On March 2, the Virginia Legislature unanimously approved a bill (SB 675) that would require private health insurers, health care subscriptions plans and HMOs to cover for the cost of health care services provided through telemedicine technology.
Virginia Gov. Bob McDonnell (R) is expected to sign the bill into law, making Virginia the 12th state in the country to adopt mandates for the coverage of telemedicine.
State Sen. William Wampler (R) and state Delegate Clarence Phillips (D) introduced similar legislation in 2009, but that bill was referred to the Special Advisory Commission on Mandated Health Insurance Benefits.
Karen Rheuban -- a pediatric cardiologist, as well as a professor of pediatrics, senior associate dean for continuing medical education and external affairs, and medical director of the Office of Telemedicine at the University of Virginia -- explained that payers are concerned about any sort of mandate and that the legislation "was tabled with the provision that we work with the payer community to try to develop a process by which they reimburse for telemedicine services."
Rheuban -- who also is the president of the American Telemedicine Association and president and chair of the Virginia Telehealth Network -- said, "So it was not thrown out, and it wasn't approved."
Wampler decided to reintroduce the bill in January, but he narrowed the scope of the legislation by using the term "telemedicine," rather than "telehealth" to ensure that it was budget neutral.
"The concern was that if it was a broader telehealth bill, which could include distance learning as well, it would be viewed as not budget neutral," Rheuban said.
The new version of the bill received unanimous approval by the Virginia General Assembly.
Effect on Telemedicine Adoption
June Collmer, interim executive director of the Virginia Telehealth Network, said she believes that the legislation "would certainly go towards facilitating more widespread adoption because reimbursement for services is an issue."
Rheuban agreed, noting that while Virginia has developed "fairly significant" telehealth networks using federal funds, private philanthropy and state dollars, she believes that "reimbursement always drives adoption."
Meanwhile, Gary Capistrant, senior director of public policy at the American Telemedicine Association, said, "One of the things with telehealth that's important is just having enough patient volume to support the networks. So any incremental increases can end up having a substantial impact in terms of ... making things viable."
CMS Reimbursement Still an Issue
SB 675 only applies to private insurers, not Medicare or Medicaid, so some say that the lack of federal reimbursement for telemedicine services still will hinder adoption.
Capistrant said, "The feds ... will pay hundreds of millions of dollars to set up networks and then not back that up with Medicare and Medicaid reimbursement or federal employee reimbursement or TRICARE."
Medicare only provides reimbursement for telemedicine for beneficiaries who live in "non-metropolitan statistical areas," Rheuban said, adding, "Quite frankly, we have many regions of the Commonwealth of Virginia and many regions of our nation that look rural, act rural [and] have specialty shortages, but don't qualify because of their proximity to an urban area."
Capistrant said, "One of the big issues will be whether Medicare gets with it or not," adding, "They are important in their own right, but they're also important as kind of an example. Everybody will take a look at what Medicare does."
Meanwhile, Medicaid reimbursement is determined on a state-by-state basis. Virginia's Medicaid program provides telemedicine reimbursement for both rural and urban Medicaid beneficiaries. Rheuban explained that Virginia's Department of Medical Assistance Services decided to cover telemedicine after seeing a financial analysis of their costs for transporting patients via taxicab or ambulance or other transportation services for outpatient care.
Other Remaining Barriers
While reimbursement certainly is a significant determinant in whether health care providers will embrace telemedicine technology, other barriers still remain.
For example, effective July 15, the Medicare Conditions of Participation standards will require hospitals' medical staff to be credentialed and privileged at every remote site.
"If CMS would prevail in their kind of hard-line attitude, this could shut down a lot of the telehealth networks that exist today," Capistrant said, adding, "It could in effect make mute the kind of action that the Virginia legislature has taken."
Rheuban said, "We're actively working with CMS and Congress ... to look at the challenges that these standards present for telehealth providers."
Another barrier is that physician licensure is conducted on a state-by-state basis, making it difficult to provide telemedicine services across state lines.
Rheuban said, "From my perspective as the medical director of a large telemedicine program, we have enough patients to take care of within our own state. But there are some states that have sufficient challenges in terms of limited specialty providers that they would truly benefit from inter-state relationships."
In addition, some physicians argue that the use of telemedicine could depersonalize the doctor-patient relationship, add liability issues and potentially lead to medical errors.
Capistrant called such concerns "completely unfounded." He said, "People don't like change, and since doctors are people, they don't like change either." Capistrant compared doctors' reluctance to embrace telemedicine technology with their earlier resistance to the introduction of the stethoscope.
Rheuban said, "As someone who has actually used telemedicine to provide care, I can say that it does not depersonalize the doctor-patient relationship at all." She added that "there is a great deal of data about the efficacy of telemedicine" and that practice guidelines and standards have been developed with specialty societies to ensure care quality.
Patients Are Interested in Telehealth
Research shows that many patients are interested in and willing to receive care via telemedicine. For example, a recent report by PricewaterhouseCoopers found that half of U.S. consumers are interested in using the Internet, computers and telephone to access health care services.
Rheuban said, "It is a huge burden for patients to travel long distances for access to care," adding, "There are so many examples of patients who have sincerely benefited just from the convenience of telemedicine and having access to high quality care."
Capistrant predicted than in five years, telemedicine "will be a much bigger deal much more part of mainstream health care in mainstream America. Right now, it's something that's very much focused on rural areas and ... isolated populations."