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Technology was the first speed bump telehealth faced: While video conferencing was first possible in the 1960s and '70s, the equipment was too expensive. Equipment became more affordable and reliable in the 1980s, but bandwidth on old-fashioned copper phone wires was a problem. That cleared up as fiber-optic cable began to replace copper, but then telehealth hit the still-ongoing problem of state-based licensing. Varying state requirements for physicians make it more complicated to treat a patient in another state by video conference. If the patient is in one state and the doctor is in another, in which state is the treatment taking place, and whose laws take precedence?
Another ongoing problem that first arose in the early 2000s is reimbursement. "That remains a 'chicken and egg' problem: Payers only cover standard practice, but practitioners won’t make telehealth standard practice until receiving reimbursement for it," England writes. But there's hope: "The process of bringing telehealth into mainstream medicine accelerated recently as some states have adopted parity rules that require equal reimbursement for telehealth and in-person medical services. Insurers have also discovered telehealth is a marketable benefit. For programs like Medicaid or the VA that cover patient travel costs to medical appointments, the adoption of telehealth has been much faster because the savings are obvious."
The Centers for Medicare & Medicaid Services must expand its definition of telehealth for the process to work more efficiently, writes Mario Gutierrez, executive director of the Center for Connected Health Policy’s National Telehealth Policy Resource Center. CMS "limits the definition of telehealth to only the use of live video, which is its most inefficient form. Rural elderly could benefit from being around their families in their own home and community if they are monitored remotely but instead, because that remote home monitoring is not reimbursed or allowed under Medicare, they have to move to an urban facility."
Another problem with Medicare and Medicaid, Gutierrez writes, is that "a medical facility has to be located in a narrowly defined rural location designated by the Federal Office of Rural Health Policy in order to receive coverage for telehealth services. The unintended consequence is that this limits Medicare reimbursement for many rural beneficiaries. For example, if you are a Medicare beneficiary who resides in a rural area, and it takes you two hours to get to your healthcare facility in a town that does not meet the rural definition, then that facility cannot use telehealth to provide you care."
Despite the logistical issues, England believes telehealth is on the brink of mainstream acceptance because providers and patients are changing the way they think about health care. "Telehealth is not a tool but a concept – a paradigm shift for both providers and patients. In the past, we have not chosen health plans or shopped for doctors based on their telehealth availability. The next generation that is growing up on smartphones will expect and demand telehealth, both as patients and as providers. The work of perfecting technology, negotiating regulations, and chipping away at reimbursement may soon pay off."