The telemedicine policy landscape continues to be complex, as decades of evidence-based research highlighting positive patient compliance, clinical outcomes and increasing telemedicine utilization have been met with a mix of strides and stagnation in state-based telemedicine policy, according to a state-by-state gaps analysis by the American Telemedicine Association (ATA).
The ATA recently released two reports titled 50 State Telemedicine Gaps Analysis, with one focused on coverage and reimbursement and another focused on physician practice standards and licensure.
The Physician Practice Standards and Licensure report takes a look at the complex policy landscape of 50 states with 50 different telemedicine policies, extracts and compares physician practice standards for telemedicine for every state in the U.S. and ultimately assigns a grade which indicates existing policy barriers that inhibit the use of telemedicine that would enable patient and provider choice to quality health care services.
The ATA contends that since the first version of the report in 2014, medical boards have moved towards a trend of developing different regulations or guidance for medical practice via telemedicine when compared to in-person practice. Further, states are removing telepresenter requirements, while also becoming more prescriptive in the types of modalities permitted for appropriate clinical practice when using telemedicine. As a result of changing guidance and regulation for telemedicine when compared to in-person practice, more states have improved a letter grade since the report in 2016, according the 2017 report.
In all, 21 states received an A in this latest report, compared to 20 in December 2015, suggesting a supportive policy landscape that accommodates telemedicine adoption and usage.
Since the January 2016 update of this report three states (Arkansas, Florida, and Louisiana) have earned higher scores suggesting a supportive policy landscape that accommodates telemedicine. “Arkansas made the most significant improvement with the adoption of rules which allow licensed physicians to use interactive audio-video to establish a provider-patient relationship,” the report authors wrote. Twenty-nine states received a B (the same as last year) and only one state, Texas, received a C grade, which suggests many barriers for telemedicine advancement.
The report notes that with regard to physician practice standards and licensure, only Michigan saw a drop in its composite grade. Last year, Michigan lawmakers enacted legislation which creates a new definition of telemedicine and requires an additional informed consent, according to the report.
The report focused on coverage and reimbursement painted a better picture as all Medicaid agencies, since the ATA’s initial report in 2014, have adopted some type of coverage for telemedicine. Additionally, seven states have adopted policies that improved coverage and reimbursement of telemedicine-provided services, thus improving their standing since the 2016 report, while two states and the District of Columbia have either lowered telemedicine coverage or adopted policies further restricting telemedicine coverage, and thus, received lower grades.
States have made significant efforts to improve their grades through the removal of arbitrary restrictions and adoption of laws ensuring coverage parity under private insurance, state employee health plans, and/or Medicaid plans, the report authors found. Overall, no states have failing composite grades, and there are more states now with above average grades, “A” or “B”, including Connecticut and Rhode Island which improved from an “F” to “B”, compared to last year’s report.
Connecticut, Florida, Hawaii, Idaho, Rhode Island, Utah, and West Virginia have higher scores suggesting a supportive policy landscape that accommodates telemedicine adoption while D.C., Delaware, and South Carolina saw a drop in their composite grade. “South Carolina dropped from an “B” to “C” because the Home and Community-Based Service waiver allowing remote patient monitoring expired,” the report authors wrote.
Breaking down the scores by the 13 indicates, the state-by-state comparisons reveal large disparities in telemedicine coverage and reimbursement. With regard to telemedicine party laws, 10 states have enacted telemedicine parity laws since the ATA’s initial report in 2014. Of the 31 states that have telemedicine parity laws for private insurance, 24 of them and D.C. scored the highest grades indicating policies that authorize state-wide coverage, without any provider or technology restrictions. Less than half the country, 20 states, ranked the lowest with failing scores for having either no parity law in place or numerous artificial barriers to party, the ATA report, which represents a significant improvement as more states adopt parity laws. Arkansas maintains a failing grade because it is the only state that requires an in-person visit in its parity law.
The report also highlights that telemedicine in Medicaid in working, as all 50 state Medicaid programs have some type of coverage for telemedicine. “Eleven states scored the highest grades by offering some comprehensive coverage, with few barriers to for telemedicine-provided services. Connecticut, Florida, Hawaii and Iowa passed reforms that ensure parity coverage with little or no restrictions, while Rhode Island has included some coverage of telehealth-provided services in their Medicaid fee schedule,” the report authors wrote.
According to the 2017 report, the state-by-state comparisons of physician practice standards and licensure still reveal great disparities in the ways licensing boards regulate clinical practice.
Regarding physician-patient encounters, Arkansas was the only state to improve their score to a “B” in this area. The state adopted rules which allow licensed physicians to use interactive audio-video to establish a provider-patient relationship. Texas is the only state ranked the lowest with failing scores mainly because they create the most stringent clinical practice rules for telemedicine providers when compared to in-person practice.
Regarding telepresenter requirements, Texas ranks the lowest with a “B.” Alaska and Hawaii improved their low ranking scores from the last report with enacted legislation which removed telepresenter requirements. Both states now receive an “A”. All states except for Texas do not require the presence of a health professional during a telemedicine encounter.
Twenty states and D.C. require physicians to obtain patient informed consent. According to the report, this growing trend is largely due to states adopting language developed by the Federation of State Medical Boards (FSMB) and the American Medical Association (AMA) which promotes a regulatory environment for patient informed consent for telemedicine encounters.
Further, the report authors note that no state achieved a top score (A) for their licensure policies. “However, states are addressing the issue of licensure portability by establishing out-of-state registries or joining the FSMB Compact. Thus, adopting policies to uncomplicated the process of practicing medicine across state lines regardless of whether or not telemedicine is used,” the report authors wrote.
Health care providers have seen a considerable amount of state policy activity to improve coverage and reimbursement of telemedicine-provided services by various payers. However, despite improvements to address the payment challenges, health care providers are encountering conflicting and sometimes confusing policies from their own colleagues,” the report authors wrote.
The report authors note that a few state medical boards are adopting practice standards with different, and sometimes higher, specifications for telemedicine than in-person care. “Specifically, these boards have considered legal guidelines requiring an initial examination be conducted in-person and a physician-patient relationship be established in-person. Boards have also considered other telemedicine barriers including requirements for a telepresenter, in-person follow up exam, and additional patient informed consent. These decisions leave telemedicine providers no choice but to navigate the medical practice laws in their state or risk punitive action by their board,” the report authors stated.