Telemedicine Concerns
This morning, Monday, June 27, 2016, I was reading a long article in the Wall Street journal about concerns of using telemedicine. Some of the issues which seem to concern health care providers, insurance companies, and licensing bodies are:
· What services to reimburse for and how to decide how much to reimburse.
· Insuring that the rules of each state licensing agency are satisfied.
· Possible misdiagnosis.
· Continuity of care.
I have been to numerous meetings where the efficacy of telemedicine was discussed. In my own profession of counseling, I am licensed by the State of West Virginia as a licensed professional and certified by both West Virginia and Florida as an advanced or masters-level addiction counselor. I am not licensed by the state of Florida because they decided that I would need to take four more graduate level courses including one in substance abuse despite the fact that I had just retaken and passed the addiction counselor certification exam in Florida. I cannot, in Florida, call myself a professional counselor although if I work for a federal agency such as the Veterans Administration, my West Virginia licensed is honored.
For many years, one of the questions has been whether a person licensed in one state can provide services to a person via the internet or even phone to a person living in another state. In my former office in the panhandle of WV, I was less than a mile from Ohio and only a few miles from Pennsylvania. I saw clients in my office from all three states and, of course, was required by my professional ethics and insurance companies to be available by phone to all them, no matter what state they lived in. Often, family members living in other states would join the designated clients for a family session. As far as my licensing body and the insurance company was concerned as long as I was seeing the designated client in my West Virginia office I could “see” other family members since they were not officially my client.
If had been working for an insurance company as a patient advocate or in the role of a doctor or nurse giving guidance about obtaining care I would not have been considered providing treatment. Thus, the only concern would be whether I was licensed in the state in which I was physically sitting at that moment.
Licensing and certification bodies are theoretically designed to insure that individuals providing health care and other professional services are able to provide expert, ethical care to individuals and families Yet, states cannot agree on licensing and credentialing requirements which would then allow each state to honor the license of another state even though licensing and credentialing exams are frequently national exams. A federal license with state branches to handle the logistics and to identify and oversee the treatment or rehabilitation of impaired professionals could easily replace the current state licensing and credentialing bodies.
All of these issues often overshadow the question of whether telemedicine can be used to improve access to care for patients/clients. Often individuals are not able to travel to the office of a provider. In my own case, my provider is at the Veterans Administration hospital in Pittsburgh. When I lived in West Virginia, in order to insure continuity of care, I attempted to access my primary doctor whenever possible. Since I was over an hour (more likely 1 ½ hours each way) from my doctor, the most efficient way for each of us to communicate was via email. We also on rare occasions used both land line and cell phones.
As a counselor I provided services in an area where people often lived some distance from my office. Time, gas money, and access to a safe and reliable vehicle affected the ability of individuals and families to make and keep appointments with me in my Wheeling Office. Also, some of my clients traveled for work. Emotional/psychological needs did not always limit themselves to a time when it was convenient for them to meet me in the office. In fact, I have always been required by insurance companies to be on call 7 days a week, 24 hours a day. Many physicians had the same requirement. We have been providing telemedicine via phone for many years without calling it telemedicine. Generally, we not able to charge for those services and, thus, had to insure that our office fees covered the cost of the time spent on the phone. During those days, no one questioned whether the confidentiality of the conversation with client/patient was in “earshot” of other family members. Yet, some professional agencies are now questioning telemedicine’s ability to keep a conversation private.
In my mind it is not a question of whether we are going to continue to use telemedicine. It is a question of the extent to which we can afford to use high quality video, phone and written tools to provide the best possible service for the lowest possible cost to the patient/client and the insurance company.
Let’s take the concerns one by one. The first concern is:
· What services to reimburse for and how to decide how much to reimburse?
Attorneys and some other professionals long ago figured out how to track and charge by the minute for telephone calls. With some clients who need frequent service, attorneys are paid a monthly retainer. Some health insurance companies are now exploring paying a monthly or annual fee per patient to provide whatever services are needed to keep them healthy. Of course, specialized or intensive care can be billed separately. Studies will, I believe, prove overall health care cost will be reduced if patients/clients are given easy access to their health care provider and do not wait for a crisis which often means more intensive, expensive care. Will some patients/clients need to be given some boundaries? Certainly. We health care professionals can be trained to do that with love and respect while still insuring that people can the care we are reasonably provide.
The second concern is:
· Insuring that the rules of each state licensing agency are satisfied.
I have already addressed this issue. I think that we need to move to a federal licensing and credentialing system or federal guidelines of requirements. I realize that some state licensing bodies and agencies will fight this because they are convinced that only they have the best or necessary rules.
The third concern is:
· Possible misdiagnosis.
There may need to be local general health clinics where high quality telemedicine equipment is available. Already there are emergency clinics in drug stores, grocery stores and other local facilities. Perhaps health insurance including the VA, Medicare and Medicaid could form alliances with them. Will there still be misdiagnoses? Of course there will be. Are there misdiagnoses now? Yes there are. Many studies have shown however, that, as we health care professionals practice our listening skills, stay open to the fact that we are almost always making educated guesses and use more internet tools to remind us that similar symptoms can point to a variety of diagnoses, we will improve our diagnostic ability in the office and via telemedicine.
The fourth concern is:
· Continuity of care.
My guess is that there could be more continuity of care with telemedicine than is now possible. My primary care doctor, if he is in the office , traveling on business or “out of the office” can easily communicate with me. If he is out of the office and I get a message that he will return on such and such date I can then decide if I need to see another doctor at the emergency room or the doctor on a telemedicine call. I still have more frequent and easier access than if I have to see the doctor in his office. Again, coordination with drugstores and other local clinics may also be possible. Eventually we will also have access to our medical records and will be able to share them with other health care providers.
I am very fortunate to have health care providers whom I trust to provide competent, holistic, loving care. I am delighted when I can see them in person, but they and I are busy, professional people. We have used the tools available to us. Fortunately my primary care doctor is in a salaried position. I am not salaried but have managed to combine telemedicine with office visits for fees which are affordable for all my clients and which allow me to eat. Since I am now semi-retired I do not have to be concerned about insurance company reimbursement but I know that just as many insurance companies have realized that providing gym membership is cost effective, the will discover that using telemedicine is good for their bottom line.
The final question is whether a small percentage of health care providers will abuse or cheat the system. Of course; there are some unhealthy providers. The majority are, however, committed to providing respectful, competent healing services to everyone for/with whom they work. Some are not yet comfortable with telemedicine but if the issue is getting comfortable with the tools of telemedicine, perhaps we can hire a four-year-old mentor!
Written June 27, 2016
This morning, Monday, June 27, 2016, I was reading a long article in the Wall Street journal about concerns of using telemedicine. Some of the issues which seem to concern health care providers, insurance companies, and licensing bodies are:
· What services to reimburse for and how to decide how much to reimburse.
· Insuring that the rules of each state licensing agency are satisfied.
· Possible misdiagnosis.
· Continuity of care.
I have been to numerous meetings where the efficacy of telemedicine was discussed. In my own profession of counseling, I am licensed by the State of West Virginia as a licensed professional and certified by both West Virginia and Florida as an advanced or masters-level addiction counselor. I am not licensed by the state of Florida because they decided that I would need to take four more graduate level courses including one in substance abuse despite the fact that I had just retaken and passed the addiction counselor certification exam in Florida. I cannot, in Florida, call myself a professional counselor although if I work for a federal agency such as the Veterans Administration, my West Virginia licensed is honored.
For many years, one of the questions has been whether a person licensed in one state can provide services to a person via the internet or even phone to a person living in another state. In my former office in the panhandle of WV, I was less than a mile from Ohio and only a few miles from Pennsylvania. I saw clients in my office from all three states and, of course, was required by my professional ethics and insurance companies to be available by phone to all them, no matter what state they lived in. Often, family members living in other states would join the designated clients for a family session. As far as my licensing body and the insurance company was concerned as long as I was seeing the designated client in my West Virginia office I could “see” other family members since they were not officially my client.
If had been working for an insurance company as a patient advocate or in the role of a doctor or nurse giving guidance about obtaining care I would not have been considered providing treatment. Thus, the only concern would be whether I was licensed in the state in which I was physically sitting at that moment.
Licensing and certification bodies are theoretically designed to insure that individuals providing health care and other professional services are able to provide expert, ethical care to individuals and families Yet, states cannot agree on licensing and credentialing requirements which would then allow each state to honor the license of another state even though licensing and credentialing exams are frequently national exams. A federal license with state branches to handle the logistics and to identify and oversee the treatment or rehabilitation of impaired professionals could easily replace the current state licensing and credentialing bodies.
All of these issues often overshadow the question of whether telemedicine can be used to improve access to care for patients/clients. Often individuals are not able to travel to the office of a provider. In my own case, my provider is at the Veterans Administration hospital in Pittsburgh. When I lived in West Virginia, in order to insure continuity of care, I attempted to access my primary doctor whenever possible. Since I was over an hour (more likely 1 ½ hours each way) from my doctor, the most efficient way for each of us to communicate was via email. We also on rare occasions used both land line and cell phones.
As a counselor I provided services in an area where people often lived some distance from my office. Time, gas money, and access to a safe and reliable vehicle affected the ability of individuals and families to make and keep appointments with me in my Wheeling Office. Also, some of my clients traveled for work. Emotional/psychological needs did not always limit themselves to a time when it was convenient for them to meet me in the office. In fact, I have always been required by insurance companies to be on call 7 days a week, 24 hours a day. Many physicians had the same requirement. We have been providing telemedicine via phone for many years without calling it telemedicine. Generally, we not able to charge for those services and, thus, had to insure that our office fees covered the cost of the time spent on the phone. During those days, no one questioned whether the confidentiality of the conversation with client/patient was in “earshot” of other family members. Yet, some professional agencies are now questioning telemedicine’s ability to keep a conversation private.
In my mind it is not a question of whether we are going to continue to use telemedicine. It is a question of the extent to which we can afford to use high quality video, phone and written tools to provide the best possible service for the lowest possible cost to the patient/client and the insurance company.
Let’s take the concerns one by one. The first concern is:
· What services to reimburse for and how to decide how much to reimburse?
Attorneys and some other professionals long ago figured out how to track and charge by the minute for telephone calls. With some clients who need frequent service, attorneys are paid a monthly retainer. Some health insurance companies are now exploring paying a monthly or annual fee per patient to provide whatever services are needed to keep them healthy. Of course, specialized or intensive care can be billed separately. Studies will, I believe, prove overall health care cost will be reduced if patients/clients are given easy access to their health care provider and do not wait for a crisis which often means more intensive, expensive care. Will some patients/clients need to be given some boundaries? Certainly. We health care professionals can be trained to do that with love and respect while still insuring that people can the care we are reasonably provide.
The second concern is:
· Insuring that the rules of each state licensing agency are satisfied.
I have already addressed this issue. I think that we need to move to a federal licensing and credentialing system or federal guidelines of requirements. I realize that some state licensing bodies and agencies will fight this because they are convinced that only they have the best or necessary rules.
The third concern is:
· Possible misdiagnosis.
There may need to be local general health clinics where high quality telemedicine equipment is available. Already there are emergency clinics in drug stores, grocery stores and other local facilities. Perhaps health insurance including the VA, Medicare and Medicaid could form alliances with them. Will there still be misdiagnoses? Of course there will be. Are there misdiagnoses now? Yes there are. Many studies have shown however, that, as we health care professionals practice our listening skills, stay open to the fact that we are almost always making educated guesses and use more internet tools to remind us that similar symptoms can point to a variety of diagnoses, we will improve our diagnostic ability in the office and via telemedicine.
The fourth concern is:
· Continuity of care.
My guess is that there could be more continuity of care with telemedicine than is now possible. My primary care doctor, if he is in the office , traveling on business or “out of the office” can easily communicate with me. If he is out of the office and I get a message that he will return on such and such date I can then decide if I need to see another doctor at the emergency room or the doctor on a telemedicine call. I still have more frequent and easier access than if I have to see the doctor in his office. Again, coordination with drugstores and other local clinics may also be possible. Eventually we will also have access to our medical records and will be able to share them with other health care providers.
I am very fortunate to have health care providers whom I trust to provide competent, holistic, loving care. I am delighted when I can see them in person, but they and I are busy, professional people. We have used the tools available to us. Fortunately my primary care doctor is in a salaried position. I am not salaried but have managed to combine telemedicine with office visits for fees which are affordable for all my clients and which allow me to eat. Since I am now semi-retired I do not have to be concerned about insurance company reimbursement but I know that just as many insurance companies have realized that providing gym membership is cost effective, the will discover that using telemedicine is good for their bottom line.
The final question is whether a small percentage of health care providers will abuse or cheat the system. Of course; there are some unhealthy providers. The majority are, however, committed to providing respectful, competent healing services to everyone for/with whom they work. Some are not yet comfortable with telemedicine but if the issue is getting comfortable with the tools of telemedicine, perhaps we can hire a four-year-old mentor!
Written June 27, 2016
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