Although this scenario is plausible, I think it is unlikely to be realized through direct reimbursement from CMS or other payers, with the exception of very limited, high cost conditions. The current annual growth rate in health care costs (9-12%) is unsustainable. To provide reimbursement for home-based telemedicine services will require that traditonal hospital-based and clinic services be reduced. It is a zero sum game and there will have to be winners and losers. The current vested interests will no easily give up their revenue streams and therefore I'm doubtful the traiditonal fee-for-service model will be viable for Telemedicine services.

A Direct to Patient (DTP) approach is required.

In his new book 'Three Wins' Simon Dodds talks about his experience with introducing telemedicine into the UK's NHS. Working as a vascular surgeon, Simon has used telemedicine to improve the treatment of leg ulcers. He has shown that if, instead of a zero sum scenario of Win-Lose, you follow the path of creating 3 wins - for clinicians, patients and management - you can introduce telemedicine very effectively into mainstream healthcare service delivery. In Simon's view, and in my own, funding for telemedicine should come from the savings that it allows, or efficiencies it creates. We will only see substantial growth in uptake of telemedicine when it becomes an integral part of the healthcare process engineering toolkit - and in Simon's view our thinking will also need to be aided by computer flow modelling in order to simulate how telemedicine can be used to create new processes that work as part of an overall process improvement rather than just fixing part of the problem, only to see it re-emerge further downstream.

We are doing this in Hawaii on a private pay basis with a multidisciplinary care team, web app, and video house calls. Insurers have expressed some interest for very high risk patients, i.e., home vent patients. Patients and families have been interested as an alternative to hospitalization and nursing home placement.

While the current payment model continues payors are key. That means CMS, state Medicaid & provaye insurers. Another way (it seems to me) is that providers would adopt telemonitoring broadly and use it to bid more agressively for "managed care" as a result of their cost savings. A DTP approach might work for the un/under insured as Ron Pion suggests. BTW Hi Ron long time no talk. But whose goping to step into this market opportunity? Its all very frustrating for a technologist who knows what can be done.

An implicit assumption in the Medipare scenario is that CMS is a market leader, rather than a market follower.

My observation is that in fact CMS is much more of a market follower, rather than a market leader. This is an observation, not a criticism, and reflects my views that that it takes a long time for the gears to government bureaucracies to grind and that there are many players attempting to preserve their financial interests in the status quo.

Take the Medicare Health Support (chronic disease management) pilot projects as an example. Medicare adopted the guaranteed savings model which arose in the private sector in the late 90s and early 00s; Medicare is requiring contractors to guarantee 5% savings, and this must be backed either by reinsurance or by an exceptionally strong balance sheet. IMHO the guaranteed savings requirement explains why the awardees are all large disease management companies or publicly traded health plans, and NOT physician groups, hospitals, home health agencies, or other smaller, more local groups.

The guaranteed savings model arguably made sense when the DM industry was populated by small, early stage companies, but has become far less common in private sector contracting as the DM industry has grown and matured.

Thus, you see a situation in which Medicare is following about 3-5 years behind the private sector. I think you'd see a similar situation if you examined CMS initiatives relating to quality improvement, pay-for-performance, etc. Again, this is an observation, not a criticism.

Bottom line: The Medipare scenario doesn't fit market realities.

I guess I am more optimistic. The difference is that we need to take a longer view before trying to figure out ROI and re-shuffling of payment schemes. We are in this for the long haul and I think we can learn from the last 25 years. There have been lots of AHRQ and other grants awarded to prove technology works in this space. Meanwhile we have bred and raised a generation of consumers who, at a minimum are comfortable with video games, IM, and cell phones. If we apply the CMS statistics for the cost of care via education to that population and invest in methods of slowly raising the bar for access versus self control and home based monitoring..my belief is that we will see, over a 10 year period of time, unrefutable evidence of change, acceptance and acknowledgement that we are indeed migrating to the business of health instead of one of reactive care/treatment. There is not doubt of the efficacy of interventional and preventative monitoring. We also know the technology is reliable and professionals will eventually accept documented hard data comparing costs of low or no re-admits for chronic high risk patients. We cannot take a 3-5 year view..we can't even get out of our way in 3-5 years...look out 10 years or more, put a stake in the ground, stop funding research to prove the efficacy and the fact that technology can work and invest in tracking, reporting, educating(legislators, state bodies who are seeing and will see Medicaid become greater than 50% of budgets in at least a dozen states in the next 5 years, commercial payers, employers, and consumers...and CMS will figure it out.)

Sorry if this seems harsh, but, when you look at the data, it is obvious what needs to be done. We have enough and can add to that data, but focus it on the consumer, the employer, the commercial payers, the family members of those with chronic or high risk relatives...and, I bet, in 3-5 years, that will have more of an impact that waiting for CMS or HHS to work through their process.

To add to your comment about the next generation bred and raised on video games...they will now start graduating from the medical schools, bring with them the ability to work with multiple parties in the cyber-space. Will that be the tipping point? If not, what would be?

Good day, Ashok Bogha! Tanks for Your Discussion! And that You and others Members of this discassion think about using telemedicine chance for based Neuro-nets education in the fieldes of Medical Imaging?
Sincerely Yours,
Elena

Hi Elena, good to have you join the discussion. I presume you are referring to the use of artificial intelligence to automate the process of interpreting medical images. Does anyone have an opinion of how this technology will develop and make significant contributions?

Hi, Ashok Boghan and all Disputants! I must to say, that we (I am and Irina Maximova, Professor of Optic and Biophysical Department of Saratov Classic University, Russia) have long-standing reverie about Neural Net’s application including courseware in Medical Imaging. Neural Nets are more simplex than artificial intelligence to automate the process of interpreting medical images, because this is only interesting mathematics’ programs for this purposes. The main difficulty in Neural Nets application is absence of the basis with extensive evidence of Medical Imaging. Manifestly, it is necessary to receive very extensive evidence for correctly results. And Telemedicine may (and must) to help in this problems by creation database from different World Medical Centers! Sincerely all of You, Elena

I think there are at least two sub-categories of Telemedicine, with different financial incentives. One category of Telemedicine involves distinct patient-caregiver interactions via video-conferencing. This reduces costs largely by eliminating the need for human travel (e.g. no need for busy, or frail, patient to visit a doctor's office; no need for a nurse to visit a home). But this interaction is frankly just not as good (on average) as face-to-face interaction, in terms of data acquisition, communication, and human satisfaction [See a somewhat eccentric discussion of the limits of videoconferencing at http://www.discover.com/issues/jul-06/departments/jaron/?page=1. Consider, for instance, that a physician can take a lack of eye contact to indicate that the patient is not alert or thinking clearly, but this cue is lost in videoconferencing when the patient may simply not naturally look toward the camera]. Payment for such Telemedicine seems likely when (a) it eliminates a VNA (visiting nurse) who otherwise would have had to travel to the patient's home; or (b) if a busy patient is willing to pay/co-pay for the convenience of NOT traveling to a clinic, e.g., for simple follow-up appointments. I am a researcher, not business person, but I would think government payors would only be likely to pay for the former, not latter.

The second category of Telemedicine involves monitoring patients in their homes, which might lead to better diagnoses (e.g. better characterization of hypertension) and better detection of major adverse health events (e.g. fainting, congestive heart failure). Yet present monitoring technology is ripe with error: false alarms and imperfect caregiver technique are common in hospitals. These problems will be amplified when diagnostic/monitoring technology is exported to patients' homes. An uneconomical cocktail of ambiguous data and false-alarms must be expected near-term. Payment for such Telemedicine seems likely only when (a) the home data prove economical in terms of healthcare outcomes, e.g., diseases with very high true-event rates which benefit from timely intervention such as decompensation of chronic heart failure; or (b) when patients or their families are willing to pay for boutique home-monitoring services, which (in return for a substantial out-of-pocket fee) offers incremental health benefits.

Very well articulated Andrew. Does anyone have comments, points-of-view, on Andrew's hypotheses about when a payment can be expected and when it should not be?

There is one other scenario for live synchronous telemedicine (category 1), which is that it may provide patients with access to specialists they might not otherwise have.

Those living in rural or other isolated communities simply can't afford to (or be able to if they are very ill) travel to see a much-needed specialist. So it may not be a convenience issue, per se, but a real access issue. In this case, I would hope that payors would see the economic and quality benefit to reimburse virtual visits.