Chapel Hill doctor Kevin Biese was relaxing at home on a late Sunday afternoon when the parents of a young patient reached him on his smartphone. A 10-year-old boy had injured his ankle playing soccer, and the worried parents called to ask whether to take him to the ER.
Biese activated a phone app and conducted a physical exam by video, linking to the Cary family’s living room and relying on the boy’s father as a remote assistant. After zooming in on the boy’s ankle and foot, and studying his facial expression for pain reaction, Biese advised the family to stay home that night and visit an orthopedic clinic the next day.
“So he skipped the 4-hour visit to the ER,” Biese said, recalling the incident. “It’s late, it’s Sunday night, he would have been there a few hours, and they would have, at the end of that journey, told him to go to orthopedics the next day.”
The events followed the futuristic script that telemedicine advocates have predicted for years, but this scenario has yet to materialize on a grand scale. Even with the ubiquity of smartphones and Skype and Facetime, telemedicine remains a laggard in the health care world.
Biese used a new service launched by a 1-year-old Durham startup, TouchCare, which employs about 20 people. Biese, a professor of emergency medicine and internal medicine at the UNC School of Medicine, is a paid consultant to TouchCare, as the young company seeks to gain traction with insurers, doctors and health care systems.
Earlier this month, TouchCare raised its profile by raising $4 million from Mosaic Health Solutions, a newly created Durham-based funding arm of Blue Cross and Blue Shield of North Carolina, the state’s largest health insurer.
In addition to UNC, TouchCare is also being field-tested at Mount Sinai Hospital in New York City, the company said.
Mosaic was formed in July to help Blue Cross identify and support programs such as TouchCare that could help the insurer hold down health care costs – by preventing unnecessary hospital visits, for starters.
Mosaic’s investment in TouchCare should keep the startup afloat for about two years, said Tim Horan, TouchCare’s chief operating officer. The investment gives Blue Cross a seat on TouchCare’s board of directors, currently filled by Brian Caveney, with a dual role as Mosaic’s chief clinical officer and Blue Cross’ medical director.
Caveney said “instead of just going to your doctor every three months and hoping for the best,” TouchCare could provide a way for nurses and care coordinators at doctors’ offices to have some level of contact with their patients between visits. That, he said, would help make sure patients are taking better care of themselves.
“They’re more adherent with their medications, they’re getting questions answered, getting medication refills,” he said.
Limits of telemedicine
Still, widespread acceptance by doctors is not guaranteed. Patients can download the TouchCare app free, but doctors have to pay to use it.
TouchCare’s fee ranges between $149 and $199 per month, with volume discounts for practices with more than five providers, Horan said. That means a physicians practice with a half-dozen providers could pay $12,000 a year to use the app with patients.
Because some insurers don’t reimburse for telemedicine over nonsecure lines, TouchCare would let more doctors bill for their virtual appointments.
“I know doctors who use Skype and Facetime, but it’s not HIPPA compliant,” Biese said, referring to the patient privacy provisions of the federal Health Insurance Portability and Accountability Act. “To me as a doctor, HIPPA compliance is everything.”
TouchCare’s encrypted app works much like Skype or Facetime, Horan said, and is designed for convenience and simple consultations, not as a substitute for a full physical exam or a diagnostic test.
At some point in the future, however, the TouchCare app could be enhanced by digital devices to measure pulse, temperature and glucose levels, Horan said.
But like distance learning, telemedicine remains subordinate to the genuine article. The federal Medicare program limits coverage for telemedicine consultations to rural areas, where there are doctor shortages. The American Medical Association’s guidelines state that telemedicine can supplement medical consultations but “must never replace” personal contact between a doctor and patient.
The N.C. Medical Board’s guidelines acknowledge that telemedicine could increase access to care and provide other patient benefits. But the board advises doctors using telemedicine to verify a patient’s identity to prevent fraud and identity theft.
The Medical Board also discourages the prescribing of controlled substances by telemedicine. The board warns that prescribing pain medications by means of telemedicine could expose a North Carolina-licensed doctor to state disciplinary proceedings.
Restrictions in N.C
North Carolina law does not require insurers to pay for telemedicine services, as is required in 21 states and the District of Columbia.
Nevertheless, Blue Cross has provided some form of telemedicine reimbursement here since 1997. Blue Cross covers “E-Visits” if they take place over a secure online connection, but physicians are paid only if there is an established patient-doctor relationship.
Blue Cross also covers doctor-to-doctor consultations about a patient’s condition when one of the doctors is not physically in the office.
Unlike most states, North Carolina’s Medicaid program restricts in-state video consultations to doctors who are located a “sufficient distance” from the patient, according to the state’s telemedicine and telepsychiatry policy. The distance is not specified, but Indiana’s Medicaid program requires a minimum distance of at least 20 miles for the doctor to be reimbursed.
North Carolina’s Medicaid policy also requires real-time consultations, so it won’t reimburse a doctor for reviewing emailed video or photos of a cut, burn or rash.
Such restrictions have resulted in North Carolina getting a “C” grade from the American Telemedicine Association.
“NC has a lot of room for improvement where telehealth is concerned,” Latoya Thomas, director of State Telehealth Policy for the American Telemedicine Association, wrote by email.