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Will July 15 be a Dark Day for Telemedicine?

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 Health I.T. is marching forward on many fronts. But July 15 might be the day, barring Congressional intervention, that telemedicine moves in the opposite direction. On that day the Joint Commission’s “privilege by proxy” program bites the dust, which could have serious ramifications for the industry.

Privilege by proxy permitted hospitals to credential telemedicine practitioners from a distant site based on the credentialing/privileging decisions at that distant site. In a nutshell, it allowed physicians from large hospitals to provide telemedicine services to small or rural facilities without having to go through the credentialing process twice (as long as both hospitals were Joint Commission-accredited).

In July 2008 the Joint Commission lost its statutory deeming authority for accrediting hospitals. In order to get that authority back the commission had to reapply to CMS and brings its accreditation standards in line with Medicare’s conditions of participation for hospitals.

CMS subsequently put the kibosh on privilege by proxy. I spoke with Gary Capistrant, senior director of public policy at the American Telemedicine Association, about the move by CMS, and he had a few choice words on the subject.

“We’re still dealing with a bunch of Luddites at CMS who don’t want to think in different ways and harness the value of telehealth,” he said. “You hear all kinds of talk on the federal level about the wonders of technology to bring health care to the underserved, but then you have a few people in CMS who are interpreting the rules however they want to.”

What’s galling to Capistrant is how the elimination of privilege by proxy flies in the face of common sense.  After July 15, the onus would be on telemedicine recipient sites to privilege and credential telemedicine physicians. But those recipients are typically small or rural facilities that don’t have the expertise to evaluate the specialists who provide the telemedicine services--which is why they need the services in the first place.

“A 25-bed hospital doesn’t have the expertise to evaluate a neurologist or other specialist, nor do they have the financial means to go through the privileging process. So where does that lead them? This move by CMS threatens the years of work and millions of dollars the providers have invested in telemedicine programs.”

That’s not the only schizophrenic policy that irks Capistrant. Medicare limits (with some exceptions) reimbursements for telemedicine services to those where the originating site (where the Medicare patient is) is located in a rural health professional shortage area or a county outside of a Metropolitan Statistical Area. That doesn’t sound too bad, unless you consider situations like in Massachusetts. By Medicare’s computations, the only state residents outside of Metropolitan Statistical Area are the 4,000 inhabitants of Cape Cod. “You can’t support a viable telemedicine network with only 4,000 possible beneficiaries,” Capistrant said.

I brought these issues up with a couple of Medicare officials during a background call. They contended that the privilege by proxy program was eliminated not by any change in Medicare policy or subjective interpretation by agency officials, but as the result of the Joint Commission having to comply with straightforward, long-standing Medicare conditions of participation for hospitals.

They also noted that the agency is at the mercy of legislative whims, and has limited ability to tackle licensing, credentialing and other telemedicine roadblocks without directives from Congress.

Fingers can be pointed at a lot of the actors in this drama, but the bottom line is telemedicine in the United States will suffer a setback this summer. So much attention is being directed at health care reform and HITECH that many that spend their lives in telemedicine are worried that these and other blockades to expanding telemedicine services aren’t receiving the attention they deserve.


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