The symposium is designed for clinicians – physicians, nurses, nurse practitioners, physician assistants, and students – and healthcare executives interested in expanding their scope of knowledge about currently popular health policy topics.

1. Leveraging Telemedicine to
Improve Care
Megan Douglas, JD
Associate Project Director, Health IT Policy
National Center for Primary Care
Morehouse School of Medicine

2. Overview
• Define telemedicine
• Telemedicine in practice
• Policy issues
– Licensure
– Reimbursement
– Scope of Practice
• Teladoc v. TMB
• Discussion

3. Learning Objectives
• Define telemedicine
• Describe how telemedicine is being used to improve
clinical outcomes
• Identify policies that create barriers or facilitate the
use of telemedicine

4. What is telemedicine?
“Use of medical information exchanged from one site
to another via electronic communications to improve
a patient’s clinical health status”
-American Telemedicine Association, www.americantelemed.org
Includes:
• Patient consultations via video conferencing
• Transmission of still images
• E-health (including patient portals)
• Remote monitoring of vital signs
• Continuing medical education

5. Prevalence of telemedicine
• 200 telemedicine networks
– 3,500 service sites
• Over 50% of hospitals use some form of
telemedicine
• Nearly 1 million patients use remote cardiac
monitors
• 300,000 remote consultations by Veterans Health
Administration (2011)

6. Telemedicine in Practice
Primary Care
– Consultations
– Medication
management
– School-based health care
– Public health programs
– Healthcare for the
Homeless
Emergency Medicine
– Stroke
Specialty Care
– Mental health
– Dermatology
Remote Patient
Monitoring
– Chronic disease
management
– Post-surgical monitoring

7. Equipment

8. Why telemedicine?
• Increased access
– Rural
– Underserved communities
• Efficiency
– Financial
– Staff
– Travel
• Quality
– Supplement
– Substitute
– Health Equity
• Consumer empowerment
– Convenience

9. Cost
“[Hospital at Home] program achieved savings of 19%
over costs for similar inpatients...predominantly
derived from lower average length-of-stay and use of
fewer lab and diagnostic tests”
Cryer L, Shannon SB, Van Amsterdam M, Leff B. Costs for 'hospital at home' patients
were 19 percent lower, with equal or better outcomes compared to similar inpatients.
Health Aff (Millwood). 2012 Jun;31(6):1237-43.
“The simulation predicted savings of $4.3 billion per
year if hybrid telehealth systems were implemented in
emergency rooms, prisons, nursing home facilities, and
physician offices across the United States”
Pan E, Cusack C, Hook J, Vincent A, Kaelber DC, Bates DW, Middleton B. The value of
provider-to-provider telehealth. Telemed J E Health. 2008 Jun;14(5):446-53.

10. School-based health clinics
“[I]ncreased communication across the school and
specialty mental health systems and facilitated
greater input across child, parent, school personnel,
and mental health professionals”
Nelson EL, Duncan AB, Peacock G, Bui T. Telemedicine and adherence to national
guidelines for ADHD evaluation: a case study. Psychol Serv. 2012 Aug;9(3):293-7.
“[R]esulted in improvements in asthma symptom
control and quality of life similar to improvements
reported in face-to-face encounters provided by
specialists”
Romano MJ, Hernandez J, Gaylor A, Howard S, Knox R. Improvement in asthma
symptoms and quality of life in pediatric patients through specialty care delivered
via telemedicine. Telemed J E Health. 2001 Winter;7(4):281-6.

11. Stroke
“[U]tilization facilitated rapid transfers and followed
recommended clinical protocols for patients needing
serious and/or urgent attention
(e.g. stroke symptoms, chest pain)”
Ward MM, Ullrich F, MacKinney AC, Bell AL, Shipp S, Mueller KJ. Tele-emergency
utilization: In what clinical situations is tele-emergency activated? J Telemed Telecare.
2015 May 29.
“Fifty-two percent of the telemedical group achieved
excellent outcome compared to 43% of the
neurologist on-site group (P = .30)”
Fong WC, Ismail M, Lo JW, Li JT, Wong AH, Ng YW, Chan PY, Chan AL, Chan GH, Fong
KW, Cheung NY, Wong GC, Ho HF, Chan ST, Kwok VW, Yuen BM, Chan JH, Li PC.
Telephone and Teleradiology-Guided Thrombolysis Can Achieve Similar Outcome as
Thrombolysis by Neurologist On-site. J Stroke Cerebrovasc Dis. 2015 Jun;24(6):1223-8.

12. Discussion
• What have been your personal experiences using
and/or observing telemedicine?
• What patient safety issues are involved with the
delivery of health care through telemedicine?
• What are some barriers and/or facilitators to
implementing telemedicine into a medical practice?

13. Policy Issues – Reimbursement
Medicare - 1999
• Health Professional Shortage
Areas (HPSA)
• Fee-for-service only
• Limited CPT codes
• NO home monitoring
• 75%/25% fee split for
originating and distant sites
• Estimated expenditures: $60
million-$690 million
• Actual expenditures: $20,000
(301 encounters)
Medicare - 2015
• HPSA, non-MSA
• $24.83 originating site fee
• Limited (but expanded from
original) CPT codes
• No ACO reimbursement
• Actual expenditures (2012):
$5 million
Whitten P, Buis L. Private payer reimbursement for telemedicine services in the United States. Telemed J E Health. 2007
Feb;13(1):15-23.
Neufeld JD, Doarn CR. Telemedicine Spending by Medicare: A Snapshot from 2012. Telemed J E Health. 2015 Apr 3.

14. Policy Issues – Reimbursement
Medicaid
• Varies from state-to-state
• 46 states reimburse for telemedicine
– Limitations similar to Medicare (specific CPT codes,
providers, geographic location)
• 10 states reimburse for store-and-forward
• 13 states reimburse for remote patient monitoring
• 24 states reimburse for facility fee (originating site)

15. Policy Issues - Reimbursement
Medicaid
Utilization (2008-2009): 0.1% of all claims for telemedicine
ICD-9 Codes Frequency Percent ICD-9 Codes
296 33,684 29.7% bipolar
314 23,866 21.0% ADD/ADHD/Hyperkinetic disorder
295 9,186 8.1% Schizophrenia
309 6,647 5.9% Depression/Anxiety/PTSD
304 5,339 4.7% Drug addiction
300 5,280 4.7% Anxiety
311 4,989 4.4% Depression
313 4,731 4.2% Child/Adolescent emotional disturbance
312 3,518 3.1% Socialization/Manias
299 2,203 1.9% Autism/PDD
113,425 telemed
claims

16. Policy Issues – Reimbursement
Private Payers
• Varies from state-to-state
• Parity: requires private payers to reimburse same
amount for telemedicine as for in-person encounters
• 24 states have private payer parity laws for
telemedicine
– Similar limitations as Medicare (geographic location,
provider, CPT codes)

17. Policy Issues – Licensure
• Ability to practice across state lines varies from state
to state
– Federal initiatives discussed, but no action yet
• State policies:
– Physician delivering services must be licensed in state in
which patient is located
– Special purpose license or telemedicine license
• 10 states
– Exemption:
• Emergency or natural disasters

18. Policy Issues
• Informed Consent
– 28 states
• Telepresenter
– Qualifications of individual located with patient
• Scope of Practice/Practice Standards
– Different standards for in-person vs. telemedicine
encounters
– Physician-patient relationship
• Most common: Patient must be an established patient of the
physician or has had an in-person physical examination from that
provider
• Acceptable methods of establishing relationship

19. Discussion
• Which of the policy issues mentioned incentivize
providers to adopt telemedicine?
• Which of the policy issues mentioned pose the
largest barriers for providers interested in adopting
telemedicine into their practice?

20. Teladoc
• Offers services to individual consumers, insurance
carriers, health care organizations
• According to http://www.teladoc.com:

21. 2010
TMB issues
new rule
requiring in-
person
physical
exam prior to
prescribing
medications
2011
TMB letter to
Teladoc claims
physicians failed to
properly establish
Dr-patient
relationship
Teladoc sues TMB
for improper
rulemaking –
Teladoc wins on
appeal in 2014
2014
TMB issues
emergency
ruling
requiring
in-person
encounter
2015
TMB rule
effective
Teladoc
sues TMB
on federal
antitrust
claims –
Injunction
issued
Teladoc v. Texas Medical Board

22. Teladoc v. Texas Medical Board
22 TAC § 190.8. Violation Guidelines.
(1) Practice Inconsistent with Public Health and Welfare. Failure to
practice in an acceptable professional manner...includes, but is not
limited to:
(L) prescription of any dangerous drug or controlled substance without first establishing
a defined physician-patient relationship.
(i) A defined physician-patient relationship must include, at a minimum
(II) establishing a diagnosis through the use of acceptable medical practices,
which includes documenting and performing:
a) patient history;
b) mental status examination;
c) physical examination that must be performed by either a face-to-
face visit or in-person evaluation
http://www.sos.state.tx.us/texreg/pdf/backview/0206/0206emer.pdf

23. Teladoc v. Texas Medical Board
Teladoc’s claims:
TMB’s conduct has harmed competition, competitors,
and consumers:
1. New Rule 190.8 Would Harm Patients By Raising Prices And
Reducing Supply of Physician Services
2. New Rule 190.8 Would Harm Public And Private Payors By
Raising Prices And Reducing Choice
3. New Rule 190.8 Is Not Reasonably Necessary Or Narrowly
Tailored to Any Legitimate Objective
4. New Rule 190.8 Will Cause Irreparable Harm to Plaintiffs

24. Teladoc v. Texas Medical Board
Patient Safety
Consumer
Choice

25. Questions?