Government

Slow connection: Medicare and telehealth

Using this techology shows promise, but it is hampered by inflexible payment and regulation, wary physicians, and uneven evidence of its value.

By David Glendinning — Posted Sept. 3, 2007

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

Many physicians think that telehealth could be the wave of the future for Medicare, but so far it's registered barely a ripple. Although the program reimburses for some services, it has been too slow to embrace the technology, they say.

Telehealth is relatively new to Medicare. Congressional legislation in 1997 and 2000 largely established the telehealth component of Medicare as it is known today.

In 2006, the program spent only $2 million on medical services conducted electronically, out of more than $400 billion in total spending, according to the Centers for Medicare & Medicaid Services. Some doctors see countless missed opportunities for better care in those figures.

The idea is to improve the health of people in underserved areas by linking them electronically with doctors they would have difficulty seeing otherwise. For instance, a primary care physician could recommend that a chronically ill senior in a rural area come to a nearby satellite clinic to get needed treatment from a faraway specialist. A specialist visit could be conducted using videoconferencing equipment. Medicare coverage of the encounter could save the patient hundreds of miles of travel.

Better yet, problems could be solved before they grow out of control. Medicare payment for a home monitoring device that alerted disease managers and doctors when a patient's chronic disease first started to worsen could prevent multiple office visits, specialist consultations, hospitalizations or emergency department visits down the road.

But the conditions under which Medicare will commit the funds for these types of telehealth services are limited.

Remote patient visits, consultations and other care can generate payment only if they fall under a handful of Medicare payment codes approved for telehealth applications. The patient must be physically present with a health professional at the originating call site, which must be located outside of a metropolitan area. Some types of facilities are not approved to get paid for these services. In addition, Medicare will only pay for home telehealth devices and care as part of an approved pilot project.

A major factor in Medicare's cautious stance is federal officials' concerns that a large expansion would strain the system's finances by opening the doors for physicians and others to bill for a whole host of costly and potentially unnecessary telehealth services, said Richard S. Bakalar, MD, chief medical officer for IBM's health care and life sciences division and immediate past president of the American Telemedicine Assn.

"If Medicare were just motivated by what's best for the patients, then they would be more expeditious in trying to make these services available," he said. "However, that's counterbalanced by the concern that there might be overwhelming use of these new codes, and that might break the bank."

For years the American Telemedicine Assn. has pushed CMS and Congress to approve Medicare telehealth payment for any remote service not covered by the policy but deemed appropriate by eligible medical professionals. The group also wants all other types of Medicare facilities, including nursing homes and dialysis clinics, to be able to receive payment.

American Medical Association policy calls on CMS to fund demonstrations to evaluate physician care delivered using telehealth technology.

Slow going at both ends

A few physician practices have found that the current coverage allows them to extend the use of their existing technology to deliver care in ways that are much more convenient and efficient for both doctors and patients.

Avera Weskota Memorial Medical Center in Wessington Springs, S.D., for instance, has a videoconferencing link with its 10 remote clinics, said Thomas M. Dean, MD, chief of staff at the center and a recent appointee to the Medicare Payment Advisory Commission. When it is not being used for physician staff meetings between the facilities, doctors can access the equipment to conduct telehealth visits and consultations.

"We have a psychiatrist that comes to our clinic about every two weeks and can do consults with any of the other 10 clinics," he said. "In many of these areas, it would be next to impossible to get a psychiatrist on site and very difficult for patients to get to places where psychiatric services are available."

Still, extremely low Medicare spending on telehealth means that not enough physicians are even aware that any reimbursement is available, which is one reason why Medicare telehealth has failed to take off, said Mark B. McClellan, MD, PhD, former CMS administrator and a senior scholar with the Brookings Institution. Others want to take advantage of the option but lack the capital or are fearful that accepting a technology donation will violate anti-kickback laws.

Doctors can request additions to Medicare's suite of approved telehealth services. Largely because of ATA requests, in recent years CMS added codes for psychiatric diagnostic interview exams, end-stage renal disease-related services and individual medical nutrition to the approved list, said Craig Dobyski, a CMS health insurance specialist.

But some of these requests have been denied. Dobyski said the agency is authorized to add new types of services only when enough evidence exists to convince CMS that the remote service is just as appropriate, effective and safe as the "hands-on" service. Medicare recently denied a request to allow reimbursement for electronic diabetic self-management training because it determined that allowing doctors to demonstrate self-administered insulin injections over a video monitor could be dangerous for patients. For some services, telehealth likely will never be an acceptable alternative to hands-on care, Dr. McClellan and Dobyski said.

Some coverage requests stagnated because not enough comparative evidence exists showing that a telehealth application is just as good as in-person care. These studies will take some time to emerge, Dr. Bakalar said.

An electronic eye on patients

Electronic devices designed to help control patients' chronic conditions at home are showing some promising results through the few Medicare pilot projects that do exist.

In its largest project to date, Medicare spent nearly $60 million over seven years to install and maintain home monitoring computers for patients with diabetes in underserved rural and inner-city areas in New York State. Computers were equipped with devices to assess blood pressure and blood sugar levels, as well as to take photographs of skin and foot conditions. This allowed case managers and doctors to keep track of diabetes patients over the Internet and try to head off potential complications.

Initial reports on the Informatics for Diabetes Education and Telemedicine initiative, which wrapped up in February, were very positive, said Steven Shea, MD, a professor of medicine at Columbia University in New York and the project's supervisor. One 2005 preliminary study showed that patients who used IDEATel showed measured improvements in their hemoglobin A1c, blood pressure and cholesterol levels over a control group.

Another example of a Medicare home telehealth project aims to show that even a low-complexity device can improve patient care. The Health Buddy program, operating at two medical centers, uses Medicare funds to install and maintain small computers in homes of patients with congestive heart failure, diabetes or chronic obstructive pulmonary disease. By replying to automated questions about such issues as weight gain or shortness of breath, patients automatically can alert disease managers and doctors electronically if their conditions seem to be worsening.

Although the Health Buddy pilot is only about halfway though its three-year run, doctors are reporting some benefits. Sean Rogers, MD, medical director of the program at Bend (Ore.) Memorial Clinic, and Pete Rutherford, MD, who heads the initiative at Wenatchee (Wash.) Valley Medical Center, said they were able to prevent hospitalizations by taking quick action when case managers told them that patients had taken turns for the worse.

"We catch people not infrequently, especially in the heart failure category," said Dr. Rutherford, an internist. "Their blood pressure starts spiking or their weight goes up or their swelling goes up."

But Medicare officials are not yet sold on the home telehealth concept. Patient compliance, for instance, plays a big role in determining how well a home monitoring system will work. A preliminary CMS report in 2005 on the IDEATel initiative noted that scores of patients dropped out of the project and that the majority of those who remained failed to use all of the applicable devices for their conditions, likely decreasing the technology's value to Medicare.

The jury also is still out on whether the upfront expenses associated with either IDEATel, which costs several thousand dollars per patient every year, or Health Buddy, which costs several hundred, are offset enough by the long-term savings associated with better patient outcomes.

Connecting to the future

Telehealth might someday play a much larger role in Medicare, but the program and physicians will need to undergo major changes before that can happen, experts said.

The slow, incremental drive to ramp up the coverage likely will stay at its current pace as long as Medicare acts as a strictly fee-for-service program, Dr. McClellan said. But if policymakers embraced a "medical home" model of coverage that pays primary care physicians a set fee for care management, telehealth would be a much more natural fit, he said.

"If physicians are getting paid more for care coordination, that frees up some money to move toward telehealth," he said.

For their part, doctors said they also need to become much more comfortable with conducting remote health services and monitoring patients at home. Some physicians worry, for instance, that a home telehealth device would simply inundate them with patient information that is of little use, Dr. Rutherford said.

Dr. McClellan predicted that telehealth technology's availability will rise once physicians and hospitals become more comfortable with recently drafted federal safe harbors protecting technology donations from anti-kickback laws. In the meantime, Medicare and other public telehealth proving grounds such as the Dept. of Veterans Affairs, which covers roughly 250,000 telehealth procedures per year for VA patients, will continue to generate information for doctors and policymakers on the value of the practice. As the price of the technology decreases, it will become more cost effective for certain types of patients.

As the years go on, more physicians will discover that telehealth can not only make the lives of many of their patients better but also make them better doctors, Dr. Bakalar said. A physician, for example, may learn from a telehealth consultation how to identify a patient condition without needing outside help in the future.

"One advantage of telehealth is that it allows physicians to stay closer -- to retain control and retain relationships with their patients," he said.

Back to top


ADDITIONAL INFORMATION

Telehealth FAQs

What is the difference between telemedicine and telehealth? The American Telemedicine Assn. defines telemedicine as the process of improving patient health status by exchanging medical information from one site to another via electronic communications. Telehealth is a broader term defining remote health care that does not always involve clinical services. It includes home monitoring, videoconferencing and nursing call centers.

What telehealth services does Medicare cover? Medicare covers telehealth for selected codes corresponding to office visits, consultations, psychiatric diagnostic interview exams, individual psychotherapy, pharmacologic management, services related to end-stage renal disease and individual medical nutrition therapy. It covers home telehealth only under approved demonstration projects.

What about teleradiology? Teleradiology and other remote diagnostic services that don't require the patient to be present at the originating site while the medical information is exchanged and processed are not considered telehealth by Medicare.

Who can provide covered telehealth services and where can they provide them? Physicians and selected health professionals, such as nurse practitioners and physician assistants, can bill for the services. The site that originates the telehealth call with the patient present must be a physician office, hospital, critical access hospital, rural health clinic or federally qualified health center that is outside of a metropolitan area. There is no restriction on the site that receives the call.

How does Medicare pay? The professional at the site that provides the medical service receives the standard payment for the service under the Medicare fee schedule. The site that initiates the call is eligible for a telehealth facility fee, generally about $20 per call.

Back to top


ADVERTISEMENT

ADVERTISE HERE


Featured
Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story


Read story

Goodbye

American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story


Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story


Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story


Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story


Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story


Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story


Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn