Health Care

Legislation boosts potential for remote medicine

In rural Vermont, connecting patients with doctors – and especially with medical specialists – can be a major challenge.

Now, state lawmakers have approved a bill that could help bridge that gap without building new medical offices or hiring more doctors.

Instead, S.50 aims to expand the use of telemedicine, defined as health care services delivered via a live interactive audio and video connection. The bill also mandates that all insurers reimburse for such services.

BMH telemedicine
A Dartmouth-Hitchcock Connected Care doctor remotely demonstrates a new teleneurology service available at Brattleboro Memorial Hospital. Photo courtesy Brattleboro Memorial Hospital
The bill’s broadening of telemedicine practices could benefit hospitals like the Brattleboro Retreat, which recently launched three projects intended to connect patients and doctors remotely.

“We have recognized that telemedicine offers great opportunities for us to expand access to vitally needed psychiatric services,” said Dr. Mark McGee, the Retreat’s chief medical officer.

Sen. Debbie Ingram, D-Chittenden, said she introduced S.50 at the request of a constituent who wanted to see telemedicine expand further into mental health care.

The legislation requires that all insurers, including Medicaid, cover telemedicine services “to the same extent that the plan would cover the services if they were provided through in-person consultation.”

Insurers can charge a deductible, copayment or coinsurance payment for telemedicine. But the bill says those payments can’t be any higher than those charged for in-person visits.

The Vermont Association of Hospitals and Health Systems endorsed the bill, which “will provide Vermonters with better access to care,” President and Chief Executive Officer Jeff Tieman said.

Ingram noted that the effort also was supported by the state’s two main insurance providers, Blue Cross Blue Shield of Vermont and MVP Health Care. In legislative testimony in late March, a Blue Cross representative said the insurer backed S.50 and had “recently introduced telemedicine services” for its membership.

Ingram said a key factor behind the bill was “giving people greater access to specialists in regions where they are scarce.”

“I think everybody thought it was a good way to provide access without raising costs astronomically,” she said.

By the time the bill passed the House on May 4 and the Senate on May 10, there had been a few key changes in S.50.

In an attempt to expand the reach of telemedicine, the legislation initially featured a long list of health care providers including mental health workers, social workers, therapists and dietitians.

That list is now gone.

In its final version, the bill offers a broad definition of a health care provider who can practice telemedicine – “a person, partnership or corporation, other than a facility or institution, that is licensed, certified or otherwise authorized by law to provide professional health care services in this state to an individual during that individual’s medical care, treatment or confinement.”

Ingram believes that definition will cover any qualified provider who wants to offer telemedicine, while allowing more flexibility for future types of telemedicine practices.

Lawmakers also added detailed language requiring that a health care provider receive a patient’s “informed consent” before using telemedicine.

That conversation has to include “an explanation of the opportunities and limitations” of providing remote medical consultations, the bill says. Also, a patient must receive assurances that telemedicine will be delivered via a secure connection that complies with federal medical privacy laws.

There are some exceptions to the informed consent mandate: For example, there is no such requirement in the case of a medical emergency.

Jeff Tieman
Jeff Tieman is president and CEO of the Vermont Association of Hospitals and Health Systems. File photo by Erin Mansfield/VTDigger
Tieman said the hospital association “worked to soften informed consent requirements that were added to the bill, which we believe could have created barriers to care.”

The association “does not oppose informed consent,” Tieman said. “We just believe it needs to be carefully outlined and managed so that it does not interfere with patient care.”

One other addition to S.50 is aimed at ensuring privacy: Neither a provider nor a patient is permitted to record a telemedicine consultation.

There is, however, a provision called “store and forward” that allows medical information to be transmitted and reviewed by a specialist at a later date. Officials said such a provision might commonly be used in dermatology.

Overall, Vermont hospitals’ use of telemedicine has been increasing – even prior to S.50.

At the Retreat, for instance, administrators a few months ago implemented a pilot program that allowed a psychiatrist who is not on site to remotely consult with an inpatient unit.

The program was an immediate success and is being expanded, McGee said.

In a similar vein, administrators are looking into providing on-call psychiatric services when a patient needs immediate after-hours consultation.

The Retreat also may establish partnerships with hospitals so a psychiatrist can rapidly, remotely evaluate a mental health patient who has gone to an emergency room for treatment.

McGee said “the work that we’re currently doing is based on existing statutes that allow us to provide this care.”

But he said S.50 could open up new opportunities for hospitals to expand the use of telemedicine. He speculated that telemedicine might even help address physician recruitment problems.

“We could, I think, begin to chip away at these access issues,” McGee said.

The Retreat is not alone in making forays into telemedicine in southern Vermont.

In Townshend, Grace Cottage Hospital – Vermont’s smallest hospital – has embarked on a pilot program meant to connect health care providers with diabetes and hypertension patients in their homes.

And Brattleboro Memorial Hospital earlier this year engaged in a partnership with Dartmouth-Hitchcock Connected Care. The New Hampshire hospital’s neurologists are available via video to patients in Brattleboro’s emergency room.

“It’s a good process,” said Dr. Kathleen McGraw, Brattleboro Memorial’s chief medical officer. “It’s a tight turnaround time in terms of getting that clinician available for the patient.”

McGraw said administrators are examining ways to increase the telemedicine practice at Brattleboro Memorial. Provisions in S.50, she said, might make that easier.

For instance, the bill says there can be no special limitations placed on the number of telemedicine consultations a patient can receive. The legislation also says a telemedicine patient can be in his or her home “or another non-medical environment such as a school-based health center, a university-based health center or the patient’s workplace.”

“It opens up more flexibility for where a patient is. They don’t have to be in a hospital bed to receive that service,” McGraw said.

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