The Supreme Court's 5-4 decision upholding the federal health reform law paves the way for wider adoption of telemedicine, experts said. Still, roadblocks remain that are preventing the technology from becoming truly mainstream.
Those roadblocks include adequate payment mechanisms, provider credentialing and support for fostering innovation in the sector.
"The Supreme Court decision opens a door to more creative and more accepted uses of telemedicine," Neal Neuberger -- executive director of the Institute for e-Health Policy -- said, adding, "The whole goal of the Patient Protection and Affordable Care Act is to reform the way health care is delivered and improve access. We are pretty sure that telehealth will have a serious impact there."
The telemedicine industry is rapidly expanding and evolving in the private sector, so if the Supreme Court had struck down the law, it wouldn't have halted the march toward adoption, according to Molly Coye, chief innovation officer at the University of California-Los Angeles Health System.
"But we would have easily lost a year or a year-and-a-half," Coye said.
Telemedicine in the ACA
The Affordable Care Act included telemedicine in some of its provisions. For instance, the Center for Medicare and Medicaid Innovation, which was created by the law, is funding pilot programs in telemedicine and remote health care services.
At least 18 telemedicine programs nationwide have received federal funds totaling more than $120 million through CMMI. The programs mostly focus on targeting patients with chronic diseases for interventions via telemedicine supported by a team of clinicians, according to a list of CMMI grantees.
Jonathan Linkous, CEO of the American Telemedicine Association, said these pilot programs are important, noting that telemedicine is moving beyond its roots as an academic pet project serving rural areas.
Telemedicine is being rapidly adopted by hospitals with multiple facilities to link specialists in different locations, and it is being deployed for home care, as well as care at the workplace and care through mobile devices.
"It's become more of a business decision that involves a host of issues that weren't even a factor a few years ago," Linkous said.
John Ryan, telehealth business director for home monitoring at Phillips Healthcare, agreed. "It's an incredibly broad category," Ryan said, adding, "Telehealth means a lot of different things."
Ryan said the ACA is spurring innovation in the sector because of the law's provisions that nudge the health care system away from the traditional fee-for-service model and towards tying payment with quality. For instance, the law ties Medicare reimbursement to hospitals' success in keeping patients from being readmitted within 30 days of discharge.
"Now there's a financial incentive to keep people at home rather than get readmitted," Ryan said. "Hospitals are looking for solutions to reduce their 30-day readmission rates."
Phillips Healthcare provides home monitoring services such as smart medication dispensers, interactive scales and other devices that take and assess vital signs.
Ryan said these home devices and services are increasingly valuable to providers working in new payment models such as accountable care organizations, which are supported in the Affordable Care Act. To date, more than 100 organizations nationwide have signed on to participate in Medicare's accountable care programs. Over time, participating providers will share savings as long as they reduce the cost of care and hit quality targets.
Telemedicine can help providers achieve these goals, Ryan said. "Providers will be looking for evidence that solutions lead to better outcomes," he said.
However, much of health care today is still paid through fee-for-service, and payments for telemedicine services are restricted to certain types of care and for rural areas under current law. This limits the adoption of telemedicine, Linkous said.
The federal health reform law didn't waive these restrictions on reimbursement, despite requests from telemedicine advocates. The law also didn't address credentialing of clinicians across state lines so they could treat patients in remote locations.
"The administration intends to have telemedicine be deployed and widely accepted, but if we can't cut the stupid red tape that's in the way, it can't get done," Linkous said.
ATA is now working on a legislative fix to allow for broader Medicare and Medicaid reimbursement for telehealth services, which it hopes Congress will pass in the next two to three years, Linkous said.
"There are a few glitches to be worked out," he said
Some states have approved legislation to remove some of these roadblocks, Neuberger said. On a federal level, there is a certain reluctance to "open the floodgates because of concerns about abuse," Neuberger said. "That's been my impression."
Coye said while the Affordable Care Act didn't create new problems for telehealth, "there were opportunities that could have moved things along."
The Supreme Court's decision to uphold the individual mandate requiring people to carry health insurance will help fund telemedicine innovations, Linkous said.
However, the high court also ruled that the federal government can't compel states to expand their Medicaid programs to eligible individuals up to 133 % of the federal poverty level, raising concerns about uncompensated care costs to safety-net providers. The reform law included a requirement that states expand the program starting in 2014 or lose all Medicaid funding. The Medicaid expansion was expected to cover an estimated 17 million people.
Now, more than half a dozen Republican governors -- including those in Florida and Texas -- have announced they will not expand Medicaid. This could create financial troubles for hospitals in those states.
Bruce Seigel -- president and CEO of the National Association of Public Hospitals and Health Systems -- said in a statement that he is very concerned about states opting out of the expansion.
"Safety-net hospitals and health systems lead innovation in quality of care and access, and do so with limited resources," Seigel said.
Hospitals are where much of the innovation in telemedicine today is happening, Linkous said, and so adequate funding is necessary.
"It will create interesting questions in terms of payment for electronic services," Linkous said of the Medicaid expansion decision.
Demand for Telemedicine To Continue
Still, with millions of Americans compelled to purchase insurance, primary care physicians, specialists and other clinicians will be in greater demand. Telemedicine has the ability to alleviate that pressure by connecting physicians to patients across geographies, Linkous and others said.
And telemedicine can create new career opportunities, Coye said. "It's a huge culture change and a new workforce that's required," she said, including data analysts, coaches and tech support. "You need to have your 'geek squad' to help people like the elderly and those with chronic diseases get comfortable with the technology," Coye said.
Overall, telemedicine enjoys broad bipartisan support for these and other reasons. "Fortunately telemedicine is not politically charged," Linkous said.