State laws on telehealth are antiquated, contradictory and confusing, according to a recent comprehensive report on how all 50 states oversee the use of technology to deliver health care remotely.
No two states are alike in how telehealth is defined and regulated, according to the report by the Center for Connected Health Policy, an independent not-for-profit telehealth planning and technical assistance group based in Sacramento, Calif.
“Generally speaking, the policies and regulations that govern telehealth are not keeping up with where telehealth is today,” said Mario Gutierrez, executive director of the CCHP, which is partially funded by the California HealthCare Foundation. CHCF publishes iHealthBeat.
Meanwhile, the number of U.S. residents using telehealth services is expected to reach nearly 1.3 million by 2017 — a nearly six fold increase over 2012, according to a report by IMS Research released in February.
The main drivers of telehealth are expected to be federal rules including hospital penalties for 30-day readmissions and demands from providers, payers and patients, according to the IMS Research report.
CCHP Report Highlights
The report sheds light on telehealth laws related to Medicaid and the private sector in all states as of December 2012. The survey focused on 11 policy areas, including reimbursement, consent, service location, online prescribing and licensure. The report will be continually updated at a new website scheduled to launch in March.
Among the key findings:
- Forty-four states have some form of telehealth reimbursement for Medicaid programs;
- Live video was the most prominent form of reimbursed telehealth services, with 44 states paying for live video sessions;
- Seven states provide Medicaid reimbursement for remote patient monitoring;
- Ten states require informed consent;
- Nine state medical boards issue special licenses or certificates for telehealth;
- Sixteen states have laws that affect reimbursement of private payers; and
- Thirteen states have legislation pending on telehealth.
Where the States Stand on Telehealth
Some states have no telehealth laws on the books at all, including Iowa, Vermont, Massachusetts, Rhode Island, Connecticut and New Jersey.
A few stand-out states are further along in developing their laws and regulations around telehealth, Gutierrez said, such as Alaska, California, Colorado and New Mexico. But “no state really has it together in terms of being fully engaged,” he said.
State rules on telehealth use in Medicaid programs differ greatly. For instance, Colorado reimburses for remote patient monitoring at a flat fee only for a narrow set of medical conditions, such as congestive heart failure, and only when the patient requires monitoring at least five times weekly and has been hospitalized at least twice in the past year for related conditions.
Alaska’s Medicaid program, meanwhile, reimburses for a wide range of real-time telehealth services including initial or follow-up visits, psychiatric care, substance misuse treatment and consultations to confirm a diagnosis, according to the CCHP report.
Very few states reimburse for “store and forward” telehealth, whereby patient information is sent securely to providers, analyzed and then sent back to patients. For instance, California only reimburses for dermatology and ophthalmology store and forward care, the report said.
On the bright side, there is movement on the state level to modernize telehealth laws, Gutierrez said.
Finding a Balance
Even proponents of telehealth are cautioning states to not move too quickly to allow telehealth in all circumstances.
States must strike a balance between patient safety protections and supporting innovative approaches to care delivery, Greg Billings — executive director of the Center for Telehealth and e-Health Law — said.
“In some cases, I don’t envy the challenges states face in threading that needle,” Billings said.
One question states are grappling with is the criteria needed to establish a physician-patient relationship to prescribe medications. In most states today, that relationship must begin with an in-person visit. Only 13 states allow that relationship to be set up through a two-way audio and video communication, Billings said.
While the Center for Telehealth and e-Health Law is encouraging states to legitimize in their statutes on two-way audio and video communications to set up a prescribing relationship, the center is cautioning states to be careful in their approaches.
“Right now all the media coverage on telehealth is warm and fuzzy,” Billing said. “Our fear is if someone is misdiagnosed using telemedicine, the pendulum of public opinion could swing in the other direction.”
Meanwhile, there is some interest in Congress to restrict remote prescribing. Rep. Bill Cassidy (R-La.) and Sen. Dianne Feinstein (D-Calif.) last year co-sponsored the Online Pharmacy Safety Act that would have required prescribers to be a “qualified offsite telehealth practitioner,” be licensed in the state where the patient is located and conduct a medical encounter in real-time.
Licensure is “probably the most controversial area for telehealth,” Gutierrez said. “We already have a [misdistribution] of primary care doctors and specialists. If you overlay that with federal health reform, timely access will be a real challenge.”
Only a handful of states — such as Louisiana — allow out-of-state providers to render services via telemedicine, according to the CCHP report.
Late last year, Rep. Mike Thompson (D-Calif.) introduced the Telehealth Promotion Act, which would allow physicians to practice telehealth across state lines and expand federal reimbursement for telehealth services such as remote monitoring, among other provisions.
California’s landmark telehealth law, the Telehealth Advancement Act of 2011, relaxes rules on who can provide telehealth services and allow Medicaid patients to receive care via telehealth without first having an in-person visit with a provider.
Despite these changes, Gutierrez said California isn’t moving quickly enough to issue regulations on the law, which went into effect in January 2012. The bill was co-sponsored by the CCHP.
“It’s a very progressive law, but the state is moving fairly slowly to implement and describe it,” he said. “It is a bit frustrating because the law was very clear in lifting the obstacles to telehealth currently in place.”
A spokesman for the California Department of Health Care Services said a policy change on Medicaid billing for telehealth services will be released in the next 60 to 90 days.
Overall, states can do more to support innovations happening in telehealth, according to CCHP.
Moving from a fee-for-service delivery system to one based on value and quality will require the use of technology, Gutierrez said. “Telehealth has a valuable role to play,” he said. “If we are truly committed to a new paradigm of care delivery, telehealth will be a critical component.”