Experts say La. law needs more clarity after rise in telemedicine
With the advent of new technology come questions about how it should be regulated to ensure that patients receive the same quality of care
By Richard Thompson
BATON ROUGE, La. — More than half of U.S. hospitals are turning to telemedicine to provide clinical services in a range of settings, in some cases enabling patients to consult a physician directly from home with a few taps on their smartphone.
However, the head of one large national company says Louisiana's telemedicine regulations are ambiguous, and that Louisiana State Board of Medical Examiners inquiries into some physicians' practices could stymie the industry's growth in the state.
Other in-state health care providers also are seeking clarity from state regulators as they look to dive deeper into providing telemedicine services directly to patients.
With the advent of new technology come questions about how it should be regulated to ensure that patients receive the same quality of care from a distant doctor that they get in person.
Some of the concerns center on whether adequate equipment is being used to diagnose, monitor or treat patients outside a medical facility and on the potential use of third-party doctors unfamiliar with patients.
Telemedicine technology already is being used in different ways by several of the state's big-name health care providers, including Ochsner Health System and LCMC Health, which manages University Medical Center and Children's Hospital, both in New Orleans.
Industry supporters argue that, if used correctly, telemedicine can improve access to health care services, especially in rural areas, and can save patients the time and expense of traveling to a doctor, particularly for some routine visits, while reducing congestion in doctors' offices and lessening a patient's exposure to illnesses.
Additionally, they say, it can improve outcomes and lower costs. For instance, Blue Cross and Blue Shield of Louisiana's telemedicine platform, BlueCare, bills just $39 or less per online visit, depending on the patient's health plan. Patients can download apps that connect them to a doctor and get prescriptions sent to a pharmacy in minutes.
Asked about concerns over telemedicine, Blue Cross Chief Medical Officer Vindell Washington said the insurer is having "collaborative, ongoing communication" with all the parties involved to ensure "the ongoing, appropriate availability" of online doctor visits through BlueCare.
'Working out wonderful'
One believer in telemedicine is Zachary resident Breshaunya Young. After having surgery last summer, the 24-year-old has been able to use her smartphone to seek medical advice from Dr. Aaron Martin, the clinical director of Children's Hospital's and LSU Health New Orleans' telemedicine-to-home programs.
"I had never heard of it, and after I tried it out the first time, I actually enjoyed it," said Young, whose surgery was done at Children's Hospital.
Young has avoided the long trek into New Orleans since September. Instead, when she has questions—like when a blister recently appeared near her incision—she can send Martin a photo, and he can recommend a course of treatment.
"Right now, with it being flu season, I'm trying not to go to a doctor's office," she said. "This app is working out wonderful."
While such programs are operating successfully, the Boston-based telemedicine firm American Well, which provides telehealth technology to insurers, hospitals, health systems and employers, says the Louisiana State Board of Medical Examiners has begun probing whether some physicians are flouting rules, even though they believe they're operating within the prescribed limits.
Few details have emerged publicly about the board's closed-door reviews, and state officials have declined to confirm or deny that such investigations are underway.
However, Jennifer Thomas, a partner in Kean Miller's Baton Rouge office, said the law firm has a few clients who have gotten investigatory letters from the state board. Thomas said she could not disclose the details of the letters, but the queries fell along the lines of equipment. The firm's clients are still practicing telemedicine without interruption, Thomas said.
Louisiana law regulating telemedicine does not require physicians to first conduct an in-person visit with a patient, nor are the doctors required to be located in Louisiana, as long as they are properly licensed to practice medicine here and meet a handful of stipulations.
However, there are questions about whether a physician has to have access to the patient's medical record, which isn't always immediately available if the patient hasn't been treated previously by that physician.
In some respects, American Well's smartphone app is similar to an Uber for getting basic medical care. But American Well CEO Dr. Roy Schoenberg said his service has languished in Louisiana amid the regulatory uncertainty. Physicians are reluctant to use it if they believe they're at risk of being investigated by the state, which could potentially lead to their medical license being revoked.
The message the board is sending, Schoenberg said, is that telemedicine patients' homes must be equipped with a variety of pricey diagnostic devices.
Dr. Vincent Culotta Jr., executive director of the state Board of Medical Examiners, said he could not discuss specifics of any investigation. However, if an investigation was underway, he said, it would have been spurred by a complaint received by the board.
Culotta stressed that the board is not seeking to stifle new technology but is focused on maintaining the same level of medical care.
"They seem to think that Louisiana is anti-telemedicine. We are not," he said, "but we can't have two separate standards of care."
Culotta said the board's rules are simple and straightforward: If a doctor can't provide the necessary evaluation with the equipment available, then the doctor shouldn't be doing it.
American Well feels the state regulations put the burden on patients to buy equipment, Culotta said. But the board and other health industry members believe that in the not-too-distant future, doctors will provide telemedicine kits to their patients once a relationship has been established. He noted kits are available and declining rapidly in price.
In Baton Rouge, state lawmakers have worked to accommodate the fledgling industry. In 2016, the Legislature passed a law removing some barriers to telemedicine. As long as doctors were licensed to practice in Louisiana, the law said, they no longer had to have an office in the state or be under contract with an in-state provider. In addition, visits could be accomplished with interactive audio instead of two-way video.
Children's Hospital is looking to roll out the service, but it would have patients consult with its physicians, rather than a third-party service. Meanwhile, Ochsner's chief medical officer hinted recently that it is exploring the use of third-party doctors when its own physicians are not available.
The Children's Hospital initiative, called TECH, short for Telemedicine for the Enhancement of Children's Health, was launched last year. More than 200 patients have enrolled, and the hospital expects to add more specialties.
"The temptation is to see telemedicine as a replacement for an in-person visit, and I feel that is a mistake," said Martin, the Children's Hospital doctor. "Telemedicine needs to be an enhancement of the patient's care, not a substitute, not a replacement, not a way to get around something. It's a way to enhance it."
"We're very careful that we can provide the same quality of care as if you showed up in any of our clinics, and to do that we believe that you need to be seeing one of our physicians whom we trust and that you'd see in person yourself, as opposed to talking to a physician who doesn't know you," he said.
In a recent letter to the State Board of Medical Examiners, Dr. Robert Hart, Ochsner's chief medical officer, said the nonprofit "has been developing and growing its telemedicine capacity to improve availability, accessibility and affordability to patients in Louisiana."
"Whenever possible, Ochsner uses its own employed physicians to provide these services. However, Ochsner may enter into contractual relationships with third parties to provide telemedicine services to its patients in certain circumstances," Hart wrote. "This may be done as a way to use the technology owned by the third party that enables telemedicine or to provide physician coverage where Ochsner cannot satisfy the demand."
In those cases, Hart said, the outside physicians would be "either credentialed with an Ochsner entity or required to meet similar credentialing standards."
Ochsner's telemedicine consultations grew by nearly 70 percent in 2017, with further growth expected in 2018.
Ochsner uses the technology in several ways. Ochsner's CareConnect 360 telemedicine program, which has been in operation for nearly a decade, partners with hospitals in Louisiana and Mississippi. Nearly 700,000 patients have received treatment in dozens of specialties, such as having cardiologists remotely interpret angiograms for rural patients.
In a pilot program started last year, Ochsner began using the technology to connect directly with some patients, including recent transplant recipients, to provide follow-up care without them having to travel to the hospital.
"Telemedicine is not a different practice from medicine. It's just a different way for our patients to be able to interact with their specialist," said Dr. David Houghton, medical director of CareConnect 360.
In general, Houghton said, Ochsner is not at odds with the state's regulations. However, it has requested clarity as it considers potentially enabling patients to consult with a third-party doctor when Ochsner's own physicians are not available.
From a technology perspective, Houghton sees few roadblocks to expanding the services. Most people have broadband internet access or a smartphone.
"I think 'game changer' is the right word," he said. "We're really at an exciting inflection point, looking at the way medicine can be practiced virtually, providing the same or even better levels of care."
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