Enthusiasm for and anecdotal evidence of telemedicine’s potential abound, but some say there is simply not enough research to show the effectiveness of telemedicine compared to in-person treatment, especially when it comes to the use of mobile devices. Texting health reminders to patients and similar tactics have potential and are popular with consumers, but simply sending out text messages doesn’t mean that recipients will change their behavior, says Patricia Mechael, PhD, director of strategic applications of mobile technology at Columbia University. “We need to move away from research on user satisfaction and actually look at the impact on outcomes,” she said at a recent m-health summit in Washington, DC. There is “a lot of hype around m-health and we need to come back to the reality of what works, what doesn’t, and how to integrate mobile technology in a realistic fashion.”
Just as the field of telemedicine is emerging, so is research into its clinical effectiveness, ability to improve efficiency, and return on investment. But there are studies that show promise for some forms of telemedicine.
For the past five years, the Wenatchee (WA) Valley Medical Center has been studying a home monitoring program as part of a Medicare demonstration project. The goal of the physician-owned network of eight clinics and a 20-staffed-bed hospital was to reduce hospitalizations, and, as a result, lower costs among patients with diabetes, congestive heart failure, and chronic obstructive pulmonary disease.
“In a lot of ways a hospitalization for many of these people with chronic disease is a failure of their outpatient management. We need to beef up the outpatient management, reduce the hospitalizations—at least [so that] the people who need to go in are clearly there because they really need to go there,” says WVMC CEO Peter Rutherford, MD.
Using a home telephonic device, patients answer a series of questions specific to the current state of their disease, as well as some educational questions. Overnight, the device uploads the data and analytic software flags potential problems. In the morning, case managers review and intervene if necessary. Written protocols dictate what to do for each patient based on his or her condition—that might include making a simple follow-up phone call, adjusting the patient’s medication, or scheduling a doctor’s appointment.
“The idea is that you would try to catch exacerbations at a milder stage before they require hospitalization,” Rutherford says.
There is one case manager for every 125 enrollees—a ratio that allows managers to get to know their patients, Rutherford says. “Case management is the key piece of this. The device is a very useful tool in making the case management efficient, but you can’t do it with just the device,” Rutherford says.
In the first three years of the randomized trial, the organization met the program’s goal of saving 5% net of costs. The number of clinic visits went up—and because patients had already been triaged by case managers, those visits were more productive. At the same time, hospitalizations and emergency room visits declined.
“The cost to provide care to these patients is frequently higher than the DRG [payment]. And there is a higher readmission rate in these patients, and that’s no longer paid for by Medicare. So sure, they’re losing volume, but they’re losing volume on money-losing or lower-margin patients,” he says.
“As a clinic, we feel that the fee-for-service system is a dying beast and if we’re going to provide good care at lesser cost we have to basically cut out some of the expensive pieces of the care, which, realistically, are hospital stays and ER visits.”
The study is currently in its second phase, which will expand screenings to include other disease states such as asthma and comorbidities such as depression.
Reimbursement for telemedicine is slowly growing, but it is hardly widespread or standardized. Some payers have launched pilot programs to test telemedicine reimbursement models. Currently, 32 state Medicare programs provide at least some reimbursement for telemedicine services. And 11 states have enacted laws requiring that private insurers reimburse services provided via telemedicine if the same service would be reimbursed when provided in person. But only six of 11 states with reimbursement laws have specifically addressed the manner in which physicians should be reimbursed and whether they should receive the full allowable rate for an in-person visit. Of the six states that have addressed the issue, only Louisiana set the reimbursement rate lower (not less than 75% of the reasonable and customary amount of payment). The other states, including California, seem to be trending toward equal reimbursement.