As shortage looms, tele-rheumatology offers solutions, novel legal risks
MAUI, Hawaii — As patient demand for care continues to outpace the available rheumatology workforce in the U.S., the use of telemedicine has been strongly endorsed as a way to alleviate the shortage. However, whether the benefits of virtual rheumatology care justify the potential legal risks remained hotly debated during the 2020 Rheumatology Winter Clinical Symposium.
“Today, patients expect – and indeed demand – to be seen in a timely fashion,” Alvin F. Wells, MD, PhD, director of the Rheumatology and Immunology Center in Franklin, Wisconsin, and adjunct assistant professor at Duke University Medical Center, told attendees. “The days of waiting 4 to 6 months to be seen by a rheumatologist are gone. Whether you are in academic or private practice, in 2020, if you are not thinking about tele-rheumatology, you will not be able to compete with growing patient demands, expectations and clinical monitoring.”
Although the specialty is trying to train nurse practitioners and physician assistants to play larger roles in delivering rheumatology care and services, Wells noted that the workforce shortage “isn’t isolated to rheumatology.”
“If you look at information coming out of the Association of American Medical Colleges, examining which specialties are going to see shortages as doctors retire, all the specialists are there — rheumatology, cardiology, pulmonary medicine — expecting similar shortages,” he said.
Wells cited that, despite the pressing need for its services, rheumatology has already fallen behind other telemedicine early adopters. In a 2019 study, Doximity reported on which specialties were most engaged in expanding their patient-base to underserved areas: radiology, psychiatry, internal medicine, neurology, family medicine, dermatology, pediatrics, emergency medicine, geriatrics and allergy/immunology.
“Rheumatology doesn’t even make the top 10,” he said.
Telemedicine offers several alternatives to the traditional rheumatologist referral, Wells said, especially through the use of e-consults with primary care providers or physical therapists to help evaluate and track patients without requiring them to travel to meet with a rheumatologist in person. “Does every patient need a physical exam?” Well said. “Yes — how frequently is the question.”
Wells highlighted the considerable benefits offered through telemedicine on both sides of the patient divide. For providers, telemedicine allows more frequent and effective follow-up visits, increased consults and the ability to perform problem-oriented visits and discussions, while the patient benefits time saved in travel, child care and any decrease loss of work productivity.
“If you do not have virtual medicine as part of your health care strategy in 2020, you do not have a health care strategy,” Wells said.
However, Orrin M. Troum, MD, from the division of rheumatology at the University of Southern California Keck School of Medicine, was quick to point out that as potential for tele-rheumatology continues to grow, so do its considerable legal risks.
Troum noted that knowledge of individual state laws regarding telemedicine is essential — and an easy pitfall when a rheumatologist consults with patients even just across state lines.
“Multiple state licenses might be required to conduct a telemedicine consult,” Troum said. “You need to know the patient’s location when you are doing this — also known as the ‘originating site’ — and understand that different states have different licensure requirements. For example, in California, they require the originating site to obtain and document patient consent, where in Kentucky, it has to be the treating physician who does that. If you don’t know this, you’re going to be in trouble.”
Although telemedicine could theoretically be managed through Facetime or similar video conferencing systems, Troum noted that current requirements for telemedicine sessions requires a HIPAA-compliant video conferencing system.
“Telemedicine must meet all of the HIPAA requirements, which means that physicians must use technology compliant with HIPAA,” he said. “For example, you have to have fully encrypted data transmission and secure connections.”
Insurance coverage of telemedicine adds another layer of complexity to the issue. Wells noted that as of January 2020, “for all their commercial plans, Aetna covered 100% reimbursement for telemedicine” and Medicare also now pays coverage for telemedicine. That coverage, however, is variable from state to state and subject to additional stipulations.
“For Medicare, both the originating site and physician providing the service must submit documentation of that visit,” Troum said. “Failure to do that really means noncompliance to federal laws. Additionally, patients themselves must also be ‘telemedicine eligible’ and use only approved communications equipment, which generally do not include telephone, a fax or email — think about who makes up the majority of your Medicare population.”
In 2018, a report from the HHS Office of Inspector General found that approximately one-third of claims submitted between 2014 and 2015 did not meet the Medicare conditions for payment for telemedicine services, resulting in $3.7 million in excess payments.
In its report, the Office of Inspector General identified five specific indicators of potentially problematic issues for telemedicine, and Troum noted how common these pitfalls could be for physicians getting into the field:
- Claims where beneficiaries received services at nonrural originating sites. “Currently, Medicare only covers telemedicine claims where the beneficiary is in a rural area,” noted Troum, which does not address areas with statewide/regional rheumatology shortages.
- Billed by an ineligible institution provider.
- Services provided by an unallowable means of communication. “This is a big deal,” Troum noted. “You have to get extra equipment. You have to have two-way audio and visual communication.”
- Noncovered service.
- Services provided by a physician located outside the U.S.
Although Troum is encouraged by the move to telemedicine as a way to address the rheumatology shortage, he maintains that more awareness of the Medicare telemedicine requirements is needed among would-be practitioners before this trend can be fully embraced. – by Robert Stott
Troum O; Wells AF. Point-Counterpoint: Telemedicine is the future of rheumatology. Presented at RWCS Annual Meeting; Feb. 12-15, 2020; Maui, Hawaii.
Disclosure: Troum and Wells report no relevant financial disclosures.