FCC and Telehealth

The area of telehealth has been an ongoing process of incremental implementation. At one extreme it was merely assisting in the ability to perform diagnoses at a distance. In fact I was one of the earliest developers of such a system for use in radiology. (See 1, 2, 3, 4) All of the original work was done in the late 1980s, some thirty years ago. There is now a rush to provide a variety of such systems but understanding healthcare one must understand efficacy and costs.

Notwithstanding the facts, the FCC has announced a $100 million program in this area apparently based on a single trip to the South! Beckers notes that:

... a commissioner of the Federal Communications Commission, on July 11 revealed the agency's plan to establish a $100 million connected care pilot program. The program, which would support the use of telehealth for low-income Americans, spun out of a visit to Mississippi Mr. Carr took six months ago, during which he learned about a remote patient monitoring trial that improved medical outcomes for diabetes patients living in rural areas. Since his visit, Mr. Carr said he has met with telehealth experts and visited rural healthcare facilities to determine how the FCC can support the movement toward "connected care."

The FCC notice on this action notes:

 The FCC will vote on a Notice of Inquiry at its August Open Meeting that seeks comment on:

• Budgeting for $100 million in USF support
• Targeting support to connected care deployments that would benefit low-income patients, including those eligible for Medicaid or veterans receiving cost-free medical care
• Supporting a limited number of projects over a two- or three-year period with controls in place to measure and verify the benefits, costs, and savings associated with connected care deployments

Investments in connected care have resulted in substantial savings, particularly in the management of chronic diseases, which account for over 85% of direct health care spending in the U.S.:

• The Mississippi Delta trial resulted in nearly $700,000 in annual savings due to reductions in hospital readmissions alone. Assuming just 20% of Mississippi’s diabetic population enrolled in this program, Medicaid savings in the state would be $189 million per year.
• The Veterans Health Administration’s (VHA) remote patient monitoring program cost $1,600 per patient compared to more than $13,000 per patient for VHA’s home-based primary services.
• A telehealth project in the Northeastern U.S. found that every $1 spent on remote monitoring resulted in a $3.30 return in savings.

The problem is several-fold:

1. First, this is a complex issue relating to cost and efficacy in area which are well outside the expertise of the FCC.

2. Second, there is already a complex set of private sector developments in this area and CMS and other agencies are extensively evaluating them. Modern Healthcare has noted:

CMS on Thursday proposed paying doctors for virtual visits and overhauling Medicare billing standards it has had in place since the 1990s. In a lengthy proposed rule, the agency said it would pay doctors for their time when they reach out to beneficiaries via telephone or other telecommunications devices to decide whether an office visit or other service is needed. In addition, the CMS also proposed paying for the time it takes physicians to review a video or image sent by patient seeking care or diagnosis for an ailment. "This is a big issue for elderly and disabled population for which transportation can be a barrier to care," CMS Administrator Seema Verma said. "We're not intending to replace office visits but rather to augment them and create new access points for patients." Most physicians bill Medicare for patient visits under a relatively generic set of codes that distinguish level of complexity and site of care, known as evaluation and management visit codes. Doctors long have been concerned about the codes' documentation standards. The CMS has used evaluation and management visit codes since 1995.

The CMS proposed allowing practitioners to designate the level of a patient's care needs using their medical decisionmaking or time they spent with the patient instead of applying the decades-old E/M documentation guidelines.

3. It is not at all clear what expertise the FCC brings to bear. It was akin to my time at NYNEX now Verizon. A big opportunity and early entry but a clueless management. They were pole climbers, not diagnosticians.

4. The example of Type 2 Diabetes management is a classic one. As we have noted in a multiplicity of places, management of this disease is all too often a simple problem of diet and weight control. Yet that has always been a stumbling block because we just do not want to admonish patients for their own diseases. However with tobacco we did just that and lung cancer rates for males are plummeting. Fear, trembling and shame may really work, as well as a financial incentive.

5. Telemedicine is not just communications. In fact it barely needs a great deal now. Thirty years ago when I first started this we had 256Kbps lines and 100 Mbps Ethernet. Now we have wireless that beats it hands down. It requires software, medical procedures, changes in coding and billing, physician interaction and facilitation etc. None of this is in the FCC's purview. Thus what does the FCC bring to the table. Such an issue as licensing alone needs to be addressed. If I have a Massachusetts license how do I treat a patient in West Virginia? None of this can be handled by the FCC.

Given the current Federal Deficit one wonders in what Universe this program should see the light of day!