Wednesday Mar 12, 2014

Barriers Impede Telemedicine's Potential

Editor's note: During the AAFP's Scientific Assembly in San Diego, a panel discussion on practice transformation generated far more questions than the panelists could answer in the time allotted. This is the fourth post in an occasional series that will attempt to address the issues members raised -- including payment for telemedicine -- during the panel.

We know that telemedicine, the use of technology to deliver care at a distance, has the potential to expand access to care in underserved areas, reduce ER visits and save patients time. Questions remain, however, about how we can best expand telemedicine's use in primary care.

Telemedicine already is used in subspecialty care, including dermatology and radiology. But in our current fee-for-service model, can telemedicine be integrated into primary care without significantly increasing health care costs?

Kimberly Becher, M.D., left, the resident member of the AAFP Board of Directors, accompanied me on a trip to Capitol Hill while I was a visiting scholar at the AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care. I interviewed more than a dozen representatives of federal government health agencies and congressional staff about telemedicine for my project.
I recently spent a month in Washington researching telemedicine and the barriers to its expansion as a visiting scholar at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. Participating in the Larry A. Green Visiting Scholars Program was an invaluable educational experience, and I acquired skills that will help me for the rest of my career. The Graham Center staff provided me with in-depth training on research, including how to plan a project from beginning to end, proposal writing, information and data gathering, manuscript writing and more.

The training actually started months in advance as I worked with Graham Center staff to define what my project would be so that I could hit the ground running when I arrived in Washington for one month of intense work.

I picked telemedicine as my topic, in part, because the Graham Center was already in the midst of a research project on the subject. Funded by a $200,000 grant from WellPoint, the project produced a literature review, a report from the meeting of an expert panel, and -- coming later this year -- a survey of AAFP members about our knowledge and use of telemedicine.

It is hoped that the member survey results and my manuscript will be published in peer-reviewed journals. The Academy also intends to share the report from the expert panel.

For my project, I interviewed 14 representatives from government health care agencies and congressional staff to gauge their understanding of telemedicine and to identify barriers to its expansion in primary care and what is required to move beyond those barriers.

Barriers, it turns out, are not in short supply. One of the biggest issues is payment because of the constrained rules that exist in the current payment systems. There are certainly ways that telemedicine can be integrated into care delivery now, but I hope with alternative payment models on the horizon -- where physicians are paid based on quality and value -- we will see more physicians use it to deliver care at a lower cost for their patients.

Reimbursement for telemedicine services vary widely by payer and state. Ten states require Medicaid coverage of telemedicine, and 43 states require Medicaid coverage for some telemedicine services. Eighteen states mandate private payer coverage for telemedicine, and 14 other states have legislation pending.

But telemedicine is complicated in many other ways. According to the American Telemedicine Association, more than half the state legislatures are considering bills related to telemedicine. One of the most prevalent issues is licensure.

In Florida, for example, the state medical association has said that it supports the expansion of telemedicine, but the association is lobbying against a bill that seeks to create statewide standards and establish reimbursement requirements for telemedicine. The association is fighting the bill, which also would create a system for registering out-of-state physicians, because it opposes the idea of physicians licensed in other states treating Florida patients via telemedicine.

That's a significant issue in Florida because of the annual migration of people who spend the winter months in the Sunshine State.

What's at stake? A nonpartisan, nonprofit public policy research institute released a report this month that said reducing costly interventions, such as ER visits, by as little as 1 percent could reduce the state's health care costs by $1 billion a year.

Among my interview subjects, there was broad recognition that telemedicine is an important issued related to access to care. But another barrier we must overcome is that many rural and underserved parts of country still don’t have access to broadband internet. That's important because although the "tele" in telemedicine might prompt people to imagine a physician on a telephone, there's much more to it. Telemedicine can involve video conferencing with a patient from his or her home, electronic monitoring of chronic conditions and so much more. The fact that telemedicine means different things to different people could be a barrier as well. There's no consensus on what the term actually means.

That's unfortunate because more than 50 percent of U.S. hospitals already are using telemedicine in some manner. Incorporating the use of this technology in care delivery is happening, and it will continue to expand, so we have to figure out how it fits in primary care.

A good step forward would be finding a way to expose medical students and family medicine residents to telemedicine. I'm a fourth-year medical student and have yet to experience it. Medical school and residency is where we get our feet wet, and the models we train in influence how we will practice later.

We have the technology and the ability to extend ourselves, improve access to care and save our patients time and money, but there are many questions left to answer. I hope that when the Graham Center's survey lands in your in-box later this year, you will take a few minutes to give us your thoughts on telemedicine. The more people who participate in this important survey, the more valuable our data will be.

Tate Hinkle is the student member of the AAFP Board of Directors.

Posted at 12:30PM Mar 12, 2014 by Tate Hinkle  | 

Research Highlights Patient Demand for Primary Care Physicians

Robert Graham Center Tabulates Chronic Care Visits

January 15, 2014 02:35 pm Sheri Porter – Even though 70 percent of U.S. physicians report undergoing subspecialty training that involves specific chronic diseases, such as asthma and diabetes, new research shows that a majority of patients seeking care for most of 14 high-cost chronic conditions examined turn to primary care physicians.

Conducted by researchers at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, the study is summarized in a policy brief( in the January-February issue of the Journal of the American Board of Family Medicine.

Specifically, researchers used data from the 2008 National Ambulatory Medical Care Survey to track outpatient visits for each of 14 high-cost chronic conditions listed by CMS in its Chronic Conditions Dashboard to determine if patients were seen by a primary care physician or a subspecialist.

Primary care physicians were designated as those in family medicine, general practice, internal medicine or pediatrics.

Researchers found that of more than 10 million patient visits for asthma, 85.5 percent were to a primary care physician. For depression, 53.3 percent of visits were to a primary care physician, and for chronic obstructive pulmonary disease, 84.5 percent of visits were to a primary care physician.

Story highlights
  • New research published in the Journal of the American Board of Family Medicine shows that many patients with chronic diseases receive care from primary care physicians.
  • Of the 14 high-cost chronic conditions for which researchers tracked data, more patients sought care from primary care physicians versus subspecialists in all but three disease categories.
  • Researchers noted that patients' dependency on primary care may not be fully appreciated.

In addition, researchers found that primary care physicians handled

  • 66.8 percent of nearly 5 million patient visits for osteoporosis,
  • 50.2 percent of more than 15 million visits for diabetes,
  • 63.6 percent of nearly 25 million visits for chronic kidney disease,
  • 77.9 percent of more than 30 million visits for hyperlipidemia and
  • 68.9 percent of more than 50 million patient visits for hypertension.
In fact, of the 14 chronic conditions for which researchers reviewed data, in only three disease instances -- arthritis, atrial fibrillation and ischemic heart disease -- did patients more often see a subspecialist than a primary care physician.

"These data demonstrate how much patients depend on primary care physicians to take care of these complex and chronic conditions," said Graham Center Director Andrew Bazemore, M.D., M.P.H., in a Jan. 8 press release(

"Many of these patients have multiple chronic conditions, so a physician with expertise in the whole person and the broad range of medical diagnoses is instrumental to ensuring that all their health needs are met," he added.

In the research summary, Bazemore and his colleagues noted that primary care "has been acknowledged as essential to the success of health care reform and the nation's triple aim" (i.e., improving patient care and outcomes and lowering costs).

The researchers added that the degree to which chronically ill patients depend on primary care physicians "may not be fully appreciated," and they suggested that primary care physicians be described as "complex care physicians" given their obligation to not only identify patient needs, but also to oversee preventive services, facilitate behavioral change and coordinate care with other health care professionals.

The findings are particularly relevant to family physicians, according to corresponding author Manisha Sharma, M.D., of Baltimore, medical director of Evergreen Health Care and a visiting scholar at the Graham Center. As a practicing family physician, Sharma is all-too-familiar with the crush of patients seeking care for chronic health conditions.

However, even she was caught off guard by the sheer numbers of patients who sought primary care versus subspecialty care, as well as by the lengthy list of chronic diseases involved.

"It's a large chunk of chronic conditions, and that did surprise me," Sharma told AAFP News Now. She said America's health care paradigm is shifting toward preventive care and interventions, functions that some would call the heart and soul of family medicine.

"Family physicians are the true leaders when it comes to the art of complex care," said Sharma. "We're multi-focused and knowledgeable in many areas of care."

According to Sharma, family physicians -- more than physicians in any other primary care specialty -- are trained to look at social determinants of health, such as the neighborhoods and conditions in which patients live, work and play.

"We need to start looking at the things that are the 'underbelly' of all these chronic conditions and how they are layered one on top of the other," said Sharma. "If we want to have a healthier America as we move forward, I really do believe the conversation needs to shift toward the social determinants of health."

In addition, said Sharma, health care policymakers in the midst of creating new models of care and making important decisions about the care that is delivered would do well to listen to physicians in the trenches.

Primary care physicians and, in particular, family physicians "need to be in the room and at the table," said Sharma. "We need to be part of those conversations, because we know what goes on day-to-day with our patients."

Family physicians top list of most-recruited specialties in the U.S.
Data from Merritt Hawkins' 2013 Review of Physician and Advanced Practitioner Recruiting Incentives showed family medicine was the most-recruited medical specialty in the U.S., followed by internal medicine. Hospitalist, psychiatry, emergency medicine and pediatrics were also among the top 10. (8/28)

More Medical School Students Opting For Family Medicine Careers, Data Show

September 04, 2013 04:45 pm James Arvantes – The percentage of medical school graduates choosing family medicine residencies has jumped by nearly 10 percent during the past five years, an increase that demonstrates the growing popularity of family medicine as a career choice, according to Perry Pugno, M.D., vice president for medical education at the AAFP.

The AAFP conducts an annual survey of the nation's family medicine residency programs, and according to those data, 67.4 percent of first-year family medicine residents graduated from U.S. allopathic or osteopathic medical schools this year, making 2013 the fifth straight year the percentage has increased. In 2009, 58 percent of first-year family medicine residents graduated from a U.S. allopathic or osteopathic medical school.

"This is another indicator that medical students realize primary care is the foundation of health care," said Pugno in a recent press release. "The number of students choosing family medicine in the annual Match (National Resident Matching Program) continues to increase, and the attendance at the AAFP's National Conference for Family Medicine Residents and Medical Students has really increased. All of these point to a trend toward primary care careers."

Pugno added, however, that the nation is not producing enough family physicians to meet the growing demand for primary care and family physician services, especially as the population ages and more people gain access to health care coverage through the Patient Protection and Affordable Care Act.

The nation is producing about 3,500 family physicians a year, but will need about 40,000 more FPs by 2020 to address current and anticipated demand, said Pugno in an interview with AAFP News Now.

He described medical students as "savvy consumers of information," saying "they recognize that the demand for primary care is clearly going to escalate."

"They see the results of studies from across the nation showing that a robust primary care base achieves better care, better patient experience and better health, and that it does so at a lower cost," said Pugno.

How Health Insurance Reform Proposes to Help Rural Americans

Lower Costs

Preventive Care for Better Health: Health reform will ensure that all Americans have coverage of preventive services.

Ending the Hidden Tax:  Insured families pay a “hidden insurance tax” for the unpaid costs of the 20% of rural families who don’t have insurance by offering affordable insurance.

Financial Relief for Working Families: By ensuring coverage of basic health care services health reform will help rural families with their health care bills.