16 Feb Proposed National Telemedicine Bill: Great Step Forward or Bureaucratic Nightmare?
Recently, Utah senator Tom Udall (D-Utah) has announced plans to introduce a bill this spring that would create a national telemdicine license, thus, in theory, breaking down some very difficult barriers to delivering efficient national healthcare. This bill is specifically relevant to the field of teleradiology, as many teleradiology groups exist today face many challenges related to providing radiology reading services across state lines.
Today, regulation and monitoring of medical licensing is performed at the state level. While most states have very similar requirements for physicians to obtain a license, each state’s medical board has independent authority to regulate and police licensing for the physicians who practice medicine within its state boarders. Because a physician must be licensed in both the state where he or she is physically sitting while providing medical care, as well as the patient is being cared for, individual state licensing requirements present a large challenge for teleradiologists who many times will be sitting in a different state than the patient.
What needs to be considered
At first glance, a national telemedicine license would seem to break down this barrier, both increasing efficiency and lowering cost of delivery quality radiology interpretations across state lines. However, there are many considerations here, and it remains unclear how well the proposed national telemedicine bill will address these considerations.
First, for physicians to practice medicine at individual facilities, they must not only be licensed, but also credentialed by those facilities’ medical staff departments. This credentialing process requires “primary source verification”, which in short, means that the facility’s medical staff department must contact every other facility and state medical board where the radiologist has worked or been licensed. The national telemedicine license bill proposed by Senator Udall suggests a national database that would act as a repository for all of this “primary source verfication” data. Good idea, in theory; however, this is not the first time that such a database as been proposed, and just as with any similar type of database, there remains the question of who will maintain this data, verify this data, and how reliable the data will be. It seems that such a database would almost require a new federal agency to oversee- a federal medical board of sorts. If this is inteneded, it certainly will add a great deal of cost to this project for which there seems little if no available room in the already stretched federal budget to pay for.
Federal vs. State Oversight
Second and perhaps most importantly, it is unclear in the bill whether the federal license will be administered by a federal agency, or by state medical boards in accordance with federal guidelines. In the first alternative, a federal medical board would certainly have to be created, again, increasing costs and perhaps raising questions related to federalism and Constitutionality, exposing this bill to possible Constitutional challenges. It is even more unclear who would be responsible for policing the medical license. Today, each state medical board is responsible for ensuring the quality of the physicians who it licenses, and thus, each state medical board has authority to investigate and discipline the physicians who it licenses. Legal doctrine and precedent has been established state-by-state. A national telemedicine bill has the potential of rewriting this legal doctrine raising questions of whether state or federal administrative agencies would police the physicians who hold the license, and even which courts would have jurisdiction over disciplinary action appeals. These issues need to be considered and clarified for such a bill to be successful in achieving its goal.
Finally, there are questions raised of how this bill will work in conjunction with other healthcare agency authority and regulation, such as reimbursement from Medicare and Medicaid as controlled today by the Centers for Medicare and Medicaid Services (CMS). Today, CMS delegates reimbursement claim processing to 3rd party intermediaries who typically reside within state boarders, and vary state by state. While CMS sets policy and gives directive, the individual intermediaries actually process claims, and as of today, physicians must submit claims to the intermediary in the state where they sit (the “place of service”), regardless of where the patient is being treated. It is unclear how a national telemedicine bill will integrate into this environment, which could potentially present another complexity that must be considered in the proposed bill.
What is clear today is that much of how this bill will actually work in practice is unclear. Over the next month or two, I plan to post some follow up blogs discussing each of the concerns listed as well as discussing any new developments related to this proposed legislation. Stay tuned, and I look forward to your comments and responses!
-Jesse Salen, CTO, ONRAD, Inc.