telehealth

Direct-to-consumer retail health options are fast-growing in the U.S. health ecosystem. CVS Health brought three telemedicine vendors to its pharmacy brick-and-mortar stores. CVS also acquired Target's pharmacies, expanding its retail health footprint. Rite Aid has added HealthSpot kiosks to its pharmacies, while Walgreens expanded its relationship with MDLive. And, Cox Cable acquired Trapollo to bring remote health monitoring into subscribers' homes.

Coupled with the growing supply side of telemedicine vendors, the latest National Business Group on Health survey found that most large employers plan to expand the telemedicine services they offer. Three in four large employers (74%) plan to offer telemedicine to workers in 2016, a dramatic increase from 48% in 2015. This trend is part of business' continued challenge of bending corporate cost curves for health and designing the health benefit to deliver lower-cost, convenient on-ramps to health care for employees looking for lower-cost services paid out by their own high-deductible health plans.

As telemedicine mainstreams to Main Street, what does the growth of retail health, enabled through technology, mean for health care providers?

Health industry stakeholders who caution against the growth of retail telemedicine warn about the potential of further fragmenting care delivery -- a real risk. How can retail telemedicine bridge back to a patient's medical home, primary care provider and electronic health record to ensure continuity of care?

Depending on how Cox Cable rolls out their telehealth offering, the project might provide a good example of how to leverage retail/home convenience while working with an established and respected health care provider.

In a release about the Trapollo acquisition, Asheesh Saksena, executive vice president and chief strategy officer at Cox Communications, said, "We believe that the home will be an increasingly important node within the health care delivery architecture."

Trapollo already has been working with employer benefits, senior living and disease management programs. Furthermore, Cox signed a joint venture with Cleveland Clinic earlier this year to form Vivre Health and is an investor in HealthSpot, the health care kiosk company that is also channeling through Rite Aid pharmacies.

A Strategy& consumer survey found that the same percentage of consumers (about 40%) trust large retailers and digitally enabled companies as trust health care providers to help manage their health. Underneath this statistic is consumers' belief that they can "trust to receive quality care at lowest cost." That trust is grounded in transparency, the kind of which health consumers -- consumers -- find in retail and eCommerce shopping formats, say in a pharmacy with posted prices in urgent care clinics delivered through a trusted store brand, on Amazon (where in some communities goods can be delivered same-day or, via Prime, in 2 days) or through one of the growing health data ecosystems growing at Apple, Google, Microsoft, Samsung or Under Armour.

There are signs that health care providers are warming up to telemedicine used by consumers for self-care. The American Association of Medical Colleges observed that a "growing body of research substantiates telemedicine's effectiveness." The American Academy of Family Practice convened a panel where Jason Mitchell, director of AAFP's Center for Health IT, asserted that, "Telemedicine is not different medicine. It's a different interaction. It's an integration of technology and care."

However, the American Medical Association adopted a telemedicine policy that focuses on the technology as a "foundation for physicians to utilize ... to help maintain an ongoing relationship with their patients, and as a means to enhance follow-up care, better coordinate care and manage chronic conditions," believing that a patient-physician relationship must be established before the telemedicine contact "to ensure proper diagnoses and appropriate follow up care."

There are signs, though, that many consumers would welcome the opportunity to interact with a physician who is not their medical home in favor of just-in-time convenience, access and price. Sixty-four percent of American consumers told the American Well 2015 Telehealth Survey that they would see a doctor via video. Consumer research among Millennials shows them to be somewhat less concerned about establishing an ongoing relationship with a physician than Baby Boomers and older patients, favoring convenience and cost.

Certain parts of the legacy health system -- nurses, pharmacists and doctors (that is, "my" doctor) -- have long enjoyed consumers' trust, according to the annual Harris Poll and Gallup Poll. Those pharmacists working in community pharmacy settings have a leg up on the nurses and doctors when it comes to retail convenience and price transparency.

Can doctors, nurses and hospitals (a trusted institution compared with, say, Congress and car dealers, the Harris Poll shows), combine their consumer trust equity with telemedicine and EHR technology to ensure care continuity and quality? This is the challenge that health care providers face in the growing world of consumer-driven retail health.

Telehealth has the potential to solve some of health care's most persistent problems -- high costs and access to care, in particular -- but concerns about reimbursement, licensure and standards stand in the way of realizing the technology's promise, stakeholders said at the American Telemedicine Association's 2015 Fall Forum.

"It's a new solution to old problems, but we can't innovate for the sake of innovation," ATA President Reed Tuckson said. Instead, these technologies "must deliver on quality and improve cost effectiveness so as to sustain access to care that meets the needs of people around the country."

Tuckson was among several speakers at ATA's 2015 Fall Forum in Washington, D.C., who highlighted telehealth's potential to improve health care, the barriers limiting adoption and the steps necessary to overcome those hurdles.

The Potential of Telehealth

"Telemedicine is another tool in clinicians' tool boxes," Randy Schubring, director of state government relations and health policy development at the Mayo Clinic, said. "We see how it can supplement our current services."

Stakeholders noted that telehealth can:

• Empower consumer choice and allow patients to decide how they want to receive care;
• Expand the availability of providers in locations with physician shortages; and
• Reduce disparities in access to care resulting from limitations in mobility and transportation.

Adam Pellegrini, vice president of digital health a Walgreen, said, "Telemedicine is a way to remove friction and make things convenient."

What's Standing in the Way?

Despite the benefits, speakers said several barriers are hindering widespread telehealth use.

Reimbursement

"One of the biggest barriers to adoption is reimbursement," Kristin Schleiter, senior legislative attorney at the American Medical Association, said. "More physicians would use [telehealth] if they were paid for it."

There is no "widely-accepted" telehealth reimbursement standard for private payers, according to the Health Resources and Services Administration. Some insurers reimburse for a variety of services, while others have not yet developed comprehensive policies for doing so.

Meanwhile, Medicare covers certain telehealth services, such as:

• Diabetes self-management training;
• Remote consultations;
• Pyschotherapy; and
• Smoking cessation services.

But Medicare will only reimburse for telehealth services under certain conditions. For example:

• Office visits and consultations must be provided using an interactive, two-way telecommunications system with real-time audio and video;
• The originating site (where the patient is) must be in a Health Professional Shortage Area or in a county that is outside of any Metropolitan Statistical Area; and
• The originating site must be a medical facility, not the patient's home.

There was a consensus among speakers that Medicare's coverage and reimbursement options for telehealth should be more flexible. They also noted that there is a need for more private coverage.

"The best thing" that the federal government can do is expand Medicare reimbursement for telehealth services, Cybil Roehrenbeck, counsel at Kilpatrick Townsend said, noting that "then private payers will follow suit."

She added that "a lot of states have reimbursement parity laws" that require private payers, and in some cases Medicaid, to reimburse for telehealth services to the same extent and in the same amount as care provided in person.

Right now, 29 states and the District of Columbia have enacted telehealth parity laws, according to ATA. Other states have legislation pending, while 13 have no telehealth parity legislative activity as of this year.

One federal bill (HR 2948), called the Medicare Telehealth Parity Act, aims for a three-phase approach to align Medicare telehealth visits with in-person services. Among other things, it would:

• Allow Medicare reimbursement of telehealth services in rural, underserved and metro areas;
• Expand the list of reimbursable providers to include physical therapists and speech pathologists, among others;
• Expand telestroke services;
• Allow for remote patient monitoring of chronic conditions, such as heart failure and diabetes; and
• Allow Medicare beneficiaries' homes to be the site of care for some outpatient services, dialysis and hospice.

Rep. Gregg Harper (R-Miss.), who co-sponsored the bill, said that under the measure, "providers could see more patients in a day and conceivably be better compensated by seeing more patients if we get into a parity situation."

He added, "You can have the greatest tech in the world, but if you can't get reimbursed for it or paid for it, it stifles that innovation for future use."

Standards

Another common theme during the conference was trying to decide who or what entity should define the evidence-based standards of care in the telehealth sector. Speakers concluded that the lack of comprehensive standards is holding back widespread telehealth use.

Peter Antall, president and CMO at American Well, called telehealth standards the "Wild West."

"Standards are being developed, but we need more," he said. "We need more research. We need associations and academies to be more proactive."

Speakers throughout the conference offered some ideas.

Schleiter said that "many expectations don't change when practicing medicine," whether it's in person or online. That's why, she said, "medical boards have a role in setting these standards, because they protect public health through licensing and regulation and ensuring physicians comply."

Tay Kopanos, vice president of health policy and state government affairs at the American Association of Nurse Practitioners, said those conversations should happen among "clinicians, professional associations, regulators and policymakers to ensure we strike the right balance between patient protections and quality and assured access to care."

Interstate Licensure

Interstate licensure and whether physicians can provide services across state lines is another major issue as telehealth networks try to expand, Schubring said.

"In some cases, physicians have five licenses to their name. That's a major administrative burden," he said.

According to ATA, state-by-state approaches to licensure can:

• Create economic trade barriers by "artificially protecting markets from competition"; and
• Restrict treatment options.

Marina Lao, director of policy planning at the Federal Trade Commission, said licensure practices "ensure that only competent stakeholders are treating people."

However, she suggested that states apply an antitrust law concept "called the least restrictive alternative," which "means even when regulation is necessary, what we should try to do is choose the least restrictive means to accomplish that legitimate activity."

The American College of Physicians has made several policy recommendations for the use of telemedicine in primary care, noting that the potential benefits of the practice must be weighed against its associated risks and challenges, FierceHealthIT reports.

The recommendations were published in a position paper in the Annals of Internal Medicine.

Position Paper Details

According to FierceHealthIT, the paper is a follow-up to one written in 2008, when the ACP addressed the use and effects of various technologies, such as:

• Electronic health records;
• Patient portals; and
• Telemedicine (Hall, FierceHealthIT, 9/8).

In the new position paper, ACP said it supports the expanded role of telemedicine in health care for its potential benefits (Feller, UPI, 9/8).

However, the organization noted that policymakers and other stakeholders must bolster oversight and develop implementation guidelines and policies that mitigate the risks of telemedicine (Gruessner, mHealth Intelligence, 9/8).

Recommendations

Specifically, ACP recommended that:

• Physicians ensure their use of telemedicine is compliant with federal and state security and privacy laws;
• Physicians protect themselves against liabilities and ensure their liability coverage has provisions for telemedicine;
• Telemedicine services be held to the same practice standards as those for in-person visits; and
• Telemedicine services support all patients, taking into account literacy levels, affordability and availability of technology and Internet access, as well as ease of use.

ACP also said that:

• Physicians should use their professional judgment to determine when the use of telemedicine is appropriate for a patient; and
• Valid patient-provider relationships must be established, noting that physicians with no prior direct contact with a patient before a telemedicine visit should take steps to establish the relationship or consult with another physician who has a relationship with the patient.

Meanwhile, ACP said it supports:

• Establishing a streamlined process for obtaining multiple medical licenses to allow providers to offer telemedicine services across state lines;
• Committing federal funding to support the infrastructure necessary for telemedicine services;
• Allocating federal funding to establish an evidence base for the safety, efficacy and cost of telemedicine;
• Lifting geographic restrictions that limit Medicare reimbursements for telemedicine services that originate outside of Metropolitan Statistical Areas or for patients who live or receive services in a Health Professional Shortage Area;
• Providing reimbursement for "appropriately structured" telemedicine communication, noting that such services are a comparable alternative to face-to-face encounters;
• Using telemedicine as a way to enhance patient-provider collaboration, improve outcomes and increase access to care; and
• Allowing hospitals to "privilege by proxy" under a CMS rule that lets facilities rely on information from the originating site of telemedicine services when providing medical credentialing and privileging for those who provide the services (ACP release, 9/8).