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3 Critical Issues to Unleash the potential of Telehealth

Posted by Michael Greiwe, MD | April 3, 2018 |
Michael Greiwe, MD

I’ve written previously about the wonderful ways telehealth can improve and expand your practice, as well as the ways it can give you happier, healthier patients. I believe telehealth can provide tremendous benefit, but I’m not so naïve as to think that it’s a simple matter of getting a bunch of videoconferencing equipment and implementing it in your practice. It’s been a long time since the 1940’s when radiology images were first transmitted for real-time assessment, and while the beginnings were slow, telemedicine is finally taking off.

Technology has boomed during that time, but until recently, telehealth has not grown as quickly. There has been lots of literature on barriers to implementation of telehealth. Looking through all of it, I see 3 critical issues that jump off the page we need to address for telehealth to be successful.

1. Reimbursement

It’s really easy to get excited when I see all the potential innovation telehealth can bring (It’s why I believe in Ortholive so much). However, if we can’t figure out how to be reimbursed by payers, telehealth ceases to be a great tool and instead is a novelty.

It’s like the boat in your neighbor’s driveway. It’s fun to show off and lots of heads turn, but you’ll notice he isn’t actually on the lake much.

The payer that is the most stringent is also the one with the deepest pockets: Medicare. Medicare has demanded that you be physically located in a doctor’s office for them to pay for the overwhelming majority of visits. In 2014 only 0.2% of beneficiaries had a telehealth service covered.

However, there are a lot of exciting changes happening that, if not completely knocking down the barriers, are at least making doorways. One exciting development is with the move towards bundled payments where value is being appreciated more than volume for service. Postoperative telehealth consults via telehealth can be included in the bundled payment. Unfortunately rehab and physical medicine procedure codes still are only covered for an in-person visit.

We are seeing some really interesting developments at the federal level in revamping the telehealth parts of Medicare. The CONNECT for Health Act and the Medicare Telehealth Parity Act are just some of the proposed legislation aimed at easing restriction on how telehealth can be used under Medicare law. The Federal spending bill of February 2018 greatly expands the role of telehealth under Medicare.

All of these laws have broad bipartisan support, so we should continue to see progress on the federal level. States have done a lot to not only reduce barriers to telehealth, but sometimes even promote its use amongst private payers and Medicaid. Over 29 states have enacted these laws which, to different degrees and ways, require insurance companies to reimburse for telehealth services the same as in-person visits. Thankfully, there has been a massive improvement in the private payer side, and it appears that Medicare is now rushing to catch up.

Not all of the friction is gone, but federal and state governments have certainly reduced some rough edges.

2. Physician Licensure and regulations

Another big issue for physicians is licensing. It’s hard for telehealth to expand across state lines because of state-specific medical license. You have a medical license for the state you live in, but you need another license for the state your patient is in. It’s mostly paperwork to be sure, but government paperwork is rarely ever easy, and you can be sure that there are plenty of fees attached.

We want telehealth to save us time and make us money. So how can we fix this?

Thankfully there is robust discussion occurring around interstate license compacts. We have seen them work great with nursing licenses, where nurses licensed in one state of the compact can practice freely in the other states. The Federation of State Medical Boards has created a language framework so that states can create an Interstate Medical Licensure Compact.

These compacts allow for licensure in each state to be much less of a hassle. States still get to make patient safety a priority, but you spend less time having to jump through hoops.

Another group looking to give a fresh perspective to the issue of state-specific licensure and telehealth is the Federal Trade Commission. From their point of view, it’s all about competition. There’s talk they will be taking a hard look at state licensing bodies and making sure that it isn’t anti-competitive to place extra burdens on providers who use telehealth than those who don’t. It’s a novel idea, but some of our best solutions are “off-label.”

3. Limited Broadband Access

If we want patients to be able to interface with us through telehealth, they need to be able to transmit large amounts of data. They need broadband. However, in many areas of the country, patients have limited or no access to the broadband required to support telehealth.

The health clinic and organizations in these rural areas may have broadband, but it operates at about one-fifth the speed necessary to support telehealth. Montana recently saw the breadth of this problem.

A bill designed to create standards for telehealth was voted down because half the residents there don’t have access to the broadband needed for the video stream required for telehealth. It’s the reason several coalitions have petitioned the FCC to increase the cap on telemedicine from $400 million to $800 million for the Rural Health Care program which financially supports telemedicine capability in rural healthcare organizations. This could go a long way toward building the kind of infrastructure needed to build robust telehealth for non-urban areas.


These are by no means the only issues raised with telehealth treatment of patients, but they are the “giants.” Like any giant, they are imposing. But one by one we are seeing them cut down to size. In the near future we will be able to step right over them and do what we were trained to do: take care of patients.

Topics: About Telemedicine, Provider, Practice

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