CALIFORNIA STATE UNIVERSITY, NORTHRIDGE Telemedicine: a Public Policy Review and Solutions for Underserved Communities a Gradua

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CALIFORNIA STATE UNIVERSITY, NORTHRIDGE

Telemedicine: A Public Policy Review and Solutions for Underserved Communities

A graduate Project submitted in partial fulfillment of the requirements

For the degree of Master of Public Administration, Health Administration

Lanae Rivers

August 2020

The graduate project of Lanae Rivers is approved:

______Dr. David Powell Date

______Dr. Frankline Augustin Date

______Dr. Kyusuk “Stephan” Chung, Chair Date

California State University, Northridge

iii Table of Contents

Signature Page iii

Abstract vi

Introduction 1

Background 3

Methodology 5

Literature Review 6

Benefits of Telemedicine 6

Privacy & Security 7

Patient Barriers in Telemedicine 8

Government-Sponsored Programs 9

Medicaid 9

Medi-cal 11

Medicare 12

Cares Act 13

Private Insurance 14

Employer-Sponsored Health Insurance 15

Uninsured 17

Provider Barriers in Telemedicine 17

Hospital Credentialing & Privileging 19

iv Payment 21

Malpractice in Telemedicine 22

Findings and Analysis 24

Future of Telemedicine 25

Conclusion 27

References 28

v Abstract

Telemedicine: A Public Policy Review and Solutions for Underserved Communities

Lanae Rivers

Masters of Public Administration, Health Administration

The use of telemedicine in healthcare in the United States is not a new concept, but it is something that is being taken advantage of as technology advances. Telemedicine aims to provide coverage from anywhere to patients and reduce the costs of healthcare to those living in underserved communities across the United States. Although access to telemedicine benefits is increasingly growing, the research of how costs and delivery impact underserved areas is at a minimum. For every 100,000 patients in an underserved community in the U.S., there are 40 subspecialists to treat them. Many communities lack access to providers, and many providers lack the resources needed to be able to provide care to patients via telemedicine. The purpose of this qualitative research is to review the literature and policies needed to examine how the continuing expansion of telemedicine increases the reach of healthcare in underserved communities. A multitude of legislations have been proposed or put into place such as the

vi Balanced Budget Act of 1997 and more recently, the Cares Act to aid the expansion of telemedicine. This present review of literature critically examines the challenges that both patients and providers face when using telemedicine such as cost, reimbursement for patients and payment for providers. It also assesses the benefits of telemedicine, such as cost reduction and privacy and security in present legislations like the Health Insurance Portability and

Accountability Act (HIPAA). The way in which providers interact with their patients is changing due to the evolution of telemedicine, and most challenges presented show that further research is needed to show what legislation needs to be passed to support the expansion of telemedicine in underserved communities.

vii

Introduction

As Americans, we obtain health insurance in many ways, through our employers, private insurance companies, or government-based programs such as Medicare or Medicaid. Companies like Teladoc, MDLIVE, and even healthcare provider Kaiser Permanente are among the few companies expanding telemedicine or telehealth services (Sahdev, 2011). Telemedicine seeks to offer many advantages to both patients and physicians while reducing costs, improving access to physicians, cutting out travel times, and creating more opportunities for care (Downing,

2015). According to the article by Fred Bazzoli (2016), “Value-based care puts a whole new set of reimbursement incentives before providers-now, healthcare organizations benefit when they can provide care cost-effectively. The technology has improved; patients are savvy and want the best care available; and Medicare and insurers are waking up to the potential benefits of care provided at a distance”. With technology vastly improving, everyone including those in medicine must start to keep up with the times, including offering care to patients who are not close to them, particularly those in underserved communities.

As the United States healthcare system undergoes profound changes, telemedicine is attracting much attention (Masys,1997). In addition to offering a value-based care health system, telemedicine offers structure for centralizing specialists and reduces costs for both primary and specialty care in metropolitan and underserved areas (Masys,1997). According to the 2010

Census, underserved areas are home to 20% of the United States population (Marcin, 2016).

According to the Department of Health and Human Services an underserved community is determined by the community’s shortages of primary health services as well as mental health services (U.S Department of Health and Human Services, Health Resources and Services

Administration, 2012). Communities with high elderly populations, high infant mortality, and

1 high poverty are also considered underserved (U.S Department of Health and Human Services,

Health Resources and Services Administration, 2012). Physicians and other care providers must be ready to offer the same services and same care that they would offer to someone who is in their clinic to someone who is speaking to them through a speaker or viewing their complaints through a video monitor.

Concerns about access to health care coverage, doctors, and costs have prompted the interest in the use of telemedicine (Masys,1997). This study aims to review the literature and policies needed to examine how the continuing expansion of telemedicine increases the reach of healthcare in underserved communities.

2 Background

The World Health Organization (WHO) defines telemedicine as “the delivery of health care services, where distance is critical factor, by health care professionals using information and communications technologies for the exchange of valid information for diagnosis, treatment and prevention of diseases and injuries, research and evaluation, and for the continuing education of health care providers, all in the interest of advancing the health of individuals and their communities” (Gupa, 2015). Telemedicine covers all aspects of healthcare at a distance.

Telemedicine and Telehealth can now be used interchangeably. The American

Telemedicine Association defines both as “the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status”

(Downing, 2015). Both terms can be broken into categories based on their functions and services provided. According to Downing (2015), “synchronous telemedicine includes using hardware such as video-conferencing applications like Skype or Zoom that are dedicated to the two-way communication among the provider and patient(s)”. Asynchronous telemedicine also involves the use of video and audio, but photographs can be used as well. This does not require the physician and the patient to be available at the same time, so this would be something like an email or a portal that you can message all of your physicians on like the one that Kaiser

Permanente has (Downing, 2015). Both asynchronous and synchronous telemedicine can be used in other aspects of healthcare as well; many radiologists, psychiatrists, urologists are taking advantage of telemedicine today (Dowling, 2015). The next two terms that can be used to describe telemedicine are remote patient monitoring (RPM) and Mobile health (mHealth). RPM uses devices to collect and deliver data remotely to an agency (ATA, 2020). Data may include vital signs used in an EGG monitor. Mhealth is consumer health and medical information that

3 includes the use of wireless devices and the Internet for patients to obtain specialized health information (ATA, 2020).

Regardless of the type of telemedicine or delivery mechanism, telemedicine is used to communicate with a provider at a distance, making appointments possible for those in rural or underserved communities. Telemedicine can be provided by multiple delivery mechanisms such as networked programs, point to point connections, monitoring center link, and web based consumer device sites. A Network program links low level clinics and community centers with higher ranked hospitals and clinics. It is estimated by the ATA that around 200 higher ranked hospitals are providing around 3,000 lower level clinics telemedicine network assistance.

Monitoring centers are used for specialties such as cardiology and pulmonology to monitor patients' care in their home (ATA, 2020). These services often use a wireless connection to upload data and communicate directly to the ATA. Families living in underserved communities are often left with fewer resources, including healthcare and medical resources.

4 Methodology

This research is a qualitative analysis of archival data that focus on government published articles as well as peer reviewed articles that are the primary source on telemedicine and telehealth in underserved communities. Studies published between 2001 and 2020 were retrieved from the California State University, Northridge Database using the following search engines:

General OneFile (Gale), Data.gov, Govinfo, ProQuest, and PubMed. Additionally, non-peer reviewed articles and government sites were used in this research such as EHealthInsurance.com and Health Policy Issues: An Economic Perspective, Seventh edition, by Feldstein, P. The keywords used to search and retrieve the data for this research include: Telemedicine, telehealth, underserved communities, rural, Medicare, Medicare, Public Policy, Healthcare Policy,

California, BIPA, HITECH, COVID, COVID-19 and the United States. The keywords used helped to identify public policies related to the expansion of telemedicine in underserved communities across the United States.

The keywords search yielded more than 100,000 articles per database. By using the year filter and filtering every 5 years starting in 2000, the number of articles was reduced to what was needed for the research at the time of writing. More than half of the articles needed to discuss telemedicine, telehealth, or cybermedicine to ensure that the article was essential to the research.

The remaining half of the articles needed for research had to discuss public policies such as

Medicare, Medi-Cal, and Medicaid. The search strategy yielded 53 peer reviewed articles for review relating to telemedicine, telehealth, or cyber medicine, as well as public policies relating to healthcare coverage.

5 Literature Review Benefits of Telemedicine

Electronically acquiring, storing, retrieving, exchanging, and dispersing information are necessary components of telemedicine technology (Bashshur, 2009). This information is used for the purposes of disease prevention, chronic illness management, and rehabilitation in an effort to protect public health and safety (Bashshur, 2009). Telemedicine systems consist of health networks and facilities working collaboratively to demonstrate the following objectives:

● Improve access in all aspects of healthcare

● Promote value-based care in underserved communities

● Increase long-term care in facilities and at home for chronic diseases

● Promote independence in healthy lifestyles

Telemedicine seeks to offer benefits to both patients and providers while reducing costs, improving access to physicians and patients, cutting out travel times, and creating more opportunities for care (Downing, 2015). Telemedicine can be used to improve workforce inconsistencies, assist with providing access to specialists for patients and primary providers, reduce the need for hospital transfers and yield savings in travel costs for families in underserved communities (Bagot, 2020). With technology vastly improving, everyone including those in medicine must start to keep up with the times, including offering care to patients who are not close to them. Higher-level hospitals that offer digital teleconsultation, digital telediagnosis, and digital telemonitoring are much more helpful to patients and low level clinics(Yu,2020). In underserved communities this is important because the hospitals and healthcare systems overall may be less developed than the city(Yu,2020)

6 Offering the best care to patients involves keeping patients healthy and finding a way to reward healthcare providers for providing the care and keeping patients healthy. According to

Bazzoli (2016), “Value-based care puts a whole new set of reimbursement incentives before providers-now, healthcare organizations benefit when they can provide care cost-effectively.

Technology has improved; patients are becoming savvy and tech-reliant and want the best care available”. Physicians and other care providers must be ready to offer the same services and same care that they would offer someone who is in their clinic to someone who is speaking to them through a speaker or viewing their complaints through a video monitor. Telemedicine is not only something that is beneficial to patients but can also be as beneficial and rewarding to providers.

Privacy & Security

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) sets the standard for overall security and privacy that will apply to telemedicine services (Baker, 2011).

The main focus of HIPAA is protecting patients' Privacy and Security, which is also a main focus of medical staff (“HIPAA,” 1996). Section 1173 Subtitle D sets Security Standards for

Health Information transmitted electronically. The security enacted in this law focuses on protecting against the divulgence of protected health information (PHI) and the loss of electronic records (“HIPAA,” 1996). Similar to in-person visits, providers are responsible for maintaining patient privacy and confidentiality for visits over video or phone(Baker,2011). Patient information, electronic files, and images must be protected by providers in the same manner as physical documents (Baker,2011). The Security Rule of HIPAA applies primarily to practitioners who store or transmit electronic PHI (Baker, 2011). The common approach of the Security Rule

7 is adaptable and does not pertain to communication with patients by phone or video; providers are not required to comply with specific proscriptions for handling PHI (Baker, 2011).

The Health Information Technology for Economic and Clinical Health (HITECH) Act of

2009 was passed by the Obama administration as part of the American Recovery and

Reinvestment Act of 2009 (“HITECH,” 2009). The Act was signed into law on February 17,

2009 with the intention of promoting the use of health information technology (Gold, 2016).

HITECH stimulated the adoption of Electronic Health records by following the guidelines set out by HIPAA (Monpara, 2020). Electronic Medical Records (EMRs) are defined as “computerized medical information systems and in advance seem to change the existing, often paper based, medical practice” (Mohammadhiwa, 2016). The enhancement of clinical efficiency, improvement of quality and the decrease of healthcare costs are all reasons for the adoption of health Information technology. (Mohammadhiwa, 2016).

Patient Barriers in Telemedicine

Despite the ways that telemedicine can help transform health care in underserved communities, it faces a number of major challenges, from coverage and reimbursement, paying out of pocket or simply not having access to a provider or access to telemedicine to a lack of

Internet. The option for medical professions to implement telemedicine options to patients is increasing in the healthcare setting. Healthcare providers, state and federal governments, and private insurance companies must all try to keep up with the times. According to an article written by Hana Sahdev (2011), despite the eagerness for the expansion of telemedicine by practitioners, and patients, both access and the expansion are restrained because of policies at the state and federal levels. Physicians currently need to be licensed in each state that he or she wants to practice in, whether virtually or in person (Sahdev, 2011). Many Americans obtain

8 health insurance through their employers, private insurance companies, or government-based

programs, all varying in price and coverage. States with large underserved communities have

found the use of telemedicine to be cost-effective to traditional appointment types. Current

telehealth coverage and reimbursement policies hinder the expansion of it. Many states,

however, have implemented guidelines for reimbursements through current healthcare plans.

Telemedicine is a new beneficial way to deliver health care services to underserved

communities.

Government-Sponsored Programs

Governments-sponsored programs such as Medicaid, Medicare and private entities in some instances pay for some telemedicine services, but in most cases, they do not (Gupta,

2011). This is an example of how the United States’ health care reimbursement process can interfere with the progression of telemedicine in underserved communities (Gupta, 2011). An overview of these three insurers will show how the billing processes currently being used impede the practice of telemedicine.

Medicaid

Medicaid programs are state-run programs and vary state by state. This means that the reimbursement process for telemedicine services would vary state by state as well. According to

Medicaid, telehealth services can take place in two ways—originating sites and distant sites.

Originating sites are defined as the “location of the Medicaid patient at the time the service being furnished via a telecommunications system occurs” (Telemedicine-Medicaid, (nd)).

Distant sites are “sites at which the physician or other licensed practitioner delivering the

9 service is located at the time the service is provided via telecommunications system”

(Telemedicine-Medicaid,(nd)).

It has been reported by The National Conference of State Legislatures that 43 states and the District of Columbia provide a form of reimbursement through Medicaid for primary care services (Branon,2012). A legislation adopted by Kentucky in July allows telemedicine visits to take place from a patient's home under Medicaid (Lagasse, 2019). Parity legislation passed in

Tennessee which focuses on growing Medicaid coverage for services received through telemedicine (Critikos, 2018). According to an article posted by Johns Hopkins, Arizona and

Colorado are two states that place geographic limitations on telemedicine reimbursement

(Sahdev, 2011). Arizona will only reimburse telemedicine services based on where the person receiving them lives (i.e., a rural area) (Sahdev, 2011). According to Alan C. Roga, MD and his work published by the Telemedicine journal and E-health, CEO of Copper Queen Hospital,

James Dickson, has shown that telemedicine has been able to provide evidence-based care to patients, improve support for their providers, and reduce overall costs. Copper Queen Hospital is located in a very rural area in southeastern Arizona, and the adoption of telemedicine has improved their overall position in caregiving in their region (Alverson, 2019). Dickerson states,

“Telemedicine counterbalances disparities between urban and rural medical environments, results in better disease management, improves potential to practice evidence-based standards, and lowers cost on several levels (Alverson, 2019).” Outside of helping those consumers, telemedicine helps to reduce costs paid by state and federal governments. The use of telemedicine would be beneficial to any person who struggles to get to and from doctor appointments and especially someone who lives in a rural area where access to doctors, medical centers, and hospitals is limited.

10 Medi-Cal

California’s Medicaid program, Medi-Cal, considers telemedicine a way for providers to deliver healthcare (California Health Benefits Review Program, 2018). Services done via telemedicine such as Email, phone, or fax services are not reimbursed by Medi-Cal (California

Health Benefits Review Program, 2018). In September 2016, California's governor signed

California Assembly Bill 2861 into law. AB 2861 mandates the Department of Health Care

Services to allow a “licensed practitioner of the healing arts” or a “certified substance use disorder counselor” to receive Medi-Cal reimbursement for substance use disorder services provided through telehealth (California Health Benefits Review Program, 2018). The majority of Medi-Cal members are from underserved communities in the state, making them more susceptible to abuse drugs and alcohol. Allowing members in these underserved communities the opportunity to receive care at their fingertips is a step towards the innovation of telemedicine. Telemedicine coverage is not something distant within Medicaid or Medi-Cal

(California Health Benefits Review Program, 2018). Medi-Cal reimburses for telemedicine services that are “appropriately provided”, there are several types of services that apply:

Teledermatology, teleophthalmology, teledentistry, selected psychiatric diagnostic interview examination and selected psychiatric therapeutic services.

Since 2010, more people have gained health care coverage through the Affordable Care

Act (ACA). The ACA is “contentious legislation passed in 2010 that expanded coverage to an additional 13.6 million people by increasing Medicaid eligibility and providing federal subsidies to those enrolled in state and federal health insurance exchanges” (Feldstein, 2019). The use of telemedicine provides an alternative to the standard face to face interaction with the consumer's primary care physician or any doctor who is available. Majority of the consumers who fall under

11 the qualifications of the ACA come from an Underserved Community. Though the ACA has prompted providers to offer telemedicine options by offering incentives, without appropriate reimbursement or licensing of providers, members are finding it difficult to find a provider who will utilize this new technology.

Section 3021 (b) of the Affordable Care Act tasks the Center for Medicare and

Medicaid Innovation (CMI) with testing new care models that include “electronic monitoring” done at a distance it also grants the CMMI access to distributing grants to applicants who propose new “electronic care” models, including those proposing the use of telemedicine(Critikos, 2018). In addition to providing grants to applicants through the CMMI, the ACA provides funding to providers who use telemedicine services to treat patients who are insured under Medicaid or Medicare (Critikos, 2018). Furthermore, the passing of the ACA has prompted more access to those in underserved communities because it has accelerated the development of telemedicine.

Medicare

With technology advancing at a rapid pace, many people ages 65 and up are finding that they have to be up with the times. More people in that age group have smartphones that allow them to keep in touch with their families near and far, and even their physicians. But is connecting with their physician covered by their insurance? About 15 percent of Americans are covered through Medicare in the United States. Reimbursement through Medicare remains difficult for beneficiaries (Weinstein, 2014). CMS limits reimbursement to services provided in underserved areas unless it is teleradiology or telepathology (Weinstein, 2014). H.R.5661, the

Benefits Improvement and Protection Act (BIPA) was introduced in 2001 to reduce regulations of telehealth and increase covered telehealth services. Section 223 of H.R. 5661 revises the

12 Balanced Budget Act of 1997, setting a time limit for Medicare reimbursement for telehealth and to provide an extension for the services. In conjunction with H.R. 4577, H.R. 5661 became the Consolidated Appropriations Act of 2001. The basis of the bill covers more than telemedicine benefits but is a start for telemedicine coverage in the U.S. H.R. 4577 called for the revision of current telemedicine reimbursements. The language in the law is as follows

(“BIPA”, 2001):

“(A) Distant site--The Secretary shall pay to a

physician or practitioner located at a distant site that

furnishes a telehealth service to an eligible telehealth

individual an amount equal to the amount that such

physician or practitioner would have been paid under

this title had such service been furnished without the

use of a telecommunications system”.

H.R. 4577 requires that the practitioner be paid the same amount that they would be paid for a service provided in person, resulting in face to face appointments and telehealth appointments being equal in payment (“BIPA”, 2001). As a result of both appointment types being the same payment, we can now consider telemedicine to be fee-for-service. Payment for medical services that are made for each unit of service provided is considered a fee-for-service

(Feldstein, 2019). Fee-for-service is not always the case, and payment and reimbursement will differ based on who healthcare insurance is through. Additionally, “Parity” legislation has been passed by 19 states. Telemedicine payment requirements under “Parity” vary state by state, but most require reimbursement for telemedicine services.

13 In 2015, 2017 and again in 2019, the Telehealth Innovation and Improvement Act was introduced to the Senate by Cory Gardner (R) of Colorado and Gary C Peters (D) of Michigan.

The bill seeks for the CMI to determine the impact of incorporating telehealth services in

Medicare delivery reform models. This includes the effectiveness, cost, and the reimbursement of healthcare providers through Medicare. This legislation was and is still needed today because many people in underserved communities do not have access to healthcare providers at hand and are going without care. Many people on Medicare are not meeting the “criteria” for reimbursement and are going without care as well.

Cares Act

Under the Trump administration, the Coronavirus Preparedness and Response

Supplemental Appropriations Act (CARES) was passed on March 17, 2020, authorizing the

Administration to loosen the restrictions on telemedicine services in order to expand access during COVID-19 pandemic through September 2020 (“CARES,” 2020). This includes many

Medicare beneficiaries who are vulnerable to COVID-19. In the event of future emergencies, they will not need to come in for care. The CMS will allow Medicare Advantage organizations that submit and meet all requirements for risk adjustment payment (AMA, 2020). Requirements are the same as a face-to-face visit.

The Trump administration passing this law on a tentative basis shows the actual need for telemedicine services in our older population (“CARES,” 2020). Prior to COVID-19, Rural

Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) had a shortage of providers and resources (AMA, 2020). The CARES Act has made some changes during the pandemic benefiting the RHC and FQHC such as allowing providers to provide services from

14 their home. In addition, the CMS will now pay $92 for telehealth services provided by the providers to the health centers (AMA, 2020). COVID-19 has also allowed physicians to use any two-way audio or visual device such as Skype or Facetime. However, physicians are encouraged to not use social media platforms to perform telemedicine services. The Drug

Enforcement Administration (DEA) will permit providers to prescribe controlled substances based on telemedicine visits during COVID-19. This will be on a state by state basis (AMA,

2020).

Private Insurance

Private insurance companies are the government's largest competition when it comes to healthcare coverage. Most of the United States requires private insurance companies to cover telemedicine, but laws vary state to state on how much the private payers have to reimburse or pay (Fanburg, 2018). In January 2013, 16 states began requiring private insurance companies to cover telemedicine services, most of which encourage these policies to cover telemedicine in non-rural areas (Horton, 2014). According to the University of Memphis Law Review, 29 states and D.C. have passed “private payer parity statutes” (Brannon, 2012). These payer parities are categorized as comparable coverage reimbursements for telemedicine services. However, some states require private insurers to reimburse for telemedicine services "on par" (Fanburg, 2018), meaning that the insurer would pay the same price they would pay for seeing the provider in person. On the other hand, states like New York are requiring private payers to cover telemedicine services, but either do not require or may be silent with respect to parity for reimbursement. Other states have a requirement for telemedicine that may not be “on par” with reimbursement for the services. Telemedicine today can be used to provide fully functioning

15 care without stepping foot outside of your home. Yet, this fully functioning way of care is still not being utilized all over the United States. A private insurance “parity” legislation is more important than ever if telemedicine is going to expand to underserved communities. According to Brannon (2012), Vermont and Maryland have become the 13th and 14th states in the U.S. to mandate that telemedicine services are paid for by private-sector companies. Maryland law, for example, prohibits insurers from covering patients living in underserved communities and patients who live in a city setting (Horton, 2014).

Like all aspects of healthcare, telemedicine is only profitable based on the number of payers, this includes Private Payers (Fanburg,2018). Some states have a form of reimbursement for telehealth services that does not quite equate to reimbursement and other states do not require any type of reimbursement (Brannon, 2012). There are many variations, regulations, and payer requirements for telemedicine services in state and federal laws. Even in states that do not mandate telemedicine coverage, private insurance companies are beginning to offer telemedicine coverage to those in non-rural areas (Horton,2014). Leaving those in underserved communities, or rural areas without care if they receive care through a private insurer

(Horton,2014).

Employer-Sponsored Health Insurance

For almost 70 years, employer-sponsored health insurance has been the foundation of the United States healthcare system (Bergner, 2013). Due to collective bargaining done by labor unions in the United States, health insurance has been linked to employment (Bashshur, 2009).

Patients living in underserved communities are more than likely receiving their healthcare benefits through their employer or one of the many government-sponsored programs and in

16 some cases, both. Approximately 156 million people, or 49% of the population, in the United

States receive employer-sponsored health benefits (Ehealth, 2019). Some of the largest states in the country have almost half or over half of the people living there benefiting from employer- sponsored health coverage. 47% of California's population is covered through employer- sponsored health insurance, while Texas has about 48%. Other states like Utah, North Dakota, and Minnesota have more than half of their residents covered through employer-sponsored programs (eHealth, 2019). Noting that, telemedicine costs much less than your typical emergency room visit or routine visit, including telemedicine coverage or reimbursement is an opportunity to decrease costs in terms of healthcare and lost productivity from having sick employees who have to leave for appointments (McLeese, 2016). Work losses related to health are estimated to cost companies in the United States about $260 billion each year (Mitchell,

2011). The 25% of patients in the United States living in underserved communities struggling to access healthcare say they opt to not seek care because of the costs that come with seeing a physician in-person, which in most cases includes taking time off of work and arranging to get to the appointment (Sahdev, 2015).

Many state legislatures have enacted laws creating telemedicine mandates for health insurance plans--for instance, the impact of the ACA (McLeese, 2016). If the patient’s employer provides the coverage, the services used are considered to be within the patient’s health plan making the patient eligible for all the market amenities of the ACA (McLeese, 2016).

Uninsured

More than 2 million adults living in underserved communities fall into the “coverage gap” due to states deciding to not expand their Medicaid programs (Garfield, 2020). Those in

17 the “coverage gap” typically live below the poverty level. The majority do not have a family income but make above Medicaid eligibility. A third of the population who fall under the

“coverage gap” live in Texas, which also has a large uninsured population, as well as limited

Medicaid eligibility (Garfield, 2020). Patients who are uninsured are more likely seek care in an emergency room for low-acuity health problems. Low acuity is defined as the billing code of somewhat urgent or nonurgent (Howell, 2016). Improving telehealth in underserved communities includes making changes and improvements for the uninsured. It is important that we offer uninsured Americans opportunities to receive care as well. While many healthcare providers, both private and government based, have their own set of physicians within their network, there are many telehealth companies that will provide services to patients who are not insured and charge them out of pocket. Costs for these services vary by company.

Provider Barriers in Telemedicine

Patients living in underserved communities may skip out in seeing their provider because they cannot afford it. They may also not be given the opportunity to speak with practitioners, and insurance providers are finding new challenges in practicing telemedicine such as licensing, hospital credentialing, malpractice, privacy and security, payment, and in some cases, delaying the care of patients or causing telemedicine to not be offered.

Licensing

16 states agreed to accept a “Uniform Application for Physician State Licensure”. The

Health Resources Services Administration reported in 2010 that in order to improve access to quality care by using telemedicine, licensure portability was needed (Taylor, 2018). In addition to the Uniform Application for Physician State Licensure, the State Alliance for e-Health

18 recommended that the state licensure be simplified to allow doctors to facilitate state to state telemedicine (Taylor,2018). When it comes to state-to-state licensing in other states, medical boards have implemented the following guidelines or something similar for physicians using telemedicine (Kmucha, 2015):

● The doctor must be licensed by the medical board of the state where the patient is

located.

● The doctor speaking with the patient must document the relevant history collected

during the encounter.

● The medical evaluation done during it must be consistent with that of an in person

encounter before providing recommendations, treatment, or prescriptions.

Alabama, Louisiana, Minnesota, Montana, Nevada, New Mexico, Oregon, Tennessee,

Texas, and Washington have established limited licensure provisions, which allow physicians licensed in another state to treat patients via telemedicine (Critikos, 2018). On the other hand, states like California offer physicians special telemedicine licenses created to reduce any barriers and costs that may come from practicing out of state (Weinstein, 2014). The National

Health Service Corps healthcare professionals and military health professionals are the only agencies that are authorized to practice nationwide, provided that they are licensed in any state or by the Secretary of State (Taylor, 2018).

The Interstate Medical Licensing Compact (IMLC) is working to create practical multistate licensing agreements, which offer an expedited pathway for doctors to receive licensure in many states (Sacopulos, 2018). To qualify for multistate licensing, a physician must be licensed in the traditional method, and his or her state of principal license provides a letter of qualification in which they agree to share any investigative or disciplinary information as part of

19 a background check (Sacopulos, 2018). If the applicant qualifies, the non-SPL state then issues a license to practice medicine. Unless the doctor lives in a state where the IMLC is working to create an easier way, time and money required to obtain additional state licenses will likely make practicing telemedicine impractical (Sacopulos, 2018). Requiring doctors to obtain licenses state-to-state may total up to $300 million a year, and that could increase as more doctors start to provide telemedicine services state-to-state (Robeznieks, 2014).

Hospital Credentialing & Privileging

Credentialing is a verification process performed by hospitals and health plans to verify training, residency, licensure, and board certification of providers looking to practice medicine in the United States (Taylor, 2018). Privileging is the following step in the hiring of the physician. The Center for Connected Health Policy (CCHP), considers the competence of the practitioner in a specific are of care is assessed through the privileging process (CCHP,(nd)).

Despite not physically working in the hospital, doctors practicing via telemedicine must also go through both processes. The Joint Commission on Accreditation of Healthcare Organizations

(TJC) and hospital accrediting agencies have altered their credentialing requirements multiple times (Weinstein, 2014). In May of 2011 The Centers for Medicare & Medicaid Services (CMS) altered its credentialing requirements by permitting hospitals to “rely on the credentialing and privileging decisions of the distant hospital where the telemedicine consulting physician practices” (Weinstein, 2014). We may see this new rule start to help hospitals explore other future uses of telemedicine, such as using it as a tool to follow up with patients who have been transferred back to the community, help patients with ongoing chronic conditions in minor situations, and connect with the patient's primary care physicians (CMS, 2011). The hospitals in underserved communities that do not have access to specialists have contracted specialists in

20 other locations they use to provide care virtually to patients so that their patients do not have to travel to be seen. In the past, hospitals have relied on the “privileging proxy” set by TJC to make the credentialing and privileging process less burdensome on hospitals in underserved communities (CCHP,(nd)). The privileging proxy allowed hospitals to accept the credentialing and privileging of the specialist (CCHP,(nd)). However, TJC’s process was said to be in conflict with CMS’s Conditions of Participation, making specialists unable to be reimbursed

(CCHP,(nd)). To resolve issues that hospitals in underserved communities ran into, CMS approved its own set of regulations that are optional for hospitals to use. However, if they choose to utilize CMS's proxy process, the following requirements must be met (CCHP,(nd)):

● The telemedicine provider must be licensed by the state the appointment is taking place

● The distant-site hospital must be Medicare participating

● The provider must be privileged at the distant site hospital

● The providers’ privileges must be provided to the originating site (underserved hospital)

● A written agreement between the provider and the originating site must be established

The credentialing and privileging process for a physician can be very extensive and expensive

(CCHP,(nd)). Underserved communities may still suffer if the hospitals in which providers work do not allow or follow protocols, making it difficult for patients to receive care.

Payment

Providers practicing telemedicine are finding that there are no consistent reimbursement policies when it comes to payment for visits. Currently, there is no overall telemedicine reimbursement policy in the United States where the majority of payments to providers come from private insurance, Medicare, and Medicaid (Baker, 2011). A common challenge among lawmakers is evaluating the different ways that providers bill for telemedicine services; some do

21 not charge different than a face-to-face visit unless they are required to under Medicare.

The first federal law mandating the way that telemedicine reimbursement is billed by providers is known as the Balanced Budget Act of 1997. Section 4206 of the bill states (“BBA”-1997):

“(1) The payment shall be shared between the

referring physician or practitioner and the consulting

physician or practitioner. The amount of such payment

shall not be greater than the current fee schedule of

the consulting physician or practitioner for the health

care services provided.

(2) The payment shall not include any reimbursement

for any telephone line charges or any facility fees,

and a beneficiary may not be billed for any such

charges or fees”.

The BBA set the standard for payment for telemedicine services for Medicare members in underserved communities. Medicaid programs, on the other hand, do not have as clear of a standard as Medicare. About 35 states in the US offer reimbursement under Medicaid

(Baker,2011).

To date, Colorado, Georgia, Hawaii, Kentucky, Louisiana, Maine, New Hampshire,

Oklahoma, Oregon, Texas, and Virginia have enacted legislation requiring private insurance companies to pay or reimburse for telemedicine (Baker, 2011). However, other states like

Arizona and New Mexico allow telemedicine services but do not make reimbursement by private payers mandatory and North Dakota allows for reimbursement in certain workers’ compensation claims (Fanburg,2018). Doctors practicing telemedicine in the state of California

22 could soon see changes due to AB-744 (Lagasse,2019). The California Senate approved AB-744 in September and if signed by the Governor, telehealth reimbursement under Medi-cal would be the same rate as in-person doctors’ visits (Lagasse, 2019). Telemedicine reimbursement is not governed, making doctors shy away from offering telemedicine services to their patients. AB-

744 could be the precursor to a future telemedicine expansion in underserved communities, ultimately causing patients in underserved communities to go without care because there are not enough ways for them to go about getting the help they need.

Malpractice in Telemedicine

Telemedicine is used to eliminate face-to-face visits with a practitioner, ultimately making it hard to establish a relationship with the person offering you medical advice. The elimination of face-to-face visits, especially when they are with someone you have never met, can create some issues for providers practicing telemedicine. Medical malpractice insurance and local licensing are two obstacles that hinder the advancement of telemedicine in the United

States (Gupta, 2015). Insurers face the challenges of following the requirements in different states because as with licensing malpractice insurance, requirements can be different in each state (Gupta, 2015). In 1945, the McCarran-Ferguson Act confirmed such power in local governments (Gupta, 2015) and essentially regulates every aspect of health insurance within the state lines you are practicing. Most require malpractice insurance before a license will be given to the practicing provider (Gupta, 2015).

Along with malpractice insurance are the malpractice claims that accompany treating patients. Malpractice in healthcare is similar to traditional negligence claims, both involving a duty owed by the physician to the patient and a breach in that duty, an injury to the patient being treated (Kasper, 2014). Telemedicine has few malpractice cases in any state, cases that have

23 been filed involving practitioners prescribing medications to patients without speaking to them which places them in the realm of cybermedicine (Kasper, 2014). Cybermedicine and telemedicine differ in that cybermedicine is “the science of applying Internet and global networking technologies to medicine and public health, of studying the impact and implications of the Internet, and of evaluating opportunities and the challenges for health care” (Lewis,

2006). Cybermedicine can be commonly used to prescribe medication from answers to a questionnaire filled out by the patient (Kasper, 2014).

24 Findings and Analysis

By 2030, the United States could see a shortage of nearly 120,000 providers

(Chandrashekar, 2020). 60% of the provider shortage areas are located in non-metropolitan or underserved areas in the United States (Marcin, 2016). About 15% of doctors use telehealth with their patients (Kaiser Permanente, 2019). The expansion of coverage under the ACA and the increasing number of aging Americans who need additional service highlight the shortages of primary care physicians. Patients in underserved communities are experiencing increasing wait times to see their providers. The expansion of telemedicine in these areas will limit the need for expensive urgent care visits and emergency visits for minor concerns (Sahdev, 2015).

Government sponsored programs such as Medicare and Medicaid cover low-income communities and Americans over 65 years old in the United States. 1.9 billion Medicaid members in Massachusetts will now have access to psychologists, psychiatrists, behavioral health nurses, and professional counselors via telemedicine (Lagasse, 2019).

The American Hospital Association (2019) reports that 76 percent of United States hospitals meet with consulting practitioners and patients remotely through telemedicine

(AHA,2019). In hospitals where telemedicine has been implemented, the number of bed days has decreased by 25% and hospital admissions similarly by 19% (Lafolla, (n.d.)). The American

Telemedicine Association (ATA) predicts that virtual doctor visits in the U.S. this year will rise by 20% from last year, to 1.2 million. It is very common for costs related to the ICU and surgeries to be high. After implementing an “eICU” in a surgical unit used to teach surgeons, a

10% reduction in ICU stays and a 20% reduction in admits were reported (Lafolla, (n.d.)).

Between $700,000 and $940,000 for the ICU and between $2.1 million and 2.8 million for admissions were reported by the same facility (Lafolla, (n.d.)). With its different ways of reach,

25 telemedicine has helped patients in underserved communities receive care (Lafolla, (n.d.)).

Telemedicine visits among Medicare beneficiaries in underserved communities increased from

7,015 in 2004 to 107,955 in 2013 (JAMA, 2013). Nursing homes have seen a reduction of

387,000 transports to emergency rooms, saving around $327 million per year. They have also seen a reduction in transports to physician offices by 6.87 million, saving around $479 million per year.

25% of doctors practicing in the U.S. hold a license in more than one state (Robeznieks,

2014). Telemedicine has been reported to be used by 15.4% of doctors who worked in practices for their patient interactions and 11.2% of doctors reported using it to interact with other healthcare professionals (Kane, 2018). Telemedicine varies in use by specialty: 27% of psychiatrists, 24.1% of cardiologists, 39.5% of radiologists and 23% of pathologists reported that their practices used telemedicine for patient interactions in 2018 (Kane, 2018). Tele radiologists working for commercial telemedicine companies maintain medical licenses in all 50 states (Weinstein, 2014).

In 2010, the telemedicine equipment market was at $163.3 million and is predicted to grow to $6.28 billion by the end of 2020 (Kaspar, 2014). Research shows that telemedicine has the potential to save healthcare companies in the United States $6 billion a year (Kaiser

Permanente, 2019). 93% of consumers who have used telemedicine say that it lowered their health care costs (Kaiser Permanente, 2019). Between 22% and 25% of doctors practicing in the

U.S. hold multiple licenses (Robeznieks, 2014). This year, employee sponsored telemedicine has grown by 74%; 48% of large companies report offering it to their employees

(Chandrashekar, 2020).

26 Future of Telemedicine

As health care takes on a more value-based care approach to medicine, doctors will need to provide more ways to communicate with patients. Those patients who are more technology advanced will want more flexibility in how they seek care, thus making more room for telemedicine and its expansion among underserved communities in the United States.

Telemedicine in its current state faces many challenges on both the patient and provider ends.

Many legislations do not set clear standards for reimbursement for government sponsored programs or coverage of telemedicine services for patients who receive their healthcare through their employer, and many providers struggle to practice telemedicine due to licensing and payments for services. To start, if the government does not mandate the expansion of Medicaid in the United States, many patients will be left uninsured, driving both Emergency room visits and costs of care up. One of the main goals of telemedicine is to reduce costs while still allowing patients to receive the same care. Furthermore, if payments for services for doctors are not standard across the United States, we will see an even greater shortage in doctors willing to practice telemedicine. Assembly Bill 744 would be a precursor for other states and could aid the expansion of telemedicine in underserved communities. Lastly, if the restrictions on licensing and credentialing for providers’ state to state are standardized or removed completely, that would open up access to patients in underserved communities who struggle to find an available doctor.

27 Conclusion

This study has shown how the continuing expansion of telemedicine is needed in underserved communities. While there are obstacles to the expansion of telemedicine, it shows promise in reaching those in underserved communities by reducing costs and still allowing patients to receive quality care. As with most new approaches to healthcare, some things can still be improved, such as reimbursement through government sponsored programs, payment to providers, and the restriction of licensing in each state. The CARES Act passed by the Trump administration during the COVID-19 pandemic shows the many benefits of receiving care at a distance. Providers being allowed to practice via telemedicine during a time in medicine when physical distancing is being enforced, has shown the capabilities of telemedicine. Remote specialist consultations and remote patient monitoring systems are just a few examples of how telemedicine has helped expand care to those in underserved communities. Both methods have shown through this research to be cost and time efficient. Similar to most new branches in technology, many changes are yet to come. Furthermore, as the use of telemedicine increases in underserved communities across the United States, further data collection will be needed to capitalize on what legislation needs to be passed.

28 References

"Statement on Signing the Consolidated Appropriations Act, FY 2001." Weekly Compilation

of “Fact Sheet: Telehealth,” American Hospital Association, February 2019,

aha.org/system/files/2019-02/fact-sheet-telehealth-2-4-19.pdf. (n.d.). Retrieved from

https://www.govinfo.gov/content/pkg/CRPT-105hrpt217/html. Accessed 5 September

2019.

Alverson, D. C., Krupinski, E. A., Erps, K. A., Rowe, N. S., & Weinstein, R. S. (2019). The

Third National Telemedicine & Telehealth Service Provider Showcase Conference:

Advancing Telehealth Partnerships. Telemedicine journal and e-health: the official

journal of the American Telemedicine Association, 25(4), 332–340. Accessed 17 May

2020

Archer, B. (1996, August 21). Text - H.R.3103 - 104th Congress (1995-1996): Health

Insurance Portability and Accountability Act of 1996. Retrieved from

https://www.congress.gov/bill/104th-congress/house-bill/3103/text. Accessed 5 June

2020.

Bagot, K.,PhD.B.B.Sci(Hons) B.Sci, Moloczij, Natasha,M.HlthSc, B.A.(Psych), Arthurson,

L.,M.H.S.M.B.SpPath, Hair, C.,N.N.GradCert, Hancock, S., B.PsychSc(Hons), Bladin,

C. F.,PhD.M.B.B.S.F.R.A.C.P., & Cadilhac, Dominique A,PhD.M.P.H.B.N.(post-reg)

R.N.(Div 1). (2020). Nurses' role in implementing and sustaining acute telemedicine: A

mixed-methods, pre-post design using an extended technology acceptance model.

29 Journal of Nursing Scholarship, 52(1), 34-46. Retrieved from

http://dx.doi.org.libproxy.csun.edu/10.1111/jnu.12509. Accessed 5 June 2020.

Baker, D., & Bufka, L. (2011). Preparing for the Telehealth World: Navigating Legal,

Regulatory, Reimbursement, and Ethical Issues in an Electronic Age. Professional

Psychology: Research and Practice, 42(6), 405-411. Accessed 5 September 2019.

Bashshur, Rashid L., and Gary W. Shannon. "National telemedicine initiatives: essential to

healthcare reform." Telemedicine and e-Health, vol. 15, no. 6, 2009, p. 600+. Retrieved

from https://link-gale-

com.libproxy.csun.edu/apps/doc/A206465688/HRCA?u=csunorthridge&sid=HRCA&x

id=9f97d321. Accessed 17 May 2020

Bazzoli,2016 Fred Telemedicine no longer on hold. (2016, September 1). Health Data

Management, 24(6), 6. Retrieved from https://link-gale-

com.libproxy.csun.edu/apps/doc/A466015291/ITOF?u=csunorthridge&sid=ITOF&xid=

23e5e970. Accessed 9 October 2019.

Bergner, A., & Thompson, M. (2013). The New Economics of Health Care Benefits. Financial

Executive, 29(2), 29-32. Accessed 17 May 2020

Brannon, J. A. (2012, July 3). Two States pass telemedicine coverage mandates: Vermont and

Maryland join 12 other states in requiring private payers to cover services delivered

remotely. ASHA Leader, 17(8), 8. Retrieved from https://link-gale-

com.libproxy.csun.edu/apps/doc/A297136784/ITOF?u=csunorthridge&sid=ITOF&xid=

db3f3ebd. Accessed 9 October 2019.

30 California Health Benefits Review Program. (2018). Analysis of California Assembly Bill

2861: Medi-Cal Telehealth Substance Use Disorder Services. UC Office of the

President: California Health Benefits Review Program. Retrieved from

https://escholarship.org/uc/item/6832h89n. Accessed 17 May 2020

CARES Act: AMA COVID-19 pandemic telehealth fact sheet. (n.d.). Retrieved from

https://www.ama-assn.org/delivering-care/public-health/cares-act-ama-covid-19-

pandemic-telehealth-fact-sheet. Accessed 5 June 2020.

Chandrashekar, P., & Jain, S. (2020). Eliminating barriers to virtual care: Implementing

portable medical licensure. The American Journal of Managed Care, 26(1), 20-22.

Accessed 17 May 2020

Cohen, A., & Linneman, T. (2020). Expanding telemedicine coverage under Medicare

Advantage. Journal of Health Care Compliance, 22(1), 47-52. Retrieved from

http://libproxy.csun.edu/login?url=https://search-proquest-

com.libproxy.csun.edu/docview/2351563746?accountid=7285. Accessed 17 May 2020.

Critikos, P. (2018). License To Screen: A review of the Medical Licensure schemes impacting

Telehealth Proliferation in the United States, the European Union, and Australia. Emory

International Law Review, 32(2), 317-349. Accessed 5 September 2019.

Dowling, R. (2015). Telemedicine: Are we reaching a tipping point? Technology may see

wider adoption in our specialty as a potential solution to work force woes. Urology

Times, 43(2). Accessed 9 October 2019.

EHealthInsurance. (2019, December 06). How Many Americans Get Health Insurance from

their Employer? Retrieved from https://www.ehealthinsurance.com/resources/small-

31 business/how-many-americans-get-health-insurance-from-their-employer#:~:text=How

many Americans get health insurance from their employer?also called group health

insurance). Accessed 5 June 2020.

Fanburg, J. D., & Walzman, J. J. (2018, October). Telehealth and the law: The challenge of

reimbursement. Contemporary OB/GYN, 63(10), 59+. Retrieved from https://link-gale-

com.libproxy.csun.edu/apps/doc/A563181338/ITOF?u=csunorthridge&sid=ITOF&xid=

926fb82b. Accessed 9 October 2019.

Feldstein, P. (2019). Health Policy Issues: An Economic Perspective. Seventh

edition. Health Administration Press, Chicago, IL. Accessed 17 May 2020.

Garfield, R., Orgera, K., & Damico, A. (2020, January 14). The Coverage Gap: Uninsured Poor

Adults in States that Do Not Expand Medicaid. Retrieved from

https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-

states-that-do-not-expand-medicaid/. Accessed 9 October 2019.

Gilman, Matlin, & Stensland, Jeff. (2013). Telehealth and Medicare: Payment policy, current

use, and prospects for growth. Medicare & Medicaid Research Review, 3(4), E1-E17.

Accessed 5 June 2020.

Gupta, Amar, & Sao, Deth. (2011). The constitutionality of current legal barriers to

telemedicine in the United States: Analysis and future directions of its relationship to

national and international health care reform. Health Matrix, 21(2), 385. Accessed 9

October 2019.

32 Havranek, Erik G, Abdel Raouf Sharfi, Seif Nour, Hanif Motiwala, and Omer Karim. (2011) .

“Low-Cost Telemedicine.” BJU International 107 (11): 1701–172. Retrieved from

https://doi.org/10.1111/j.1464-410X.2011.10229. Accessed 5 June 2020.

Horton, K., Malcarney, M.-B., & Seiler, N. (2014). Medicare Payment Rules and

Telemedicine. Public Health Reports, 129(2), 196–199. Retrieved from

https://doi.org/10.1177/003335491412900214. Accessed 9 October 2019.

Howell, T. (2016). ED utilization by uninsured and medicaid patients after availability of

telephone triage: JEN JEN. Journal of Emergency Nursing, 42(2), 120-124. Retrieved

from http://dx.doi.org.libproxy.csun.edu/10.1016/j.jen.2015.08.015. Accessed 5

September 2020.

Kahn, J. M. (2015). Virtual visits — confronting the challenges of telemedicine. The New

England Journal of Medicine, 372(18), 1684-1685. Retrieved from

doi:http://dx.doi.org.libproxy.csun.edu/10.1056/NEJMp1500533. Accessed 9 October

2019.

Kane, C. K., & Gillis, K. (2018). The use of telemedicine by physicians: Still the exception

rather than the rule. Health Affairs, 37(12), 1923-9. Retrieved from

http://dx.doi.org.libproxy.csun.edu/10.1377/hlthaff.2018.05077. Accessed 9 October

2019.

Kaspar, B. J. (2014, January). Legislating for a new age in medicine: defining the telemedicine

standard of care to improve healthcare in Iowa. Iowa Law Review, 99(2), 839+.

Retrieved from https://link-gale-

33 com.libproxy.csun.edu/apps/doc/A357863405/ITOF?u=csunorthridge&sid=ITOF&xid=

4d1b989c. Accessed 5 September 2019.

Kmucha, Steven T, MD,J.D., F.A.C.S. (2015). Physician liability issues and telemedicine: Part

2 of 3. Ear, Nose & Throat Journal, 94(12), 466-466,469. Retrieved from

http://libproxy.csun.edu/login?url=https://search-proquest-

com.libproxy.csun.edu/docview/1752073612?accountid=7285. Accessed 5 June 2020.

Knebel, K. (2016). More companies offer telehealth; now workers need to use it. Managing

Benefits Plans, 18(10), 16. Accessed 5 September 2019.

Lagasse, J. (2019, December 11). Telehealth laws and regulations in 2019 have set the stage for

increased access and use. Retrieved from

https://www.healthcarefinancenews.com/news/telehealth-laws-and-regulations-2019-

have-set-stage-increased-access-and-use. Accessed 9 October 2019.

Lenier, S. (2019, April 15). Telemedicine, teleophthalmology programs in action at Johns

Hopkins: Improving technology opening new opportunities for physicians, their

patients. Ophthalmology Times, 44(7), 34+. Retrieved from https://link-gale-

com.libproxy.csun.edu/apps/doc/A588082327/ITOF?u=csunorthridge&sid=ITOF&xid=

0d029dc1. Accessed 20 July 2020.

Lewis, C. (2015). Private payer parity in telemedicine reimbursement: How state-mandated

coverage can be the catalyst for telemedicine expansion. University of Memphis Law

Review, 46(2), 471-502. Accessed 17 May 2020.

Lewis, C. E. (2006, Winter). My computer, my doctor: a constitutional call for federal

regulation of cybermedicine. American Journal of Law & Medicine, 32(4), 585+.

34 Retrieved from https://link-gale-

com.libproxy.csun.edu/apps/doc/A157588149/ITOF?u=csunorthridge&sid=ITOF&xid=

ecb55557. Accessed 5 September 2019.

Marcin JP, Shaikh U, Steinhorn RH. Addressing health disparities in rural communities using

telehealth. Pediatr Res. 2016;79(1-2):169-176. Retrieved from

https://doi:10.1038/pr.2015.192. Accessed 9 October 2019.

Masys, D. R. (1997). Telemedicine: A Guide to Assessing Telecommunications in Health

Care. Journal of the American Medical Informatics Association : JAMIA, 4(2), 136-

137. 9 October 2019.

McLeese, K. R. (2016, Winter). Telemedicine: an employee benefit? Benefits Law Journal,

29(4), 84+. Retrieved from https://link-gale-

com.libproxy.csun.edu/apps/doc/A472989578/ITOF?u=csunorthridge&sid=ITOF&xid=

517674e8. Accessed 17 May 2020.

Mehrotra, Ateev, Jena, Anupam B, Souza, Jeffrey, Landon, Bruce E, Busch, Alisa B, &

Uscher-Pines, Lori. (2016). Utilization of telemedicine among rural medicare

beneficiaries. JAMA - Journal of the American Medical Association, 315(18), 2015-

2016. Accessed 20 July 2020.

Mitchell, R. J., & Bates, P. (2011). Measuring health-related productivity loss. Population

health management, 14(2), 93–98. Retrieved from

https://doi.org/10.1089/pop.2010.0014. Accessed 5 September 2019.

Monpora,MD, A. (2020, May 13). HIPAA vs HITECH - Understanding the Difference.

Retrieved from https://intivahealth.com/blog/understanding-the-difference-between-

35 hipaa-and-hitech/#:~:text=HITECH provisions enhance the HIPAA,the government and

affected individuals. Accessed 5 September 2019.

Nesbitt, Thomas S, Madan Dharmar, Jana Katz-Bell, Gunnar Hartvigsen, and James P Marcin.

(2013). “Telehealth at UC Davis—A 20-Year Experience.” Telemedicine and e-Health

19 (5): 357–62. Retrieved from https://doi.org/10.1089/tmj.2012.0284. Accessed 17

May 2020

Obey, D. R. (2009, February 17). Text - H.R.1 - 111th Congress (2009-2010): American

Recovery and Reinvestment Act of 2009. Retrieved from

https://www.congress.gov/bill/111th-congress/house-bill/1/text. Accessed 17 May

2020

Pratt, M. K. (2019, July). How to avoid the legal risks of telemedicine: Obtaining license

among several considerations when adding virtual visits. Urology Times, 47(7), 28+.

Retrieved from https://link-gale-

com.libproxy.csun.edu/apps/doc/A602994990/ITOF?u=csunorthridge&sid=ITOF&xid=

a53f665d. Accessed 17 May 2020

Presidential Documents, vol. 36, no. 52, 1 Jan. 2001, p. 3167. Retrieved from https://link-gale

com.libproxy.csun.edu/apps/doc/A71563402/ITOF?u=csunorthridge&sid=ITOF&xid=6

523181e. Accessed 7 March 2020.

Richards, J. B., & Wilcox, S. R. (2019). Practical Considerations for the Academic Physician

Moving to a New State. Southern Medical Journal, 112(6), 305-309. Accessed 5 June

2020.

36 Robeznieks, A. (2014). State boards' policy for telemedicine may present roadblocks. Modern

Healthcare, 44(12), 12. Retrieved from

http://libproxy.csun.edu/login?url=https://search-proquest-

com.libproxy.csun.edu/docview/1510595186?accountid=7285. Accessed 7 March

2020.

Sacopulos, M., J.D. (2018). Going the distance: Navigating the evolving legalities of interstate

telemedicine. The Journal of Medical Practice Management : MPM, 33(4), 259-262.

Retrieved from http://libproxy.csun.edu/login?url=https://search-proquest-

com.libproxy.csun.edu/docview/2010639123?accountid=7285. Accessed 20 June 2020.

Sahdev,Hanna Can I Skype My Doctor? Limited Medicare Coverage Hinders Telemedicine’s

Potential to Improve Health Care Access, 57 B.C.L. Rev. 1813 (2016). Retrieved from

http://lawdigitalcommons.bc.edu/bclr/vol57/iss5/9. Accessed 9 October 2019.

Stoltz, Richard TELEMEDICINE: The doctor will call you now; Employers are adopting

telemedicine kiosks to reduce lost productivity, avoid costly ER visits and deliver

quality care. (2016, August 1). Employee Benefit News, 30(7), 12. Retrieved from

https://link-gale-

com.libproxy.csun.edu/apps/doc/A459643150/ITOF?u=csunorthridge&sid=ITOF&xid=

24c227ff. Accessed 7 March 2020.

Taylor, L., Capling, H., & Portnoy, J. M. (2018). Administering a telemedicine program.

Current Allergy and Asthma Reports, 18(11), 1-7. Retrieved from

:http://dx.doi.org.libproxy.csun.edu/10.1007/s11882-018-0812-8. Accessed 17 May

2020

37 Telemedicine. (n.d.). Retrieved from

https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html. Accessed 17

May 2020

U.S. Department of Health and Human Services, Health Resources and Services

Administration (2012). Shortage designation: Health professional shortage areas &

medically underserved areas/populations. Retrieved from http://bhpr.hrsa.gov/ shortage.

Accessed 5 June 2020.

Weinstein, R., Lopez, A., Joseph, B., Erps, K., Holcomb, M., Barker, G., & Krupinski, E.

(2014). Telemedicine, Telehealth, and Mobile Health Applications That Work:

Opportunities and Barriers. The American Journal of Medicine, 127(3), 183-187.

Accessed 7 March 2020.

Yu, Jinna, Zhang, Tingting, Liu, Zhen, Hatab, Assem Abu, & Lan, Jing. (2020). Tripartite Data

Analysis for Optimizing Telemedicine Operations: Evidence from Guizhou Province in

China. International Journal of Environmental Research and Public Health, 17(1), 375.

Accessed 17 May 2020

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