Wednesday, January 25, 2012

State Telemedicine Challenges

The Maryland Telemedicine Task Force is addressing the challenges to the widespread adoption of a comprehensive statewide telemedicine system in the state. The Task Force established a Leadership Committee to prepare specific recommendations on the use of telemedicine that was submitted to the Maryland Quality and Cost Council in December.

Key recommendations to improve the use of telemedicine in the state are for:

• State-regulated payers to provide reimbursement for healthcare services delivered through telemedicine to the same extent as healthcare services provided face-to-face, regardless of the location

• An interoperable telemedicine network to be built on existing standards and integrated into the state designated health information exchange. This would enable broad provider participation, allow networks to connect to other networks, and provide access to clinical information through the exchange

• Regulations to be aligned with revised CMS rules to permit privileging and credentialing by proxy, a process by which an originating-site hospital may rely upon the credentialing and privileging decisions made by distant site telemedicine entities. Future changes in licensure will be needed to enable reciprocity of licensure for physicians practicing in border states

Today 12 states covering over 106 million Americans have legislated mandates for the reimbursement of telemedicine. In most states, payers may not create barriers to care or reimbursement solely because the care is being provided via telemedicine.

In general, according to the Environmental Scan of Telemedicine Initiatives in Maryland, existing telemedicine initiatives are fragmented and oversight of the functions to render care at a distance using licensed providers and health IT rests within several state agencies. These agencies include the Maryland Board of Physicians, Maryland Health Care Commission (MHCC), Maryland Institute for Emergency Medical Services System (MIEMSS), and the Department of Health and Mental Hygiene, Office of Health Care Quality.

Some of the stakeholders involved feel that a state entity should be designated to be a lead agency with regard to telemedicine, a telemedicine Advisory Council should be established consisting of public and private representatives, the state should designate a not-for-profit private entity to provide expert guidance to telemedicine providers, and the barriers to telemedicine adoption need to be addressed.

Payment policies for telemedicine services were reviewed. Determining when telemedicine services are medically necessary or when clinically equivalent to face-to-face services are required still remains a significant challenge in setting payment.

To support adoption of telemedicine, payments must accurately reflect the cost of delivery for providers and the effectiveness of the treatments must be proven to payers and patients. Payment must be sufficient to cover actual costs but should not favor telemedicine over face-to-face services.

Paying for medical services via telemedicine is now being implemented by some states, federal programs, and private payers. A number of initiatives are underway and while there is some overlap, the initiatives are largely fragmented.

Medicare’s incremental approach to reimbursing for telemedicine was reviewed as a potential model for provider reimbursement in Maryland. Medicare’s FFS model includes reimbursement for limited professional services only and limits distant site practitioners eligible for reimbursement. Distant site practitioners are paid 80 percent of the appropriate Medicare Physician Fee Schedule amount while originating sites receive a small fee that is billed separately. Originating sites must be located in a rural Health Professional Shortage Area or in a county outside of a Metropolitan Statistical Area.

Some of the participants in the clinical advisory group identified the need to establish a demonstration project at MIEMSS to improve access to specialty center consultations for patients with time critical conditions such as acute stroke, heart attack, and trauma. The pilot program could reside in the 24/7 emergency medical resource communications center at MIEMSS and would be able to test the feasibility of providing immediate access to specialty consultants for patients with time critical conditions.

Potential benefits of the pilot would reduce unnecessary and costly transfers to tertiary care facilities, faster access to emergency interventions, and improved patient outcomes. A demonstration project might yield information around broadly deploying telemedicine that could be applied to a statewide telemedicine initiative.

Go to to view the complete report prepared for the Maryland Quality and Cost Council in December.