Families in Delaware struggling with Parkinson’s disease often have to travel to Baltimore or Philadelphia for care because there are no Parkinson’s specialists in the state. Many of those patients have worked with Ray Dorsey, M.D., of Johns Hopkins University in Baltimore, whose research focuses on the use of telemedicine for neurological conditions.
But those families also got involved with the nonprofit Delaware Telehealth Coalition and this year successfully petitioned the state legislature to pass a bill to require commercial insurers to cover telehealth visits. “There may have been policies that covered telemedicine services in private insurance, but we couldn’t find them,” says Carolyn Morris, a member of the coalition and director of telehealth planning and development in the Delaware Department of Health and Social Services. “This is going to benefit many people who have not been able to access certain services using telehealth in the past because there were no provisions in Delaware for insurance coverage for services using technology.”
State Policies Not Comprehensive
For almost 20 years, telehealth advocates have faced the Sisyphean task of trying to get the U.S. Congress to expand Medicare coverage for telehealth beyond traditional rural settings. Meanwhile, they continue to hammer away at the uneven and confusing landscape of state laws and regulations. For instance, the rules regarding Medicaid coverage of telehealth are different in each state.
“One of the biggest frustrations for healthcare providers, administrators and CIOs is that the technology is so far ahead of the policy,” says Danielle Louder, program manager for the Northeast Telemedicine Resource Center, which is funded by the Health Resources and Services Administration (HRSA) Office for the Advancement of Telehealth to provide technical assistance, education and other resources. Although Louder wouldn’t describe the policy pace at the state level as rapid, there has been an uptick recently. “We had 80 bills introduced about telehealth just in our eight-state region this year,” she says.
Nate Lacktman, a healthcare attorney and partner with Foley & Lardner LLP, says state telehealth coalitions such as the one in Delaware are having an impact as more states grapple with issues of commercial payer statutes. “It is important to fund telehealth through the private sector,” he says. “Relying solely on Medicaid and Medicare changes is not the way to go. The private market will help drive adoption. The provider community is beginning to have a more focused voice on this issue. People are seeing the value and embracing it.”
Twenty-eight states now have laws that require insurance parity for services delivered via live video, several of which were passed in their most recent legislative session. “State legislatures are recognizing that parity laws are the easiest policy issue to deal with from their vantage point to recognize that telehealth is just a way to deliver care and to ensure that there are no discriminatory barriers that prevent telemedicine providers from getting reimbursed for services that are already covered under healthcare plans,” says Latoya Thomas, director of the State Policy Resource Center at the American Telemedicine Association (ATA).
Yet Mario Gutierrez, executive director of the HRSA-funded Center for Connected Health Policy (CCHP), which tracks telehealth policy nationwide, says that with the exception of California, which passed comprehensive legislation in 2011, efforts to reform telehealth policies have been piecemeal in every state. “States are taking a cautious approach,” he says. “When we meet with legislators, we are often surprised by how little information they have about telehealth.”
Although many states are starting to address how private payers treat telehealth, the devil is in the details of the language in each state, he adds. Gutierrez also questions whether it makes sense to require equal payment for telehealth services that are designed to create efficiencies and reduce costs.
“To create a requirement that the insurer pay the same for remote monitoring, where you are creating efficiencies, is counterproductive to the intent of the benefits of telehealth,” he says. “I don’t think the people who are developing those policies have really thought it through. It makes sense that a live videoconference should be paid the same. But where remote patient monitoring could save money, if you require they pay the same, what’s the point?”
State Medicaid programs have been much better at identifying telemedicine as a worthwhile tool for providers to use to help underserved communities access healthcare services, says Gary Capistrant, the ATA’s chief policy officer, “but what we have seen is disparities in the way that Medicaid covers services. States implement arbitrary barriers like a distance requirement or not allowing statewide coverage or limiting the types of technology that can be used.”
California, Gutierrez says, now has a framework for both public and private systems to use telehealth in a much broader way. It is still lagging in terms of reimbursement for remote patient monitoring, but with the entire Medicaid program now under managed care contracts and a greater push toward value-based care, telehealth is becoming more attractive, he says. “In a fee-for-service world, it is always going to be seen as a cost, not as a cost saver.”
Crossing State Lines