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Doctors limit US expansion of telehealth -- but the VA knows the value

The VA continues to "set the telehealth table." That line is from 2010 when the VHA's telehealth pioneer Adam Darkins observed: "“The patients have to do less travel, and they can get problems resolved quickly.… They feel the care coordination system is their lifeline." The program was cited as having 43,000 Veterans enrolled with a long road ahead. Fast forward to 2014 -- the VA's Telehealth program served 690,000 veterans in its most recent fiscal year, or 12% of all veterans. And the long-term study of members of the Geisinger Health Plan showed a 44% reduction in readmission rates of those monitored in a 4-year telehealth study.

Telehealth definitions are confusing. So let's assume for the moment that telehealth is the technology market of providing remote care and/or monitoring of a patient's status or condition. I made that up. Here is the real definition from the US Government (broader than telemedicine and referencing 7 other definitions). And here's another policy site that links to the policies in all 50 states and another linking to the Institute of Medicine that limits the concept to serving those that are 'underserved.' Call me crazy, but that waffling sounds like doctors weren't fully on board with the idea of non-rural and well-served patients avoiding a trip to the office.

How big is the telehealth market as viewed then -- now and in the US? Slipping back to 2010, a mere four years ago, the global 'telehome' (telehome? seriously?) market was valued at $2.9 billion. Oh maybe not, a Forbes article cited another analyst firm which sized the US portion at $240 million today growing to $1.9 billion in 2018.   And the global telehealth market?  Oh my! From just $6.5 billion in 2013 to nearly $24 billion in 2019.  Not in the United States, though. Medicare restricts the growth of telehealth in non-rural areas by only reimbursing providers for telehealth visits that are "in a professional shortage area or outside of a metropolitan statistical area."  

Lift the restrictions and watch the explosive growth to the benefit of seniors. One can theorize that this restriction can only have been designed by and for the benefit of those very professionals who have fixed infrastructure costs in urban locations. Of course they have reimbursement rates that are tied to in-person -- if very brief -- face-to-face contact. Note the new Medicare Parity bill and its supporters -- of course the American Telemedicine Association was noted. Absent but predictably accounted for, was the American Medical Association. The AMA has spent anywhere from $15 million to more than $22 million annually between 2010 and 2014 lobbying issues that its members care about.  Does the AMA want telehealth to be a broad-based reality?  Uh, not exactly. It appears that doctors don't really want the patient to 'do less travel and get problems resolved quickly.' How sad for American seniors.


It’s never soon enough, but the US will eventually adopt telemedicine just as Europe has - the financial weight of our aging population will require it. No matter what gets spent in AMA lobbying dollars, the US must either adopt or go broke.

When I talk with people about telehealth, the objection that I hear most often is two-fold: (1) telehealth will lead to over-prescribing of antibiotics and increased antibiotic resistance; and (2) telemedicine will be practiced by physicians who don’t have a long personal history with the patient, thus leading to poor care.

The first objection sounds like an AMA media-ready sound-bite - we wouldn’t have widespread concern about antibiotic resistance if over-prescribing weren’t already a problem.

As to the second objection, like much of health care, telehealth will work best with an infrastructure that supports it, starting with a HIPAA-compliant but sharable electronic medical record so that telehealth doctors can “know” the patients that they’ve likely never seen before. Even though our challenges in HIPAA-compliant data sharing are real, this objection is a bit of a red herring: our military and their dependents have been seeing different doctors every visit for at least 50 years. I’m an army brat and my care didn’t suffer by seeing different physicians each visit — but at the same time, there were no reimbursement agencies pressuring my doctors to see me for 10 minutes or less.

The below statistics are from the VA's original Rural Health Study done with the most basic equipment available prior to 2003 EX: Health Buddy. When I saw these numbers I knew Telehealth was going to be everywhere in a few years. I sure got that wrong. We prefer to continue to provide care with one hand tied behind our back.

Rural Home Care outcomes data is as follows: (-for decrease; + for increase)
*data derived from comparison with usual care group

RHCP Usual care
Hospital Admissions -60% +27%
BDOC -68% +32%
NHCU Admissions -81% +11%
NH BDOC -94% +18%
Clinic Visits -4% +22%
ER Visits -66% +19%
Pharmacy -59% +37%


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