Telehealth proof before payment- an antiquated barrier to care

     Telemedicine (tmed) has moved from technology to an opportunity for care.  Where there is limited access to experts (eg...rural stroke care), it is compensated- the right person at the right time can make all the difference.  However, widespread adoption of has been limited by two critical issues. First, licensure issues limit providers from crossing state lines.  Second, and more importantly, payment models are complex.  The same rural service delivered may not be paid for across town in a city.  Additionally, reimbursement for virtual care may be possible for one condition but not another in the same rural hospital.
    Parity legislation attempts to simplify these issues. In short, parity legislation requires, in fact mandates for private insurers, that the same billing codes apply whether the patient is seen is an office or on a computer. Almost every State is considering some form of this legislation.  Unfortunately, “mandate”  equates to cost for many legislatures and most insurers.  Mandate is viewed as a 4 letter word.

    In an effort to slow parity legislation, payers have suggested there needs to be proof tmed’s value related to specific clinical scenarios before payment.  Although this makes sense new drugs and devices, I am less certain it applies to tmed.
    Ultimately, healthcare "value" depends on 2 people- the provider and the patient.  The provider needs to be comfortable they can adequately assess the patient. This may require a physical exam, but more often providers need to see the patient and hear their concerns.  For most patients, a visit to the doctor is about reassurance, getting a sense that their cough isn't cancer, that the pain they feel is normal or worthy of further investigation.  If the provider or the patient feel a virtual visit is insufficient, either can choose to have the visit become an in person experience.  For the cost of one emergency room visit,  we could buy 50 to 100 virtual visits.  Access manages disease before it requires expensive tertiary care. Value is not determined by physical presence, but rather the communication, relationship and ultimately the patient’s outcome.      
    Virtual care offers an additional advantage over the standard office practice.  By eliminating physical barriers, care coordination can improve.  Many chronically ill patients have between 12-18 providers, most whom never meet or talk about the patient.  Leveraging mobile devices, care teams could be together, reducing costs and improving care.

    An alternative approach to no proof/no payment might be a stage introdcution for virtual serivces.  Allow reimbursed, but set a limit for a certain number per month per patient.  This would enable providers and patients to discover the most cost effective virtual alternatives while limiting the perceived financial risk to the payer.      Allow market forces to determine the best possible solutions rather than stifling innovation.  To compare tmed to traditional care would take years of work and thousands of patients.  And in the end we would be left with an ever evolving, and confusing landscape for virtual reimbursement.
    Healthcare in America is in transition.  We are moving from transactional care and reimbursement, get paid for what you do,o shared risk, wellness model.  Virtual care is one of the many tools that can help improve the care/cost curve moving forward.  Hopefully antiquated thinking will not limit tomorrow's possibilities.