Telehealth is defined as the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across distance (Doarn et al., 2014). The use of telehealth has grown dramatically since its earliest modern use in the 1960s. In fact, it is predicted telehealth visits will reach 300 million in the coming years and be a $25 billion market by the end of 2015 (Deloitte, 2014). Despite this apparent rapid adoption, there are several significant barriers preventing the adoption of telehealth in rehabilitation. Three of those barriers include practice, licensure, and reimbursement (Lee & Harada, 2012). Infinity Rehab has been using telehealth since 2008 and continues to seek innovative ways in which to apply telehealth to post-acute care practice.
Telehealth Background
There is a growing body of evidence to support the clinical efficacy of telehealth in various practice settings and with various populations. For example, telerehabilitation, a subset of telehealth, has been found to achieve outcomes comparable with those from conventional in-person rehabilitation (Russell, Buttrum, Wootton, & Jull, 2011). In addition, patient satisfaction, the most studied element of telehealth, has consistently high levels of satisfaction with the technology (Johansson & Wild, 2011; Russell et al., 2011; Schein, Schmeler, Saptono, & Brienza, 2010). Telehealth is often cited as a way to reduce health care costs to meet one arm of the triple aim of health care reform. Studies involving Medicare beneficiaries found that care delivered by telehealth was more economical than conventional care (Baker, Johnson, Macaulay, & Birnbaum, 2011; Cryer, Shannon, Van Amsterdam, & Leff, 2012; Edirippulige et al., 2013). Infinity Rehab completed a study of its telehealth practice this year and found no significant difference in functional outcomes between patients supervised by a PT in-person and patients supervised by a PT via telehealth. Despite this evidence there continue to be barriers to the adoption of telehealth in rehabilitation clinical practice.
Barriers
Practice
Physical, Occupational, and Speech therapists are required to not only practice within the guidelines outlined by their professional associations, but they must also abide by practice guidelines governed by the states in which they practice. Unfortunately, most state practice acts are silent on the use of telehealth. For example, for physical therapy, only Alaska, Kentucky, and Washington have language that specifically addresses the use of telehealth for physical therapists (Federation of State Boards of Physical Therapy [FSBPT], 2014). Some states use vague language pertaining to telecommunications. As a result, therapists in most states that choose to practice using telehealth do so at their own risk.
The good news is that more states are addressing this important practice barrier. In the past year, the Oregon PT and OT licensing boards approved new practice act language for telehealth. Infinity Rehab participated in the work groups for both disciplines that were responsible for creating the language. In addition, the Federation for State Boards of Physical Therapy (FSBPT) recently issued a policy document for states to use as guidance. The solution for this particular barrier to telehealth adoption is a grass roots movement by therapists of bringing this to their Chapter’s attention. Rural parts of many states have severe access problems to physical therapists. Telehealth could help alleviate this problem.
Licensure
Telehealth nearly completely removes geography from consideration when providing health services to a distant patient. A clinician can treat a patient literally from anywhere on the globe with the use of technology. Unfortunately, archaic licensure laws in the U.S. make practicing telehealth across state lines extremely cumbersome. For example, Portland, OR and Vancouver, WA are adjacent to one another separated only by the Columbia River. However, licensure rules prohibit an Oregon licensed PT from treating a patient located just minutes away in Vancouver, WA via telehealth. This requires clinicians to become licensed in multiple states, with some clinicians maintaining licenses in all 50 states (Weinstein et al., 2014). Of course, the time and costs to maintain multiple states licenses is considerable.
The Federal government believes the licensure barrier is a public protection issue. In a report to Congress, the Health Resources and Services Administration states that “overcoming unnecessary licensure barriers to cross-state practice is seen as part of a general strategy to expedite the mobility of health professionals to address workforce needs and improve access to health care services, particularly in light of increasing shortages of healthcare professionals” (Wakefield, 2011, p. 5). A solution to this problem is the licensure compact.
Compacts between states are very common. There are more than 215 interstate compacts in existence today with each state belonging to an average of 25 compacts (DeGolian, 2015). In health care, a compact license allows a clinician to work in another state without having to obtain licensure in that state. There are several notable medical and licensing compacts. The most recognized is the drivers licensing compact, which includes all 50 states. Medical compacts include the nurse licensure compact (24 states), mental health compact (45 states), and the emergency management assistance compact (50 states). Licensure compacts in development include EMS, medicine, and physical therapy. This is very exciting for physical therapy. I will write more about this specific topic in a future article. OT is also taking steps towards the development of a compact. Licensure compacts would greatly facilitate the adoption of telehealth.
Reimbursement
Finally, reimbursement is another significant hurdle for telehealth adoption. Despite the growing body of evidence-based research demonstrating positive clinical outcomes and increasing telehealth utilization, improved state and Federal reimbursement for telehealth services has remained stagnant (Thomas & Capistrant, 2015). The American Telemedicine Association (ATA) gives just five states a grade of A, based on a composite score of 13 indicators. The goal of telehealth reimbursement is full parity, which is classified as comparable coverage and reimbursement for telehealth-provided services to that of in-person services. Twenty-three states and the District of Columbia have enacted full parity laws while 48 state Medicaid programs have some type of coverage for telehealth. Only 8 states provide reimbursement for telerehabilitation services within the home health benefit.
Innovative payment models and recent proposed bills are encouraging solutions for the reimbursement problem. For example, the Comprehensive Care for Joint Replacements (CCJR) bundled payment program proposal waives restrictions that require a patient to be located in a rural health professional shortage area (Center for Connected Health Policy [CCHP], 2015). In addition, the next generation Accountable Care Organizations (ACOs) announced by the CMS earlier this year remove rural and institution restrictions as well (“Expanded Telehealth Coverage,” 2015).
There are several bills before the 114th Congress that would expand access to and reimbursement for telehealth services. One of the more significant bills is the Medicare Telehealth Parity Act of 2015 (H.R. 2948, 2015). This bill expands Medicare reimbursement for telehealth services and broadens approved providers for reimbursement to include PTs, OTs, and SLPs, among other providers.
Patients and providers are increasingly demanding access to health care via telehealth. It is important that barriers such as state practice acts, licensure laws, and reimbursement be removed to meet this demand. Telehealth could play a significant role in helping the U.S. meet its triple aim health care reform objectives with these barriers removed. Infinity Rehab is active on both state and national levels to help find solutions to these barriers.
References
Baker, L. C., Johnson, S. J., Macaulay, D., & Birnbaum, H. (2011). Integrated telehealth and care management program for Medicare beneficiaries with chronic disease linked to savings. Health Affairs, 30(9), 1689-1697. https://dx.doi.org/10.1377/hlthaff.2011.0216
Center for Connected Health Policy. (2015). Proposed rule: Comprehensive care for joint replacement model. Retrieved from https://cchpca.org/sites/default/files/resources/CCJR%20Model%20Factsheet.pdf
CMS approves American Telemedicine Association’s request to expand telehealth coverage [News Landing comment]. (2015, March 11). Retrieved from https://www.americantelemed.org/news-landing/2015/03/11/cms-approves-american-telemedicine-association-s-request-to-expand-telehealth-coverage#.Vi1GP3yFM6Y
Cryer, L., Shannon, S. B., Van Amsterdam, M., & Leff, B. (2012). Costs for ‘hospital at home’ patients were 19 percent lower, with equal or better outcomes compared to similar inpatients. Health Affairs, 31(6), 1237-1243. https://dx.doi.org/10.1377/hlthaff.2011.1132
DeGolian, C. (2015, January 12). Top 5 issues for 2015: Interstate compacts [Blog post]. Retrieved from https://knowledgecenter.csg.org/kc/content/top-5-issues-2015-interstate-compacts
Deloitte. (2014). eVisits: The 21st century housecall. Retrieved from https://www2.deloitte.com/global/en/pages/technology-media-and-telecommunications/articles/2014predictions-eVisits.html
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Edirippulige, S., Martin-Khan, M., Beattie, E., Smith, A. C., & Gray, L. C. (2013). A systematic review of telemedicine services for residents in long term care facilities. Journal of Telemedicine and Telecare, 19, 127-132. https://dx.doi.org/10.1177/1357633X13483256
Federation of State Boards of Physical Therapy. (2014). Telehealth in physical therapy: Policy recommendations for appropriate regulation. Retrieved from https://www.fsbpt.org/FreeResources/RegulatoryResources/TelehealthinPhysicalTherapy.aspx
Johansson, T., & Wild, C. (2011). Telerehabilitation in stroke care: A systematic review. Journal of Telemedicine and Telecare, 17(1), 1-6. https://dx.doi.org/10.1258/jtt.2010.100105
Lee, A. C., & Harada, N. (2012). Telehealth as a means of health care delivery for physical therapist practice. Physical Therapy, 92(3), 463-468. https://dx.doi.org/10.2522/ptj.20110100
Medicare Telehealth Parity Act of 2015, H.R. 2948, 114th Cong. (2015).
Russell, T. G., Buttrum, P., Wootton, R., & Jull, G. A. (2011). Internet-based outpatient telerehabilitation for patients following total knee arthroplasty. The Journal of Bone and Joint Surgery, 93(2), 113-120. https://dx.doi.org/10.2106/JBJS.I.01375
Schein, R. M., Schmeler, M. R., Saptono, A., & Brienza, D. (2010). Patient satisfaction with telerehabilitation assessments for wheeled mobility and seating. Assistive Technology, 22(4), 215-222. https://dx.doi.org/10.1080/10400435.2010.518579
Thomas, L., & Capistrant, G. (2015). State telemedicine gaps analysis: Coverage and reimbursement. Retrieved from American Telemedicine Association website: https://www.americantelemed.org/docs/default-source/policy/50-state-telemedicine-gaps-analysis—coverage-and-reimbursement.pdf?sfvrsn=10
Wakefield, M. K. (2011). Health licensing board report to Congress (DHHS Senate Report 111-66). Washington, DC: Government Printing Office.
Weinstein, R. S., Lopez, A. M., Joseph, B. A., Erps, K. A., Holcomb, M., Barker, G. P., & Krupinski, E. A. (2014). Telemedicine, telehealth, and mobile health applications that work: Opportunities and barriers. The American Journal of Medicine, 127(3), 183-187. https://dx.doi.org/1
