Telehealth is growing rapidly, with one recent survey finding that inpatient adoption of such solutions and services has surged from roughly 54% in 2014 to 85% in 2019. Some pundits view telehealth as a means to effectively solve or at least significantly reduce many of the hurdles facing healthcare today, including patient access, physician access, patient engagement, costs, and patient compliance.
Unfortunately, telehealth has its own obstacles that not only stand in the way of achieving these objectives but also create new obstacles to delivering safe, effective patient care. Here are four of the most substantial telehealth challenges.
Often pointed to as the most significant barrier to telehealth's further growth and adoption, insurance coverage for telehealth services is often inadequate, if not lacking entirely, and inconsistent.
A report from the University of Michigan's Institute for Healthcare Policy, notes that, "Currently, telehealth is reimbursed in limited circumstances, and part of that is related to our fee-for-service healthcare environment and incentives around providing care. … At the state level, there are many different policies on coverage, which makes the entire reimbursement space very difficult to navigate for the people who are implementing telehealth. From the patient standpoint, this is also very confusing, because one insurance company may pay for a service while another may not."
A 2019 NPR survey of more than 1,400 adult patients living in the rural United States found that, "About four in 10 video/email/text/app telehealth patients (41%) say they were charged by their health insurance for their most recent visit, and among those charged, more than one in five (22%) say their health insurance covered none of the bill, while only 14% say their health insurance covered all of the bill."
The good news is that there have been several recent positive developments concerning coverage. In April, the Centers for Medicare & Medicaid Services finalized policies that allowed Medicare Advantage plans to include additional telehealth benefits. A 2019 report from the American Telemedicine Association (ATA) found that, "40 states and the District of Columbia have adopted substantive policies or received awards to expand telehealth coverage and reimbursement since 2017," among other encouraging findings.
But there is still significant work to be done in this area, notes an American Association for Physician Leadership article. "Payment policies and reimbursement models need to catch up with this major advance in healthcare technology and delivery, which works best in a prepaid, or capitation, model vs. a fee-for-volume scenario. There is discussion in Washington about creating parity in payment so that care providers would be paid the same for a digital visit as for an in-person visit. But so far only limited telehealth services are being covered by the federal government and other payers."
2. Legal Requirements
Want to provide and get paid for telehealth services? Understanding what you need to do (and not do) can be very confusing, and mistakes can be costly.
An American Hospital Association (AHA) report notes that, "Significant federal and state legal and regulatory issues will determine whether and how providers can offer specific telehealth services. In general, the provision of telehealth services requires compliance with an array of federal and state rules." Legal and regulatory challenges highlighted include coverage, licensure, credentialing and privileging, online prescribing, and privacy and security.
A Center for Connected Health Policy (CCHP) report found that "Remarkably, no two states are alike in how telehealth is treated despite some similarities in the language used. For example, some states have incorporated telehealth-related policies into law, while other states address issues in their Medicaid program guidelines. In some cases, CCHP discovered policy inconsistencies within a single state. This variability creates a confusing environment for those who use (or intend to use) telehealth, especially health systems that provide healthcare services in several states."
Failing to follow laws has ramifications, as Blue Cross Blue Shield found when it was fined $125,000 by North Dakota state officials for telehealth coverage violations, reports mHealth Intelligence.
In a Medical Economics article, Dr. Neal Sikka, chief of the innovative practice and telemedicine section at the George Washington University Medical Faculty Associates, offers the following advice for physicians considering adding telehealth services to their practices: "You do have to be careful. You can be successful if you're meticulous, use good resources, have risk managers looking at policies and procedures, and have good technology selection, appropriate documentation and training around telemedicine."
Telehealth has the potential to improve many people's lives, but not all. That's because large parts of the country lack the internet speeds required for these services.
As the NPR survey discussed earlier found, "One in five rural adults say accessing high-speed internet is a problem for their family, and without reliable, broadband (high-speed) internet access, rural communities are unable to participate in the digital economy, creating a major divide between rural and urban areas."
The AHA report includes this: "According to the Federal Communications Commission (FCC), 34 million Americans still lack access to adequate broadband. And, there is a large digital divide, with almost 40% of those living in rural areas lacking access. The FCC's Rural Health Care Program supports broadband adoption, but it is administratively burdensome and provides an insufficient level of subsidy for remote healthcare providers."
In addition, gaining access to broadband to just part of the equation. If patients cannot afford the cost of broadband, they may lose the ability to use telehealth services. A report from BroadbandNow, a data aggregation company focused on internet options, found that, "Roughly 146 million people in the U.S. (about 45% of the population) do not have access to a low-priced plan for residential wired broadband."
Access and affordability have caught the attention of federal leaders. A Healthcare Dive report notes, "The Federal Communication Commissions is attempting to alleviate rural concerns through a pilot program that gives a discount on connectivity for broadband-enabled telehealth services directly connecting doctors and patients."
Democratic presidential candidate [RK1] and U.S. Senator Michael Bennet, as part of his platform, "… pledged to make a $40 billion capital investment to connect the 'entire country to high-speed, reliable, affordable broadband' to better enable rural health providers to communicate with patients and monitor health conditions remotely," reports Healthcare IT News.
The rapid proliferation of telehealth has created a challenge common for healthcare technology and one that lacks an easy solution: interoperability.
As an mHealth Intelligence report notes, "… telehealth interoperability is currently mired in competing interests — between pay-for-service and pay-for-value, consumers and providers, and clinical interests and business cases. It's siloed in departments and programs that have proven telehealth's value but haven't been scaled out to the enterprise or embraced by the entire health system. And it's been stymied by parties who see value in data but not in sharing it."
A Healthcare IT News report shares excerpts from a recent ATA white paper on interoperability, including the following: "In many cases, telehealth clinical services and settings are fragmented, and data is siloed, with low-volume telehealth services such as those for specific locations or clinical specialties standing alone rather than being designed as part of a larger, integrated system. As these fragmented systems proliferate, they result in costly, redundant software infrastructure and endpoints that limit the potential to improve overall quality and access to care."
Other Noteworthy Telehealth Challenges
While the challenges discussed above represent some of the most significant impediments to the continued adoption and use of telehealth technologies and services, there are many others. Here are four more:
- As an American Medication Association report states, "Since telehealth visits are through a screen, misdiagnoses could increase. This could also end up increasing costs for the patients if they have to go back to see a doctor in person to confirm the diagnosis or treatment."
- Privacy and security. A report from the American Institute of Healthcare Compliance notes, "… in the excitement of developing telehealth programs, organizations should not lose sight of privacy and security regulations that apply to these new services. After all, protected health information under HIPAA can include data that is transmitted during the provision of telehealth services."
- Technical support. Technology inevitably has problems. Organizations that want to offer telehealth services need to consider how they will provide the technical support required when issues crop up. Important questions organizations will need to answer: Will support only be available for providers, or will it extend to patients? And if it extends to patients, how will that support be provided, to what extent will it be available, and at what cost?
- Patient preference. Finally, not all patients are eager to embrace telehealth. While much of the pushback against telehealth tends to come from older patients who are uncomfortable with technology, patients may prefer in-person visits over a virtual experience or have concerns about security. Patients may also worry about costs and whether using a technology-driven approach to care will lead to higher expenses.