Passing Congress with bipartisan support, the Health Insurance Portability and Accountability Act (HIPAA, Public Law 104-191) became the legislative vehicle to address those issues. Your health information cannot be used or shared without your written permission unless this law allows it. Because telemedicine allows medical information to be sent anywhere in the world, there is a possibility that protected patient information may fall into unauthorized hands. For example, the information could be sent to the wrong addressor left out on the telemedicine desk for unauthorized personnel to look at. Extra security must be built into the telemedicine system to prevent information falling into the wrong hands.
The absence of consistent, comprehensive reimbursement policies is often cited as one of the most serious obstacles to total integration of telemedicine into health care practice. This lack of an overall telemedicine reimbursement policy reflects the multiplicity of payment sources and policies within the current United States health care system.
A. Medicare and Medicaid Reimbursement
Partial Medicare reimbursement for telehealth services was authorized in the Balanced Budget Act (BBA) of 1997. The narrow scope of this reimbursement prompted efforts towards expansion and revision of the Medicare reimbursement regulations. The Benefits Improvement and Protection Act of 2000 (BIPA) included amendments to the Social Security Act and removed some of the prior constraints, yet maintained substantial limitations related to geographic location, originating sites, and eligible telehealth services.
Unlike Medicare, most state Medicaid programs provide reimbursement for health care-related transportation costs. A number of states with telemedicine programs entered into collaboration with state Medicaid programs to develop telemedicine reimbursement policies, often with the anticipation that telemedicine could offer transportation cost savings. Currently, 27 state Medicaid programs acknowledge at least some reimbursement for telehealth services.
B. General Reimbursement
Another barrier to the expansion of telemedicine is a lack of reimbursement for services from private insurance providers. In addition to Medicare and Medicaid payments for telemedicine, several Blue Cross/Blue Shield plans, as well as other private insurers, pay for telemedicine services. The telehealth market operates on the assumption that private payers do not pay for telemedicine and will resist any kind of claims if asked. However, AMD Telemedicine conducted a survey that found that there is a critical mass for private payer reimbursement. According to their findings, 38 programs in 25 states currently receive reimbursements from private payers. Three programs receive reimbursement for store and forward, and seven programs receive reimbursement for facility fees. While the market assumption is that private payers do not reimburse for telemedicine, in reality over 100 private payers currently reimburse for telemedicine.
As with Medicaid, regulations for telemedicine reimbursement by private insurers are set by the states. Five states have enacted laws requiring that services provided via telemedicine must be reimbursed if the same service would be reimbursed when provided in person. Some insurance programs cover specific telehealth services, e.g., behavioral health. Even in the absence of a definitive policy, some insurers and Medicaid agencies will reimburse for telemedicine services as long as the rationale for using telemedicine is justified to the agency's satisfaction. State waivers or special programs offering remote diagnostics, remote monitoring for specific disease entities or for particular populations, allow additional coverage of telemedicine services. A few states simply pay claims regardless of whether the encounter was in person or via telemedicine.
Even a few years ago, however, a console video conferencing system cost approximately $100,000, but now the cost has decreased due to the availability and lower cost of components, including the increased use of very large scale integration semiconductor technology. In recent years, entry-level systems were introduced that brought the cost down to about $30,000 for a rollabout console, and recently new compact systems have been introduced that begin at under $10,000. Now desktop systems are coming to the fore, which can cost only a few thousand dollars. (Grisby & Sanders, 1998)
Federal agencies, state governments, and other organizations fund telemedicine programs. However, more and more, hospitals and other private institutions are designing telemedicine programs and facilities to be selfsustaining.The United States General Accounting Office (GAO) identified nine federal departments and independent agencies that invested a total of at least$646 million in telemedicine projects from fiscal years 1994 to 1996. State-supported telemedicine initiatives are growing. Frequently a program combines federal funds with funding from state governments and/or other organizations, such as the UT South Texas program and the Missouri Telemedicine Network. The private sector is also involved in funding telemedicine programs. The Missouri Telemedicine Network, for example, is a public-private partnership. In addition to money, companies may contribute equipment or telecommunications. A problem arises when telemedicine projects are funded from external sources. If the funding is withdrawn, the project often falls by the wayside. Many telemedicine projects have been effective and satisfied the users, but the project could not be sustained when funding was withdrawn. (Bowers, 1998)
A. Credentialing and Privileging
Licensure is regulated by the individual states and bill have been introduced or passed in some states that limit the intestate practice of medicine through telemedicine. Examinations assessing the competence of physicians are conducted using national standards, and patient outcome studies are conducted and practice standard guidelines are being developed on a national level. State licensure -- considered archaic by many -- will continue to delay the spread of telemedicine. (Shannon, 1997).Also, there is the problem of the accredition of telemedicine program by JCAHO.. JCAHO (Joint Commission on the Accreditation of Health Organizations) evaluates the quality and safety of care for more than 15,000 health care organizations. To maintain and earn accreditation, organizations must have an extensive on-site review by a team of Joint Commission health care professionals, at least once every three years.
B. Medical Records
Widespread implementation of telemedicine raises issues about the security of medical records. The present system of medical records is already insecure, but there are additional concerns about the ability of the electronic medical record to maintain an adequate level of security. In general, electronic records are probably more secure than paper-based charts, although a possible breach of security may mean that more unauthorized persons can gain access to the data.
VII. Summary and Conclusions:
Telemedicine eliminates distance as a factor in receiving medical care by allowing a patient to stay close to home while receiving the quality of care to which they would usually have to travel large distances in order to receive. Although there are many policy issues that need to be solved (for example, reimbursement, assuring the privacy of information, and malpractice), telemedicine has proven itself effective in serving traditional underserved medical population and reducing the medical costs involved in serving these populations.
Bower, L. L (1998) Strategic Directions InTelemedicine. MegaTech Resources:Dallas, TX.
Field, M.J. Telemedicine: a guide to assessing telecommunications in health care. Washington, D.C.:: National Academy Pr, 1996.
Granade, P.F. Malpractice Issues in the practice of telemedicine. Telemed Journal 3: 269-96.
Grisby, J. And Sanders, J.H. (1998) Telemedicine: Where it is and where it is going. Ann Intern Med, 129: 123-127.
HIPAA's Privacy Rule Summarized: What Does It Mean For Telemedicine? Retreived February 3, 2005 from http://telehealth.hrsa.gov/licen/index.htm
Other Benefits of Telemedicine." (n.d). Retrived February 3, 2005 from. http://www.ncjrs.org/telemedicine/c4.html