"Improving Access in Healthcare through the Use of Telemedicine, Telepharmacy and Telenursing"

There is no question that the delivery of health care services has changed dramatically since the days of doctors making house call, nurses wearing white caps while providing services at community centers, and Mr. Gower sending his delivery boy to a patient's home with compounded medications packaged in powder papers to treat the malady of the day. One thing that has not changed, however, is consumer demand for affordable, convenient and effective health care. In today's health care world, telehealth delivery systems are increasingly replacing house calls, community center nursing stations and the George Baileys of the world, leveraging technology to make health care more convenient and affordable without compromising care.

Telehealth can be defined in many ways, but in essence, it is the delivery of health care services to patients who are located remotely from the provider, through the use of technology. The business case for telehealth is self-evident. The Affordable Care Act has created millions of new health care consumers and, as discussed in a recent InsideCounsel article, President Obama's November 2014 Executive Action on Immigration will add to the burdens imposed on some state governments to provide health care to a new set of eligible beneficiaries. New and innovative ways to provide quality health care cost-effectively to more people is needed, and telehealth has emerged to answer the charge.

Some of the many examples of telehealth services in use today include:

• Remote patient monitoring systems that allow providers to monitor blood pressure, pulse, blood sugar and other vital signs of patients in their homes.
• Audio and/or video communications between nurses and patients in their homes to replace home visits to provide patient education, and to assess and triage a patient's condition.
• The provision of specialist referral services including consultations with a primary care physician in rendering a diagnosis through the use of interactive video or the transmission of diagnostic images.
• The dispensing of medications by pharmacies via remotely operated automated dispensing systems that include a live audio video link with a pharmacist to provide pharmacy services at the point of care in hospital emergency rooms, specialty clinics, employer based health clinics and other deployment settings to improve compliance and adherence with a patient's drug therapy.

According to a report by IHS Technology, the global telehealth market is expected to grow by more than a factor of 10 from 2013 to 2018. The United States, as the world leader in health care expenditures, should account for a large percentage of that growth. However, there is some concern that regulatory hurdles could slow down, or in some cases, prevent the implementation of telehealth services. The delivery of health care is governed by state law, and with 50 different sets of state laws, it is in some cases difficult to create a “one size fits all” telehealth solution. Licensing hurdles also present a problem. Medical and nursing boards in many states have passed regulations to make it easier for doctors and nurses to provide services across state lines. Pharmacy boards have also addressed that issue, at least with respect to mail order delivery of medications. More work needs to be done by many states, however, to recognize the technology that is being used to deliver medical, nursing and pharmacy services remotely.

Payment for telehealth services by private insurers and government payers also needs to be addressed in a more uniform — and in some cases fairer manner. For example, some state Medicaid programs may not prohibit, but may not provide a mechanism for payment for telehealth services. This could lead to a scenario where the most vulnerable patient populations do not have access to the same type or quality of services as are available to patients who are covered by private or employer provided insurance.

Although payers, including government payers, are increasingly recognizing and paying for telemedicine services, there is still in many cases a failure to recognize remotely operated automated medication dispensing services, particularly by state Medicaid agencies. The problem in most cases is not that reimbursement is prohibited, but that there is no mechanism in place to obtain reimbursement. Yet, it is widely recognized that access to and the proper use of prescription medications, along with patient monitoring and counseling by a pharmacist, can significantly reduce health care costs.

Studies show that between 25 to 33 percent of prescriptions issued by prescribers are not filled by the patient. There are significant costs associated with this noncompliance. Remote pharmacy dispensing systems are addressing that problem to ensure that patients are able to obtain their prescribed medications at the point of care in hospital ERs, urgent care centers, clinics and other settings. If a Medicaid patient cannot access medications at the point of care via this type of technology because the state Medicaid system does not provide a mechanism for reimbursement (and the hospital or provider cannot provide the medication for free due to antikickback and beneficiary inducement prohibitions), there is a real risk that the patient will not fill his prescription at all, because of transportation issues or other difficulties in getting to a local community pharmacy. State Medicaid agencies need to address this issue and ensure that patients have the same access to pharmacy services as are available to patients who have private or employer provided insurance coverage.

House calls and home delivery services still have a role in health care but cannot fully respond to the ever increasing demand for convenient, cost-effective and quality health care services. State and federal regulators and third party payers must takes steps to ensure that patients have access to telehealth services to help meet that demand.