Medical societies are joining the call for better support for telemedicine, stating that when appropriately used, it can help address physician shortages and improve quality of care.
The American Medical Association’s policy-making body – the House of Delegates – approved a set of guiding principles at its annual meeting in June, including the following:
• A physician should have a valid face-to-face relationship with the patient before telemedicine services are provided, except in the instance of on-call or cross-coverage situations.
Courtesy AMA
Dr. Robert Wah
• Those who deliver telemedicine services must abide by state practice and licensure laws and should be licensed in the state where the patient receives services.
• Delivery of services should be consistent with in-person services in scope and standards and follow evidence-based practice guidelines.
• Services should be documented, including providing a visit summary to the patient and a copy of the record sent to a primary or referring physician.
"We believe that a patient-physician relationship must be established to ensure proper diagnoses and appropriate follow-up care," AMA President Robert M. Wah said in a statement. "This new policy establishes a foundation for physicians to utilize telemedicine to help maintain an ongoing relationship with their patients, and as a means to enhance follow-up care, better coordinate care and manage chronic conditions."
The AMA delegates also called for a study of the issues associated with the state-based licensure and the portability of state licensure for telemedicine services.
The Federation of State Medical Boards (FSMB) has drafted model legislation that would expedite licensing in multiple states in an effort to address the concerns of medical practices that straddle state lines.
Currently, according to the American Telemedicine Association, some states restrict the practice of telemedicine across state borders, while others have varying license requirements. The FSMB is hoping to complete a final draft of the model legislation within a few months; it will then work to convince state legislatures to adopt the model.
The American Academy of Neurology also seeks a streamlined licensing process, according to a recent position paper.
The AAN weighed in on telemedicine partly because neurologists are increasingly including the service as part of their practices, most often in emergency stroke care and other acute neurologic conditions. It also is being employed more often for treatment of chronic conditions, including migraines and epilepsy, according to the paper.
The policy also calls for clear liability policies. "The decision to administer or not administer thrombolysis for acute stroke is a prominent source of malpractice claims for neurologists, and telemedicine physicians managing acute stroke patients may be exposed to complex liability issues," the AAN said in the statement. Both physicians and patients need to be protected, it noted.
The organization also called for reimbursement that’s on par with traditional services.
The American Academy of Family Physicians recently said in a letter to members of the House Energy & Commerce Subcommittee on Health that, while it agrees with removing barriers to delivering telemedicine across state lines, it opposes a federal license. It is backing the FSMB process.
Payment Issues
More private insurers are starting to cover telemedicine, with 21 states and Washington, D.C., requiring coverage of the service and reimbursement on par with in-person visits, according to the American Telemedicine Association: Arizona, California, Colorado, Georgia, Hawaii, Kentucky, Louisiana, Maine, Maryland, Michigan, Mississippi, Missouri, Montana, New Hampshire, New Mexico, Oklahoma, Oregon, Tennessee, Texas, Vermont, Virginia.
Five states – Massachusetts, Michigan, North Dakota, Pennsylvania, and South Dakota – do not allow out-of-state physician-to-physician consultations.
Licensure requirements vary. Maryland, New York, Virginia, and Washington, D.C., have licensure reciprocity for bordering states.
Ten states – Alabama, Louisiana, Minnesota, Montana, Nevada, New Mexico, Ohio, Oregon, Tennessee, and Texas – allow physicians to practice with a conditional license or a specific telemedicine license.
Medicaid coverage varies on a state-by-state basis but is better than Medicare in many states, according to the ATA. Medicare only pays for telemedicine services if a beneficiary lives in a rural Health Professional Shortage area; several additional requirements must be met:
• The service must be furnished via an interactive telecommunications system, which is defined as multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.
• The practitioner furnishing the service must meet the telehealth requirements, as well as the usual Medicare requirements.
• The individual receiving the services must be in an eligible "originating" site.
Medicare then pays a fee to the originating site and a separate fee to the distant site practitioner.