Analysis of expansion of access to care through use of telemedicine and mobile health services

12 Pages·1993·0.57 MB·English

by  Grigsby, Jim

AnalysisofExpansionofAccesstoCare
ThroughUseof
TelemedidneandMobileHealthServices
TELEMEDICINEPOUCY:
COVERAGEANDPAYMENT
by
JimGrigsby,Ph.D.
February1995
CenterforHealthPolicyResearch
Denver,Colorado80222
Thisreportispartofthestudyentitled"AnalysisofExpansionofAccesstoCareThroughUseof
TelemedidneandMobileHealthServices,"fundedbytheHealthCareFinancingAdministration
(HCFA),DepartmentofHealthandHumanServices(ContractNo.500-92-0046)totheCenterfor
HealthPolicyResearch.
TELEMEDICINE: COVERAGEANDPAYMENT
A. INTRODUCTION
Report3underthiscontractdealtwithqualityassurance,utilizationreview,coverage,and
paymentpolicyfortelemedicine(Grigsby,Barton,Kaehnyetal.,1994). Thepresentmanuscripthas
asitsfocusseveralissuesrelatedtocoverageandpayn.entpolicy. Ourintentwastoexaminethe
issuesinsomewhatmoredepththanwasdonepreviously. Towardthatend,adraftmanuscriptwas
preparedanddiscussedwithseveralindividualsknowledgeableinpaymentpolicy. Theircomments
havebeenintegratedintothisversionofthereport
ThetaskofwritingthispaperwascompUcatedbythefactthatthereexistfewdatauponwhich
recommendationsmaybemade.Becausetelemedicineprogramsareonlynowbeingestablished,and
becausepatientvolumesarelow,ithasnotbeenpossibletocollectvaliddataregardingthecostsor
effectivenessoftelemedicine. Evenrelativelysimplequestionsremainunanswered. Forexample,
istheworkdonebyaspecialist using telemedicineequivalent totheworkdonebythatsame
specialistinthecourseofa face-to-facepatientcontact? Withoutanswerstosuchelementary
questions,itisnotclearhowtocodetelemedicineservicesforMedicarebillingpurposes.
AsnotedinthereporttoCongressofthePhysicianPaymentReviewCommission(PPRC,
1994),"thelimitingfactorforgoodcoveragedecisionstodayisthelackofhigh-quaUtyinformation
onwhich tobasethem. Because health plansgeneiallydonot gatherprimarydata to usein
technologyassessments,theassessmentstheyperformdependheavilyontheevidenceavailable.They
typicallyfindthatfew,ifany,relevantrigorousstudieshavebeendone"(p.223). Itisthusnot
surprisingthatthisshouldbethesituationvisavistelemedicine,especiallygiventhatmostexisting
telemedicineprogramshavebeeninoperationforlessthanthreeorfouryears,andgiventhesudden
developmentofpowerfulmarketforcespushingforexpansionandapprovaloftelemedicine.
B. GENERALISSUESINCOVERAGEPOUCY
1. NewTechnologiesandHealthCareExpenditures
Historysuggests thatcoverageoftelemedicinewill increaseMedicareexpenditures. The
introductionofnewhealthcaretechnologiestendstobefollowedbytheirrapidproliferationand
subsequentincreasesinspendingformedicalservices. Moreover,itisreasonabletoanticipatethat
telemedicinewillincreaseaccesstocare,furtheraddingtoMedicarecosts. Asthepurchaserof
healthcareservices.Medicareisfacedwiththechallengeofcoveringsafeandeffectivemedicalcare
while avoiding excessive expenditures. This involves the establishment of a coverage and
reimbursementstructurethatisfairtoprovidersandpatientswithoutbeingtoocostlytoMedicare.
2. ConceptualDifficultieswithTelemedicineCoverage
Unlikemosttechnologicaladvancesinmedicine,telemedicineisnotusedforthediagnosisor
treatmentofspecificconditions. Instead,telemedicineisamediumviawhichawiderangeofservices
maybeprovided(PeredniaandAllen,1995). Ineffect,itextendsthereachoftheprovider'soffice.
Itoffersnothingthatcannotbedonecurrentlybyaphysicianinhisorheroffice,andinfactitis
capableofprovidingfewerservicesthanconventionalmedicalcare. Mostofthesearediagnosticor
consultativeinnature,withthepossibleexceptionofcertainpsychiatricservices.
TheCenterforHealthPolicyResearch,Denver,CO I
Inprinciple,iftelemedicineisprimarilyanextensionoftheproviderandnotanewdiagnostic
ortherapeutictool, itlogicallyoughttobetreatedlikeconventionalmedicalcare. Thereare,
however,severalcomplicatingfactors. First,fromtheperspectiveofresource-basedrelativevalue,
itisnotclearwhethertheworkperformedbythetelemedicineconsultantisidenticaltothework
performedbyaconventionalconsultant. Further,whentheprimarycarephysicianisinvolvedina
consultalongwiththeconsultingspecialist,thisdifferssubstantiallyfromthecurrentpatternof
practice,andtherelativevalueoftheworkperformedbyeitherproviderinthatcasehasnotbeen
established. Second,becausetheeffectivenessoitelemedicinehasnotbeendemonstratedfora
numberofapplications,wecannotassumeapriorithattelemedicineandconventionalservicedelivery
areidenticalinthisregard. Athirddifficultyliesinthefactthattelemedicineisnotaunitary
phenomenon, butawidespectrumofservicesconductedutilizing a rangeoftechnologies and
transmissionmedia.
Onethornyissueisthesimilarityoftelemedicinetotelephoneconsultation. Theuseofthe
telephonealonetoprovidemedicalcareiscurrentlynotreimbursedbyMedicare. Presumablythis
tiseilneplhaorgneepcaorntsualtfautnicotni.onNoofneHtCheFlAe'sss,nteheedretoarceondtartoalscuosgtgse,stainndgctohantcetrenleapbhoounteacbounssiuvletauttiiloinzamtaioynboef
aneffectivemeansofprovidingatleastsometypesofhealthcare(BerteraandBertera, 1981;
Conrath,Dunn,Bloor,andTranquada,1977;Sorum,1994;Wasson,Gaudette,Whaley,etal.,1992).
In theworkcompleted underthis contract, we havedefined telemedicine as the use of
telecommunicationstechnologytoprovidemedicalcaretopersonswhoareatsomedistancefrom
theprovider(Grigsby,Kaehny,Schlenker,etal,1993). Thisdefinitionwouldincludetheuseofthe
telephonealonetoprovidehealthcareservices. Itseemsprobablethat,usingthetransmissionof
sctoinlltaicmtageevsenintchoonujguhnctthieosntiwllitihmatgeelecpohnotnreibcuotnetdaclti,ttlpehoysrincoitahnisnmg.ighItnbtheisabmlaennteorb,illitfwoorualdtebleempeodsisciibnlee
tocircumventthelackofpaymentforphonecalls,whileessentiallyconductingbusinessviatelephone.
The basicissue is aconceptual one. TheworkofConrathet al. (1977)suggested that
telephonecontactalonewasaseffectiveformostpurposesastheuseofmovingorstillimages. It
maybethatasmuchas 75% to80% oftelemedicinecouldhr conductedbythetelephone--a
technologythatiscertainlycost-effective. Ifthatisthecase,thenadditionofvideoimages,whether
sitnilclreoarsmedovcionsgt.,mItaycoyuiledldboenleyxpaecstmeadllthiantcrtehmisenctoasltiwmopurlodvbeemepnatssiendqouna,limtysofomcearweaayt,atosutbhsetapnatyiearl.ly
WhetherornotMedicaredecidestoaddresstheuseofthetelephonealonetoprovidemedical
care,itshouldbeclearthatdefiningtelemedicineastheuseoftelecommunicationstechnologies
otherthanthetelephoneisarbitrary,andmayhaveanumberofsignificantpracticalramifications.
Especiallyinveryremotefrontierareas,wherepat-ntvolumeswillalwaysbetoolowtosupportthe
unsubsidizeduseofvideoimagingtechnology,itisimportanttoconsidertherelativemeritsof
increasedaccess,theuseofexpensivebutofficiallysanctionedtechnology(videoconferencing),and
low-technologysolutions(telephone).
Insomecases,telemedicineprovidesservicesthatsubstituteforsomethingprovidedunder
conventionalmedicalcare. Teleradiology,forexample,maymerelysubstituteforanotherwayof
doingradiology. Ontheotherhand,manytelemedicineconsultswillinvolveservicesthatwouldnot
havebeenprovidedwithouttelemedicine. Ruralpatientswithchronicillnesses,forexample,mayb-
followed more closely by subspecialists. This distinrtion may be important in the process of
establishingcoveragepolicy,sincetheformerwillostensiblynotincreasecostsandthelatterislikely
todoso.
TheCenterforHealthPolicyResearch,Denver,CO 2
C COVERAGEPOUCYANDTELEMEDICINE
1. SafetyandEffectivenessofTelemedicjae
Inthefirstreportunderthiscontract(Grigsby,Kaehny,Schlenker,etal.,1993)weconcluded
that,whilethepublishedresearchliteraturesupportedtheuseofteleradiologyformanyapplications,
therewerefewdatashowingtheeffectivenessoftelemedicineconsultation. Inthesecondreport,
we discussed a series of case studies of telemedicine programs, during which we observed
telemedicine consultation and discussed telemedicine with users of the system. We found
considerableprovidersupportforthetechnology,butalsoobservedthatprofessionalacceptanceof
telemedicineisnotuniversal Aminorityofproviders,mostofwhomhadusedorwerecurrently
usingtelemedicine,expressedreservationsabouttheeffectivenessofthetechnology. Nevertheless,
themajorityofprovidersinterviewedexpressedtheopmionthattheycouldperformtheirworkquite
adequatelyviatelemedicine. Inouropinion,theprovisionofcoverageforanumberoftelemedicine
apphcationsseemstobewarranted
SubsequenttoourUteraturereviewandcasestudies,weconcludedthatvarioustelemedicine
applicationscouldbecategorizedwithrespecttothedegreetowhichtheywereconsideredeffective.
WeconceptualizedtheseapplicationsasfaUingintoseveralclassificationsreflectingtheamountof
supportthatexistedfortheireffectiveness. InReport4(Grigsby,Schlenker,Kaehny,etal.,1994)
underthiscontract,wesuggestedasecondtaxonomythatwasbasedonprocessesofcare. Inmaking
decisionsaboutcoverageandpayment,bothofthesetaxonoraicschemesmaybeofsomeassistance.
2. ShouldTelemedicineServicesbeCoveredandReimbursedUnderMedicare?
Toomanyaspectsoftelemedicineremaininvestigational,andtoolittleisknownaboutthe
possibleeffectsoftelemedicineonthehealthcaresystem,topermitablanketendorsementofthe
technology. Moreover,asnotedabove,telemedicineisnotamonohthicphenomenon. Nonetheless,
certaintelemedicineapphcationsappeartobeeffectiveandtheircoverageseemsreasonable.
Followingaresuggestionsforapplicationsthatmightbecovered. Thislisting,whichcombines
thetaxonomicschemesfromReports2and4,isnotintendedtobeexhaustive.
a. ApphcationsWidehrAcceptedasEffective: Itseemsreasonablethattelemedicineapphcations
inthiscategoryshouldbecovered. Theyappeartobeeffectiveandforthemostpartprovide
improvedaccesstocare,especiallyforpersonsinfrontier,remote,orpoorruralareas. Whileone
mightarguethatnoservicesshouldbecovereduntiltheirmedicaleffectivenesshasbeendemon-
stratedbymeansofrandomizedcontrolledtrials,werejectthispositionastooextreme.
Apphcationsinthiscategoryincludethefollowing:
o Medicalandsurgicalfollow-upwithestablishedpatients
o Medicationcheckswithestablishedpatients
o Brief periodic consultation with specialists regarding chronic disorders (e.g., diabetes,
Parkinson'sdisease,endstagerenaldisease)
o Emergencyevaluationoftraumapatients
o Evaluationofmedicalemergencypatients
o Triageandpretransferarrangements
o Provisionofprimarycaretoremoteareaswherenophysicianisavailable
o Short-termmanagementofacutemedicalillnessinestablishedpatients
o Transmissionofcertaindiagnosticimagesordata(EKG,EEG,nuclearmedicinescans)
TheCenterforHeaitbPolicyResearch,Denver,CO 3
b. ApplicationsthatareProbablyEffective,butwithUnknownEffects:Telemedicineapplications
inthiscategoryareprobablyeffective,butresearchonthisissueneedstobecarriedout. Here,the
optionsrangefromdenialofcoverageunti'adequateresearchhasbeencompletedthroughfull
approval. Althoughareasonableargumentcouldbemadeforeitherofthesepositions,inour
opinionsomeformofcoveragemaybewarranted. Programsprovidingtheseservicescouldbe
requiredtocollectdataonoutcomes,effectiveness,andcompUcations.
Apphcationsinthiscategoryincludethefollowing:
o Extendeddiagnosticworkupsoveraperiodoftwoormoretelemedicinesessions
o Managementofself-limitedconditionssuchaspregnancy
o Short-termmanagementofacutemedicalillnessinnewpatients
o Routineconsultationandsecondopinions
o Physical,speech,andoccupationaltherapyforrehabihtation
o Psychiatricevaluations
o Emergency/crisispsychotherapy
o Transmissionofdermatologicimages
wc.ouldApprpohbcaabtliyonnseetdhactarReefquulicroensBiadseircatRieons,eaprecrhh:apDsecoinsiaoncassce-obnyc-ecransiengbasaipsp.hcWateiodnosniontthriesccoamtmegeonrdy
fullcoveragefortheseservices. Inmanycases (e.g.,roboticsurgery),theapplicationisclearly
experimental,notobviouslysafeoreffective,andshouldnotbecovered. Considerableresearch
remainstobeconductedontheseapplicationsbeforetheycouldbeapproved. Ingeneral,itseems
reasonabletoexpectthatthedevelopersofthesetechnologiesshouldbearthecosts(privatefunding,
grants,pubUcofferings)ofdemonstratingsafety,efficacy,andeffectivenesswithoutexpectationof
reimbursementfromMedicare.
d. ApphcationsUsingNewandUntestedTechnologiesAdaptedforTelemedicine: Applications
inthiscategory(e.g.,theuseofteleroboticlaparoscopictechnologyorvirtualreahtyinterfacesfor
surgery)shouldbeconsideredexperimentalorinvestigational,andshouldnotbecovereduntiltheir
valuehasbeendemonstratedbysufficientmethodologicallysoundresea'-ch.
e. Teleradiology: Teleradiology is aheadycovered byMedicare and otherpayers, although
becausetheseservicescannotbeidentifiedfromclaimsdataitisimpossibletoestimatethevolume
ofsuchservices. Inordertotrackteleradiology,wereconmiendestablishmentofaseparateidentifier
forteleradiology(probablyamodifier)thatwouldpermittrackingoftheuseofthisapplicationfrom
claimsdata.
3. RestrictionsonCoverage
Wepreviouslydiscussedplacingrestrictionsoncoverageinthecontextofdemonstratingthe
effectivenessofcertainapphcations. Otherkindsofrestrictionsmightbeusedinordertocontrol
costsandutilization,inparttoallowtimetoassesstheeffectsoftelemedicinecoverageonhealth
careexpendituresasreimbursementisphasedm. Itmightalsobethecasethatapolicydecisionis
madetopermitcoverageonlyforspecificgroupsorregions(ruralorfrontierareas,forexample).
ForfurtherdiscussionofthisissueseeReport3underthiscontract.
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D. PAYMENTPOUCYANDTELEMEDICINE
1. Introductioii
Inaddressingpaymentpolicy,wewilldiscussseveralissues. Theseincludecoding,provider
characteristics,numberofproviderstobepaid,relativevalueunits,geographicvariation,payment
methodsfordifferentapplications,andpaymentrates. Inthisdiscussionwewillfocusprimarilyon
paymentforMedicarePartBservices.
2. Coding
Codingoftelemedicineservicesisnotasstraightforwardasitmightatfirstappear. For
example,thearrangementbetweentheMedicalCollegeofGeorgiaandthelocalfiscalintermediary
involvesfiveinitialservicecodesandfourfollow-upcodesforphysicianservicesutilizingtelemedicine.
Under this scheme, telemedicine was treated as a single entity. We contend that different
applicationsshouldbecodeddifferently,andsotheapproachwefavorissomewhatmorecomplex.
a. ComparabilityofTelemedicineandConventionalMedicalCare: Ithasnotbeenestablished
thattelemedicine isstrictlyanalogous toconventionalcaredelivery. Whilemanyofthesame
processes takeplace regardlessofthe modeofcare, some aspectsofthephysical exam (e.g.,
palpation)cannotyetbedoneremotely,andmustbedonebyaproviderwhoispresentwiththe
patient. Anecdotalevidencesuggeststhattelemedicineconsultsmaytakeeithermoreorlesstime
thanface-to-faceconsultation,butso farnodataartavailableonthiswithrespectto specific
processesofcare.
b. i^proachestoCoding: Werecommendthatoneoftwoapproachesbetakentothisproblem.
First,usingmethodologyUkethatutilizedinestabUshingaResource-BasedRelativeValueScale
(RBRVS),telemedicinecouldbecomparedwithconventionalcaredelivery.Thisshouldnotbedone
acrossailapplications,butshouldbedonewithineachoftheapplicationcategoriesrecommended
inReport4(e.g.,managementofchronicdiseases,medicalfollow-up). Second,acombinationof
qualitativeandquantitativeresearchmightbeconductedonthe-rocessoftelemedicineconsultation
(again,bycategoryofappUcation),andthefindingscomparedwithface-to-facecaredelivery.
Ifitisestablishedthattelemedicineandface-to-facecaredifferUttleintermsoftime,effort,
orcomplexity,itseemsreasonabletousecurrentCPTcodesfortelemedicineservices,appendinga
modifierthatwouldindicatetheuseoftelecomir'nicationstechnology. Ifinsteaditisfoundthat
thetwoapproachesdiffersignificantlyfromoneanother(again,withincategoriesofappUcation),
differentCPTcodesshouldbeestablishedfortelemedicine,usingtheRBRVSprocess.
Inexaminingthecategoriesofapplicationsdiscw>sedinReport4, itshouldbeclearthat
differentapproachestocodingshouldbeestablishedformanyofthese. Forexample,thereviewof
stillimagesisafundamentallydifferentprocessthaninteractivevideoexamination. Stillimagesdo
notneedtobeexaminedinrealtime,andcouldbetransmittedusingastoreandforwardsystem.
Itseemsreasonabletoapproachdermatologicimages,forexample,inmuchthesamewaythat
Medicarepaysfortheinterpretationofradiologicimages,ifthedermatologistneedsonlytoseethe
imagesanddoesnotrequireareal-timeexam. Surgicalfollow-upmightbeincludedinthesurgeon's
globalsurgeryfee,andcouldbedistinguishedastelemedicinebyasimplemodifier. Psychiatric
evaluationusinginteractivetelevision,ontheotherhand,maybesufficientlyuniquethatitshould
haveitsownsetofcodes.
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Althoughtheevidenceforabuseby"codecreep"issomewhatequivocal,wewouldnevertheless
recommendthatagivenappUcationwithseverallevelsofcomplexitybeclassifiedintofewerlevels
ratherthanmore. Thusaroutineconsultationforasecondopinionwithanewpatientmightbe
codedas'T5rief,""intermediate,"or"comprehensive,"andthelevelsshouldbedefinedwithreference
tostandardtelemedicineprocedures. Theuseoffivelevels,forexample,mightmakeclassification
somewhatlessclear,andencourageuseofthehigherlevels.
3. WhoShouldbePaid?
TheschemeforpaymentworkedoutbetweentheMedicalCollegeofGeorgiaandthelocal
fiscalintermediaryinvohespaymentofboththeprimarycarephysician(whomustbepresentatthe
referringsite)andtheconsultant. Inordinaryconsultation,theprimarycareproviderisnotpresent.
TheGeorgiaapproachisnotcost-effective,andrepresentsachangeinthewaymedicineisusually
practiced
Itseemsreasonabletopayaprimarycareproviderwhenheorshehassoughtanurgent
consult,andmayalreadybedoingbillableworkaspartofaninitialpatientexam. Itdoesnotseem
reasonablefora primarycarephysiciantorefera patientforteleconsultation, andon another
occasionbepaidforhisorherpresenceduringanexaminationbyaconsultant. Insomecases,a
providerwillnotbenecessarywiththepatientatthereferringsite. Thiswouldbethecaseinmany
instancesofpsychiatry,forexample. Inothercases,someproviderwillneedtobepresentinorder
toassistintheconductofathoroughphysicalexam. Intheseinstances,itseemsreasonablethata
faciUtycouldbereimbursedforprovidingtheservicesofanonphysicianprovideratthereferringsite
whoparticipatesintheexamination. Theamountreimbursedeachparticipantintheconsultation
shouldbeafunctionofthetime,effort,complexity,andresponsibilityofeachparticipant. Aswe
notedaboveinthesectiononcoding,thismightbeestablishedusingastandardRBRVSprocedure,
oronthebasisofqualitativeandquantitativeresearchontelemedicineconsultation.
Whenconsultations are performedbetween physicianswithout thepatientbeing present,
differentapproachesmightbetaken. First,itshouldberecalledthatthisapproachesthe"curbside"
oi telephoneconsultinmanyrespects,sothatcoverageforthesecontactsmayraiseanumberof
difficultquestions. Nevertheless,withtheestablishmentofappropriatepolicies,thismaybeacost-
effectivemeansofconsultation. Insuchcases,itmaybereasonabletoreimbursebothphysicians,
butataratethataccuratelyreflectsthetimeandeffortinvolved. Sincetnereisnopatientexam,one
wouldanticipate thatthe payment forthis kindofconsultwouldbelessthanforface-to-face
consultation,especiallyfortheprimarycareprovider.
Ingeneral,werecommendagainstpaymentforconsultationsthatinvolvesimilarprovidersat
bothreferringandconsultingsites. Foiexample,anursepractitionerataremoteoutpatientclinic
mightbeabletoobtainconsultationfromarinternistatatertiarycarefaciUty,butnotfromanother
nursepractitioner. Aspecialist(e.g.,neurologist)mightbeabletoreferapatienttoasubspecialist
(e.g.,epileptologist),butthespecialistwouldnotnecessarilybeeligibleforpaymentiftheconsult
wereconductedwiththepatientpresent(seeabove).
Whenthereisnoneedforaprovideratthereferringsitetoassistduringtheteleconsultation,
onlytheproviderattheconsultingsiteshouldbepaid. Itmaybethataphysicaltherapist(PT)is
prescribingtherapeuticexercisesforastrokepatientandisabletodothiswithonlythepatient?'
theotherend. If,however,thepatientisunlikelytoremembertheexercises,orifthetherapistvwll
requiresomeassistanceinassessingtoneorrangeofmotion,anurseorPTaidemaybeabletoassist
intheconsult,anuthereshouldbesomereimbursementforherorhisservices.
TheCenterforHealthPolicyResearch,Denver,CO 6
4. ApproachestoPavinent
Althoughmanyapproachestopaymentarepossible,methodsofpaymentforPartBservices
includefee-for-servicepaymenttotheinvolvedprovidersandcapitatedpaymentsforproviders.
Theremayalsobefacilityfees fortelemedicineservices,DRGinclusionforinpatienthospital
telemedicineservices,andbundling. Werecommendthatvariationsinexistingpaymentapproaches
beempiricallyevaluatedandthatdemonstrationstestnewpaymentapproachesastelemedicine
servicesandtechnologiesareevolving.
a Fee-for-ScrvicePaymenttoPhysicians: Fee-for-servicepaymentprovideslittleincentiveto
controlutilization. Appliedtonewtechnologiesitmayleadtooverutilizationandincreasedhealth
careexpenditures. Nevertheless,bothinpatientandoutpatienttelemedicineconsultationarelikely
tobereimbursedonthisbasis.
Fortheworkcomponentofphysicianfees,itwillprobablybenecessarytoestablishrelative
valuesfortheseservices. SuchchangescouldprobablybemadeusingthecurrentMedicareupdate
andrefinementprocess,withouttheneedfornewtimestudies. Thephysicianpracticeexpense
componentofthefeeschedulemightbeadjustedtoreflectthecostsofpurchasingandusingthe
telemedicineequipment(includinglinecharges,whichvarymarkedlyindifferentregionsofthe
countryandevenwithinsinglestates). Thereappearthusfartohavebeennomalpracticeclaims
arisingoutoftelemedicine,anditisimpossibleatthistimetodeterminewhetherthemalpractice
componentoffeesshouldbeadjusted. Itthereforeseemsreasonablenottoalterthatcomponent
untilgreaterexperiencewithtelemedicineprovidessufficientdatauponwhichtomakesuchdecisions.
Theusualapproachofassignmentofbenefitsforparticipatingprovidersshouldbeappliedto
telemedicine.
bt.oredAulcteercnoasttisv,esestpoecSiiamlpllyeaFseteh-feonr-uSmebrevirceofPatyemleemnetd:icCionmepeptriotgirvaemcsonitnrcarcetasbeisddsiinggniifsiacannottlhy.erAopttitohne
currenttime,therearefewareasthatareservedbymorethanonetelemedicineprogram,soitmay
besometimebeforethiswouldbeaworkablemethod. Overthenext.everalyears,however,itmay
bethatsomeprogramsbecomemajorregionalornationalplayersinthetelemedicinemarket,and
competitivebidding,suchashasbeendonewithCaliforniaMedicaid(Medi-Cal)contractinghospitals,
maybeareasonablewaytodealwithpayment
tomakWehialceatpeiltaetmeeddipcaiynmeecnotulfdorbeteilnecmleuddiecdiinneasecravpiicteasttehdehmesaelltvhesc.areAssyisntgelme,pitamyimgehnttamlisoghbtebpeosmsiabdlee
toafacihtyorprovider,anddistributionofthatpaymentamongthevariousparticipants(andtocover
thecostsoflineaccessandequipmem)wouldbeattheirdiscretion. ThiswouldeUminatetheneed
forMedicaretoaddresssomeoftheissuesregar Ingtherelativevaluescale,insteadplacingtheonus
onproviders. Certainapriorirestrictionsmightbeplacedonthenumbersandtypesofprovidersthat
couldbeinvolved,andutilizationcouldbemonitoredinastandardmanner.
c. Geographic DifferentialsinReimbursement: Althoughtelemedicineisbeinghailed as a
providerofcaretoruralareas,itislikelythatmanyfrontierandotherruralareashavetoosmalla
populationbase(andhencetoolowavolumeofreferrals)topermitruralprovidersandfaciUtiesto
maintaininfrequentlyusedtelemedicineequipment Someconsiderationshouldthusbegivento
possibledifferentialreimbursementratesasafunctionofgeographiclocation. Thesemighttakethe
formofbonuspayments,possiblytobothprovidersandfacihties. Medicaremightalsomakelarger
paymentsforremoteareasthathavefewproviders,perhapsconsideringthisaspartofthepractice
TheCenterforHealthPolicyResearch,Denver,CO 7
»
'componentofphysicianpayment. Iftherationaleforcoveringteiemedicineisinlargepartto
increaseaccesstocareinruralareas,thisisanimportantissuethatmustbeaddressedfromthe
outset. Otherwise,teiemedicineprogramsinruralareasarelikelytohavetheirfinancialsupport
withdrawnunlesstheymaintainasufficientvolume.
Itseemslogicaltohavepaymentratesbasedonthelocationoftheprovider(s).Thus,assuming
thataurologistinametropolitantertiarycarecenterdidacystoscopyviateiemedicineforapatient
inaruralhospital,theurologistshouldbepaidaccordingtohisorherlocation,whiletheindividual
whoinsertedthescopeattheremotesite(perhapsaprimarycarephysician)wouldbepaidthefee
appropriateforruralproviders,forthatlevelofservice.
d- FacilityFeesforTeiemedicineServices: Manyprovidersofteiemedicineservicesarecurrently
lobbyingforfacilityfeesforuseofteiemedicineeq'iipment. Underonescenario,ateiemedicine
consultwouldyieldafeefortheconsultantandtheprimarycarephysician,andfacilityfeesforboth
theruralandhubsites. WhenoneconsidersthatusingconventionalhealthcaredeUveryresultsin
onlytheconsultantfeebeingpaid,itisclearthatMedicareexpenditvirescouldincreasesignificantly.
Ifaccessisaprimarypolicyobjective,facilityfeesmightbelinkedtovolumeofservices,with
centersprovidingfewerteiemedicineservicesreceivingahigherfee(althoughthiscouldencourage
thespreadoflow-volumeteiemedicineprograms,withpossibleoutcomequalityeffects). Facilityfees
might also be paid only to rural hospitals or clinics. Because small rural hospitals have less
opportunitytousetheirequipment(andthuspayforit)thanmighthospitalsinareaswithalarger
population,theequipmentisessentiallymorecostlyforthemtopurchaseandmaintain. Ifdesired,
thiscouldbedealtwithbymeansofadjustingfacilityfeesforgeographic,demographic,andcase-mix
factors.
Analternativeapproachwouldbetoprovidenoservice-basedfacihtyfee,buttoadjiistthe
capitalcomponentofMedicarehospitalreimbursementtoreflecttheavailabilityandutilizationof
teiemedicine. Anannualpaymenttoeachfacilitycouldalsobenegotiatedforcapitalcostsand
operatingexpenses. Thispaymentmightbeindependentof volume,inordertoavoidsomeofthe
concernsdiscussedabove. Anegotiatedpaymentwouldbesuperiortoaretrospectivelydetermined
costreimbursementsincethelattermightencouragefaciUtiestopurchaseuimecessarilyexpensive
equipment,andnottomakeeffortstocutcostsinareasonablemanner. Thisapproachmight
tentativelybeconsideredatemporarymeansofsupportingteiemedicineprogramsuntiltheydevelop
greatervolume. Iftheclaimsofcost-effectivenessmadebyteiemedicineproponentsareaccurate,
theneedforsuchpaymentsoughttodecreaseovertime.
Fortheuseofstillimagesinconsultation,anapproachsimilartothattakenwithradiology
mightbeappropriate. Thatis,thephysicianwouldreceiveafeeforinterpretationoftheimage(s),
andasecondfeemightbepaidfortheuseofthjequipment.
e. InclusionofInpatientTeiemedicineServicesinDRGPayments: Insomecases,apatientin
aruralconmiunityhospitalmaybeprovidedaconsultwithanurbanspecialist\iateiemedicine. For
thisPartBservice,theconsultantwouldordinarilybepaidonafee-for-servicebasis. Itmight,
however,bepossibletoincludeasinglebundledpaymenttothehospitalundertheProspective
PaymentSystem(PPS),whichcouldthenbedistributedappropriately. Thiswouldsimplifytracking
billingsifprovidersatthehospitalweretobepaidaswellastheconsultant,andthisapproachwould
workparticularlywellforprovidersatdifferentsitesthatarepartofasinglehealthcaresystem.
StandardDRGpaymentsareah-eadyadjustedaccordingtogeographicregionandurbanization,and
someadjustmentofthenon-laborcomponentoftheseratesmightbemadeforruralhospitalsthat
arepartofateiemedicinenetwork.
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V
fa.capitCaatpiiotnatpiaoynm:eTnetlreamteed.icTihinsewseoruvlidcebsecaanvibaebliencalpupdreodaacshpfaorrtMoefdaicbaerneefiHtMpOasc.kagTehecoovregraendizuantdieorn
receiving,lhecapitationpaymentshasfinancialincentivetoavoidoverutilizationoftelemedicine.
However,thevalueofservicesprovidedbytelemedicineTShotddijeTeflcctedbyappropriatelevelsof
capitationpayments. Thequalityofcaremaybeimprovedbytelemedicinethrough,forexample,the
provisionofregularfollow-upcontactbetweenspecialistsandpatientswithchronicdisorders.
E. SUMMARY: COVERAGEANDPAYMENTPOiICYFORTELEMEDICINE
Although effectiveness is questionable for some applications of telemedicine, it seems
reasonableforMedicaretoprovidecoverageforawiderangeoftelemedicineservices. Inth'spaper
wehaveaddressedseveralspecificcategoriesofeffectiveapplications,andhaveaddressedissues
regardingpaymentmethods. Thereappeartobefewalternativestofee-for-servicepaymenttomost
providers,althoughwesuggestedsomealternativesthatmightbeworkableindifferentsituations.
Wehavealsodealtwithissuesofwhoshouldbepaid(providertypesandnumbers),andgeographic
differentialsinreimbursement.
RegardlessofthecoursechosenbyMedicare,theissuewillrequireresearchandrefinement
overthefirstseveralyearstoarriveatarationalapproachtocoverageandpayment. Itwillalsobe
importanttoconsidersomeoftheconceptualissues(especiallycoveragefortelephoneconsultations)
thatcomphcatepolicydeliberationsanddecisions.
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