Telemedicine is one of the great healthcare promises of our time. So why isn't it everywhere? Because no one has figured out how to bill patients yet.
It’s hard not to second-guess the school nurse. If they make the all-clear call after an incident, you want to trust the school’s judgment, but only because the alternative is a pain in the ass. You must leave work, pick up the kid, and then call your pediatrician on your way there, hoping that they are able to see your kid in a reasonable amount of time. A half-day later, you probably get verification on that bill of health. If only you trusted the nurse. If only there was another way.
This scenario is part of the reason a growing number of clinics, hospitals, and other healthcare professionals are starting to develop telemedicine systems. Instead of whisking your kid off to some distant room, the idea is that you set an appointment to meet your doctor over a Skype-like video call, getting care wherever you happen to be. Instead of taking that nurse’s call on their experience, you make it a three-way correspondence with your doctor. Judgments are made in real-time. Everyone is happier.
Dr. Anthoney Lim, Medical Director of the Pediatric Emergency Department and Pediatric Short Stay Unit at Mount Sinai Beth Israel is setting up a telemedicine system within some New York City schools that works just like this, giving a school’s nurse the ability to rope in someone on Dr. Lim’s team for a second opinion.
“Just because there’s the highest concentration of doctors to patients in the world in New York City certainly doesn’t mean that students should come out of school for things that they may not necessarily need to come out of school for,” Lim says. “What we offer is an additional resource — us offering that extra level of ‘I have a physician who specializes in the case of pediatric emergencies available for support’ is a value add for keeping our kids healthy.”
The technology has been there for years — it requires little more than the marriage of a smartphone camera with secure software. And numerous studies have found that telemedicine would make doctors’ offices more efficient, especially by improving access to families who live far away from the nearest or best doctors. So where’s our telemedicine? It turns out the delay of it all comes due to one rather large catch: paying for it. Healthcare’s Achilles heel is often billing (from overcharging to ever-fluctuating yet somehow outdated billing codes) and with telemedicine, this is not different.
“That is the work in progress now,” says Lim when asked how his team would charge for these consulting sessions and whether it would be the school, the student’s family, or some insurer along the way who’d get stuck with the bill.
“The landscape of billing and coding in this new sphere of healthcare changes every day,” he says. “There are changes in coding and what diagnoses are available, what billing codes are available, where you can call from and where you can call to — they can all can change on a quarterly basis and it’s difficult to keep up with those things.”
It’s no longer novel or interesting to make the moral of a story that American healthcare is confusing and difficult to navigate. But every telemedicine expert who spoke to Fatherly specifically identified reimbursement as one of the main hurdles blocking more widespread deployment of remote healthcare — and none of them were able to succinctly explain how Medicaid handles telepediatrics.
“The rules are state-specific. Different states have different rules both generally for telehealth and specifically for Medicaid,” says Dr. Saira Haque, the Director of Telehealth Research at the research and development firm RTI International.
“Is it the same as a face to face visit? Are there some services that aren’t covered? Are there requirements that the patient has to be located in an underserved area? There are all these different requirements and the landscape is changing every year,” Haque adds.
In response to questions about reimbursement protocols, a spokesperson for the Centers for Medicare and Medicaid Services sent links to resources that lay out some of the restrictions and requirements for getting remote healthcare. In general, the resources suggest that remote medical care would cost patients the same amount as in-person care — once those conditions are met. The spokesperson also cited a press release from April suggesting that comprehensive telehealth would be coming soon to Medicare and Medicaid recipients.
But even if the out of pocket cost is the same, a remote doctor’s appointment means lower transportation costs, less time off work for parents, and less valuable class time missed for kids.
All the same, the bureaucratic confusion surrounding the emergence of telemedicine illustrates how technology and policy almost never develop at the same rate. Dr. Shalini Manchanda, an otolaryngologist and the Director of the Indiana University Health Sleep Disorders Center, has experienced difficulty helping her patients navigate all of the special rules that come with Indiana University’s new telehealth portal.
“Some of my patients are winter birds. They’ll go away to Florida and they’re like ‘Hey, we can call you’,” Dr. Manchanda said, “I’ll say ‘no, you have to be in Indiana.’ I have an Indiana license, so if I’m going to bill you, you have to be in the state.”
“That’s something that people don’t understand: you have to be in the state. When I schedule my patients, we tell them you have to be in Indiana, you can’t be driving,” Manchanda, who primarily treats adults for sleep disorders, added.
Many states require that patient, doctor, and medical facility all reside within the same state, both legally and whenever the remote appointment happens to occur, explained Haque. That’s because doctors are licensed on a state-by-state basis, and beyond that, they need to be credentialed at every single facility at which they offer care.
“It’s a sophisticated barrier, because it takes a lot of time, it might be for one or two patients,” Haque said. “Some hospitals require a board meeting. By that time the patient might already be out of the hospital. And then the reimbursement issues are at play: will that provider even be reimbursed?”
It’s also difficult for doctors or advocates to convince medical institutions to sign on for the initial cost of a new telemedicine program — and the confusion surrounding reimbursement doesn’t help. After all, it’s not like doctors can just Facetime patients. Indiana University, Dr. Manchanda explains, recently set up its own video chatting portal — a necessary step to ensure medical privacy for patients and a productive appointment for doctors.
“It’s a very convenient resource — the patients I have that utilize the technology do really like it,” said Dr. Andrew Cunningham, a family medicine physician at Indiana University Health who treats children over the new video platform.
Like Cunningham, the doctors who spoke to Fatherly were generally optimistic about the future. They all spoke about how much more convenient healthcare could become if patients could consult doctors from their homes — or their kids’ schools, in Lim’s case.
“To come to see a doctor is for some a half-day adventure, and for some a full day adventure if they live far away,” said Manchanda. “And for sub-specialists, many do live far away. If we are able to accommodate those patients, that’s better.”
Haque, the researcher from RTI, mentions that her team studied a provider network — she couldn’t share too many specifics because the study hasn’t yet been published — that connected its various locations through a telemedicine system. Within the system, doctors who spoke the same language as patients could connect over a video call at whichever location of that particular network was nearest the patient’s home — a significant improvement over the status quo, in which those language-barrier-affected patients had to travel significantly farther just to find a doctor with whom they could communicate.
“They couldn’t replace all face to face visits, typically there are some parameters,” Haque said. “But even if you can minimize or alternate face-to-face visits, that can really make a big difference for those patients.”
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