decades. I frankly don’t know how any physician could provide high-quality care over the phone to a patient the physician does not know or has not seen in person.”
Physicians who violate TMB telemedicine rules face penal- ties ranging from a fine to having their licenses suspended or revoked, depending on the facts in the case. Ms. Robinson says the board can’t quantify the number of telemedicine com- plaints it receives or issue a data report for telemedicine-relat- ed complaints. She did highlight a formal complaint TMB filed with the State Office of Administrative Hearings in July 2011. The board’s complaint states a physician licensed in Penn- sylvania and Texas violated telemedicine rules, engaged in nontherapeutic prescribing, prescribed drugs without first establishing a proper professional relationship with a patient, and failed to maintain adequate patient medical records. The complaint stems from the physician’s treatment of a
1-year-old patient in September 2010. Teladoc directed the patient’s mother to the physician, who the board says had no established relationship with the child, hadn’t examined the patient, and hadn’t reviewed the patient’s medical records. The complaint says the physician determined over the phone that the child had an upper respiratory infection and prescribed an insufficient dosage of Amoxil. According to documentation, the patient’ temperature reached 104 degrees the day after taking the medication. The board asked the administrative law judge to conduct a hearing and issue a proposal for decision. At press time, the case was pending.
Telemedicine in the legislature Lawmakers filed several bills on telemedicine this session. Dr. Curran says legislators’ interest in telemedicine reflects their desire to expand access to care to patients in all parts of Texas. “As more people acquire health insurance and if Medicaid coverage is expanded, the state is going to have to explore ways of connecting more patients with physicians,” he said. House Bill 2017 by Rep. Four Price (R-Amarillo) would re-
quire insurance companies to pay physicians for after-hours telephone consultations. Thomas Kim, MD, an Austin internist and psychiatrist, testified for the bill on behalf of TMA. Dr. Kim uses telemedicine in his practice and develops and evalu- ates telemedicine technologies.
He told House Insurance Committee members that technol-
ogy can improve access to care and quality and reduce costs. Typically, insurance companies pay vendors to provide insured patients with access to the vendors’ physicians for after-hours care via phone. This arrangement often means local physicians — who don’t have contracts with the vendors — are not paid for these phone consultations. Disallowing payment for tele- phone consultations provided by local physicians is counter to TMA’s mission to improve the health of all Texans. “Advances in technology, including broadband Internet, smart devices, and social media, have created an extraordinary level of connectedness. But even with the growing number of ways to share, message, or connect, the telephone continues to serve as an important way to communicate with one another,
20 TEXAS MEDICINE June 2013
including health care service delivery,” he told the committee. Like many physicians, Dr. Kim relies on the telephone in caring for his patients. The nature of his calls can vary from simple medication questions to exploring whether a patient should go to the emergency department. He says being avail- able by phone ensures support for his patients in challenging circumstances. Without telephone support, Dr. Kim testified, “patient care can suffer in terms of rising costs and diminished quality of care.” Dr. Kim recounted for the legislature instances in which telephone consultations improved patient care and contained health care costs. In one situation, Dr. Kim worked with mem- bers of his health care team by phone to evaluate a patient in a juvenile detention center who had voiced suicidal thoughts. Dr. Kim was out of town but was able to determine over the phone that his patient was upset and not suicidal, avoiding a costly visit to the emergency department.
“By establishing parity for telephone consultation payment,
all parties involved can realize value. Avoidable costs are re- moved from the system, patient satisfaction improves by low- ering the access bar, quality of care rises with improved patient engagement, and community practices become more sustain- able and potentially more effective,” he said. Dr. Chenven echoes the need to ensure physicians receive payment for phone consultations. “Physicians who provide continuity of care via phone con- sultation should be paid for their time and the infrastructure costs. It doesn’t make sense to have physicians spend hours on the phone caring for patients and not getting paid for it.” Howard Marcus, MD, an internist at ARC and a consultant
to Teladoc, says the primary challenge facing physicians who practice telemedicine is an economic one. “We don’t get paid unless we see the patient in person. If
third-party payers compensated telephone and email consul- tations, we could provide health care more efficiently and at lower cost for that subset of health care issues that do not require a hands-on physical examination,” Dr. Marcus said. He adds that the failure to compensate physicians for these
services undermines the viability of primary care practices while driving up the cost of care.
The House Insurance Committee also heard testimony on House Bill 1806 by Rep. John Smithee (R-Amarillo). Dr. Cur- ran testified on the bill on behalf of TMA and the Texas Acad- emy of Family Physicians (TAFP). Dr. Curran cited TMA’s con- cerns with the bill as originally drafted:
• The bill creates a new standard of care for telemedicine, which conflicts with the Medical Practice Act and TMB rules.
• It contains an overly broad definition of telemedicine, which does not contain necessary elements to address scope of practice and the specific exclusion of telephone services.
• It does not require a distant site presenter. • It allows a physician assistant or advanced practice regis- tered nurse to provide telemedicine services and, as written,
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