Telemedicine use growing, but slowly

The number of doctors and hospitals delivering care via telemedicine is likely to stay small until reimbursement issues and other obstacles are addressed.

By Tyler Chin, amednews staff. July 31, 2000.

Telemedicine activity is growing, but the practice of delivering clinical care remotely through telecommunication and videoconferencing equipment is likely to remain a niche within the health care sector until certain obstacles are eliminated, according to some experts.

More than 52,000 teleconsultations were performed in 1998, up from 41,740 in 1997, according to the 1999 Annual Report on U.S. Telemedicine Activity by the Assn. of Telehealth Service Providers, a nonprofit trade group of clinics, group practices, hospitals and companies offering telemedical services and equipment, and Telemedicine Research Center, a nonprofit research group. Both organizations are based in Portland, Ore.

Total clinical teleconsultations
Telemedical activity for most active clinical specialties

By extrapolating statistics for calendar year 1998 and the first quarter of 1999, the survey estimated that the 132 telemedicine networks out of the 179 that responded to the survey will perform nearly 75,000 teleconsultations in 1999, said Bill Grigsby, PhD, co-author of the report.

A key reason driving the growth is that some of the respondents have become established players; as a result, they are doing more teleconsultations, Dr. Grigsby said. This dynamic is expected to continue because half the survey respondents have been around less than four years, meaning that they will likely conduct more teleconsultations as they mature.

Increased use of telemedicine in prisons also fueled growth, accounting for 30% of the teleconsultations in 1998. Many correctional systems are interested in deploying telemedicine because it's more cost effective than guarding and transporting inmates in and out of prison for medical treatment, said ATSP's president, Douglas Perednia, MD. "On average, it costs $1,000 to have a prisoner seen in [a physician's] office," he said.

Despite its growing use, telemedicine is largely irrelevant to most of the country's doctors. Dr. Grigsby estimates that fewer than 10,000 primary care and specialist physicians are involved in telemedicine, which is typically practiced between providers in rural and urban areas as well as in medically underserved urban areas.

This is not likely to change any time soon unless obstacles hampering wider adoption of telemedicine are eliminated. One of the biggest roadblocks is a lack of systematic reimbursement for telemedicine.

The Health Care Financing Administration last year agreed to pay for teleconsultations. But the payment process is cumbersome for doctors, which helps discourage them from doing telemedicine, Dr. Perednia said.

"HCFA agreed to pay the specialists, but then the specialists have to pay and send 25% of the compensation [they receive] to the primary care physician who referred the patient to them," Dr. Perednia said. "Normally this would violate the federal antikickback provision, but what HCFA said is that a kickback is legal for this application." The problem is that specialists have to carry two sets of books because their billing systems don't have mechanisms for fee splitting, which of course is illegal under most circumstances.

Another problem with HCFA's policy is that only physicians located in an area deemed by the U.S. Dept. of Health and Human Services to have a shortage of primary care physicians can be paid for teleconsultations, Dr. Perednia said. Few areas meet HHS's definition. "You can be in a place where there isn't a cancer doctor for 250 miles" and HHS would not consider it to be medically underserved, he said. Yet there is an effort in Congress to address these problems, Dr. Perednia added.

Other hurdles include the high cost of implementing a network; lack of awareness about telemedicine among physicians and patients; concerns about whether it is cost effective; and technology that is hard to use.

If these obstacles are addressed, however, telemedicine could be a boon to many physicians. "Telemedicine dramatically improves the availability of any doctor in the world, and that's the main reason why it's an important practice tool," Dr. Perednia said. "The kinds of doctors for whom this is really useful are those for whom availability is key to their practice; those who serve large numbers of patients for whom travel is difficult; those who have skills that aren't easily replaced and those who have capital intensive equipment that is rather unique," such as lasers for eye, ear, nose and throat, and dermatological surgeries.

ADDITIONAL INFORMATION:

Total clinical teleconsultations

1994: 2,110
1995: 6,138
1996: 21,732
1997: 41,740
1998: 52,223
1999: 74,828 *

Source: Assn. of Telehealth Service Providers, "1999 Annual Report on U.S. Telemedicine Activity."
* Extrapolated from figures for calendar year 1998 and first quarter of 1999.

Telemedical activity for most active clinical specialties

                       1996    1997    1998 
                       -----   ----   ------
Mental health          2,886   7,404  11,974
Cardiology             2,282   6,839   3,469
Dermatology            1,958   2,345   3,278
Orthopedics            1,083   2,306   2,556
Neurology                555     699     801
Emergency med./triage  2,574   1,006     714
Infectious diseases      323     851   1,514
Internal medicine        861   1,940   2,080
Endocrinology            N/A   1,242     214
General surgery          575   1,026   2,161
Pediatrics               371     572   1,161

Source: Assn. of Telehealth Service Providers, "1999 Annual Report on U.S. Telemedicine Activity"