Thank you Chairman Collins, Ranking Member Hahn, and members of the Subcommittee. I am honored to have been invited to testify before you today on this important policy topic. My name is
My testimony is organized around three points:
1. By adopting telemedicine services, small physician practices may be better prepared to participate and succeed in new payment and delivery models, such as bundled payment.
2. Reimbursement and state licensing policies serve as barriers to the adoption of telemedicine by small practices.
3. Any policy that expands the use of telemedicine should be carefully monitored. While there is promising evidence about the value of telemedicine, the evidence is not conclusive (or easily accessible to physicians in small practices).
Telemedicine and New Payment and Delivery Models
There is widespread agreement that the traditional fee-for-service system, which pays providers for each visit, procedure, or test, is an obstacle to achieving the triple aim of better health care, better health, and lower cost. n1, n2 Researchers, health care advisory groups, and policy makers have called for public and private payers to move away from the fee-for-service system toward reimbursement models that reward providers for the quality of care delivered, cost consciousness, and patient satisfaction.n3-n5 As a result of these calls, the way in which physicians and hospitals are paid is beginning to change. For example, the
Telemedicine has an important place in these value-based purchasing models. Reimbursement is not contingent upon in-person services; instead, providers have the flexibility and the financial incentive to care for patients using the best means possible at the lowest cost. Several studies have shown that telemedicine costs less than in-person visits, and may reduce utilization of high-cost services. One study found that the availability of telemedicine videoconferencing after hours in nursing homes reduced hospital readmissions and led to approximately
Given the momentum towards value-based purchasing, small physician practices and hospitals would be well-served by exploring whether and how telemedicine could be used to support high-quality care at a reduced cost.
Challenges to the Adoption of Telemedicine by Small Practices
While there are several barriers to the adoption of telemedicine by small physician practices, the two that are arguably the most important and policy relevant are reimbursement and licensing.
However, through the rulemaking process, the
Although research on the impact of telemedicine on cost, quality, and access is promising, the evidence is not conclusive. As a result, I believe the gradual expansion of telemedicine coverage under
While state borders may be irrelevant to the delivery of quality care via telemedicine, they do present an important legal barrier. In most instances, physicians are limited to practicing in states where they are licensed. Telemedicine practice is regulated at the state level by state medical boards, which are given authority by state legislatures. Some state medical boards require telemedicine providers practicing across state lines to have a valid state license in the state where the patient is located. n12 Those who support requirements for physicians to be licensed in the same state as their patients, including the
My personal opinion is that the current medical licensure system is inadequate to address the growing practice of telemedicine. There are several alternative models that could be considered, though each presents challenges. For example, federal licensure and regulation would inevitably raise federalism concerns as professional licensure has historically been a state power. Another option is an interstate agreement that would grant privileges in all participating states, provided that the physician has a valid license in at least one of the participating states. However, when this approach was attempted by the nursing profession, only half the states adopted the interstate agreement. n13
Notably, decisions by state medical boards may come under greater scrutiny with the
Evidence on the Impact of Telemedicine
The academic literature on the impact of telemedicine is voluminous and still growing. Overall, the evidence suggests that telemedicine can improve access to care and the value of care. Here are just two examples:
* Using store-and-forward teledermatology (where a referring physician uploads a patient history and images of a skin lesion to a secure site for a consulting dermatologist to review), dermatologists at
However, evidence of the impact of telemedicine is not entirely consistent. For example, one study found that physicians were more likely to prescribe antibiotics when the visits occurred via telemedicine, suggesting that telemedicine may result in a more conservative care plan, which could have unintended consequences, such as antibiotic resitance. n17 A randomized controlled trial found that telemonitoring for frail older adults did not reduce hospitalizations or emergency department visits, and was associated with greater mortality. n18 In a recent compilation of systematic reviews on telemedicine, twenty reviews concluded that telemedicine was effective, 19 were less confident about the effectiveness of telemedicine but noted its potential, and 22 concluded that its effectiveness was limited or inconsistent. n19
Clearly, there is a need for continued research in this area. Additionally, there are two other issues concerning research that should be addressed. First, many studies of the effectiveness of telemedicine have been conducted within hospitals or large physician practices affiliated with health systems. As a result, our understanding of the impact of telemedicine among small, independent practices is much more limited. Second, information about the impact of telemedicine is typically published in the academic literature, which is not easily accessible to leaders of small practices. This limits physicians' ability to make informed decisions about whether or not to adopt telemedicine.
Despite the gaps and inconsistencies in the evidence, I believe that telemedicine holds great potential to expand access, improve care, and reduce cost. This past year, my colleagues and I at
In conclusion, telemedicine is an important tool for small practices as payers transition away from the fee-for-service model. State and federal policy makers have the ability to facilitate the adoption of telemedicine through policies related to reimbursement and licensing, but expansion should be coupled with oversight to monitor impact.
Again, I would like to thank you for allowing me to appear before you today and share my opinions on this topic. I would be happy to take your questions.
n1. Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health, And Cost. Health Affairs.
n6. Sood N, Huckfeldt PJ, Escarce JJ, Grabowski DC, Newhouse JP.
n7. Grabowski DC, O'Malley AJ. Use Of Telemedicine Can Reduce Hospitalizations Of Nursing Home Residents And Generate Savings For Medicare. Health Affairs.
n11. Gilman M, Stensland J. Telehealth and medicare: payment policy, current use, and prospects for growth.
n15. Kvedar J, Coye MJ, Everett W. Connected health: a review of technologies and strategies to improve patient care with telemedicine and telehealth. Health Aff (
n16. Whited JD. Teledermatology research review.
n17. Mehrotra A, Paone S, Martich GD, Albert SM, Shevchik GJ. Characteristics of patients who seek care via eVisits instead of office visits. Telemedicine journal and e-health: the official journal of the
n18. Takahashi PY, Pecina JL, Upatising B, et al. A randomized controlled trial of telemonitoring in older adults with multiple health issues to prevent hospitalizations and emergency department visits. Arch Intern Med.
Read this original document at: http://smbiz.house.gov/UploadedFiles/7-31-2014_McHugh_Testimony.pdf
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