Use of telemedicine has resulted in decreases in hospital readmission rates and better patient engagement, both of which make a strong business case for its increased use. But while the technology that drives telemedicine is evolving rapidly, the legal environment is changing much more slowly. However, the Federation of State Medical Boards (FSMB) and the American Medical Association (AMA) have recently issued separate sets of guidelines to help states as they begin to develop regulations concerning telemedicine.
FSMB Guidelines
Recognizing that physician practices are regulated by state medical boards that gain their authority from state legislatures, the FSMB has issued telemedicine guidelines in an attempt to help states develop a certain level of consistency through voluntary model policies. In particular, physicians who practice in multi-state areas must be able to understand state policies on telemedicine if they are to effectively incorporate telemedicine into their practices.
FSMB Definition of Telemedicine
The FSMB defines telemedicine as “The practice of medicine using electronic communications, information technology or other means between a licensee in one location, and a patient in another location with or without an intervening health care provider.” It describes the different telemedicine techniques that are common, including “store-and-forward” technology that delivers relevant patient information to healthcare providers, as well as secure videoconferencing, and older technologies like telephone conversations, fax, and email.
Guidelines for Appropriate Telemedicine Use
The FSMB recommends that collection of relevant clinical history as well as documentation of medical evaluation be obtained in person prior to telemedicine treatment. It also posits that any treatment or consultation made in an online setting must adhere to the same standards of appropriate practice as those of a traditional, in-person medical visit. The FSMB goes on to emphasize the importance of informed consent on the part of the patient, as well as the importance of patients understanding what security and privacy measures are taken with use of telemedicine, such as encryption and password protection.
Recommendations to State Boards
State boards, says the FSMB, should ensure their policies and definitions concerning telemedicine are drafted to accommodate rapid technological change, cautioning that when policies or definitions are too narrow, the result could be the board or the state legislature having to enact changes, often a slow process, that could slow the adoption of telemedicine, causing patients and doctors to potentially miss out on the many benefits telemedicine can offer.
AMA Guidelines on Coverage and Payment for Telemedicine
The American Medical Association acknowledges that telemedicine addresses key AMA focus areas, namely that it can improve healthcare outcomes, accelerate changes in medical education, and improve physician satisfaction and practice sustainability if delivery and payment models are developed thoughtfully. It also acknowledges that practice guidelines and standards of care related to telemedicine are evolving quickly, and differ based on medical specialty and services offered.
AMA Definition of Telemedicine
While there is no overwhelming consensus on the definition of telemedicine, the AMA lists three broad categories of telemedicine technology: store-and-forward technology, remote monitoring, and real-time, interactive medical services. Because of varying state regulations, coverage and payment for telemedicine services vary considerably too. Public and private payers (such as Medicare, Medicaid, and private insurers) are developing policies for payment for telemedicine services, but many inconsistencies in these policies create barriers to the expansion of telemedicine.
AMA Policy on Payment for Telemedicine
The AMA states that physicians should be compensated for telemedicine services at a fair fee for patients with whom physicians have previously met in person, and that this compensation should be provided whether the consultation is done by phone, email, or other types of telecommunication. It states that the Center for Medicare and Medicaid Services (CMS) should reimburse telemedicine similarly to how other forms of consultation are reimbursed, with payments based on individual claims rather than fee splitting or fee sharing payment schemes. The organization also wants to work with private insurers to develop appropriate telemedicine reimbursement based on demonstration projects evaluating the effectiveness of telemedicine in terms of cost and care quality.
AMA Recommendations to Physicians on Telemedicine
In their guidelines, the AMA states that physicians and other healthcare practitioners delivering telemedicine services must abide by all state licensing laws and medical practice laws, including (for example) laws concerning:
- Consent involving treatment of minors
- Prescribing
- Reproductive rights
- End-of-life concerns
It also advises physicians to verify their medical liability insurance coverage of telemedicine services, including services provided across state lines where applicable.
Widespread adoption of telemedicine still faces several barriers. Concerns among physicians include questions about effectiveness and malpractice issues. Legislative and licensing concerns must also be addressed before telemedicine adoption can be used more widely. Each state has different laws, with some providing for private insurer and Medicaid reimbursement for telemedicine, and others not. Additionally, since physicians must be licensed in every state in which they practice, telemedicine could present problems when doctors visit patients virtually and those patients happen to be located in a different state.
Conclusion
Telemedicine regulation is complex for many reasons. Not only is technology evolving rapidly, differing state requirements for physician practice affect whether and how physicians can offer telemedicine services. Moreover, physician reimbursement for telemedicine is complicated, with public and private payers moving slowly in terms of developing reimbursement guidelines.
Not all states allow private insurance reimbursement for telemedicine, and not all states allow Medicaid reimbursement for telemedicine, complicating matters further. Physicians, however, are optimistic about the potential for telemedicine to improve care quality and reduce costs. Several recently testified in front of the Small Business Committee in the US House of Representatives, urging Congress to streamline some of the processes (like physicians obtaining licenses in multiple states) that could assist with the expansion of telemedicine.
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