Some may not be happy with the pace of change surrounding health systems, especially since a lot of the change involves adopting telecommunications technology for remote treatments and diagnoses - also known as telemedicine. Generally, in the telemedicine industry there needs to be an understanding of guidelines and standards around the proper use of telemedicine. But the regulatory landscape of telemedicine can be tricky.
State medical boards generally work with experts in a medical specialty to determine best practices for providing quality care using evidence-based research. They then establish rules and guidelines for standards of care and physicians run the risk of losing their medical license if they fail to abide by them.
The American Telemedicine Association’s State Telemedicine Gaps Analysis reported telemedicine adoption has seen some strides in recent years as well as some stagnation in state policies. While medical boards have made guidance or regulations for telemedicine that differ from those for in-person care, they have become more rigid with requirements like an additional patient informed consent, resulting in more states dropping a letter grade in ATA’s scorecard than have improved since 2014.
Alabama, Michigan, and South Dakota earned the highest scores for which states demonstrated "a supportive policy landscape that accommodates telemedicine,” according to the analysis. Arkansas and Texas had the lowest composite scores due to barriers to clinical practice and to the advancement tof telemedicine.
Telehealth and telemedicine have yet to be integrated into the federal healthcare system, though a pending bill would federally establish standards.
Several telemedicine companies in the U.S. began providing remote care to their clients long before federal health officials expressed their support for such services. These companies sometimes feel the need to protect their clients’ rights to receive remote care. For example, Dallas-based Teladoc, the first and largest U.S. telehealth company, filed a lawsuit last year against the Texas Medical Board, claiming its revision to rule 190.8 would limit patients’ access to telemedicine as it requires an in-person or face-to-face visit prior to providing prescriptions via telemedicine.
Carena, which provides 24/7 private-label virtual clinics for health systems across the country, questions Teladoc’s litigious approach and believes that telemedicine companies should be working with the boards rather than against. “The reality is that you have to work within the limitations of the existing care delivery system because the technology that Teladoc, Carena, other people use is not the right thing all the time,” Carena's CEO Ralph Derrickson told Healthcare Dive.
The question Derrickson asked himself when he wanted to take house calls to the next step was, “How much of that amazing experience a patient has when a doctor comes to their house can be expressed virtually?” Carena evaluated about 35,000 house calls to get a sense of what would be clinically appropriate for telemedicine. Derrickson believes telemedicine should be an extension of local healthcare delivery systems, and the need for local healthcare is determined by state medical boards.
“Our view has always been that we should practice consistent with the rules as established by those local medical boards,” Derrickson said, adding, “Antagonizing these organizations and questioning them, especially when it comes to patient safety and quality of medical care, is really the wrong thing for technology organizations to be doing and I think it’s bad for the industry.”
Carena contributed to the American Telemedicine Association’s development of telemedicine guidelines for primary care and has worked with various different medical boards.
The medical boards are "generally extremely favorable with our approach, which is to work with the local medical community,” Derrickson said. “The Texas Medical Board came out saying we’re fine with medicine as practice as part of the mobile healthcare delivery system.”
Thwarting bad reputations one medical board at a time
COO and VP of finance at Carena Matt Thorne says the telemedicine industry gets a bad reputation for its lack of clear boundaries around what can and should be done via telemedicine and the quality of that care that’s delivered.
Medical boards are concerned with prescribing rates and tracing the appropriate medium of telemedicine as well as services that shouldn’t be provided via telemedicine, according to Thorne. “So demonstrating quality and a model for quality via telemedicine is really important and it resonated with states.”
A lot of the discussion that Carena had with the South Carolina Medical Boards was around how house calls were integrated into its client, Boeing. “Really, only about 65% of the time can we, as a telemedicine company, treat what the patient comes to us for, and the other 35% of the time they need to go somewhere,” Thorne said.
The South Carolina board approved Carena’s model to move forward in the state. Teladoc’s model of care delivery was also evaluated in South Carolina, Virginia, West Virginia, and Ohio.
Avoiding a 'black eye' through collaboration
The nonprofit American Antitrust Institute (AAI) filed an amicus brief in the 5th U.S. Circuit Court of Appeals last month urging for the dismissal of the Texas Medical Board's appeal of a lower court's refusal to dismiss the antitrust lawsuit brought on by Teladoc.
Teladoc currently has about 15 million members and is planning to do about 900,000 telehealth visits by the end of this year - a significant increase from the 576,000 visits it did in 2015.
Jason Goveric, Teladoc's CEO, told Healthcare Dive the company prefers to always collaborate with state regulators "and Texas is no exception to that," he said, adding, "In Texas, we’ve tried multiple times to work with the medical board to rely on the data and the evidence in order to help shape regulation rather than conjecture or protectionism.
"It's only when we’re unable to do that and feel like our customers and consumers are in danger of having their right to access care diminished that we have to take a different tact."
The U.S. healthcare industry is in the early adoption stages of telemedicine, according to Derrickson. In the immediate term, Carena’s objective is to “make sure that telemedicine doesn’t get a black eye because people are using the technology in ways that they shouldn’t and preserve opportunities for all of these additional ways that it will be used,” Ralph said.
“Improving access is an enormous opportunity for lower costs,” he added.
Medical groups and regulators are feeling the pressure for telemedicine utilization due to their financial benefits as well as its ability to increase access to care. But while the regulatory framework remains a work in progress, collaboration is key.