There has been a lot of progress in telehealth over the last three years. In 2013 there were only 13 states that were cleared for consultation and prescribing and three states restricted consultation in the absence of a prior in-person relationship. According to American Well, a telemedicine technology solutions company by January 2016 most states had been cleared to consult and prescribe, with various exceptions in Alaska, Louisiana, and Indiana. Inconsistent state definitions create challenges for national providers. Clinical permissibility, licensure, and reimbursement remain the flagship challenges.
It’s often said that the only thing consistent about telehealth is that it’s inconsistent.
The Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine was reported by the State Medical Boards’ Appropriate Regulation of Telemedicine (SMART) workgroup and later was adopted as policy by the Federation of State Medical Boards (FSMB) in April 2014. This new policy guided regulation of state medical boards in the use of telemedicine technologies in the practice of medicine and educates licensees as to the appropriate standards of care in the delivery of medical services directly to patients via telemedicine technologies. This policy blazed the path for telemedicine adoption by superseding the Model Guidelines for the Appropriate Use of the Internet in Medical Practices previously adopted April 2002.
Clinical permissibility comes down to whether or not providers can deliver care via telehealth. Mainly this discussion swirls around telehealth policy. However, the Medical Boards have made significant strides to get the policies right. Informed consent, the evidence documenting appropriate patient informed consent for the use of telemedicine technologies must be obtained and maintained. Informed consent is a primary consideration with telehealth policy and includes:
1. Identification of the patient and physician (physical credentials),
2. Types of transmissions permitted using telemedicine technologies (prescription refills, appointment scheduling, patient education),
3. Patient agreement (that it’s the physician’s decision as to whether a telemedicine encounter is appropriate),
4. Adequate security measures (data, passwords, files, identification and authentication techniques),
5. Hold harmless clause (if due to technical failures information is lost), and
6. The requirement for express consent to forward patient-identifiable information to a third party (administration, billing, care).
These six factors ensure that informed consent is appropriate. However, even after informed consent is secured other clinical issues surface. Can the provider establish a treatment relationship sufficient to prescribe using telehealth? Must a prior relationship have been established? Is this the same standard of care as a facility visit to a provider? Does this encounter include a prescription for controlled substances or does this encounter trigger a limited formulary? Each of these questions needs to be addressed and communicated to the patient, to ensure the patient understands whether of not a prior examination is required before care is administered.
These questions also weigh on the minds of the state medical and pharmacy boards and national organizations such as the American Medical Association and Federation of State Medical Boards.
Reimbursement and licensure
State legislation defines the telemedicine reimbursement models for commercial and Medicaid reimbursements. Understanding how providers expect to be paid for telehealth is essential.
Credentialing and privileging are the same challenges providers face with facility-based care models. Providers are pressured to offer a large number of health plans across a diverse network of providers. Providers must also select privileged practitioners who can provide credentialed care. It’s tough for providers to keep up with multiple state licensure for clinicians that are decentralized.
Anticipating this licensure, the Federation of State Medical Boards issued the Interstate Medical Licensure Compact Legislation. According to the FSMB, the Interstate Medical Licensure Compact offers an expedited licensing process for physicians interested in practicing medicine in multiple states. The Compact is expected to expand access to health care, especially to those in rural and underserved areas of the country, and facilitate the use of telemedicine technologies in the delivery of health care. The Compact legislation to expand access to healthcare by expediting medical licensure has been adopted by 16 states including Kansas, Mississippi, Alabama, Arizona, Idaho, Illinois, Iowa, Minnesota, Montana, Nevada, New Hampshire, South Dakota, Utah, West Virginia, Wisconsin and Wyoming.
For states without compact legislation provider complexity is magnified. While NCQA and URAC accreditation help to ensure provider quality, they don’t do much to ensure multi-state licensure interoperability.
Evidence of progress
There are 29 states including Washington D.C. that have mandated commercial reimbursement for telehealth, as of mid-2016. Several states subscribe to parity mandates, which are a form of commercial mandates that require services be paid to the same extent and at the same level as in-person services (NV, MT, MN, CO, MS, LA, ME, DE, and CT). More cautious states, offer commercial reimbursement with limitations or restrictions, that mandate coverage for commercially provided telehealth services but contain limitations and site restrictions.
As patients demand to be the CEO of their health, the healthcare ecosystem will need to work together to tackle clinical permissibility, licensure, and reimbursement before telehealth goes mainstream.