Frank Anderson kept running into the same problem, over and over again.
“Paperwork has been wasting so much time and money right now,” Anderson said. “Staff has to comply with so many unnecessary things. Definitely it has been a waste of energy.”
Anderson works in rural Northern California, directing telehealth services in Eureka for the Open Door Community Health Centers. He said physicians and patients have to jump through too many hoops to use the telehealth system.
That’s why Anderson is such a big fan of AB 415, a bill by Assembly member Dan Logue (R-Linda) that Gov. Jerry Brown (D) recently signed.
The new law, effective Jan. 1, is designed to streamline the practice of telehealth in a number of ways and will improve patient care significantly in rural areas, according to Anderson.
Streamlining the System
The telehealth system in California already is pretty advanced, according to Logue, in part because of the the California Telehealth Network, one of the largest telehealth operations in the nation.
But in the daily practice of telehealth medicine, he said, particularly in rural areas, a number of hurdles kept appearing.
For instance, the law addresses an existing requirement that physicians and other health care providers have dual credentialing — that is, they need to be credentialed both at the facility where they work and the facility where the patient is being treated remotely using telehealth.
Further, under the current system, patients need to give written consent. The new law requires only oral consent.
Also, the current system requires health care providers to explain exactly why they need to use telehealth before they can use it.
That last one seemed to irk Logue the most. “The doctor had to write a reason why they wanted to use telehealth,” Logue said. “It was almost as if they had to prove they had no other choice. And this removes that barrier.”
Logue said the new law could save the state about $1.2 billion in health care costs each year through improved efficiencies and wider access to care.
Changes Matter
The changes in the new law are not major shifts in telehealth policy, but they go to the heart of actual telehealth practice, according to Thomas Nesbitt, associate vice chancellor for strategic technologies and alliances at UC-Davis Medical Center.
“Whenever you get a request for written consent in medicine, usually it’s the equivalent of saying this is a risky procedure, which is what we use them for,” Nesbitt said. “Risk of infection, risk of surgery, that kind of thing. By having oral consent, it’s a standard way of providing health care services.”
That’s particularly true with non-English-speaking patients, Anderson said, who are reluctant to sign forms they don’t fully understand.
“In medicine, written consent means it’s experimental, it’s research or it could hurt you. And that’s not telemedicine,” Anderson said. “What’s implied is that it’s scary and unknown, and that has stigmatized the whole field to me.”
If health care providers have to get credentialed at every facility, they’re much less likely to participate, Nesbitt said, particularly in the less-populated remote areas.
“The tendency is to say, well, I’m not going to do it in places where I’m going to see one or two patients a year,” Nesbitt said. “But the thing is, those are the people who need it the most. The value of telehealth is greater in the places that are smaller.”
That cuts right to the core of the biggest problem in rural areas: access to health care providers. “To people in these remote areas,” Nesbitt said, “it’s more than a convenience. If you don’t have the providers signing up for it, that changes how many people get access.”
Remote Primary Care
Most people think of telehealth as a technology to connect specialists to patients in remote areas, but it also can be a resource for primary care, Nesbitt said.
“It can provide chronic disease management in a patient’s home, we’ve seen increasingly good use of telemedicine in the medical home model,” Nesbitt said. “If you can manage diabetes three times a week over telehealth visits, that quality of care is so much better than seeing someone every three months, where the health care provider has to say, ‘This is horrible. Let’s fix it.’ We’ve been trying to move care to the home, and this is one way primary care providers can do that.”
Telehealth has the potential to change the model of care in rural areas, Nesbitt said. “For non-physicians who are providing care in very small areas where you don’t have physicians,” he said, “you can create this virtual, team-based model of care. I think there’s an opportunity to expand the team-based model over an entire region.”
For Steve Barrow of the California State Rural Health Association, telehealth is one of the few solutions for the entrenched and ongoing problems in rural health care. With a much higher percentage of Medi-Cal and Medicare beneficiaries, and a greater share of the state’s senior population, the demand for health services is much higher in rural areas. Medi-Cal is California’s Medicaid program. At the same time, rural areas have an extremely limited supply of health care providers.
“There are so many reasons why telehealth is so important to us,” Barrow said. “This will save lives, by expanding access to high-level specialty care. But it’s not just specialty care. There are a lot of disease states, where if you don’t get to them early, they can escalate. Telehealth allows providers to get to those people a lot earlier.”
For instance, Barrow said, he’s working with The Children’s Partnership to launch an oral health screening program in the schools, and some of that can be accomplished remotely.
“As we move more into health homes and accountable care organizations as different models of care,” Barrow said, “you have the ability to provide care even if you’re 50 miles away but you can still be part of the care team. Either asynchronously, where a physician can consult with another provider, or up to four [physician assistants] at a time in different areas. Or synchronously, where you communicate right then, by video — the primary care doc and the senior and the geriatric care doc in another city can all take part.”
Not-So-Wow Factor
The main thing the new law does, Barrow said, is to deal with real-world issues, rather than looking at telehealth as some high-tech, high-cost wizardry. Because it actually saves money for facilities and health plans, he said, that puts it into a much more utilitarian role.
“It’ll be interesting to see what happens with the [California Health Benefit] Exchange and with health plans developing telehealth plans they don’t have now,” Barrow said. “You take something like in-home monitoring in rural areas. If you have 1,000 seniors in a rural area and you have to pay for all of those doctor visits, then you’re going to take a long look at telehealth.”
In today’s health care world, “less cost” and “better care” are the buzz words, he said. “Because in telehealth, you’re going to realize savings and better outcomes,” Barrow said. “There is definitely a lot more to come.”
Anderson said one of the biggest access challenges in rural areas is getting physicians to stay put.
“Even when you get people out there,” he said, “it’s usually two years and they’re out. It’s really hard to get them to stay.”
That could change with the advent of telehealth, Anderson said. “It’s kind of cool, because some of our clinics are hard to recruit to, but when you can say we have state-of-the-art technology, and we can connect your patient instantly to a specialist at UC-Davis, well, that might keep them a little longer maybe,” he said. “And that helps keep a community vibrant.”
Telehealth has turned a corner, Anderson said, and the new law represents that, because it’s a matter-of-fact, day-to-day handling of telehealth.
“Getting rid of that raised eyebrow has been a major hurdle,” Anderson said. “People wondering if this really works.” But the new law, he said, “takes steps toward the normalizing process.”
For a long time, telehealth has been lauded as the new important thing, and it focused on getting over the hurdle of acceptance, Anderson said. Now that has changed.
“What I see now is just business,” Anderson said. “It’s not a big ol’ fancy deal anymore and people are calmer about it. It’s happening, it’s moving, it’s organized. Now we’re just doing the work. Now it’s just health care.”
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