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Telehealth Adds Patients, Uses, As Technology, Investment Grow
Reprinted from the November 2004 issue of PHYSICIAN COMPENSATION REPORT,

Technological developments as varied as robotic surgery and wristwatches that take temperature, plus investments from high-tech firms, are pushing telemedicine into new uses of interest to more and more physicians, says Jonathan Linkous, executive director of the American Telemedicine Association (ATA) in Washington, D.C.

ATA has on its Web site, www.atmeda.org, a list of telemed services that various payers around the country reimburse, Linkous says. The list is based on a survey done in early 2003, and will be updated in the next few months. Most commercial insurers cover at least some forms of telehealth, but, he adds, "often people haven't asked them to" because facilities around the country still are quite limited.

About half the state Medicaid programs cover telehealth in some form, he says, and ATA is planning a manual on that. Jeanette Hartshorn, executive director of the University of Texas Medical Branch at Galveston (UTMB) Telehealth Center  -- one of the top telemed/medical provider organizations in the country -- says Texas Medicaid is very restrictive and has paid claims in only a few instances. UTMB includes a medical school, teaching hospital and clinics, and the Telehealth Center plays roles in all those facilities.

Medicare's general rules for covering telehealth, says Linkous, are that the service be delivered in nonmetro areas and be one of a list of approved telemed CPT codes, such as for psychiatric drug counseling. He notes there are new codes approved each year. Dialysis for end stage renal disease may be added next year, which would enable nephrologists to supervise dialysis remotely. "Some of the earliest demonstrations of telemed were with dialysis," he recalls.

'People Really Like It'

The UTMB Telehealth Center provides many of the health services needed by the Texas penal system via telemedicine, Hartshorn says. This includes a full range of specialist office visits, and pre- and post-surgical visits. It employs a few physicians serving the penal system who work only through telehealth facilities.

The Center also serves the "free world" -- everywhere besides prisons -- through primary care to outlying communities and specialty services as needed in southeast Texas. A research function of the Center is to test different models of supplying telemed services, and for these efforts it obtains grants, says Hartshorn.

"Individual programs are designed to break even," she adds. UTMB "makes a little bit of money" supplying mainly urgent care telehealth services to workplaces such as construction sites and offices. It is impossible to say whether the Center's programs are profitable overall, says Hartshorn, because they are tied too closely to on-site care.

"People -- both employees and employers -- really like it," she says of the workplace services, because UTMB can serve patients faster than can primary care physicians or emergency departments. In these situations, she adds, "we're not competing with local docs."

"Given the right circumstances and equipment," Hartshorn concludes, "our position is that any specialty can be at least partially practiced through telemedicine."

Telemed Cuts Costs, Aids Marketing

While there's no reliable estimate of investment in telehealth, Linkous says, many firms have entered the field in the last two years to supply hardware or software or both, including several companies larger than those previously involved. A problem with estimating investment in the field, he adds, is that many items with telehealth capabilities also can be used for on-site services.

Among the specialties making most use of "telemed" facilities -- apart from radiology, which is clearly the leader -- are cardiology, mental health, dermatology, pathology and ophthalmology, says Linkous.

Not all telemed applications turn a profit, he notes, although teleradiology and cardiac monitoring are profitable businesses. "But the [business] reasons telemed is taking off," he adds, have more to do with saving costs, marketing and extending service. Cost savings appear in fewer hospitalizations and readmissions for better-

monitored heart and diabetic patients, and fewer needed home health visits. Marketing advantages arise from serving larger market areas, for instance, when a hospital can supply certain pediatric tests to practices 40 or 50 miles away, and then can gain inpatient referrals from those practices.

Market extensions also include the continued expansion of telemed services to patients in rural areas, where telehealth largely began, says Linkous. Increasingly, telemed services originate in vans rather than clinics or offices, to serve wider areas and more specialties less expensively. Telehealth also is growing rapidly in cities.

Telemedicine "is inextricably linked with electronic medical records (EMRs)," Linkous adds. Both work through digital technology, he says, and EMRs are essential to support the accelerating use of telemed services. Conversely, telemed services generate electronic records such as those in radiology PACS, or picture archiving and communications systems.

Telesurgery is used mainly for training surgeons in new procedures and to allow the public to view surgeries, says Linkous. The idea of doing surgery remotely is very new and limited, he notes. But robotic surgery -- in which a surgeon controls a machine a few feet away or in the next room that actually performs the surgery -- is a nascent form of telehealth, he asserts. Robotic surgery is performed today in about 300 hospitals nationwide, he notes.

Exporting health care to foreign lands is possible with telehealth. Because of the US shortage of radiologists, many images are sent to radiologists in Australia, Israel, and India for faster turnaround, particularly during nighttime in the US.

Consumer technologies such as blood pressure monitoring are among the fastest-growing forms of telehealth, Linkous says.