HHS report outlines problems, potential of telemedicine

By Heather Mack
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In response to a request from Congress, the US Department of Health and Human Services released its report on the agency’s current telehealth efforts.

While it wasn’t within the 180-day deadline Congress gave the department in December, the report was comprehensive in its scope of the potential promise of telemedicine, especially given the ever-expanding availability of services, as well as the myriad difficulties in implementation due to inconsistent policies, costs and licensing agreements.  

“…It is estimated that 61 percent of health care institutions currently use some form of telehealth, and between 40 and 50 percent of all hospitals in the United States currently employ some form of telehealth,” states the report, which includes rural/critical access hospitals, academic medical centers and urban institutions. “In 2013, the market for telehealth generated annual revenue of $9.6 billion, a 60 percent growth from 2012. Moreover, the ubiquity of internet-linked mobile computers, such as iPads and video platforms, such as Skype, enable ‘direct’ consultations between providers and patients located hundreds of miles apart.”

The report focuses on the promise of telehealth to reach those in rural or underserved populations (including many veterans), to manage chronic diseases, deliver mental health or specialist services, and to avoid unnecessary hospitalizations. It also outlined the challenges of reimbursement, licensure, credentialing and privileging, and broadband connectivity.

Four basic modalities, or methods, of telehealth were catalogued by HHS: Live, two-way interaction (such as video visits via a company like Teladoc); mobile health in the form of smartphone apps; remote patient monitoring; and store and forward technology, which is transmission of videos and digital images such as X-rays and photos through a secure electronic communications system.

The last modality has been tricky to define for some, with Arkansas and Texas still lagging far behind the rest of the country as tehy wrestle over what it takes to establish a doctor-patient relationship.

Telehealth’s ability to reach those in rural or underserved communities seems like the most obvious advantage, and fits into the department’s recent funding package that earmarked substantial portions of the $16 million in funds towards telemedicine.

“The availability of telehealth is of particular interest for patients who live in areas that are inadequately served. Access to certain medical specialties, such as oncologists, is limited in rural areas,” the report states.  

However, not all rural regions have the capability to use telehealth, the report states. Currently, 59 million Americans reside in Health Professional Shortage Areas. Many of these also lack robust broadband connections, the report finds, citing the Federal Communications Commissions’ figures of 53 percent of rural Americans lacking access to benchmark service, with a major gap in broadband access on Indian reservations.
 
The FCC recently deployed a mapping tool to better visualize such areas lacking in broadband connection, and the agency, along with the US Department of Agricultre have programs to support broadband deployment in rural areas, but an even bigger impediment may be affordability and bureaucratic red tape: the price of broadband services can be three times higher in rural areas than in urban areas.

The report states, “…the ability for healthcare providers to tap into these resources, particularly through the FCC, is a challenge due to the application process and level of cost sharing as well as a complex mechanism for pulling down funding through a telecommunications provider.”

Connectivity isn’t the only challenge in telehealth. Reimbursement remains the key question for both providers and payers.

“The payment environment for telehealth services is evolving across the public and private sector with a considerable amount of variability from one payer to another,” the report states. “Coverage of telehealth services has been uneven across payers due in part to uncertainty regarding the value of telehealth and program integration concerns regarding duplication of services.”

In the case of the Medicare fee-for-service program, the amount of reimbursement for telehealth services has been small (Medicare only spent about $14.4 million on telehealth-delivered services in 2015), but the report mentioned a possible solution: a proposal that expands the utility of Medicare Advantage plans, which are required to provide Medicare-covered telehealth services, by eliminating requirements that certain covered services be provided exclusively through face-to-face visits.

Another challenge to telehealth is the question of who is responsible for verifying the qualifications of provider, since telehealth transactions often involve providers communicating from two different hospitals. Both CMS and the Joint Commission now deem the hospital where a patient is located to have ultimate decision making authority, but the report says that still doesn’t fix the problem entirely.

“While this would appear to have removed an organizational hurdle to connected care, some concerns linger about telehealth among specialists who object to an originating site having the ability to constrain their authority or scope of practice,” the report states.

HHS went into its activities that support telehealth over the last year, including the ONC’s inventory of federal telehealth activities, the Federal Telemedicine Working Group, and AHRQ’s Evidence Map (released June 2016) to assess existing evidence on the benefits and costs associated with telehealth.

The report concluded that “telehealth holds great promise for a number of specific chronic conditions, for persons with multiple chronic conditions generally, and for people in need of behavioral services. However, the report also concludes there is insufficient evidence to judge the cost-effectiveness of telehealth broadly.”

HHS and the departments of Labor and Treasury also posted a blog commemorating the 20th anniversary of HIPAA, highlighting the ways the law has enhanced privacy and security of consumer health data, the passage of COBRA and the Affordable Care Act. The agencies look to digital health as the future of healthcare innovation.

“We have come a long way in 20 years, but our work is not yet done,” the agencies write. “Every day, we are seeing breakthroughs in mobile health, including many more consumer-facing health apps with the patient at the center of the conversation.”