In 2011, 7-month-old Malea Fox’s life was saved when her ER doctor requested a consultation with a pediatric specialist. The specialist examined the baby remotely via 2-way video, diagnosed a specific bacterial infection, and instructed the ER doctor to insert a breathing tube before she was flown to a larger hospital. Without that instruction, Malea almost certainly would have died in-flight.
This is an application of telemedicine that hospitals (and payers) are increasingly comfortable with—where a healthcare professional in a clinical setting consults with an off-site specialist using modern communication technology.
But now advanced communication technology is literally in the hands of most Americans through their tablets and smart phones, and the U.S. healthcare industry is inching towards a revolution in delivery of care. In the not-so-distant future, minor ailments may be commonly diagnosed via two-way video, while ill patients stay at home in the comfort of their pajamas. According to the American Medical Association and Wellness Council of America, up to 75% of in-person physician appointments and ER visits are deemed unnecessary, and effective care could be given via video or phone.[i]
The full benefits of in-home telemedicine are still uncertain, but the possibilities are striking—in particular when it comes to rural access and cost-control, not to mention convenience to the patient.
However, while we are seeing a gradual rise in in-home telemedicine in the U.S., significant barriers to implementation are slowing down adoption. Two of those obstacles we’ll discuss here, both of them systemic infrastructure issues:
It is estimated that one in five Americans (20%) lives in a rural area. These communities are, in general, suffering from an aging physician population, difficulties enticing younger practitioners, and the erosion of the small rural hospital, particularly critical access hospitals.[i] Telemedicine, therefore, stands to be invaluable for consumers in these areas of the country, and in fact, the professional-to-specialist model is increasing in use all the time, saving hospitals and clinics vital resources and providing much-needed specialty care for their patients.
The rural primary care physician (PCP) population is also shrinking, and in-home telemedicine could be exceptionally beneficial for patients who sometimes have to travel an hour or more each way for an appointment with their primary care doctor.
But there are systemic obstacles for widespread implementation of telemedicine that are unique to the rural population. Rural Americans tend to be late adopters of technology in general, and Internet use specifically. In 2011, telehealth of any kind—even activities as “simple” as accessing medical records online—was utilized at twice the rate by urban consumers (8% of urban internet users, vs. 4% of their rural counterparts). [ii]
While lack of awareness and consumer resistance may contribute to this difference, one of the largest hurdles to in-home telemedicine in rural areas is the lack of the reliable, fast internet necessary for video or Skype appointments. As of 2016, only 63% of rural households had broadband internet (compared to 73% of their urban counterparts).[iii] Even where the capacity exists, rural broadband speed is often slower than in urban centers, resulting in poorer connections.[iv] The physical infrastructure may simply not yet fully support the utilization of in-home telemedicine, even if it were available.
But often, it’s not.
Even where broadband internet is robust, in-home telemedicine faces intense challenges in reimbursement and regulatory practices. One of the greatest potential benefits is the convenience of reaching a doctor from the comfort of your home (most likely using an app that connects you either to a specialist or to a generalist who is part of a nationwide network of remote physicians). But both reimbursement and licensing regulations in the U.S. are largely on a state-by-state basis, which places serious restraints on the growth of remote healthcare.
Here’s the breakdown, starting with reimbursement.
Medicare covers 55 million Americans (17% of the population) and represents 20% of national health expenditure.[v] But the agency only reimburses for any kind of telemedicine if the patient is in an established rural area, and even then, the patient must be physically present in an authorized clinic, hospital, or health system when they have their appointment. Medicare does not have any reimbursement policy in place for a video chat with your doctor from your home, [vi] effectively denying Medicare patients access to in-home remote care, even for something as straightforward as a medication follow-up.
And then there’s Medicaid (being used by 74 million Americans), where reimbursement for telemedicine is totally at the discretion of the states, resulting in a complicated patchwork of coverage. To demonstrate how truly complex Medicaid can be, let’s look at school teletherapy, a field that translates readily to remote care. Twelve states allow for all special-education teletherapy to be covered. Two states cover only speech-language therapy and behavioral interventions and mental health services. Five more cover only speech-language therapy. And thirty-one states don’t reimburse for any kind of teletherapy whatsoever.[vii]
Non-government payers have been a bit swifter to move into telemedicine, but even here, the coverage is often spotty and may only reimburse for particular treatments or diseases.[viii] Further, reimbursement practices vary widely across private payers.
The point is that there are no clear, industry-wide guidelines established for reimbursement and coverage. Without that, there is little incentive for providers to invest in the technologies necessary to support in-home telemedicine and little reason for consumers to demand a convenient service that may not be covered by their insurance.
Reimbursement isn’t the only issue. Telemedicine companies—especially those providing remote, in-home video appointments—are coming up against state licensing regulations that make it difficult (or impossible) for a doctor licensed in one state to treat a patient in another. In 18 states, these laws hold even in the face of a natural disaster, let alone for a telehealth app. 19th Century licensing regulations have not caught up with the 21st Century telecommunications explosion.
In April 2017, a bipartisan group of Senators introduced legislation that would allow Medicare to cover certain kinds of in-home telemedicine for chronic illnesses, including some in-home monitoring. It is currently being reviewed by the Committee on Finance, and if it passes, the bill would open the door to greater reimbursement and, therefore, greater opportunity.
But patients may need to be nudged toward acceptance. Many patients are intimidated and frustrated by patient portals, let alone video appointments. Indeed, a 2015 study showed that two in five patients are not comfortable with the idea of video appointments. Plus, patient concern about privacy in a digital age is extremely high—87% aren’t willing to share their complete medical history with their providers.[ix]
So, while in-home telemedicine seems inevitable—a future part of an increasingly digitized healthcare industry—for now, in the U.S., it is caught in the proverbial chicken-egg quagmire. Regulations will be slow to change without demand, but consumers can’t demand a service that barely exists yet because regulations prohibit its growth.
While we wait for the regulatory environment to catch up to technology and patient needs, there are still questions to be answered, such as:
The answers will guide healthcare toward better patient access and stronger bottom lines.
 We note that there are tremendous differences between rural communities in different states and even between counties within states. For example, some rural areas have broadband access as fast and reliable as any urban center, while in others there are sections that don’t have broadband at all. Nonetheless, these are some of the issues that are unique to rural America.
[i] Ayla Ellison. “The rural hospital closure crisis: 15 key findings and trends,” Becker’s Hospital Review. February 11, 2016.
[ii] The National Telecommunciations and Information Administration and The Economics and Statistics Administration in the U.S. Department of Commerce. “Exploring the Digital Nation: America’s Emerging Online Experience.” June, 2013.
[iii] Perrin, Andrew. “Digital gap between rural and nonrural America persists,” Pew Research Center. May 19, 2017.
[iv] West, Darrell M. and Jack Karsten. “Rural and urban America divided by broadband access,” Brookings. July 18, 2016.
[v] Centers for Medicare and Medicaid Services. 2015.
[vi] Department of Health and Human Services: Centers For Medicare & Medicaid Services. “Telehealth Services.” November, 2016.
[vii] “Medicaid Billing for School Teletherapy: Which States Have It & How Your State Can Get It,” Presence Learning. 2016.
[viii] Beck, Melinda. “How Telemedicine Is Transforming Health Care,” The Wall Street Journal. June 26, 2016.
[ix] “Patients Holding Back Health Information Over Data Privacy Fears,” HIPAA Journal. January 5, 2017.