As has been widely published, the Patient Protection and Affordable Care Act (ACA) has had a significant impact on Idaho’s health care and health insurance industries. Rising health care costs, increased insurance premiums and decreasing access to care have all come together behind what many praise as “Healthcare Reform.” Others derisively refer to this effort as “Obamacare.”
From one perspective, the ACA has or will lead to better insurance coverage for many, with some insurance coverage coming through employers and some through the newly-created Idaho Health Insurance Exchange, also known as Your Health Idaho. On the other hand, many believe Obamacare will increase insurance premiums and will not materially affect the constant escalation of healthcare costs.
According to the Kaiser Family Foundation, 258,000 Idahoans are without health insurance coverage. A primary goal of the ACA is to significantly decrease the number of uninsured. In Idaho, that process has begun. Through its first enrollment period which ended on March 31, more than 76,000 Idahoans obtained insurance coverage from Your Health Idaho, the trade name for Idaho’s health insurance exchange. Many of those were individuals who had previously been uninsured. In 2015, Idaho companies who employ 50 or more workers will be required to provide health insurance coverage or face significant penalties.
The natural consequence of reducing the number of uninsured in Idaho is that more Idahoans will seek the services of primary care physicians, mainly those physicians who specialize in family practice or internal medicine. That increased demand for primary care has or will soon exacerbate the problems created by the well-documented shortage of physicians in Idaho. According to a 2013 report published by the Idaho Department of Labor, Idaho ranks last in the nation for the number of primary care physicians per capita. Idaho’s physician shortages are caused by a number of factors, including the fact that there is not a medical school located in Idaho.
The Department of Labor report also indicates that the ACA will cause a 10 to 25 percent increase in the number of primary care physicians needed in Idaho. As one would expect, Idaho’s rural communities are especially affected by Idaho’s physician shortage. Because of physician shortages, patients are likely to see longer wait times for appointments, increased travel distances to get care, shorter physician visit times, more care provided by non-physicians, and higher prices.
One option for alleviating physician shortage issues is the use of telemedicine. The Centers for Medicare and Medicaid Services (CMS) and American Telemedicine Association define telemedicine as the use of medical information exchanged from one site to another via electronic communications to improve a patient’s health. In other words, the physician and the patient are not in the same location and communicate through some means other than a face-to-face, in-person encounter. The communication between physician and patient can occur through secure on-line video conferencing, a mobile application, a telephone consultation or a walk-in kiosk. Some of the leading telemedicine companies use a business model where the telemedicine service is a part of the patient’s benefits package provided by the patient’s employer. Employers look to telemedicine as a way to decrease health insurance costs.
Telemedicine services are typically available after normal business hours and to patients who are located even in the most remote locations. In theory, telemedicine can allow Idaho-licensed physicians, who may live in other states, to provide services to patients in Idaho. Advocates for telemedicine point to the fact that telemedicine services can be provided at a much lower cost than traditional medical services. Those advocates also note the increased employee productivity based on time not lost while employees wait in a physician’s waiting room. On the other hand, critics of telemedicine point to the fact that an in-person examination is an important component to understanding the patient’s problems and diagnosing the patient’s condition.
Recently, there has been extensive debate, in Idaho and nationwide, about the appropriate standards for the use of telemedicine. As has been widely reported, the Idaho State Board of Medicine recently sanctioned an Idaho-licensed physician for prescribing medication based on a telephone consultation with the patient, without first conducting a face-to-face evaluation of the patient. The Board relied on an Idaho statute that prohibits a physician from prescribing medication without first establishing a physician-patient relationship “which includes a documented patient evaluation adequate to establish diagnoses and identify underlying conditions and/or contraindications to the treatment.” The Board also stated that the sanctioned physician failed to meet the applicable standard of care.
The Board’s position is consistent with the approach recommended by the American Medical Association, which requires at least an initial face-to-face visit, but contrary to the model policy adopted by the Federation of State Medical Bords, which included no such requirement. The Board’s position on this issue caused Teladoc ‒ the nation’s leading provider of telemedicine services ‒ to withdraw its services from Idaho, leaving its 20,000 participants with no access to Teladoc’s services.
Fortunately, Idaho’s healthcare community and its Legislature are behind an effort to establish uniform standards for telemedicine services. In this past legislative session, Idaho’s legislature passed House Concurrent Resolution No. 46 (HCR 46). HCR 46 requires that the Idaho Department of Health and Welfare convene a Council to establish “a comprehensive set of standards, policies, rules and procedures for the use of telehealth and telemedicine in Idaho.” HCR further provides that the membership of the Council should include “broad stakeholder base,” including members who represent physicians, hospitals, health insurance companies, industry associations, as well as representatives from governmental agencies charged with regulating health care and health insurance in Idaho.
Twenty-two individuals have been appointed to the Council, including the chair person, Stacey Carson of the Idaho Hospital Association. According to Ms. Carson, “the Council has a diverse representation of stakeholders including hospitals, physicians, rural health, primary care, payers, and policy makers.” The Council’s first meeting will occur in late July. Ms. Carson notes that “Idaho has many areas with limited access to specialty care due to its rural and frontier nature.” Accordingly, “telemedicine can deliver health care services to areas where there are physician shortages or patients unable to travel far from their communities due to distance or environment.” Further, Ms. Carson articulates the Council’s work as an effort to “coordinate and develop standards and rules for the use of telehealth and telemedicine in Idaho” as a means “to decrease duplication of tests, assist in improving patient management, and better serve patients.”
Of course, these are all worthwhile goals. It will be interesting to see if the Council can bring together consensus from the broad range of opinions on this topic. In my mind, the stakeholders represented by the Council (and the Legislature) are to be commended for taking a timely, proactive approach to address these issues that greatly affect Idaho and the care provided to the residents of Idaho.
Tom Mortell is a partner at Hawley Troxell and chairs the firm’s health law practice group. He is also a member of the firm’s governing board. He can be reached at [email protected].
(Updated July 24 to clarify position of the Federation of State Medical Boards)