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 By Lanae Rivers August 2020 Copyright by Lanae Rivers 2020 ii 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 Copyright ii 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 By 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