Telemedicine may provide urologists with enhanced care and unique benefits-or risks-depending on the specifics of the laws that pass.
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.
While uncertainty surrounds the Affordable Care Act and its designated replacement, the American Health Care Act, lawmakers in Washington and around the country are pushing ahead with proposals to regulate and reimburse services provided via telemedicine.
Providing care using electronic means is described by the AUA Telemedicine Workgroup as "an electronic revolution" that "is changing the very essence of how physicians practice medicine." The workgroup members attest that telemedicine is an innovation comparable to the printing press in its capacity to transform culture and medicine. Governments are scrambling to catch up with these developments, imposing laws and regulations that protect patients and promote equitable payment. Telemedicine may embody unique benefits-or risks-depending on the specifics of the laws that pass.
Patients are ready. A 2011 study reported that two-thirds of urology patients are already willing to engage in telemedicine.
Physicians are ready. Research from HIMSS Analytics finds adoption of telemedicine services across all practice types surged to 71% in 2017, up from approximately 54% in 2014.
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Not surprisingly, the same research finds "perhaps the greatest hurdle currently facing the outpatient market is confusion, specifically around reimbursement and physician liability." Nearly every state has considered legislation to address these issues, but a lack of uniformity contributes to ongoing confusion.
One area where a single standard has emerged is in licensing physicians to practice in multiple jurisdictions. As of June 2017, 19 states have passed laws to join the Interstate Medical Licensure Compact, which allows physicians to obtain a license to practice medicine in more than one state through a simplified application process. Each state's medical board retains its disciplinary authority, but agrees to share information essential to licensing, creating a streamlined process. A commission overseeing the Compact began processing applications on April 6, with the first license being issued April 20. The first applicant listed Wisconsin as his primary residence and was issued a license to practice in Colorado.
Next: Reimbursement issues
Within each state, laws must also dictate if and how physicians may provide telehealth services. By 2017, nearly every state codified the process to establish a valid physician-patient relationship via telehealth and prevent payers from mandating an in-person visit before telehealth use. But the types of eligible services and the payment structure vary from state to state.
Increasingly, states implement pay parity laws that require payers to reimburse telehealth services to the same extent as in-person services. As of January 2017, 31 states and the District of Columbia require private payer parity and 20 states and D.C. require Medicaid parity. Alaska and Arizona are the only states that impose partial parity, where not all services are covered. In Arizona, legislators have come to add services on a piecemeal basis. Coverage of telemedicine consultation services for trauma, burn, cardiology, infectious diseases, mental health disorders, neurologic diseases, and dermatology took effect on Jan. 1, 2015. Pulmonology services were added in 2016, and this year, the Arizona Urological Society (AZUS) led a campaign to include urology to the list of telemedicine services that must be given insurance payment parity.
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During a stakeholders meeting convened by a state senator, AZUS President Jason Jameson, MD, spoke in favor of adding the specialty to the list of those covered by parity. He pointed out there is a shortage of urologists in Arizona, and he cited studies that show telemedicine saved patients an average of 277 miles in driving and $200. Even more important, Dr. Jameson said that telemedicine represents an opportunity to improve patient access and care.
A representative of an insurance company complained about the piecemeal approach and opposed adding another coverage mandate. He suggested that the best course of action was to leave telemedicine reimbursements up to insurance companies and providers who would negotiate in-network rates. Although the bill enjoyed considerable support in the Arizona House, progress stalled in the Senate. "We will continue working with insurance providers and Arizona legislators,” Dr. Jameson promised, “and hope to come up with an agreement during the next session.”
At the national level, several laws and regulations restrict Medicare reimbursement for telehealth. Rare bipartisan support is emerging, however, to remove these roadblocks. The CONNECT for Health Act (S.1016) would expand remote patient monitoring programs for people with chronic conditions, define reimbursable CMS telehealth codes, give HHS the authority to lift restrictions on telehealth, and establish new allowances for global and bundled payment models. According to Sen. Brian Schatz (D-HI), one of six bipartisan cosponsors, "[Telehealth] expands access to care, lowers costs, and helps more people stay healthy. Our bipartisan bill will help change the way patients get the care they need, improving the health care system for both patients and health care providers."
The Telehealth Innovation and Improvement Act (S.787), introduced by Sens. Cory Gardner (R-CO) and Gary Peters (D-MI), requires the Department of Health and Human Services to allow hospitals to test telehealth services through the Center for Medicare & Medicaid Innovation (CMI). Additionally, it directs CMI to have an independent evaluation conducted to assess the telehealth models for cost, effectiveness, and improvement in quality of care without increasing the cost of delivery. If the telehealth model meets cost, effectiveness, and quality of care goals, then the model will be covered through the greater Medicare program. In a press release, the sponsors point to Medicare's current restrictions as "setting a poor industry standard, discouraging innovation, and restricting access to specialized services."
Bills in Congress proposing telemedicine expansion and reimbursement
Expanding telehealth services provided by the Department of Veterans Affairs (VA) is also the subject of legislation introduced by lawmakers of both political parties. Currently, the VA may only perform at-home telehealth services when the patient and provider are located in the same state. The VETS Act (H.R.2123 / S.925) addresses these barriers by allowing VA health professionals to practice telemedicine across state lines if they are qualified and practice within the scope of their authorized federal duties.
Enhancing care, improving outcomes, and managing costs must be paired with protecting licensing standards as patients, physicians, payers, and policymakers integrate telemedicine into the health care delivery system. Inconsistent laws, regulations, and payment policies threaten to undermine the great promise of this technology. Work force shortages, maldistribution of physicians, and cutting-edge technology that emulates human senses place urologists in a unique position to lead this revolution in the practice of medicine. To ensure practical and safety-conscious policies are implemented, the grassroots must be mobilized to make their voices heard.
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