The advent of telemedicine has introduced an unprecedented degree of convenience and immediacy, data sharing and communications among care teams and resource availability for value-based, patient-centered care.

But ensuring uniformly high-quality telehealth requires providers, technology vendors and ethicists to address and answer some big questions about the efficacy of remote vs. in-person care, the extent to which physicians can be reimbursed for telemedicine services and the ethical standards to which telehealth should adhere.

The quality issue
A unique intimacy attaches to medical care that is, literally, hands-on and puts physicians, nurses and patients in the same physical space. It's a valid concern that the virtual-visit character of telemedicine could depersonalize the doctor-patient relationship and compromise its pastoral element. But if a telehealth plan is put in place that caters to a patient's special needs and takes a global look at care, that concern can be eliminated or at least greatly eased.

"In thinking about how we care for all of our patients, we're not just relying on the visits we have with them," suggests Shivan Mehta, MD, director of operations at the Penn Medicine Center for Health Care Innovation and author of "Telemedicine's Potential Ethical Pitfalls," which appeared in the American Medical Association's Journal of Ethics. "I also think about how you could engage and interact with them in between visits and in an efficient way."

In Mehta's view, a whole range of possible telehealth formats, including social media and text messaging, could be employed to forge an even deeper connection – particularly for underserved populations that have few doctors in their communities or must travel long distances to see a physician.

"Telemedicine could complement existing delivery of care, and if it's designed well, in a way that maintains personality and allows for interaction and for people to connect with people, then that's very reasonable," he said.

Aside from therapeutic closeness, how do you also ensure that the effectiveness of telemedicine services doesn't suffer, either? By looking at the whole "value equation" of the healthcare in question, said Mehta.

"It's not just about the outcomes that happen but also the efficiency that leads to them," he said. "So if you can provide acceptable quality by measuring the right outcomes, but do it in a more efficient way, by using technology that actually improves quality for everyone, you can actually see and interact with more patients.

"Just as we want to measure quality for our live visits, we want to measure quality for our virtual visits to make sure that the patient experience is acceptable – just like we would in a clinical setting – and to make sure that the outcomes the patients have are comparable."

The increasing availability of telemedicine hasn't always synced up with the need to create high-quality clinical standards. That's why telemedicine care platform developer Carena has developed a set of virtual practice guidelines that are, in part, based its experience with 35,000 virtual clinic encounters. These treatment guidelines for clinicians emphasize patient safety, clinical quality and evidence-based medicine and can be customized to fit a particular health system's care protocols.

The ethics issue
Just as traditional medical care demands the highest ethical standards, the same is true of telemedicine. The need to protect the privacy and confidentiality of patient data and patient exchanges with care team members is no less paramount in the latter than in the former.

With telemedicine, however, there is "the added dimension to ensure that no one is 'off-screen' or observing that the patient is not aware of and that permission has been obtained" for that presence, said David Fleming, MD, co-director of the MU Center for Health Ethics at the University of Missouri School of Medicine.

Fleming lays out several ethical considerations that either are singular to telemedicine, or apply differently to it than to traditional care. One of these involves the need to avoid discrimination against patients who may be denied access to telemedicine venues because of logistics, cost or reimbursement barriers.

"Patients still need to be able to get to the telehealth site unless they are using mobile devices," he points out. "If the ability to travel even short distances is a barrier, then access is a problem for some patients. The cost of the equipment can be a problem for some less well-to-do healthcare systems in starting a telehealth program. And if telehealth is not reimbursed both patients and physicians will be reluctant to use it."

Part of the solution, according to Fleming, is for medicine and society to develop "more affordable and less complicated technology," make reimbursement more readily available, and adopt "better and more informed healthcare policies to deploy telehealth services in under-served areas.

Another ethical conundrum is how to prevent technology advances in telemedicine from inadvertently, or even deliberately, exploiting patients. In Fleming's view, that requires a collaborative effort by physicians, physicians' groups, healthcare systems and the larger society to develop "well-seasoned and evidence-based policies for the use of telehealth technology." The technology must be deployed "for the right reasons and in the best interest of patients – in particular, vulnerable patients who are at risk if something goes wrong. It's wrong to use telehealth primarily for financial gain."

The reimbursement issue
The scalability of telemedicine, i.e., how readily health care systems adopt that modality, depends in no small part on the extent to which government (Medicare, Medicaid) and private payers are allowed, and willing, to reimburse providers for telemedicine services. The current landscape contains a hodgepodge of practices and regulatory approaches on what, and how much, can be reimbursed and what is eligible for coverage.

The bottom line is, providers need to know they will be paid for telehealth delivery, and right now there are 31 states and the District Columbia that have payment mandates, but those vary greatly in language and scope. And Medicare fee for service providers are only paid if the patient's care happens in a rural, clinical site, so telehealth services delivered to patients in homes or in cities are excluded.

So that begs the question: Is there any movement to establish reimbursement uniformity across all types of payers?

Kofi Jones, director of government affairs for telehealth services provider American Well, said we're not there yet, in part because reimbursement rules are established in different ways for Medicare (the Social Security Act), Medicaid (the states) and private insurers (insurance codes).

But Jones said that efforts are underway to get policy-makers to view telehealth as "simply a modality of care delivery, not a different type of health care, and should be viewed in a similar light."

Hence, the momentum is towards expanded reimbursement. "From the commercial standpoint, you will see more and more health plans either complying with the laws that have been passed or even going beyond that to establish their own telehealth reimbursement policies," Jones predicts.

The corollary concern about uniformity is parity regulations, which require reimbursement for telehealth services at the same or an equivalent rate paid for in-person care. One problem is that mandates in this regard oftentimes speak to either coverage or reimbursement or both. So in some states with mandates, people still have problems getting claims paid.

Delaware is a good example of how to resolve that discrepancy. In 2015, the state passed law specifically requiring coverage and reimbursement to be paid at the same levels.

"When you have a bill that's that clear, it tends to compel greater claims payments," Jones said, adding that the upshot, in Delaware, has been that "telehealth claims are being submitted more often, that they're being paid, and that there's been great success in increasing reimbursement for appropriately provided telehealth care.

"The key to provider adoption is really provider payment," she said. "It's critical for providers to know what they're going to be paid, which is why there's such a great effort underway in the telehealth community to resolve the issue of reimbursement."

Though quality, ethics and reimbursement issues remain to be resolved, it's clear that growing attention is being paid to them.

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