Will Texas Kill the Teladoc & AmWell Business Model: Finding a Blueprint for Telemedicine Policy


Nancy W Dickey, MD telemedicine

The Texas Medical Board (TMB) has been mired in a long-standing lawsuit with Teladoc over regulations restricting the practice of telemedicine. Is this a battle to control telemedicine businesses or is it something more? Join our telehealth policy expert, Dr. Nancy Dickey, as we take an in-depth look inside the TMB’s decisions on telemedicine regulation. Discuss how the principles behind these regulations should be the blueprint for other states and find out how future policies will affect the practice of telemedicine across the nation.

Dr. Dickey is the executive director of the Rural and Community Health Institute which works with hospitals and communities across the state of Texas to facilitate best practices in patient safety, enhanced quality of care, and physician excellence. She is also the President Emeritus of the Texas A&M Health Science Center and was the first woman ever to be elected president of the American Medical Association.

Slides:  http://www.slideshare.net/VSee/telemedicine-in-the-healthcare-delivery-system

TFSS Webinar Transcript – Feb. 16, 2017

Dr. Nancy Dickey and Texas Telemedicine Policy

00:00 Dr. Nancy Dickey: My background is that I’m a trained family physician, practiced in private practice for nearly 20 years and for the last 20 years, I have been in academic medicine. I moved up to Bryan-College Station, Texas A&M, to create a Family Medicine residency program, and from there, was briefly the interim Dean of the College of Medicine and for a little over a decade, was the President of the Academic Health Center. 00:28 Dr. Nancy Dickey: Throughout my years both in private practice and here at the Academic Health Center, I have been very involved in health policy, and in the last five years, particularly involved in rural healthcare issues. And so, telemedicine is of great interest to me, and as many things, it is unique in Texas compared to many other states. So I’m going to talk a little bit about what the current policy is, what kinds of things are happening in the State of Texas, and then hopefully, Milton and I can do some discussion back and forth and lend some clarity to any issues that remain. Keep in mind, the Texas Legislature is meeting as we speak, and there are already a couple of bills that have been introduced, and so what we say today and what exists at the conclusion of the State Legislature may be two different things.

Telemedicine Is Changing the Practice of Medicine

01:31 Dr. Nancy Dickey: Telemedicine is an important topic; I’ve been in medicine, as I said, for 40 years, and technology has been exploding. It’s clearly a growing part of how we practice medicine whether you’re a primary care physician or a trauma surgeon or anything in between. And telemedicine is a growing part of that technology, partly because it allows us to expand that technology beyond a physical center of healthcare. What’s driving the growth? Well, physicians partly want to be able to use all the technology that has been proven effective, but there’s other issues too. Many physicians are having difficulty getting appropriate call coverage. The standards 40 years ago were basically that everybody traded off. If I needed Wednesday off, somebody covered me and in turn, I would cover them the next day. As we get more specialized, that becomes a little more difficult.   02:35 Dr. Nancy Dickey: But perhaps the most powerful driver is patient demand, consumer demand. They say, “I can bank on the internet, I can shop on the internet. Why can’t I get some of my healthcare on the internet?” And they ask that question particularly because they have seen the successes. After all, whenever something good happens, whether it’s on social media or on CNN, we know that surgeons can operate when they’re in a different room than the patient is. How come I can’t at least get my sore throat and my asthma taken care of by somebody who isn’t physically standing next to me?

Telemedicine, Telehealth, and Telemonitoring As Defined by Law

03:17 Dr. Nancy Dickey: One of the things that becomes very complex, and as I read over the legislative proposals, I literally have to use a highlighter and take apart some of the definitions because they are confusing. I accuse lawyers, doctors, and legislators of using very complex language just so that we’re not sure exactly what they’re trying to tell us. Telemedicine, and by the way, there’s a difference between telemedicine and telehealth in Texas. 03:46 Dr. Nancy Dickey: Telemedicine involves a healthcare provider delivering medical care to patients who are physically located someplace other than where the physician or provider is located. It entails the use of technology that allows the provider, the physician or the nurse practitioner, to communicate with and that’s specifically to see and hear the patient in real-time. If you’re watching this webinar as we’re delivering it for the first time, and if we turn on the ability for you to talk, then we would be communicating in real-time, you can see me. If I had a rash or something, you’d be able to perceive that. The provider has to be licensed in the State of Texas, and when we get down to some of the challenges, one of the questions is, what are the benefits and what are the disadvantages of having 50 different, actually, 70 different legislated licensure processes? And then, telehealth and telemonitoring are subsets of telemedicine. Definitions are important and they can become quite complex.

Established Patient, Established Medical Sites: Where can telemedicine be provided?

05:00 Dr. Nancy Dickey: Part of the definition is, where can telemedicine be provided? Well, again, if you don’t have pencil and paper, you may want to print these off. If the patient’s being seen for the first time by a telemedicine provider, somebody who is not physically located in the room with them, or the patient is presenting with a new condition, then you can only use telemedicine if the care is being provided in what Texas calls an established medical site, that is some place where there’s qualified staff who have access to significant or sufficient technology so that the medical provider can do a physical examination, whether that includes listening to the heart, looking in the ears, doing a neurologic exam, but there has to be some kind of a staff person who has qualifications at the site where the patient is communicating with the provider who’s obviously in a different location. That’s if it’s a new problem, or a patient who is been seen by telemedicine is coming in for the first time. 06:14 Dr. Nancy Dickey: If it’s not at an established site, that is, maybe I’m doing telemedicine from my office to your home, then a telemedicine provider, somebody not in the room with you, can follow up with an established patient, “I saw you in the office last week, and I’m just trying to follow up on that ulcer on your leg,” or if you were referred by a physician, who did a complete examination, and has now asked me to weigh in, but someone has actually done the full evaluation that should precede the medical care that’s rendered. Those are barriers here.

Doing telemedicine visit follow-ups

07:00 Dr. Nancy Dickey: An established patient with a new condition who is seen by telemedicine, then is supposed to be referred for and seen for follow-up within 72 hours, if they don’t get better, or if they do get better, has to seen by a physician face-to-face, if the patient has not seen that physician. If I start you for a new condition by telemedicine, then I need to follow up with you face-to-face. Again, it’s a level of security that we made the right diagnosis and we’re doing the right things. And both sites, both where the patient is and where the provider is, have to be able to provide privacy, and enable that the presentation is HIPAA compliant. So, nobody else is listening in on what you and I are doing.

Why does telemedicine need to establish a physician-patient relationship

07:57 Dr. Nancy Dickey: Further requirements, there has to be a physician-patient relationship. Again, if you’re my patient, and we’ve established all that history, and I know you when I see you, then we have met the conditions of having a doctor-patient relationship, and I can take care of you by telemedicine. When asked why you need to have that, it’s an interesting response. First, it’s to establish that the patient is who they say they are. And I gotta be honest, [chuckle] you can come in tell me who you say you are, if I [08:31] ____ telemedicine, I assume you’re still whoever you said you were, but I don’t do a lot of background checks to make sure that you have six credit cards and a driver’s license or a passport. But it is to establish that the patient is who he or she says. 08:46 Dr. Nancy Dickey: Now, I was being a little bit sarcastic, but if I’m prescribing medication, I need to be sure that, in fact, the person that I’m prescribing the medicine were is the person that I have just evaluated. And that’s why telephonic communication alone can present some problems. Second reason for having a doctor-patient relationship is to be sure that I can discuss with you in adequate detail, the diagnosis, the evidence that supports that diagnosis, and the benefits and risks for whatever intervention, their treatment, whether it’s a prescription, or whatever, come with that.

Maintaining the same high standard of care in telemedicine

09:27 Dr. Nancy Dickey: And again, that’s sometimes hard to know whether you’re communicating adequately, if you’re just talking on the telephone with someone. Second requirement, the Distant Site has to include the presence of qualified staff to assist in the evaluation of the patient, in order to establish that doctor-patient relationship. And the treatment and the consultation are held to the same standard of quality of care as any visit, if you walked into my office or I saw you in a hospital wing. High standard of care, I can’t say later on, “I was just telemedicine, you can’t hold me accountable.” The legislature says, “Oh yes,” that I am held to the same standard, however it is that I see you. 10:15 Nancy Dickey: Does the Distant Site have to see a patient in person prior to providing telemedicine? The guy with his stethoscope to the computer is kind of amusing, but the reality is, there are some things we do when we interact face-to-face that are much more difficult to do when you’re looking at me on a screen, and importantly, I’m looking at you on a screen. The answer is no, you don’t have to see each other face-to-face before we can have a telemedicine visit, if you meet those criteria we’ve already talked about. 10:50 Nancy Dickey: If you and I already have a doctor-patient relationship, number one. If we don’t have a relationship, but you are at an established site, and there’s someone there to help with the technology so that I, the physician, can do a reasonable physical examination, there are tools, so that I can do almost everything by this television screen as I could do if I was person to person, if there’s somebody there to help you, to put the otoscope in your ear, to put the stethoscope at the right places on your chest, on your abdomen, even to the point of palpating to press on your abdomen, or on your back to see where the pain happens to be. And the other alternative, if you and I have never seen each other before and we wanna do a telemedicine visit, would be if you were referred to me, if I were an orthopedic surgeon, or a neurosurgeon, and your primary care doctor had seen you, had done the exam, and said, “I want you to see Dr. Dickey for her expertise,” then your primary care doctor’s examination can serve to meet the requirement of telemedicine.

Non-reciprocal call coverage and telemedicine in Texas

12:01 Nancy Dickey: You can practice telemedicine today in Texas. You can charge for it. There are some requirements and some obligations, but for many of the things we talk about using it for, it can be done right now. However, there are some people that believe we should have a great deal more freedom to practice telemedicine, and so there are a number of pending issues that are being discussed even as we’re doing this webinar. The Texas Medical Board has created an entity to help with the call coverage situation and has said, “Okay, you can use telemedicine to cover your practice doctor, but you have to have something in writing called Non-Reciprocal Call Coverage.” It was reciprocal when you covered my patients and in turn, I would cover your patients. 12:55 Nancy Dickey: But now we’re talking about me calling some service that will take care of my patients when I’m not available, but I don’t intend to do anything back for them. I’m not gonna cover their patients at some later time. Non-Reciprocal Call Coverage, the agreement has to be in writing, the agreement has to establish the covering physician’s responsibility to meet the standard of care. That those physicians have to have the same standards of care as if I were seeing that patient face-to-face. 13:29 Nancy Dickey: It needs to include a list of all the physicians who may provide the call coverage. If I sign on with ABC telemedicine, and they have 75 doctors, all 75 names have to be listed, or if I only list five names, those are the only ones that can then see my patients when I’m asking for call coverage. The covering physician has to have access to my patient’s records. That means I would have to give them a way to get into my electronic record and be able to see things that we had done in the past, what medicines you’re on, what allergies you have and so forth. And the covering physician has to provide information within three to seven days back into my medical records. I’m out of town for a week and when I get back from my ski vacation and you’ve been seen by the covering doctor, I should be able to look in my record and see what was done and why it was done.

Teladoc vs. the Texas Medical Board: The issues

14:25 Nancy Dickey: Now, interestingly, there are people who believe those restrictions are more than they should be. And in fact, there’s a group called Teladoc, which is a commercial provider of telemedicine, that is suing the Texas Medical Board for the rules that they had written. Originally, the argument was over the right of telemedicine providers to treat a patient without having an in-person visit first. Some of that has been dealt with, with the exceptions I gave you earlier. But the argument has continued and it’s grown to the current lawsuit and the lawsuit is now an anti-trust lawsuit, Teladoc suing the Texas Medical Board (TMB), and it’s up to the second level of appeal, currently in the US District Court, 5th District, and it’s an antitrust issue in that Teladoc believes that the rules are keeping Teladoc and, more importantly, its doctors from being able to take care of patients. 15:30 Dr. Nancy Dickey: If the court invalidates the TMB rules, the ones that Teladoc is unhappy about, it will actually raise questions about virtually everything TMB does. If the rules they’ve written are invalid, what other rules that they’ve written do I not have to pay any attention to? It’s a very important court case. Good news. Despite some of this conflict that’s happening, the TMB, The Texas Medical Board, and the Texas Medical Association and other stakeholders have been meeting throughout the summer trying to agree on language that would facilitate legislation that, while it would be a compromise, would hopefully serve everybody’s needs. It’s my understanding that in the last few days, what had looked to be a fairly collegial progress has, to use someone’s words, “blown up” and those discussions may not be moving forward as collegially as they had been.

Why should we care about telemedicine?

16:34 Dr. Nancy Dickey: So, why do we care? I mean, I don’t currently participate in any commercial telemedicine things, I don’t currently charge to provide telemedicine. Well, telemedicine is important for a lot of reasons. We have a health profession shortage. It’s global. It’s certainly nationwide, and Texas has one of the biggest shortages, partly because we started out with a shortage and our population is exploding. And secondly, we have some very specific shortages. We have a primary care shortage all over the country and the ability to potentially use primary care providers who are in a relatively over-served area to provide primary care would be a boon for many places in the state. But the bigger issue is probably specialty care. Pediatrics sub-specialists in particular, but many sub-specialists across the board are located in big urban centers. They’re much more likely to be tied to a teaching hospital or a large medical center where the technology they use happens to be. But patients who live out in a much smaller town still need access to that kind of care, to that level of specialty and frankly, sometimes to the technology that they bring.

Telemedicine and rural healthcare challenges

18:00 Nancy Dickey: Tiny towns are never gonna be able to have their own neonatologist or neurosurgeon. They may not even be able to get their own dermatologist or cardiologist. How much of the care that those specialties provide could potentially be provided in small towns or rural areas if we could do it by telemedicine? For one thing, it’s much more efficient for the specialist. He/she doesn’t have to spend two hours getting to tiny town to see four patients. They can walk in exam rooms in their own office and in one hour, see four patients without any travel time attached to it, so it helps meet speciality and primary care shortages. 18:43 Nancy Dickey: It creates a solution in a state where we have a very conservative legislature. Any of you who follow the legislature know they’re telling us we’re gonna have a financial shortage this year. There’s not enough money to go around and yet, we have a growing population and a big part of that population is a Medicaid population. The state doesn’t want to spend more money, more people qualify for state assisted care, and care that oftentimes needs to be rendered by some specialists of some kind. Is this a way for us to get access to that care for a population that currently oftentimes has to go months or even longer to see such a specialist? 19:24 ND: There are transportation challenges. I’m involved in discussions with many small towns whose hospitals are threatening to close and I’ve said… But there’s care just 15 miles down the road. Well, if I’m 90-years-old, 15 miles could be a world away if I no longer drive. But if I could say we’ll keep a clinic open here and you can get your care at the clinic without driving 15 or 50 miles, then the closure of the hospital beds themselves might be much less of an issue. And finally, it may help with over-utilization of very high cost care because you can expand the access to care without having to say, “Well, now that you’re here, what all might we wanna do, let’s hurry up and do it because you don’t wanna drive back down here for something later on.” 20:17 Dr. Nancy Dickey: What are your legislators hearing? Well, they’re considering using telemedicine for a variety of problems. Again, things you’ve probably heard about in the news. They’re considering using telemedicine to cover shortages in state psychiatric care, behavioral health, in general. I told you telehealth is different than telemedicine. In fact, telehealth, which usually gives behavioral health, mental health support, does not require that in-person visit because there’s usually not a physical exam associated with providing mental healthcare. There is a great deal of telehealth that can be done that has far fewer of the restrictions that I’ve just gone through. But we have a remarkable shortage of behavioral health providers and again, they tend to be located in the large urban areas so if you’re in a medium to small town and you need counselling on a weekly basis, is it reasonable to ask you to drive 75 miles to get there if you could do it in your living room with a telephone? 21:26 Dr. Nancy Dickey: There’s talk about using it to expand timely access to trauma services. I can see you say now, [chuckle] “how’s a trauma surgeon gonna help?” But what can happen is that you roll into an emergency room and the trauma surgeon can consult with the local physicians, whether it’s an emergency room physician or a general surgeon, talk about what needs to be done right there in order to stabilize the patient and really speed up the transfer of those patients who cannot get the care they need but can be more effectively stabilized. Using coordination through telemedicine and consultation through telemedicine may not stop the transfer but it may make the transfer of those patients more timely and more effective because all the right things were done at the right time before they were put in a helicopter or an ambulance someplace.

Working out Texas telemedicine bills

22:21 Dr. Nancy Dickey: In the last legislative session, there were 10 telemedicine bills, only one passed. When I prepared for this webinar, I think there were three bills that are currently out there but we can continue to submit bills for another couple of weeks. And so, there may well be a dozen or more, especially if in fact, the collegial discussions hoping to create a bill have fallen apart. We’ll see bills coming from all sorts of different perspectives, and they will be effective either within a very short period of time if there’s a significant majority that passes them, or September if it’s just a majority that passes it. 23:04 Dr. Nancy Dickey: A summary, and I know we’re gonna go into some discussion, Dr. Chen. Without provider demand, appropriate licensure requirements, and fair reimbursements, the full benefits of telemedicine will struggle to be fully realized, and our patients, who could benefit from these, may not. Clearly, there are lots of different perspectives. There’s the patient perspective, the doctor-nurse perspective, the insurer perspective, and those regulators who are trying to assure that patients get high quality care are all part of the picture. 23:39 Dr. Nancy Dickey: Like any complex issue, we probably have to find some compromises. I may not get everything I want, you may not get everything you want, but if in the end, the patients get access to high quality care at a better price in a more timely manner, then we should have achieved that which we were seeking to do. Certainly, we believe that future applications, the reports that went to both the Senate and the House, were very careful to say, future applications should be designed by healthcare professionals, not by policy writers, because those healthcare professionals hopefully will know some of the ins and outs, some of the complications that might occur. And telemedicine should be used to support and strengthen the doctor-patient relationship. Too much of healthcare today seems to be done in a segmented fashion so that one piece doesn’t talk to the other. 24:33 Dr. Nancy Dickey: In the end, the biggest loser in that case is the patient, who ends up getting care that is inconsistent or care that ends up being duplicated when one time around should’ve been adequate. As with most policy things in healthcare, the real measure here is: What do our patients need? How do we do it safely for them? And can we do it in a way that’s cost-effective? That is, that we get more care for the dollars spent than using other alternatives. It’s a very interesting place to be. With a state as big as Texas, clearly, we should make telemedicine a more effective piece of that. It does exist already. I think each iteration of it is an attempt to make that more useful to the people who are out there. Thank you for the chance to at least present a summary, and well, now I’m all ears.

Are direct-to-consumer telemedicine models doomed without physical exam capabilities?

25:23 Milton Chen: Thank you so much for that. I’m pretty sure this is probably one of the most useful talks that the audience have heard on telemedicine this year. My question is about the standard of care, whether it’s telemedicine versus in-person… Now one of the things we know is that in a lot of these direct-to-consumer visits there’s no physical exam, right? Because they don’t have the medical devices at home. Now, does that mean that this model is really not viable in the sense that if you couldn’t do the physical exam, you would do things differently with telemedicine versus an in-person exam? 26:05 Dr. Nancy Dickey: I can appreciate the importance of the physical exam to a huge portion of what we do. On the other hand, I also know often times when I see a patient, if I’m following up a chronic disease, if it’s a problem that they were already seen in the emergency room and I’m trying to see whether what they’re doing is working or we need to change it… I have to tell you, lots of times we spend a lot more time talking and not much time doing physical exam. So, I think I’d like to see the same flexibility in telemedicine that I have when I see a patient in my office. But, I am extraordinarily appreciative that the Medical Board says we don’t want to create a new vehicle that become pharmaceutical mills, that become prescription mills for people to get medications that they may not need, that are open to abuse, or, worst case scenario, might even be sold on the street.

Does direct-to-consumer telemedicine create prescription mills and abuses

27:10 Milton Chen: Got it. That makes a lot of sense. Especially if a lot of these are follow-up chronic care patients, that feels like telemedicine is perfect for these cases. However, in the US, we have the Big Four direct-to-consumer telemedicine suppliers: Teladoc, MDLIVE, American Well, Doctor on Demand; In these cases, the idea seems to be I whip out my mobile app, I see someone, so I can get a prescription. In that case, there’s no first contact. There’s no patient-provider relationship, but I get a prescription out of that. 27:40 Dr. Nancy Dickey: Well, when I was in full-time private practice, if you were a patient of mine you could call me on a weekend or after office hours and, nowadays, it’s even easier ’cause I could pull up your record, okay? But 20 years ago it was a matter of, hopefully I at least knew your name because I was taking care of you. And I might say, “Well, tell me the symptoms, tell me how you’re feeling, and I might give you a prescription over the telephone.” How is that different than Amwell or Teladoc? And I think the answer is, they have no chance to know you. You filled out a medical history, but that’s your medicine from your perspective, okay? And there’s no doubt that that kind of consultation may help you decide how urgent this is. “Try these things to make the symptoms better and see your doctor if you’re not better in 48 hours.” Got no problem with that. You might’ve walked into the pharmacy and gotten the same instructions. How about if they provide you prescriptions? Well, I will tell you that I’ve prescribed for people over the telephone that I either have not seen in the last six months or maybe they’re here from out of town and they’re somebody’s granddaughter or something. 29:15 Dr. Nancy Dickey: Their flu symptoms don’t necessarily call for a $1,500 emergency room visit, but they’re miserable. They want something, okay? Do I do that? I’m almost hesitant to say it where it’s being recorded because I’m probably breaking the law. Yes, I do on occasion. On the other hand, most of the time if you’re sick enough, the answer should be, “Here’s the things you can do to manage your symptoms and I’ll see you at 8 o’clock tomorrow morning.” And telemedicine, by a commercial route, isn’t going to have the opportunity to say, “I’ll see you tomorrow morning.” Because they don’t have an office, they’re gonna refer you some place else. 30:04 Dr. Nancy Dickey: So, to the degree that using one of these vendors is to keep you out of the emergency room, I think it can do some of that. But I do think there is some risk in doing a huge amount of diagnosing without any ability for me to follow-up what you think your presentation is.

Was the Texas Medical Board vs. Teladoc lawsuit avoidable?

30:29 Milton Chen: Yeah. So this is a question from one audience member – right now Teladoc and the Texas Medical Board are in a lawsuit, probably the most publicized event in the entire telemedicine industry, and it seems that the lawsuit has been going back and forth for quite a period now. Is there anything in hindsight that the Texas Medical Board could have been more proactive about to avoid this lawsuit, or there an Inherent conflict here?. 31:10 Dr. Nancy Dickey: Well, I always believe that the best solution is not a lawsuit because once we have a lawsuit, both sides are beginning to present their case in the best light… Not the best light for, how do I help you understand but the best light for, how do I win the jury or the judge who’s gonna make the decision. So by definition, the conversation changes once I sue you. I always think, the best thing to do is try to reach some form of compromise, and that’s why I was very pleased that Teladoc and others were sitting down together to try to say, “Here’s my major concerns, here’s doctor’s major concerns, here is the regulator’s major concerns, and can we find a compromise that fits everybody?” 32:00 Dr. Nancy Dickey: Compromise only works if everybody is willing to give a little and heaven knows that Teladoc and telemedicine aren’t the only ones that find compromise difficult. We see it in the federal legislature on an hourly basis. So, I don’t know. I do think that sometimes we draw a line in the sand, and if it leads to a lawsuit, we might wish that we could’ve had two more conversations first, but clearly, the discussions broke down along the way and they chose to resolve it this way. I wasn’t in the middle of those conversations, I didn’t participate in the discussions, so I don’t know. Obviously, they’ve been going on for quite sometime. I think two to four years on one way or another. But ultimately, you end up in court when somebody else decides them.

Is outdated telemedicine policy holding back telemedicine adoption?  

33:04 Milton Chen: Another question. In 2015, Rock Health wrote had a long lengthy article where Rock Health drew the conclusion that telemedicine as an industry has been held back by some fairly archaic telemedicine policy. They talk about things like physician state licensing, reimbursement coverage, the quality or scope of care, HIPAA compliance, things like fraud and kickback abuse. Do you agree that it’s telemedicine policy that’s holding back the telemedicine industry or is it maybe just some other factor?

Does telemedicine need national physician licensure to grow?

33:57 Dr. Nancy Dickey: Well, telemedicine has emerged at very different rates across the 50 states. And so, some of the things you’ve outlined, I don’t think can be blamed. We might get it going faster if we had a national licensure probably. One of the things most states agree upon is, if you’re practicing telemedicine in my state, you need to be licensed in my state because that’s the only way I have any jurisdiction if you’re not practicing good medicine, you’re misusing prescriptions, or whatever. If you’re not licensed here, how do I go after you? In fact, there’ve been conversations since the mid-1990s when I was with the American Medical Association about both the value of having a single license and the value of having 50 different states that have some variation within those states. Medicine is becoming much more global, and I don’t mean national, I mean truly global in terms of sharing best practices, medical education. So I suspect that we will continue to have conversations about whether we should have a single license rather than it’s literally, 70 different licensing bodies which is more than the states obviously. 35:32 Dr. Nancy Dickey: It’s expensive to have licenses in multiple states, and yet it’s also a real pain to get a license. So I’ve known people who leave Texas but they say, “I’ll keep paying my fees just so I don’t ever have to go through their process again.” But you also lose control if you have a national licensure, then those people thousands of miles from here are gonna decide, who can get licensed, what causes you to lose your license. I think there are pros and cons to both sides.

The physician reimbursement quagmire

36:02 Dr. Nancy Dickey: But knowing you’ve gotta have multiple licenses if you’re gonna care for people across state lines does probably slow down telemedicine. How to get paid? I think that is such a quagmire right now, in that how we pay doctors is changing everywhere. The TRICARE for the federal government is looking at changes. We’re now talking about changing how we pay you if you’re in a at risk situation. So, we’re gonna pay you differently for Medicare if you’re an ACO than if you’re not, and even if you’re in, [36:45] ____ if you service Medicare, by the way, that’s gonna change too. So, telemedicine is in fact a new delivery system, and I think many states have figured out how to take care of that, and so I think to the degree that’s a barrier, I think it’s a much smaller barrier than the others are. What were some of the other things that you mentioned?

Is HIPAA holding back telemedicine?

37:13 S2: Other things, HIPAA compliance, fraud, abuse, anti-kickback…. 37:21 Dr. Nancy Dickey: Yes, I suspect that’s held it back, I’ll be honest with you. Again, I’m part of the teaching program, somewhat peripherally, but I spend time with them and I oversee some nurse practitioners in another piece of my life. And I gotta tell you that the quickest, easiest answer sometimes is “Could you just take out your phone and take a picture and send it to me?” Oops, wait a minute, that’s not HIPAA compliant.” 37:48 Dr. Nancy Dickey: I understand HIPAA and I don’t want my medical information out there anymore than anyone else does, but it is extraordinarily complex, and knowing that we might be sharing, not just information, but whole physical examinations has probably held back the process a little bit. I think it’s one of those places people are gonna be willing to drive a little slower, because they don’t wanna turn on YouTube one day, and see their prostate exam being done for the world. [chuckle]

How do dieticians fit into telemedicine

38:19 Milton Chen: Dr. Dickey, we have another question from the audience. So the question is, so she’s a dietitian, so she does not do physical evaluation, so her advice is purely based on the health history that they provide. In this case this from a dietitian, does that mean that she can practice without the rules that you just described? 38:42 Dr. Nancy Dickey: I think that a dietitian would fit within telehealth where a physical exam is not necessary, and that that could in fact be done without that doctor-patient relationship. And the other place that there’s probably some, [coverage], if you will, is that a lot of her [patients] probably are referred. So if a physician referred the patient, you would meet one of those other criteria. The physician would say, “This patient is morbidly obese, has diabetes, hypertension, I need you to do some diabetic counselling,” check, I’ve already got the referral now taken care of. So, for both reasons of telehealth and for a preceding referral, I think most of the time she would be well covered.

Blockers to doing a routine office visit from home with telemedicine?

39:28 Milton Chen: Okay, excellent. We have another question, this is from a physician. He says he has an existing patient relationship. Now what are the challenges for getting [39:43] ____ somebody to wear a sensor, medical devices, so that the patient could do a routine office visit from home? 39:52 Dr. Nancy Dickey: The biggest problem there is probably gonna be HIPAA compliance because in theory the patient could simply Skype in, that is you could see the patient, but you wouldn’t have the protections that you need. So, if you had a patient portal on your electronic record, you might be able to do that exchange through the protected portal. But if you have the pre-existing doctor-patient relationship, in fact, all you have to do is find the HIPAA compliant mechanism for seeing the patient, and you have met that annual requirement for a physical examination.

The future of telemedicine policy

40:35 Milton Chen: Another question I have is, so what do you see are some of the major, maybe the telemedicine or like telehealth major trends in policy or, the direction? What are some of your predictions for some major things that will happen within the next couple of years? 41:02 Dr. Nancy Dickey: Keep in mind, these are just predictions, and fortunately I don’t make my living betting on whether they come true or not. I think that we’ll see a great deal of flexibility for telemedicine to reach underserved areas, and areas where we can demonstrate patients are not able to access care for transportation reasons, or healthcare professional shortage reasons. And I think the barriers will fall more quickly there, just as they have, by the way for physicians who were trained outside of the United States. They’ve a pipeline to be able to come in. If you serve in an underserved area for a period of time, that you couldn’t simply walk in the door otherwise. 41:53 Dr. Nancy Dickey: I think that we have legislators who are sympathetic to the need to be able to get quality healthcare to populations who don’t live in major urban centers. I think that you will see telemedicine used in a lot more consultative roles. So we talked a little bit about the trauma surgeons. It’s also used in some places in intensive care units where… In a big hospital you probably have a physician in the hospital 24/7 who can respond to changes in an intensive care patient immediately. It’s not a telephone response. They walk in and they lay eyes and lay hands on that patient. Well, if you’re in a smaller facility, that still has intensive care patients, you may not have a physician in-house, but there is actually a service that will provide you with a consult. They can see all of the monitoring results. They can see what the nurses see without actually seeing the patient necessarily and can either give feedback to a physician telephonically now, or depending on how they’ve written the rules for that particular hospital, actually help manage those intensive care patients. 43:07 Dr. Nancy Dickey: So, bringing the very high-tech but small number of sub-specialists in a consultative role, where someone else is the primary provider, but they would value having input from the sub-specialist. It would work in trauma care. It works in stroke units all over the state already. Not enough neurologists, but there’s certain care, that if you don’t begin the initiation of that care within a very short window of time, that you can’t have that treatment. And so, what they do is consult with an emergency room physician or a primary care physician out in a small town. The neurologist agrees with the assessments and says, “Yes, start this treatment and then transport the patient so they don’t miss the window.” So I think we’ll see a lot more of that which allows existing providers to kind of expand what they’re able to safely, effectively, and high-quality do for the patients that they’re caring for.

Why did Teladoc Sue the Texas Medical Board?

44:09 Milton Chen: Got it. That makes sense. I guess, now we have another audience question. I guess their perception is that Teladoc has actually spent many years working with the Texas Medical Board and they’re trying to figure out some compromise. The perception was the TMB was not wanting to compromise with the Teladoc so that’s what triggered a lawsuit in there. I don’t know. Maybe if you could comment on that. Or maybe even, what are some of the things you mentioned or happened within the last couple of days like the collegial thing that maybe didn’t… [chuckle] 44:44 Dr. Nancy Dickey: Well, I only know because I knew this webinar was coming, and so I was checking with my sources to say, “Is there any new legislation? What’s the status?” and they said, “Well, one of the problems is that in fact these collegial discussions seemed to have disintegrated and they’re no longer sitting at the table together right now. Maybe they’ll be back tomorrow.” No, I don’t actually have a lot of insight. I know that one of the biggest concerns, I believe, with Teladoc, is the concern about the quality of care if it’s telephonic, that is not an audio video but a telephone conversation where a patient calls a provider and says, “Here are my symptoms and I want an antibiotic, or I want a steroid or I want a pain pill.” And you’ve never laid hands on the patient. You are believing what they tell you on the telephone, but you don’t have any way to confirm that in fact the patient is who they say they are or has what they say they have. And I think that’s driven a lot of the concern. 45:55 Dr. Nancy Dickey: Is it possible on the telephone to make an assessment and decide whether to write a prescription for a particular patient? Yes, I believe it is. Are there some serious problems with saying, “That’s an acceptable way to practice medicine”? Yes, I believe there are some serious problems and I think that’s just the crux of the disagreement. 46:20 Dr. Nancy Dickey: Now, part of what I read is that Teladoc says, “Yeah, you may be couching this in the terms of quality of care. I really think that you’re being influenced by physicians who say, ‘We don’t wanna compete with Teladoc and its telephonic healthcare.'” And TMB… I’m gonna put language in their mouth and I’ve never heard them say this, okay? The alternative to Teladoc saying, “You’re just protecting the economic turf of doctors” as TMB says, “No, we’re here concerned about the quality of care, and we think in order to get your 50 bucks for each of those visits, that you will see patients that ought not to be seen over the telephone. That you will prescribe things that ought not be prescribed for a patient that you don’t know anything about. So the best protection for patients is to simply say, “No. In Texas you can’t do that.” Well, you could see those are two widely different perspectives. Is there some room in between? Maybe. But you’ve got to find people who are willing to come to the middle.

Trumpcare and the future of  telemedicine

47:35 S2: Got it. Got it. I really appreciate it. Then, I guess, my final question is how do you see President Trump’s policy with some of the things maybe you’re excited about what his administration could do in terms of impact on telemedicine? 47:50 Dr. Nancy Dickey: You know, I have no idea how to answer that question. We have an individual coming in. We anticipate to be very strong in the traditional doctor-patient relationship. He is a physician himself, and obviously the Secretary of HHS will have a lot of influence. We know that we have a President who is very supportive of entrepreneurial efforts, and telemedicine is an entrepreneurial effort. At the same time, we are existing in a time that for 15 years, we’ve been saying, “We got to control the cost of care. We’re opening up a whole new venue of how to get your healthcare be a reasonable contribution to controlling cost.” I don’t know. 48:40 Dr. Nancy Dickey: So, I’ve not heard anything from President Trump specifically about telemedicine, and very little actually, about healthcare, other than the desire to make significant changes to the HCA. So, I’m not sure. I think medicine’s gonna be in an interesting place for the next couple of years while we figure out what President Trump and his Secretary of HHS decide they want the primary things to be. Healthcare is still a huge portion of the US economy, and I cannot imagine that we would have a President and certainly not a Secretary of HHS who are not concerned with quality of care, advancing care, but also cost of care. And so, I think it has to be sold as high quality for the way to expand access without expanding costs. 49:40 Milton Chen: Got it. I guess Dr. Dickey, if you were to able to let’s say whisper in President Trump’s ear to ask him to implement let’s say a couple of things into a policy change; Do you have a list that you feel like he should do? 49:56 Dr. Nancy Dickey: Specifically about telemedicine? 49:57 Milton Chen: Yeah. 49:58 Dr. Nancy Dickey: I think I would say to him that I believe telemedicine appropriately regulated can in fact expand access to care particularly to those areas where we have such limitation of sub-specialists and access to those sub-specialists. Second, I think I would say that we have to be very cautious that we don’t create unintended consequences. Telemedicine should not be a replacement for traditional healthcare. 50:35 Dr. Nancy Dickey: I’m a family doctor. I believe that my relationship with my patients allows me to reach conclusions that doctors who see a patient for one or two visits for a specific issue don’t have the advantage of. And so, giving up that relationship with my patients, I think, leads to a lesser quality of care. So, if I had my druthers, I’d make sure that telemedicine would somehow tie to the doctor-patient relationship. But I do believe that it’s the way to get modern healthcare out to areas that don’t currently have it, that it ought to be primarily driven by healthcare providers who understand the complexity of medicine, but at the same time we need to be well aware of the fact that there’s lots of things that we do that don’t require a full-up physical examination and that are of good quality of medicine nonetheless. 51:35 Milton Chen: Thank you so much, Dr. Dickey, for joining us on this week’s Telehealth Failures & Secrets To Success Webinar!

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