applications Leap

The breadth of telehealth services continues to expand as payers seek to reach more patients. Using telehealth services, providers can cover gaps in services or service areas to avoid emergent care to focus on more preventive and primary care using a patient-centric approach. Such an approach is becoming part of contemporary patient-centric care. Telehealth delivery encompasses 4 modalities:

  1. Real-time (synchronous) telehealth is used to consult, diagnose, and treat patients
  2. Store-and-forward (asynchronous) modality is used to send electronic medical communication to specialists to assist in evaluating a patient case, or to deliver a service outside of a typical face-to-face encounter
  3. Remote patient monitoring collects patient information electronically, and transmits it to a provider at another location to allow tracking and monitoring of a patient
  4. Mobile health (mHealth) is the newest modality, and includes online services and applications that are marketed directly to consumers, such as FitBit, iPhone applications, and other wearable devices that are purchased in retail stores or online.
The rapid expansion of telehealth is being driven by multiple market challenges that are impacting the traditional healthcare delivery system and infra­structure in a post–Affordable Care Act (ACA) world. For example, access to care in rural and underserved areas is a significant driver for Centers for Medicare & Medicaid Services’ programs. Under the ACA, Medicaid program expansion will stress the limited availability of primary care providers as the baby boomers transition to Medicare health benefits.

Avoiding repeat hospitalizations and managing transitions in care necessitates that providers manage and prevent emergency department visits and hospitalization through technology, by monitoring patients and addressing patient issues before they become serious, which is particularly important in patient care.

Finally, as the cost of care increasingly transitions to the consumer, and reimbursement shifts from fee-for-service to alternative payment methods, innovative collaboration between providers and patients will be key to ensure appropriate outcomes—hence, the value of telehealth modalities.

Coverage for Telehealth Services

Payment or reimbursement rather than regulations or legal restrictions is an important driver for telehealth applications in the 2016 marketplace. Overall, 23 states have telehealth parity laws for private insurances. However, the language of these laws is key to deciphering which telehealth services are covered. For example, if the law is written to mimic what is available in-person, then a gap may develop in the areas of remote patient monitoring or online application-based programs available through mHealth.

To address these gaps, some states have submitted revisions or additional bills to expand coverage to services that were not previously covered in the original bills. As a result, commercial insurance coverage and reimbursement for services may vary across the United States.

Similarly, the federal coverage of telehealth services varies by program. For example, Medicare covers a range of services from telecommunications for patient care across a distance, but contains other caveats based on rural versus nonrural service areas.

Medicaid recognizes the benefits of utilizing telemedicine as a means to promote efficiency, economy, and quality of care to its beneficiaries. Modeled after Medicare’s definition of telehealth services, Medicaid defines telemedicine as the “two-way, real-time interactive communication between the patient, and the physician or practitioner at the distant site.”4 Telehealth is not considered part of Medicaid’s entitlement definition, but is often reimbursed by states under the umbrella of telemedicine services.4 Currently, 48 state Medicaid programs have some type of coverage for telemedicine.5

Regulation of Telehealth Services

The FDA regulates equipment or software intended for use in the diagnosis or treatment of a disease or other conditions. With the passage of the Food and Drug Administration Safety and Innovation Act in 2012, the FDA received approval to go forward with its regulatory work on medical applications.

The Federal Communications Commission (FCC) regulates devices that utilize electromagnetic spectrum, or broadcast devices; the FCC regulates the device as a communications device rather than as a medical device. With potential overlapping jurisdictions, the FCC and the FDA entered into a Memorandum of Understanding, where they would collaborate with each other within the areas of their respective agencies.

The Federal Trade Commission (FTC) protects consumers from unfair or deceptive acts or practices, or misleading claims. The FTC also has jurisdiction over health data breaches when the entities involved are not HIPAA-covered entities. The FTC has focused on the claims that companies have made about the effectiveness of their mHealth devices or applications.

Malpractice insurance usually covers providers practicing telehealth services within a state for which they are licensed. Some states are writing regulations to address coverage for practitioners practicing in nonlicensed states through technology. As a result of out-of-date licensing, regulation and insurance varies by state.

Employers and Patient Care

As a result of commercial insurance changes brought about by the ACA, demographic shifts around individual insurance program coverage, and employer plan sponsor benefit coverage responses to the overall cost of healthcare, there has been growth in alternative care delivery models. Several of these models utilize telehealth applications for efficiency, cost management, and optimal care outcomes.

With some time to reflect on the objectives for healthcare coverage in a post-ACA market after the postponement of the excise tax (Cadillac tax), there is an opportunity to seek innovation in patient care services. This can be achieved by an update in types of service coverage parameters, and by breaking out of the traditional in-person–only coverage approach, similar to how surgical readmissions have been successfully reduced using multiple tactics.

Value-based care is part of the larger healthcare ecosystem. Can employers as plan sponsors establish their benchmarks for performance, drive or support needed change in care delivery models, and find a better value proposition in payments for all specialty care services? Or are plan sponsors willing to continue down the path of regulatory chaos, increased yearly costs, and unmet outcomes?

Article used with permission from Value-Based Cancer Care. 2016:(7):27.




References

  1. US Department of Health & Human Services. Telehealth. www.hrsa.gov/healthit/telehealth/. Accessed May 9, 2016.
  2. Federation of State Medical Boards. Model policy for the appropriate use of telemedicine technologies in the practice of medicine. 2014. www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/FSMB_Telemedicine_Policy.pdf. Accessed May 18, 2016.
  3. American Hospital Association. Trendwatch: the promise of telehealth for hospitals, health systems and their communities. January 2015. www.aha.org/research/reports/tw/15jan-tw-telehealth.pdf. Accessed May 9, 2016.
  4. Medicaid.gov. Telemedicine. www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-­Systems/Telemedicine.html. Accessed January 6, 2016.
  5. American Telemedicine Association. State telemedicine gap analysis: coverage and reimbursement. www.americantelemed.org/policy/state-policy-resource-center#.Vo0sX_krLVY. Accessed January 6, 2016.
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Last modified: September 15, 2016
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