1 Is TELEMEDICINE THE FUTURE PRIMARY CARE PHYSICIAN? AN ANALYSIS OF PAST, CURRENT, AND FUTURE TRENDS Presented by: Mary Kvinta TC 660H Plan II Honors Program The University of Texas at Austin Spring 2019 Dr. Richard Nauert School of Human Ecology, McCombs School of Business Supervising Professor Dr. Lance Bertelsen Department of English, College of Liberal Arts Second Reader 2 ABSTRACT Author: Mary Kvinta Title: Is Telemedicine the Future Primary Care Physician? An Analysis of Past, Current, and Future Trends Supervising Professors: Dr. Richard Nauert and Dr. Lance Bertelsen This thesis offers a new method of analyzing the trends of telemedicine in the past, current, and future states, particularly in relation to primary healthcare settings. This thesis consists of a literature review of various studies, an analysis of current legislation, and suggestions for future improvements of the healthcare system in the United States. The terms surrounding telemedicine will be defined and the history of telemedicine will be explained in order to convey an understanding of the topic and to allow the reader to deduct general conclusions from the thesis. The thesis will focus on the patient perspective, the healthcare provider perspective, and the challenges that these two respective groups of people face in relation to successful implementation of telemedicine. Conclusions from this thesis are applicable in the current age due to the rising cost of healthcare, the healthcare shortage in certain geographic areas, and the increasingly technological presence in the United States and in the world. 3 Acknowledgements I would like to thank Dr. Richard Nauert for teaching me the fundamentals of health policy and for his mentorship and encouragement throughout my thesis topic. I would like to thank Dr. Lance Bertelsen for his help improving my writing skills and for his mentorship and encouragement throughout my thesis topic. I would like to thank the Plan II Honors Program for introducing me to a wonderful education and to lifelong friends. Finally, I would like to thank my parents, William Kvinta Jr. and Anna-Maria Kvinta, for their constant encouragement and for providing me with the opportunity to be where I am. 4 Table of Contents: Abstract………………………………………………………………………………………2 Chapter 1: Introduction………………………………………………………………………5 Chapter 2: The Patient’s Perspective of Telemedicine…………………………………… 15 Chapter 3: The Healthcare Provider’s Perspective of Telemedicine……………………… 27 Chapter 4: The Economic Challenges of Telemedicine Implementation…………………. 36 Chapter 5: Business of Telemedicine………………………………………………………44 Chapter 6: Future Suggestions on Improving Telemedicine in Primary Care……………..49 Bibliography………………………………………………………………………………..55 5 Chapter 1: Introduction Background of Telemedicine According to the Institute of Medicine, telemedicine is defined as “the use of electronic information and communications technologies to provide and support health care when distance separates the participants” (Fathi et al., 2017). Telemedicine, also referred to as telehealth for the purposes of this paper, originated in the year 1905, when a Dutch psychologist used a telephone to monitor and analyze transmissions of cardiac rhythms (Fathi et al., 2017). Telemedicine expanded through several initiatives, including from the National Aeronautics Space Administration (NASA), since healthcare delivery at a distance was needed (Fathi et al., 2017). The Kaiser Foundation International utilized some of these early experimental successes to successfully implement remote monitoring systems aiding rural communities (Fathi et al., 2017). Telemedicine has continued to grow and evolve in the present day. With the growth and evolution of telemedicine, many questions regarding its impact have been raised. The following discussion is an attempt to come to terms with some of the questions telemedicine raises and provide possible solutions in order to examine how telemedicine can be better utilized in primary healthcare settings. The first section of the thesis examines the history of telemedicine in specialty care and the future of telemedicine in primary care. As the United States has undergone rapid urbanization, a greater need for accessible, affordable healthcare in urban cities has resulted. Additionally, with rising healthcare costs, the goal of affordable healthcare has been a national issue in recent years. This issue has been aided by policy decisions and consumer habits, culminating in confusion for patients and healthcare providers regarding the best treatment options for health. 6 The second section of the thesis compares the patient perspective with the healthcare provider perspective for telemedicine. Telemedicine has far-reaching implications for both healthcare providers and patients, as it affects reimbursement rates, poses logistical challenges, licensure requirements, and more. Who can offer telemedicine? What types of telemedicine are there currently available to patients? How is telemedicine conducted? These questions will be addressed in the thesis in order for misconceptions regarding telemedicine to be limited and resolved. Examining what factors motivate patients to use telemedicine compared to traditional face-to-face visits and comparing these factors with motivations for healthcare providers to deliver telemedicine will be fundamental to understating the research question. Next, economic implications of telemedicine and the business of telemedicine will be analyzed in order to understand what currently works from an economic perspective and what policies need improvement in the future. Medicaid, Medicare, private insurance companies, and other payment models will be analyzed in the context of telemedicine to understand how reimbursement rates affect the utilization of telemedicine, specifically telemedicine in primary healthcare settings. Conclusions will be drawn based on state and national telemedicine rules in order to offer suggestions for improving telemedicine legislation in the future. Specifically, the role of the states versus the national government will be a topic of discussion in relation to governing power and decision-making abilities. Finally, future suggestions for telemedicine will be examined in tHe context of the increasingly technological American society in order to understand the role of technology in healthcare and to better understand how future healthcare will operate. Furthermore, future recommendations for telemedicine in the context of primary care will be suggested. 7 Telemedicine’s History and Future in Primary Care The United States currently suffers from a primary care physician shortage (Phillips, 2018). As a result, the sustainability and success of the healthcare system currently in place is uncertain. Defining primary care can prove challenging, as boundaries of medicine often overlap. However, most health professionals agree that primary care must contain three basic functions. These are: first contact, gatekeeper, and manager (coordinator of care) (Bashshur et al., 2016). “First contact” refers to the primary care medical personnel being the first contact for patients in non-emergency situations. “Gatekeeper” means that the primary care medical personnel should limit access to specialty care to prevent fraud and overuse. “Manager” refers to managing the integration of healthcare and providing a team-centered approach. There is a concept termed the “Triple Aim” in primary medicine that aims to improve population health, enhance the patient experience, and reduce the per capita cost (Bashshur et al., 2016). Telemedicine has come into focus as a way to possibly fulfill the requirements of the triple aim. In a society where expenditures are constantly a topic of discussion, limiting expenditures is of paramount importance to ensure population health and happiness. Although primary healthcare is not a new concept to most Americans, it is filled with waste and inefficiencies. One way that telemedicine can possibly reduce the deficiencies within primary care is by greater patient engagement (Bashshur et al., 2016). Keeping patients engaged with their health will cause them to be more motivated to attend doctor appointments, take their required medications, and live a healthy lifestyle. Furthermore, patients can also use telemedicine to obtain a greater reliance on information and communication technology (Bashshur et al., 2016). In a world where a technological revolution has changed the global sphere, relying on information and communication technology in the health sector seems 8 warranted and necessary for the United States to present themselves as a leader on the world stage. Another way telemedicine can aid primary care and the broader healthcare system is to aid the transition from volume-based payment to value-based payment. This initiative has roots in the United States Department of Health and Human Services, which launched the value-based payment idea in 2010 (Bashshur et al., 2016). Included within value-based care are the aims of greater reliance on health information technology (HIT), healthcare provider incentives for high- value care, team-centered care, and improved coordination of care. From 2014 to 2024, healthcare spending is expected to increase at a rate of 5.8% per year in the United States (Bashshur et al., 2016). THis amount equates to approximately 20% of the United States’ GDP. With such a large percentage of healthcare spending going towards primary care and more expected in the future,