State and federal initiatives are starting to address regulatory hurdles.
Based on a partnership with Urology Times, articles from the American Association of Clinical Urologists (AACU) provide updates on legislative processes and issues affecting urologists. We welcome your comments and suggestions. Contact the AACU government affairs office at 847-517-1050 or firstname.lastname@example.org for more information.
The prospect of delivering patient-centered care via telemedicine is invigorating for many urologists, particularly in light of nationwide work force shortages. Integration of this technology into daily practice has been largely stymied, however, by confused licensing standards and restrictive reimbursement policies. State lawmakers and federal regulators have taken significant steps in recent months to address these constraining conditions.
The United States will face an overall shortage of more than 100,000 physicians by 2030, and more than half of that number will come from specialty physicians, according to the Association of American Medical Colleges, which reports “the supply of surgeons is projected to have little growth by 2030, but projected demand is expected to increase, resulting in a shortage of between 19,800 and 29,000 surgeons by 2030.”
Urology has seen a greater than 10% decline in the number of specialists per capita over the past 20 years, and with more than 44% of urologists aged 55 or older, that drop will grow with retirements unless Congress lifts the cap on Medicare-funded residency positions imposed in 1997. The number of urologists who practice in rural areas is falling, as well. According to the 2016 AUA Census, “Less than 10 percent of practicing urologists in the United States maintain their primary practice locations in non-metropolitan areas.”
Telehealth, according to the Centers for Medicare & Medicaid Services, is “the provision of clinical services to patients by physicians and practitioners from a distance via electronic communications.” Non-simultaneous telemedicine involves after-the-fact interpretation or assessment, such as teleradiology services, while simultaneous telemedicine includes real-time interpretation or assessment, such as electronic ICU services, psychiatry, or dermatology.
Urologist Lisa Finkelstein, DO, has become a leading authority on telehealth. As president of the Wyoming Medical Society, Dr. Finkelstein was the lead witness appearing (via HIPAA-compliant Zoom video conferencing) before a legislative committee in November 2018. She also shares her experience as a member of the AACU State Advocacy Network.
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“Here in rural Wyoming, 2019 has been one of the snowiest winters on record,” Dr. Finkelstein reported. “Passes and canyons have been closed for days at a time. I say, ‘Let it Snow and Tele-On!’ As barriers to telemedicine are removed, our patients would not have to cancel their appointments. Instead, they just sign into their Zoom account and see their urologist, cardiologist, or primary care doctor. The ideas are endless.”
Laws that authorize telehealth from a cross-state licensing standpoint are widespread, but policies that govern reimbursement and liability are inconsistent (at best). The Interstate Medical Licensure Compact facilitates physician licensing across state lines. The compact was finalized in 2014, and by 2017, the requisite number of states adopted it to allow the framework to be effective.
In January 2019, Michigan became the 25th state to join. According to the Federation of State Medical Boards, to date, 4,511 licenses have been issued and 2,400 applications processed by a commission that administers these activities.
According to the Center for Connected Health Policy, 39 states and the District of Columbia have laws that govern private payer reimbursement of telehealth. This is an increase of one state (Kansas) since spring 2018. Some laws require reimbursement be equal to in-person coverage, but most only require parity in covered services, not reimbursement amount. Washington State Senator Randi Becker, a past AACU Distinguished Leadership Award honoree, introduced several bills addressing telemedicine this year, including a proposal to ensure that health plans reimburse telemedicine at the same rate as services provided in office.
On the liability front, much depends on one’s insurer. On a case-by-case basis, policies may cover a provider’s activities that extend into another state. However, due to various reasons such as a lack of a cap on damages, many carriers may not be willing to provide coverage across state lines. Whatever the case, providers are advised to assume they will be subject to the laws of another state on issues such as professional standards and standard of care, informed consent, statute of limitations, pre-litigation screening, evidentiary rules, and expert witness qualifications.
Next: Medicare reimbursement keyMedicare reimbursement key
For urologists, integration of telemedicine into one’s practice will rely heavily on Medicare reimbursement of those services. The 2019 Medicare payment rule, for the first time, includes payment for technology-based services like brief check-ins and virtual consultations. In a November 2018 speech, CMS Administrator Seema Verma said, “…many times a virtual check-in will resolve patient concerns in a convenient manner that gets them the care they need, and avoids unnecessary costs for the system.”
Verma added that Medicare “will also be paying for virtual consultations between physicians, and evaluation of remote pre-recorded images and video. For example, a patient could now text a picture of a mole on their skin to a dermatologist for examination.”
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In another proposal issued in late 2018, CMS solicited comments on whether to allow Medicare Advantage plans to offer additional telehealth benefits in plan year 2020.
AACU President Mark Edney, MD, MBA, asserted, “In no time, caring for patients via telemedicine will happen on a daily basis. The AACU is committed to representing practicing urologists as the laws, regulations, and payer policies that govern these services are hammered out.”