Missouri Mulls Looser Telemedicine Rules

A new bill would allow reimbursement for telehealth visits that meet the same standard of care as in-person visits.

The state of Missouri is considering new legislation that aims to remove barriers to practicing telemedicine in the state.

Telemedicine adoption has been inconsistent throughout the United States for several reasons, and chief of among them is how providers would get reimbursed for such services.

Although Medicare covers certain services performed at certain locations, state regulations vary for Medicaid payments. According to the Center for Connected Health Policy, "no two states approach telehealth in the same way."

States differ in everything from how they define telehealth to which services they'll pay for. For example, some states will cover only certain services performed by certain types of specialists, while others reimburse for telehealth services similarly to the way they would reimburse for any other provider service.

The tide is moving toward a greater acceptance of telehealth on the state level. According to the Center for Connected Health Policy, "more than 200 telehealth-related bills were introduced in the 2017 legislative session," but there's still a huge variance from state to state.

If Missouri's House Bill 1617 passes, Missouri would become among the more progressive states in terms of telemedicine laws, according to Mariea Snell, DNP, APRN, FNP-C, associate professor and coordinator of the doctor of nursing practice programs at Maryville University in Saint Louis, Missouri; a telehealth clinician at Maven Clinic; and president of the Missouri State Board of Nursing.

The bill, which was introduced early in the year by Rep. Jay Barnes (R), would repeal several statutes and add others relating to telehealth.

According to Snell, current telemedicine laws in Missouri are a case of applying old rules to new technology.

"Our legislation has not kept up with the technology at all," she says.

Related: Strong Growth Forecast For Telemedicine

HB 1617 aims to remedy that by providing reimbursement to telehealth visits that meet the same standard of care as in-person visits. According to Snell, the bill would remove or prohibit several key barriers, such as expanding which specialists and services can get reimbursed via telehealth. 

"The reimbursement piece is the biggest thing, and that's been the biggest barrier," Snell says. "If you can't get paid for it, you'll go out of business in two shakes."

The bill proposes:

• Allowing store-and-forward technologies: Currently store-and-forward is limited to a handful of specialties, such as orthopedics and dermatology, but this bill would expand it to everyone.
  
  Store-and-forward technologies “allow for the electronic transmission of medical information, such as digital images, documents, and pre-recorded videos through secure email transmission,” according to the Center for Connected Health Policy.
  
  For example, that might include something like a patient emailing a picture of a surgical wound to a physician for evaluation, rather than the patient and physician talking face-to-face via live video feed.
  
  "I think people have felt like that shouldn't be allowed because you're not potentially getting enough information or creating that patient-provider relationship," Snell says.
  
  But, she says store and forward is popular with providers, is extremely efficient, and only would be used for diagnosis if the provider could glean enough information from the image, document, or video.
  
  "It's up to the providers to determine whether an appropriate diagnosis and treatment could be made using the technology," Snell says.
  
  A handful of other states, including Alaska and Washington, reimburse for store and forward.
   
• Prohibiting mileage restrictions: "The department of social service would have to reimburse providers regardless of how near or far the patient is to the provider, as long as it is greater than the distance that could be walked by an average person in fewer than 20 minutes," Snell said.
  
  "Currently they could place the restrictions on reimbursement without legislation to prohibit it," she continued. "If they place this restriction then passing this legislation would be [a] moot point."
   
• No telepresenter needed: Some states require a "telepresenter"—someone to assist the patient with the technology during a telemedicine encounter—in order for the visit to be reimbursed.
  
  But the new bill would prohibit any rules "[r]equiring another individual to be present beyond the patient and provider unless this would be required for a similar visit provided in person."
  
  Snell says requiring someone else to be in the room during a visit isn't usually part of a patient-physician encounter.
  
  "That's not the standard of care that we would do for a face-to-face encounter with a patient," she says.

Similarly, the bill would allow the telehealth visit to take place anywhere, "if the standard of care can be met based on the provider's clinical judgment."

If the technology exists, it makes sense for states to start allowing providers to use it to its fullest potential, Snell says.

"As technology improves, it starts to look ridiculous when people aren't implementing these things and utilizing this technology," she says.