The question is how soon regulation — and reimbursement — will catch up to those ideas.
"The good news is that every year there is a better and better outlook on payment," says Jonathan Linkous, CEO of the American Telemedicine Association. "The bad news is that not everyone pays for these services yet, particularly Medicare."
How big is telemedicine today? It's hard to estimate the precise size of the market, since it encompasses a wide array of inpatient and outpatient services enabled by communication technology. But this decade, by some estimates, telemedicine has been growing by up to 30 percent per year. An American Hospital Association survey found that 52 percent of American hospitals used telehealth services in 2013, with another 10 percent in the process of implementing them.
Some of the broadest telemedicine initiatives have come from large healthcare networks. In 2008, Kaiser Permanente Northern California introduced phone, email, and video tools integrated with its electronic health records. Those tools generated 4.1 million virtual visits in the first year, with their use more than doubling to 10.5 million visits in 2013.
And at Intermountain Healthcare, a Salt Lake City-based system with 22 hospitals, Valdes' team set up an e-visit service: a website where patients could talk to physicians and go through the same clinical workflow that they'd experience in person. Intermountain also experimented with 3-D videoconferencing and used remote video to connect parents with babies in the neonatal ICU.
"Consumers were starting to expect this from healthcare," Valdes says. It's even trickled to, and benefited, rural communities.
Rules and reimbursement
Valdes and other telemedicine advocates point to studies showing that telehealth can reduce costs and improve patient outcomes (PDF). But they complain that, so far, regulation has lagged behind demand.
For instance, Medicare typically pays for telehealth services only in clinical settings located in rural areas. But change could be coming.
This year, the Centers for Medicare and Medicaid Services fee schedule added six new payment codes for telemedicine related to home dialysis and prolonged inpatient physician visits. Additional changes under consideration would add certified registered nurse anesthetists to Medicare's list of approved off-site practitioners.
Meanwhile, multiple bills pending in Congress would improve physicians' ability to provide telemedicine across state lines and would expand telemedicine coverage through Medicare and veterans programs.
Individual states enjoy much broader leeway in how they spend Medicaid dollars on telemedicine. By the National Conference of State Legislatures' count:
- 49 states and the District of Columbia offered some coverage for telehealth through Medicaid in 2015.
- Nearly all of them reimburse for video telehealth services, including some mental health services.
- Half of states provide for telemedicine services that take place at home.
- 17 states pay for remote patient monitoring.
- Nine states pay for store-and-forward services, where interaction does not happen live.
As with Medicare, some legislatures have restricted Medicaid telemedicine services to rural areas, although Nevada, Missouri, Michigan, and Colorado removed this requirement in recent years.
On the private-insurance side of the equation, the Center for American Progress reported that 22 states and the District of Columbia require insurers to reimburse for telehealth at rates comparable to those for face-to-face services.
But licensing poses a challenge to the spread of virtual care. Only a handful of states allow for physicians to practice under a license issued by another state, eliminating the potential for remote access to providers elsewhere in the country.
A 2015 compact by the Federation of State Medical Boards, though, could make it easier for doctors to care for patients across multiple states in the future.
Though a patchwork of regulations makes adoption complex, advances in technology are making telemedicine more accessible for healthcare organizations of all sizes.
"You don't have to be a Kaiser or an Intermountain or a VA with all that technical prowess and investment," says Valdes. "It's possible these days for an individual solo practitioner or a small clinic group to purchase this equipment and make it work — very similar to what we've all seen with computers that have become smaller, and now they're all in our pockets."