Monday, July 7, 2014

Too Little, Hopefully Not Too Late

I was going to write about the deeply dismaying Supreme Court ruling on Hobby Lobby -- I don't think employers should be able to use their personal preferences to tell me how to spend my money, whether that money is post-tax or pre-tax -- but I thought Uwe Reinhardt addressed the topic so well in his The Illogic of Employer-Sponsored Health Insurance that I didn't see the point of rehashing it.  Instead, I'll start with some (apparent) progress on telehealth.

The Federation of State Medical Boards has recognized that telehealth requires some changes in the current state-based licensing approach.  The FSMB drafted model legislation that wouldn't require physicians to apply for licenses separately in every state in which they plan to "see" patients, as now.  The model legislation would create an interstate compact, binding on any state that adopts it.  The compact calls for an expedited licensing process, with one set of paperwork that could be used to apply for licenses in any state that was party to the compact.

The proposal would also raise the bar for physician qualifications, requiring that applicants be board certified (as I've written before, why aren't all physicians required to be board certified already?) and not be subject to disciplinary action or an active investigation by a licensing agency or law enforcement agency, neither of which is evidently true now when applying for a medical license in a new state.

The proposal would allow each state to decide what kind of fees they would charge for the expedited license, so while applicants should be saving time and effort they may still find the new process expensive.

The commission that would oversee the compact would serve as a clearinghouse for information on doctors, and any license revocation or suspension in a physician's home state would automatically have the same result on any license for other states obtained through the compact.

I have to admit that when I read that last provision I was reminded (as I wrote about in Quis custodiet ipsos custodes?) that the state medical boards too often seem to act first in the interest of their state's physicians, secondly (if we're lucky) in the interest of the state's residents, and virtually not at all for anything outside the state.  I know they are state medical boards, but -- honestly?  They're not sharing that kind of information now?  And how will complaints from patients in other states get back to the physicians' home states even under the compact?  Will they?

I'd call the proposal better than the current situation, but not nearly enough.

Telehealth advocates hailed the FSMB proposal, but, I suspect, partly out of relief simply to see any sign of progress.  It could go further.  As Jonathon Linkous, the CEO of the American Telemedine Association, told MobiHealthNews:

Their model is not a reciprocity model.  The physician would still have to pay a fee to every state, probably [also] a processing fee, and have a third party handle the paperwork, which may or may not be a good thing. And we don’t know if all the states will adopt it.
As telehealth advocates point out, so-called reciprocity for licenses is not an unheard of concept.  A valid drivers license from any state allows driving in any other state, and military physicians can practice in any state with a valid medical license from their home state.  So, yes, while FSMB is recommending some progress, one gets the sense they're being dragged kicking and screaming into the 21st century.  

It's not really clear to me exactly what we're getting for all this caution on licensing anyway.  Just within the past couple weeks we've seen the American College of Physicians say that annual routine pelvic exams aren't necessary for healthy women after all, one study find that one-third of knee replacements may be unnecessary, and another study find that the widely used steroid injections for spinal stenosis isn't really effective.  And some estimates believe as many as 100,000 health care professionals have drug addictions every year, with a lifetime risk of such abuse as high as one in ten.  No wonder experts continue to see huge waste and errors in our health care system.

It's not all due to shortfalls in the licensing process(es), but the state boards and FSMB don't get a pass on blame either.
Meanwhile, CMS is also making some progress on the telehealth front, proposing that four new telehealth services be added to the Medicare Physician Fee Schedule for 2015.  You probably also want to be living in a rural area if you expect to take advantage of these services.  As MobiHealthNews commented, the proposed rule:
...still shows a glacial pace for telehealth reimbursement, with many more requests denied than accepted, and a very dim view of reimbursement requests that involve new technology. Large scale Medicare reimbursement for telehealth still seems to be a long way off.
Say what you will about the VA (and people having been saying terrible things lately due to the recent scandal about waiting lists), in the area of telehealth they've been ahead of the private sector for some time.  They've got a broad program including real-time care, home monitoring, and store-and-forward options.

It makes one wonder why there were so many veterans waiting for appointments.  Did they not know about their telehealth options, were they not comfortable with/able to use the technologies, or were the waits for telehealth as bad as for in-person appointments?  It just goes to show that technology doesn't automatically solve problems, but requires changes in processes and attitudes to really be effective.

I was struck by a comment Jonathon Bush, the CEO of athenahealth, made at a recent Aspen Ideas Fest, as reported in The Atlantic.  Bush wants more capitalism in health care and more focus on what patients need, but that is confounded by outdated attitudes. In his words,
We act, as a society, on the unconscious level, like we're not in charge. This is a massive problem. Not just because we utilize expensive things, but because we give up the opportunity for those things to get better.
In fact, of course, it is us as individuals behaving that way.  For example, in Altarum Institute's latest consumer study, over 90% of consumers say they want to be in charge of their medical decisions or share them equally with their physicians, yet when they actually see their doctor only 41% come prepared with their questions and make sure they get them answered.  Forty-eight percent report simply being passive at their visit, only responding to what the physician asks or suggests.  And 70% would go along with their physician's recommendations despite doubts. 

It is perhaps no wonder that many of us, not just those getting care in the VA, have become too blasé about waits.  The New York Times reports that long wait times have become the norm, especially for primary care.  The VA took heat for its wait times but at least they have a mechanism for tracking and reporting them -- obviously flawed and inaccurate, but a mechanism nonetheless.  Can your doctor's practice or your health system say the same?

If only there were on-demand, real-time options to see physicians when needed.  Oh, wait -- there are.  We're just not able to take full advantage of them due to historical licensing and reimbursement barriers.

FSMB's proposal is a start, but let's not forget that it is only a start.

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