Telehealth and the levers that will move the healthcare industry

Telehealth changes how care is provided at the state and national level. Telehealth policy is a determining success factor. Thinking of rolling out a telehealth program? Providing telehealth challenges providers.

There has been a lot of progress in telehealth over the last three years. In 2013 there were only 13 states that were cleared for consultation and prescribing and three states restricted consultation in the absence of a prior in-person relationship. According to American Well, a telemedicine technology solutions company by January 2016 most states had been cleared to consult and prescribe, with various exceptions in Alaska, Louisiana, and Indiana. Inconsistent state definitions create challenges for national providers. Clinical permissibility, licensure, and reimbursement remain the flagship challenges.

Inconsistent policies

It’s often said that the only thing consistent about telehealth is that it’s inconsistent.

The Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine was reported by the State Medical Boards’ Appropriate Regulation of Telemedicine (SMART) workgroup and later was adopted as policy by the Federation of State Medical Boards (FSMB) in April 2014. This new policy guided regulation of state medical boards in the use of telemedicine technologies in the practice of medicine and educates licensees as to the appropriate standards of care in the delivery of medical services directly to patients via telemedicine technologies. This policy blazed the path for telemedicine adoption by superseding the Model Guidelines for the Appropriate Use of the Internet in Medical Practices previously adopted April 2002.l 2002.

Clinical permissibility

Clinical permissibility comes down to whether or not providers can deliver care via telehealth. Mainly this discussion swirls around telehealth policy. However, the Medical Boards have made significant strides to get the policies right. Informed consent, the evidence documenting appropriate patient informed consent for the use of telemedicine technologies must be obtained and maintained. Informed consent is a primary consideration with telehealth policy and includes:

1. Identification of the patient and physician (physical credentials),

2. Types of transmissions permitted using telemedicine technologies (prescription refills, appointment scheduling, patient education),

3. Patient agreement (that it’s the physician’s decision as to whether a telemedicine encounter is appropriate),

4. Adequate security measures (data, passwords, files, identification and authentication techniques),

5. Hold harmless clause (if due to technical failures information is lost), and

6. The requirement for express consent to forward patient-identifiable information to a third party (administration, billing, care).

These six factors ensure that informed consent is appropriate. However, even after informed consent is secured other clinical issues surface. Can the provider establish a treatment relationship sufficient to prescribe using telehealth? Must a prior relationship have been established? Is this the same standard of care as a facility visit to a provider? Does this encounter include a prescription for controlled substances or does this encounter trigger a limited formulary? Each of these questions needs to be addressed and communicated to the patient, to ensure the patient understands whether of not a prior examination is required before care is administered.

These questions also weigh on the minds of the state medical and pharmacy boards and national organizations such as the American Medical Association and Federation of State Medical Boards.

Reimbursement and licensure

State legislation defines the telemedicine reimbursement models for commercial and Medicaid reimbursements. Understanding how providers expect to be paid for telehealth is essential.

Credentialing and privileging are the same challenges providers face with facility-based care models. Providers are pressured to offer a large number of health plans across a diverse network of providers. Providers must also select privileged practitioners who can provide credentialed care. It’s tough for providers to keep up with multiple state licensure for clinicians that are decentralized.

Anticipating this licensure, the Federation of State Medical Boards issued the Interstate Medical Licensure Compact Legislation. According to the FSMB, the Interstate Medical Licensure Compact offers an expedited licensing process for physicians interested in practicing medicine in multiple states. The Compact is expected to expand access to health care, especially to those in rural and underserved areas of the country, and facilitate the use of telemedicine technologies in the delivery of health care. The Compact legislation to expand access to healthcare by expediting medical licensure has been adopted by 16 states including Kansas, Mississippi, Alabama, Arizona, Idaho, Illinois, Iowa, Minnesota, Montana, Nevada, New Hampshire, South Dakota, Utah, West Virginia, Wisconsin and Wyoming.

For states without compact legislation provider complexity is magnified. While NCQA and URAC accreditation help to ensure provider quality, they don’t do much to ensure multi-state licensure interoperability.

Evidence of progress

There are 29 states including Washington D.C. that have mandated commercial reimbursement for telehealth, as of mid-2016. Several states subscribe to parity mandates, which are a form of commercial mandates that require services be paid to the same extent and at the same level as in-person services (NV, MT, MN, CO, MS, LA, ME, DE, and CT). More cautious states, offer commercial reimbursement with limitations or restrictions, that mandate coverage for commercially provided telehealth services but contain limitations and site restrictions.

As patients demand to be the CEO of their health, the healthcare ecosystem will need to work together to tackle clinical permissibility, licensure, and reimbursement before telehealth goes mainstream.

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Peter is a technology executive with 19 years of experience, dedicated to driving innovation, digital transformation, leadership, and data in business. He helps organizations connect strategy to execution to maximize company performance. He has been recognized for Digital Innovation by CIO 100, MIT Sloan, Computerworld, and the Project Management Institute. As Managing Director at OROCA Innovations, Peter leads the CXO advisory services practice, driving digital strategies. Peter was honored as an MIT Sloan CIO Leadership Award Finalist in 2015 and is a regular contributor to CIO.com on innovation. Peter has led businesses through complex changes, including the adoption of data-first approaches for portfolio management, lean six sigma for operational excellence, departmental transformations, process improvements, maximizing team performance, designing new IT operating models, digitizing platforms, leading large-scale mission-critical technology deployments, product management, agile methodologies, and building high-performance teams. As Chief Information Officer, Peter was responsible for Connecticut’s Health Insurance Exchange’s (HIX) industry-leading digital platform transforming consumerism and retail oriented services for the health insurance industry. Peter championed the Connecticut marketplace digital implementation with a transformational cloud-based SaaS platform and mobile application recognized as a 2014 PMI Project of the Year Award finalist, CIO 100, and awards for best digital services, API, and platform. He also received a lifetime achievement award for leadership and digital transformation, honored as a 2016 Computerworld Premier 100 IT Leader. Peter is the author of Learning Intelligence: Expand Thinking. Absorb Alternative. Unlock Possibilities (2017), which Marshall Goldsmith, author of the New York Times No. 1 bestseller Triggers, calls "a must-read for any leader wanting to compete in the innovation-powered landscape of today." Peter also authored The Power of Blockchain for Healthcare: How Blockchain Will Ignite The Future of Healthcare (2017), the first book to explore the vast opportunities for blockchain to transform the patient experience. Peter has a B.S. in C.I.S from Bentley University and an MBA from Quinnipiac University, where he graduated Summa Cum Laude. He earned his PMP® in 2001 and is a certified Six Sigma Master Black Belt, Masters in Business Relationship Management (MBRM) and Certified Scrum Master. As a Commercial Rated Aviation Pilot and Master Scuba Diver, Peter understands first hand, how to anticipate change and lead boldly.