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Sorry, AMA: You're Wrong About Telehealth
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Alison_Diana
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Alison_Diana,
User Rank: Author
6/23/2014 | 5:34:35 PM
Re: Where are the Doctors?
Your points are good @GAProgrammer -- and living where you do, you certainly have the experience of dealing with two states simultaneously. It just seems extremely shortsighted to prevent a Minnesota doctor who's a world-renowned specialist in, say, brain cancer not to be allowed to consult or speak to a patient in California. Or make a rural patient travel 75 miles to the nearest doctor if she has a migraine if her state doesn't have any telehealth providers on-call at the time of her headache to call in a prescription for Imitrex or Zomig. The insurance industry can and should figure out the malpractice changes required. That's an insurance, not a medical or technology, problem. 

And I don't even think of this as gee-whiz tech -- although that is always a risk, you're right. I've been writing about telemedicine, off and on, for probably about 15-20 years so I get more frustrated by some of the regulatory blockades than animated by the tech. Apart from mobile adoption, prices dropping, and video improving, most of the capabilities haven't changed all that much. Sure, speed's improved but if you're talking about telehealth via phone or desktop/laptop, a lot is still the same as it was when I first covered the topic waaaay back when!
GAProgrammer
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GAProgrammer,
User Rank: Ninja
6/23/2014 | 4:01:09 PM
Re: Where are the Doctors?
I disagree with the headline, but agree with some of your points.

We should always strive to use technology in new ways to enable people and ideas. However, that "dreamer's" perspective MUST be tempered by reality. In reality, telemedicine is no different than in-person care - they are merely separated by distance. Therefore, the licensing issue still applies. If you could instantly teleport the doctor from Kansas to Alabama, would you feel the same? Don't let "cool tech" blind you to the real issues here. The doctor's are still practicing medicine in that state, and therefore, are subject to the laws and procedures of each state. This is why we have doctors that are licensed to begin with - to make sure that we have real doctors with the appropriate knowledge and proof of that knowldge.

Not to mention, if a doctor commits malpractice and he is on the other side of the country, now I have to fight a legal battle in two states, possibly requiring the patient to spend thousands of dollars to show for court cases.

I am usually against overregulation and overreach of state and federal government, but I am 100% with the AMA on this one for one simple fact - they ARE practicing medicine in another state and should be licensed as such. I actually live in a town that borders two states. Insurance companies, doctors, lawyers, all these professionals get licensed in both areas because they want to serve both areas, even when the business is all conducted by phone (no different really than a teleconference). It's just the cost of doing business. Teledocs should have to play by the same rules.
Alison_Diana
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Alison_Diana,
User Rank: Author
6/18/2014 | 9:26:46 AM
Re: Where are the Doctors?
Doctors' time is spread thin and, actually, it's one reason some think telemedicine could help. The doctor I cited in the story closed her practice after she and her husband had a child. When she wanted to return to work, she didn't want to open a new practice because of the long hours, so when she heard about becoming a full-time employee of American Well -- a situation that allowed her to practice medicine, see patients from anywhere, and have all the benefits of a f/t position -- she was very excited. She was an MD and familiar with tech, plus had a good bedside manner, enabling her to get the job, apparently. 

In other words, just as there are different personalities and ambitions across other fields, there are the same demands and drivers in medicine. In an interview for a separate story, an American Well exec told me the company has some retired doctors who don't want to work full-time, but enjoy putting in two or three days per week, helping patients. So telehealth actually expands the base of doctors by allowing physicians to work a day (or more) instead of retiring or stopping working. Also, while some areas of the country have only a few or no doctors or specialists, other regions -- such as cities like NYC, LA, etc. -- have many, many specialists. Through telemedicine, these specialists and doctors can see patients far away, who would not otherwise have been able to visit a doctor for many weeks or maybe months.

That's the main reason, @LeeB, I disagree so strongly with the AMA on its stance about being licensed within the patient's state.
Alison_Diana
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Alison_Diana,
User Rank: Author
6/18/2014 | 9:20:18 AM
Re: "...ways telehealth is used today"
One big reason telehealth adoption is being held up, IMHO, is because of the payment model and insurance: How do you figure out the fee for a video and/or audio consultation, where the patient's done the 'paperwork,' vs. a traditional in-office visit? And how do you get doctors to buy into this? As you say, too, how do you protect the system from fraud. There's already fraud in the in-office system; couldn't the virtual system encourage a surge of fraudulent claims?

We're seeing several cases where insurers are reaping the benefits of this approach. People are going to get sick and see a doctor, whether or not telehealth is an option. Some payers provide free or reduced-cost telehealth as an option; while only a certain percentage of employees use this, it's one of those benefits that saves time and money for users and doesn't cost employers money unless it's used. As to fraud/waste, businesses can use the same tools used to monitor fraud/waste in the nonvirtual world.
LeeB120
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LeeB120,
User Rank: Strategist
6/16/2014 | 9:46:50 PM
Where are the Doctors?
I can see another reason this might not work so well in most places.  There simply isn't enough doctors to do this.  You rarely get more than 5 minutes face time with a doctor on a regular scheduled or emergency visit now because they are already stretched thin for time. 
alegh
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alegh,
User Rank: Apprentice
6/16/2014 | 8:30:36 PM
"...ways telehealth is used today"
OK...I looked at the link offered as an example of telehealth today.  It's an Indiegogo fundraiser that's been running for a month, with 3 days until close.  Buyers: 4.  Total funds raised: $546 out of 60K target.

That may be the current state of telehealth.  No-one's buying.

I can't even get my FSA to cover OTC ibuprofen without a written prescription and filing the paperwork with my payroll company.  For less than ten bucks of pills.  And I still get a paper check mailed to my house for reimbursements.  (The OTC meds scam was a popular way to cash in on flex-spend credit cards.  Buy the OTC on the card.  Wait a while, then return for cash or credit.)

We have not yet realized the realities of electronic data.  We don't know how to detect and fight fraud, so we create rules to revert back to paperwork and human processing.

How will we detect and fight fraud with telehealth?  By requiring face time, and licensing checks...and more recordkeeping.  Not at all efficient.  And the geniuses who want audio and video recordings?  That's part of a medical record now.  Any idea how those records compress compared to text-based chat and email?  That will keep the storage vendors happy.

It's a barrier to slow things down until payors can figure out how to maintain or increase profitability in a pseudo-risk-averse way.
Alison_Diana
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Alison_Diana,
User Rank: Author
6/16/2014 | 5:23:50 PM
Re: Why stop at state borders?
I had not heard those stories, @Gary. They sound like a case of telehealth gone wild. Of course, telehealth -- like just about everything -- can be used in ways that seem to stretch creduility or good sense. You'd hope (and, quite frankly, expect) that payers treat patients in the same manner they'd expect their family members to be treated.  Telehealth is a terrific tool that's not right for every situation. But when it IS the right tool, both patients and providers appear to prefer it since patients can better use their time and so can physicians. 
Alison_Diana
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Alison_Diana,
User Rank: Author
6/16/2014 | 5:20:32 PM
Re: Why stop at state borders?
Not sure if you're being serious or have your tongue firmly planted in cheek (there are definite downsides to the typed word, although we do offer a video option!), but it's tough enough getting telehealth adoption widespread in the US; trying to take on worldwide adoption -- or allowing US patients to access treatment from elsewhere in the world -- sounds near to impossible, at least right now. I think there'd be issues from the patient's side, too. As a patient, you don't know necessarily whether your doctor was top or bottom of his/her class, but at least you have an idea of how good the school of medicine is, overall. When talking about a medical school in another country, you have no idea at all.
Gary_EL
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Gary_EL,
User Rank: Ninja
6/16/2014 | 4:14:51 PM
Re: Why stop at state borders?
Doctors operate under different laws in different states. Imagine a woman in Massachusetts consulting with an obstetrician in one of those states that have VERY restrictive abortion laws! I haven't heard about it for a while now, but not too long ago, there was a movement to require that people with certain types of conditions take the lowest cost provider - even if that lower cost provider was in - INDIA. The providers and hospitals involved were so inexpensive that insurance company saved money even when they paid the cost of air travel. NO THANKS. I'll be more than happy to take courses taught by Indian professors, but I'm not interested in being a patient of an Indian doctor - unless, of course, he or she is licensed in Massachusetts and practices Here.
Number 6
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Number 6,
User Rank: Moderator
6/16/2014 | 2:10:24 PM
Why stop at state borders?
Why require a license across national borders? We've already offshored manufacturing, customer support, software development, finance & accounting... why not medicine? The lawyers that make the laws won't lose anything-they've made sure that their own profession won't go offshore. If a physician can make a diagnosis and write a prescription from the next state, and surgeons can do telepresence surgery from 10 feet away, why not 10,000 miles? The FDA can already approve offshore prescription drug manufacturing. Why not a similar licensing for offshore doctors to ensure quality? We don't have a monopoly on the best doctors. Remember the first heart transplant was performed in South Africa. We'd have access to doctors that have the best skills needed regardless of where they were at and it would drive down healthcare costs. After all, isn't that the argument for offshoring IT? (insert SarcMark here)


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