Virtual visits: How telemedicine can improve health care

 

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Between June 2013 and June 2014, 11-year-old Carson Domey had 36 doctor’s appointments, most of which were with gastroenterologist Michael Docktor, MD, at Boston Children’s Hospital. Carson, who has a rare form of Crohn’s disease that causes oral inflammation, lives in in Dudley, MA—an hour-and-a half car ride from Boston.

“Sometimes, by the time we can schedule an appointment and drive there, my symptoms are gone,” he says. “Telemedicine would allow me to miss less school and get immediate attention when I need it.”

“The time out of school is huge,” says Carson’s mother, Michelle.

Docktor is equally passionate about this issue. “He can Skype into school!” he adds emphatically. “Why can’t he do that for a doctor’s appointment?”

Well, why can’t he? What is stopping Carson and so many other children like him from receiving follow-up clinical care via video conferences—otherwise known as telemedicine?

New technology needs new policies

As a relatively new and growing field within health care, telemedicine still faces numerous regulatory barriers, especially in the state of Massachusetts. Every state has its own definition of telemedicine as well as unique policies about how it may be practiced and paid for. Telemedicine vs telehealth. The terms “telemedicine” and “telehealth” are often used interchangeably, but they mean slightly different things. Telehealth refers to any use of technology for delivering health care, health information or health education at a distance, while telemedicine is typically reserved for clinical interactions involving a high-quality video conference tool).

Massachusetts is one of only three states that do not require Medicaid to cover the cost of video telemedicine consults. Private insurers can cover these services, but contracts with hospitals and health care facilities must be negotiated on an individual basis. Furthermore, the credentialing process for Massachusetts physicians to engage in telemedicine is excessively burdensome and time-consuming.

State licensure laws only allow clinicians to practice telemedicine within state borders, creating barriers to telemedicine for patients who live across state lines. In New England, traveling outside of one’s home state for health care services is quite common, especially when it comes to specialty care.

“To me, as a provider, it feels terrible to know that this family went through so much—taking time off of school and work, driving for three hours—all for a 15-minute conversation we could have done just as well over a video conference,” says Docktor, who is also the hospital’s clinical director of innovation.

Michelle adds, “Having an official, tracked system of video conferencing would help us with continuity of care. Our other providers could reference these encounters just as they would an in-person clinic visit. Right now, if we try to do ad hoc versions ‘off the books’ without the proper technology, it’s not tracked in any way.”

The future of telemedicine

As Carson’s story illustrates, virtual follow-up visits for chronic conditions could dramatically change the quality of life for numerous patients who travel for specialty care. Consider this: Over 80 percent of all U.S. health care spending in 2014 was for chronic care, and an estimated 33 percent of all office visits could be addressed with telehealth today.

This past winter, a bill was filed in the Mass. legislature that would dramatically widen the scope of telemedicine. The bill—co-drafted by Boston Children’s Telehealth Program and Government Relations team, along with the Massachusetts Hospitals Association—would expand insurance coverage for telemedicine to the Mass. Medicaid program, plans covered by the Group Insurance Commission plans and all managed care plans. (Currently, managed care plans are allowed, but not required, to cover telemedicine.)

Innovative applications. Despite the regulatory restrictions on certain applications of telemedicine, Boston Children’s Hospital has implemented a number of initiatives within its Telehealth Program that have already demonstrated a positive impact on patient outcomes:

  • TeleCAPE. The CAPE (Critical Care, Anesthesia, Perioperative Extension & Home Ventilation) program at Boston Children’s arranges home visits and routine clinic appointments for children dependent on medical technology (such as ventilators or feeding tubes) for everyday life. These patients are up to 375 times more likely to be admitted to an intensive care unit. During home visits, nurses check on the patient’s condition, assess equipment efficiency and address any other related medical needs. Recently, a telemedicine component was added so that many of the home visits can be performed virtually. TeleCAPE allows clinical caregivers to address urgent issues immediately while also improving their overall efficiency.

 

The bill would also streamline the telemedicine credentialing process for providers by adopting federal rules instead of the current state rules, which involve extensive paperwork and redundancy. The new law would let facilities contract with one another on behalf of their physicians.

In 2015, more than half of all large employers (defined as a company with more than 1,000 employees) in the United States incorporate telemedicine into their insurance plan offerings. If current trends continue, that number will be 70 percent by 2017. Private companies that exclusively focus on telemedicine services, such as Teledoc and Carena, are contracting with private insurers. United Healthcare and Athena Health, two of the largest insurers in America, dramatically expanded their telemedicine coverage this year. In order to ensure that all Americans can benefit from this new frontier in medicine, universal coverage of these services must be a priority in all 50 states.

For his part, Carson is making the most out of an upcoming trek to Boston to visit the Massachusetts State House with his mother and the Boston Children’s Government Relations team. Carson will meet with state representative and make his case for expanding telehealth coverage.

To see an interactive map explaining different states’ telemedicine/telehealth policies, visit http://cchpca.org/state-laws-and-reimbursement-policies.

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