Between 2008 and 2020 the number of Americans older than 65 years will have increased by 36%, while the physician supply will hardly keep up with a corresponding 7% increase, according to a report published in 2010 by the Association of American Medical Colleges (AAMC) Center for Workforce Studies.
Using the latest modeling methods and available data, AAMC projected a shortfall of between 46,100 and 90,400 physicians by 2025, most in primary care. All Americans are likely to be affected, but the shortfall may have the greatest effect on the approximately 20% of our population that lives in rural and underserved areas. As a medical community, how do we address this evolving health disparity?
One solution that has begun to be met with great success is telehealth. According to the American Telemedicine Association (ATA), “Formally defined, telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status. Telemedicine includes a growing variety of applications and services using two-way video, email, smart phones, wireless tools and other forms of telecommunications technology.” A 2012 systematic review of the telemedicine program at the University of Pittsburgh Medical Center (UPMC) found that sites using telemedicine resources had lower medical and pharmacy costs, delivered services more efficiently, and had lower rates of hospital admission and readmission.
Telemedicine also may help reduce costs associated with unneccesary hospitalizations of nursing home residents. In a controlled study, use of telemedicine instead of an on-call system for physician coverage in nursing homes was found to generate cost savings for Medicare that exceeded a facility’s investment in the telemedicine service.
In addition, telemedicine has been shown to improve self-management of diabetes by facilitating management of symptoms, diet, body mass index, and blood pressure and glucose levels. It also has been used as an effective mental-health tool: Psychiatric interviews conducted over videoconferencing have been found reliable for making a diagnosis and offering treatment recommendations.
With respect to management of chronic diseases such as congestive heart failure, stroke, and chronic obstructive pulmonary disease, telemedicine has proven to increase the quality of long-term monitoring and decrease or prevent complications. There have been many advantages of telemedicine that medical practitioners have been able to quantify.
But is telemedicine really ready for prime time? UnitedHealthcare, the country’s largest insurer, seems to think that it is just as valuable as a traditional doctor’s visit. UnitedHealthcare recently expanded coverage options for virtual physician visits, giving patients enrolled in self-funded employer health plans secure, online access to a physician via mobile phone, tablet, or computer 24 hours a day. Other insurers such as BlueCross BlueShield, Wellpoint, and Oscar also have adopted telemedicine coverage.
However, coverage and reimbursement rates for telemedicine significantly vary by state. Twenty-four states mandate some type coverage for telemedicine by private insurers. Forty-eight states have some degree of coverage in their Medicaid programs. On the flip side, some states—such as Texas, with support from the Texas Medical Association—still do not support coverage of telemedicine programs.
In addition, there are many legal hoops physicians and patients must jump through. With telemedicine, the physician and patient may be physically located in different states. When this happens, in which state or states is medicine being practiced? Practicing medicine always requires licensure by the state in which the provider is working, but a valid license in the state where the patient is located also may be required.
Although telemedicine cannot replace the sensitivity and specificity of a doctor’s touch, it is reassuring to know that there is scientific evidence to demonstrate that the technology is a viable solution for our widening physician deficit. How will telemedicine will change our practices? Will physicians become stay-at-home “telemedicine-based” practitioners? Is it possible to have an entire medical career that is solely online? Only time will be able to provide effective answers to these questions.