In June, the American Medical Association (AMA) adopted a resolution addressing telemedicine as a key innovation in support of healthcare delivery reform. Timing of the resolution melds with legislative advocacy action being made at the local, state and national levels as telemedicine goes mainstream.

Among the high points: a universally-accepted telemedicine payment model, licensure portability, ethical guidance, clinical concerns and recommendations.

“The umbrella of the reason and purpose of the resolution is that we recognized the technology of telemedicine was a very important tool we could use to take better care of our patients,” said AMA President Robert Wah, MD. “Underneath that umbrella, we firmly believe this technology shouldn’t necessarily replace face-to-face interaction between the physician and the patient. We view face-to-face interaction as the highest quality action to have with a patient because there’s so much detail and information that comes out with direct interaction with our patients. We recognize that in some cases, after a patient-physician interaction has been established, telemedicine can be very helpful. In some instances, such as urgent matters requiring a consult, the technology may be used without an initial face-to-face interaction. But we still believe strongly that face-to-face is optimal for our patients.” 

Licensure Requirements

In its resolution, the AMA made it clear that the physician providing telemedicine should be licensed in the state the patient resides.

“We believe it’s important for physicians and patients to be treated within the parameter of local regulations and laws, which differ widely across the country,” said Wah. “We want to respect those differences and not try to supersede them via the use of telemedicine. For instance, if I as an OB-GYN am going to prescribe birth control for a patient under the age of consent, some states require a parent to be notified. The best way to comply with local regulations and laws is to make sure the physician is licensed in the state he’s using telemedicine.” 

Background

In 1996, the Institute of Medicine (IOM) released the nation’s first comprehensive report on telemedicine, “Telemedicine: A Guide to Assessing Telecommunications for Health Care.” Despite the evolution of the practice, there remains no consensus on the definition of telemedicine and telehealth, often viewed as interchangeable terms. Instead, three broad categories of telemedicine technologies are defined as: store-and-forward, remote monitoring, and (real-time) interactive services.

Regardless of the verbiage, “the evolution of telemedicine impacts all three strategic focus areas of the AMA: improving health outcomes, accelerating change in medical education, and enhancing physician satisfaction and practice sustainability by shaping delivery and payment models,” said Charles F. Willson, MD, a pediatrician from Greenville, NC, and presenter of the Report of the Council on Medical Service that preceded the AMA’s adoption of the resolution on telemedicine. 

Payment Reform

In the report, Willson addressed how coverage of and payment for telemedicine has varied widely after the passage of the Balanced Budget Act of 1997 and the Telemedicine Communications Act of 1996 enabled payment for professional telemedicine consultation in 1999, and how inconsistencies remain to create barriers to the further adoption of telemedicine as public and private payers have continued to develop formal mechanisms to pay for telemedicine services.

“Each year, Medicare pays approximately $6 million for telemedicine services,” according to the report, “In 2009, there were approximately 40,000 telemedicine visits, involving some 14,000 Medicare beneficiaries. That same year, 369 practitioners, including physicians, provided 10 or more telemedicine services to Medicare beneficiaries – most of which were mental health services.

“Psychiatrists, psychologists and clinical social workers comprised 49 percent of the practitioners who provided 10 or more telemedicine services in Medicare. While physician assistants, nurse practitioners and clinical nurse specialists accounted for 19 percent of such practitioners, family medicine and internal medicine physicians accounted for 7 percent.”

The District of Columbia (DC) and 46 states offer some form of Medicaid payment for telemedicine services. Also, 19 states and DC have adopted laws mandating that private payers cover telemedicine services, as defined by various states.

“When any developing therapy or technology in medicine becomes mainstream, we want to make sure there’s a payment for the benefit that gets accrued by using the technology,” said Wah. 

Case Studies

Highlighted in the AMA’s Report of the Council on Medical Service are two case studies resulting from telemedicine outreach and research efforts:

• The University of Virginia (UVA) Center for Telehealth across the UVA Telemedicine Partner Networks includes 118 sites offering telemedicine services in more than 40 specialties and sub-specialties. The center has provided more than 33,000 patient encounters in Virginia, and provides more than 30,000 teleradiology services annually.
• The Arkansas ANGELS (Antenatal & Neonatal Guidelines, Education & Learning System) provides patients with round-the-clock and telemedical support at approximately 30 telemedicine sites statewide to address high-risk obstetrical care needs. In 2012, Arkansas ANGELS reported 5,221 telemedicine visits, 2,062 telemedicine obstetric ultrasound visits, and 130 fetal echocardiogram visits. Also the same year, 1,629 colposcopy exams were performed, which identified 303 women with high-grade lesions requiring treatment and five diagnosed with cancer.

“We made a strong statement in our resolution to lobby for continued research on the most optimal way to use telemedicine and integrate it into our current delivery system to take better care of our patients,” said Wah. “I don’t have specific thoughts about how that research would proceed. Yet, as with any therapy or technology that I use to care for my patients, I’m always looking for ways to improve that care.”

By Lynne Jeter