Empowering patients to remotely consult with a healthcare professional can be life-changing. There is though more than enough evidence to prove it.
Whether that's connecting underserved mental health patients, giving more people access to dentistry, or simply helping people in rural areas -- where doctors are scarce -- consult with a general practitioner (GP), the broad field of telehealth is producing positive health outcomes across a variety of communities.
But even today, there are still challenges holding telemedicine back. And as forward-thinking as the technology can sound, these challenges are nothing new: they're many of the same challenges the Department of Health and Human Services (HHS) mentioned 16 years ago in a report to Congress on the benefits of telehealth.
Below are five of the biggest impediments to telehealth's growth. Let's take a look at why these roadblocks still exist and what is happening today to clear them out of the way.
Eric Wicklund at mHealthIntelligence.com calls licensure "perhaps the biggest challenge to specialists looking to advance their telehealth business plan."
This is an issue as old as interstate commerce itself: Because each state has its own definitions for who qualifies as a licensed practitioner -- whether a GP, a dentist, or any other medical professional -- someone who is licensed in Maryland, for example, needs a new license to practice in Delaware.
When medical practice was confined to brick-and-mortar locations, this wasn't such a big deal. But internet connections are agnostic to state borders, so trying to fit telehealth services into state licensure models is unwieldy. The current workaround for telehealth providers is simply to scoop up as many state licenses as possible. Wicklund mentions one psychologist, an expert in death penalty cases, spends more than $100,000 per year to maintain licenses in 25 states. It is ridiculous to expect a provider to maintain such a high cost in licenses.
These challenges are poised to erode in a big way, though, thanks to pressures from the very top. According to Carrie Roll, a DC-based attorney at Mintz Levin's Health Law Practice, several state legislatures are establishing telemedicine standards that put pressure on state medical boards to normalize licensure requirements.
"By passing such laws, the state legislatures have put pressure on state boards of medicine to either issue new rules or amend existing rules to comply with these newly passed telemedicine standards," Roll says. "This is an important development and signals that state lawmakers are prepared to embrace telemedicine as a safe and cost-effective way to provide medical services to patients, even if state regulatory boards are not."
Telehealth providers have to be cautious about whom they treat and how because it isn't always clear whether they will get paid for their work. This is another product of fragmentation at state and federal levels.
HealthAffairs.org did a nice job of summarizing the byzantine issue of Medicaid reimbursement for telehealth in a 2016 policy brief:
- Each state gets to define what telehealth services are covered by Medicaid, though almost every state offers Medicaid reimbursement for some services.
- Video telehealth services are covered in most states, but other methods of care provision -- e.g. remote patient monitoring or email consultations -- do not qualify for Medicaid reimbursements in many states.
As the American Hospital Association (AHA) notes, "Medicare's policies for coverage and payment for telehealth services lag far behind other payers due to its restrictive statutes and regulations."
The AHA document does note that private payers tend to be more accommodating, especially healthcare providers that offer their own health insurance. For many other providers, however, licensure and restrictions from public payers form a Gordian knot that makes it very difficult for a healthcare professional to determine who can be treated via telehealth technology, what services can be rendered, and whether insurance will pay for it.
Many clinics and specialists are simply too busy to deal with all that red tape. Consequently, their patients get locked out of the benefits that telehealth models can offer. That's why PokitDok partnered with Doctors on Demand, which uses our APIs to significantly speed up the eligibility, claims, and claims status checks process across the majority of America's insurance providers.
Even at the level of an individual hospital or clinic, telehealth has some high hurdles. As the University of Illinois-Chicago's Department of Health Informatics and Health Information Management points out, each healthcare institution has to make high-level decisions before implementing telehealth:
- Where will the capital come from to invest in this technology?
- How does it fit into the business model?
- What human resources need to be devoted to telehealth services?
Further, TechTarget's Reda Chouffani says telehealth implementation requires that institutions first solve some thorny issues regarding EHR interoperability and even basic technical infrastructure -- after all, a video consultation doesn't do a patient much good if the call keeps dropping.
But there appears to be enough patient-side demand to make answering these questions worthwhile. In a joint survey conducted by the American Telemedicine Association (ATA) and WEGO Health in 2016, nearly three-quarters of patients who responded said they had not used telehealth services in the last year, but most of those people "thought telehealth would be more convenient, even though their provider did not offer virtual appointments."
Managing Care Providers' Expectations
Telehealth can mean different things to different people -- video appointments, email consultations, remote monitoring -- and this includes doctors and nurses too.
Jonah Comstock at MobiHealthNews, reporting from the April 2017 HIMSS Media Pop Health Forum, says many physicians get excited by the idea of telehealth, but then want to narrow the scope of the technology to their own specializations.
So, a nutritionist might see the technology strictly as a tele-nutrition solution, said Tripp Jennings and Amelia Bischoff, executives from Palmetto Health in South Carolina who spoke at the forum on the challenges of rolling out telehealth technology in a large healthcare organization.
The key, they said, is to develop a rubric that lets a healthcare organization weave in telehealth technology in a way that's useful and accessible to all specialists and general practitioners.
Even more fundamentally for many healthcare professionals, there is an initial reluctance to embrace remote communications. Jasmaine McClain at The Advisory Board Company says many doctors and nurses balk and ask, "How am I supposed to form a relationship with my patients over video?" After all, she notes, most healthcare professionals never received training in remote-communication bedside manner.
As with any other enterprise-level tech tool, telehealth solutions require user onboarding, and this includes teaching providers how to position themselves on camera and minimize background noise, McClain says.
Finally -- and this speaks somewhat to the bedside manner question, as well -- telehealth providers have to be ready to handle industry-wide objections that the technology moves medicine further away from being a practice.
When healthcare feels more like a deliverable, writes Matthew Eppinette, the executive director at the Center for Bioethics and Culture Network, is it still in line with a doctor's obligations to his or her patients?
"Many unanswered questions remain, particularly with respect to things like the tradeoff of convenience versus quality, what continuity of care looks like in virtual medicine, how to oversee these interactions appropriately, and the nature of a virtual doctor-patient relationship," Eppinette says.
"As technology develops, so too does the practice of medicine. But these developments must be evaluated in light of medicine as a practice that is rooted in understandings that go back to Hippocrates (e.g., do no harm) rather than medicine as a service to be provided at the lowest cost."
The Wall Street Journal's Melinda Beck touched on this issue, or at least the scaled-up version of this issue, in a 2016 piece in which she reported that telehealth was "shaking up traditional relationships between providers and payers," but also potentially creating a winner-take-all market dynamic.
That's not to say that having an Amazon for healthcare is necessarily a bad thing. But for healthcare to make the equivalent jump from brick-and-mortar stores to Amazon, care providers must be mindful that resulting processes still put patients first -- and that this encourages positive-sum competition across the industry.
This is the promise of a value-based care model of healthcare delivery, and we think that in light of all the challenges facing healthcare -- opaque pricing, byzantine revenue cycles, etc. -- technologies like telehealth are doing necessary work by shaking up old provider-payer relationships.
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