The American Telemedicine Association (ATA) undertook the unenviable task of capturing the complex policy landscape of 50 states with 50 varying telemedicine policies to create a telemedicine gaps analysis in two critical policy reports covering physician practice standards and licensure, and coverage and reimbursement. 

Physician Practice Standards and Licensure

According to the September 2014 ATA report, “State Telemedicine Gaps Analysis: Physician Practice Standards and Licensure,” by Gary Capistrant, senior director of public policy, and Latoya Thomas, director of state telehealth policy, a patchwork of conflicting and disparate requirements for insurance claims and practice standards inhibit fully embracing telemedicine.

“Our analysis indicates that decades of evidence-based research highlighting positive patient compliance, clinical outcomes and increasing telemedicine utilization have been met with a mix of strides and stagnation in state-based policy,” said Thomas.

Twenty-seven states show room for improvement, according to the report, with only one state – Alabama – averaging the lowest composite score, suggesting many barriers for licensed physicians using telemedicine.

States received composite grades based on four indicators: physician-patient encounter, telepresenter, informed consent, and licensure and out-of-state practice.

In the Medical News’ coverage area, the ATA provided the following state grades:

• A: South Carolina and Tennessee
• B: Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, Missouri and North Carolina
• C: Alabama

Concerning physician-patient encounters, 27 states and DC rank the highest, while Alabama, Arkansas and Missouri received failing grades in that category, along with Nebraska and Texas, primarily because in most cases, they don’t allow telemedicine in lieu of an initial in-person exam or to establish a physician-patient relationship.

Only a dozen states require physicians to attain patient-informed consent for telemedicine.

Because every state imposes a policy that makes practicing medicine across state lines difficult, regardless of telemedicine, no states achieved a top score for licensure policies.

The only states that extend a conditional or telemedicine license to out-of-state physicians are Alabama, Louisiana, and Tennessee in Medical News’ coverage area, along with Minnesota, Montana, Nevada, New Mexico, Ohio, Oregon and Texas.  

Coverage and Reimbursement

According to ATA’s sister report, “State Telemedicine Gaps Analysis: Coverage and Reimbursement,” also authored by Capistrant and Thomas in September, payment and coverage for services delivered via telemedicine remain one of the greatest challenges for telemedicine adoption.

In the Medical News’ coverage area, the ATA provided the following state grades for coverage and reimbursement of telemedicine:

• A: Mississippi and Tennessee
• B: Alabama, Georgia, Kentucky, Louisiana, Missouri and South Carolina
• C: Arkansas, Florida and North Carolina

“Telemedicine is closing the gap for many rural patients around our state,” pointed out Mississippi Gov. Phil Bryant, who signed into law last year legislation requiring health insurance plans to cover telemedicine practices and reimbursements.

Interesting tidbits:

• Even though Arkansas borders six states (Louisiana, Mississippi, Missouri, Oklahoma, Tennessee, and Texas) with private insurance parity laws, no history of proposed legislation exists within the past two years.
• Louisiana’s private insurance parity law was enacted in 1995. It’s the only state with a parity law specifying coverage of telemedicine when provided by physicians only.

When considering the numerous payment and service delivery options that enable telemedicine adoption, seven states— Maine, Maryland, Mississippi, New Hampshire, New Mexico, Tennessee, and Virginia – averaged the highest composite score, suggesting a supportive policy landscape that accommodates telemedicine adoption, said Thomas.

“Three states (Connecticut, Iowa and Rhode Island) didn’t measure up, averaging the lowest composite score … suggesting many barriers and little opportunity for telemedicine advancement,” she said. “When broken down by the 13 indicators, the state-by-state comparisons reveal even greater disparities.”

One disappointing observation, noted Thomas, includes the lack of coverage and reimbursement for telemedicine under state employee health plans. Eighty-two percent of the country received failing scores, including Arkansas, which will only cover the use of store-and-forward for diabetic retinopathy screening, and Nebraska, which requires their plans to cover autism treatment via telemedicine.

“Regarding Medicaid regulations, states are slowly moving away from the traditional hub-and-spoke model and allowing a variety of technology applications,” said Thomas, adding that 23 states and DC don’t specify a patient setting or patient location as a condition for payment of telemedicine. “Aside from this, 21 states recognize the home as an originating site, while 13 states recognize schools and/or school-based health centers as an originating site.”

Utah ranks the lowest with only one eligible originating site. South Dakota has the highest ranking for Medicaid operations because its program covers telemedicine when providers use interactive audio-video, store-and-forward, remote patient monitoring, email, fax or “phone mail.”

Idaho, Missouri, and the Carolinas prohibit the use of “cell phone video” to facilitate a telemedicine encounter.

“There’s a national trend to allow statewide Medicaid coverage of telemedicine instead of focusing solely on rural areas or designating a mileage requirement,” said Thomas. “States are also increasingly using telemedicine to fill provider shortage gaps and ensure access to specialty care.”

Florida, Idaho and Montana ranked the lowest with coverage for physicians only.

Overall, coverage of specialty services for telemedicine under Medicaid is a checkered board, emphasized Thomas.

Trend highlights include:

• Most states cover an office visit or consultations, with ultrasounds and echocardiograms being the least covered telemedicine-provided services.
• For mental and behavioral health services, typically mental health assessments, individual therapy, psychiatric diagnostic interview exam, and medication management are the most covered via telemedicine.
• Alaska is the only state with the highest ranking for telemedicine-provided services under the home health benefit. Seventy-two percent of the country received failing scores due to a lack of telemedicine services covered under the home health benefit.
• Alaska, California, and Illinois cover podiatrist services.
• Alaska, California, and Kentucky cover chiropractor services.
• California and Kentucky are the only states to specify optometrist coverage.
• New Mexico, Oklahoma, and Washington are the only states to specify telemedicine coverage for behavioral analysts. This trend is unique, Thomas pointed out, because these specialists are critical for the treatment of autism spectrum disorders.
• New Mexico, Oklahoma, Virginia, and Wyoming specify substance abuse or addiction specialist coverage for telemedicine.

Both reports are intended to serve as reference tools aimed to inform future policy decision making and to provide general information about the state of telemedicine, emphasized Thomas.

“It’s ATA’s best effort to interpret and understand each state’s policies,” she said. “Your own legal counsel should be consulted as appropriate.”

By Lynne Jeter