Telehealth Also Asking Gov't Help

Whether you call it telehealth, mHealth or remote monitoring, the deployment of telemedicine is galloping. In what direction, this is a question to be answered. We should have an answer in 2013 or 2014, possibly. Some state medical boards are so wrapped up in their own self-importance that they are opposing the expansion of telemedicine and vehemently doing this. Other state medical boards are cautious, but moving in the right direction, and some are openly embracing telemedicine.

The state medical board in my state seems to be frozen in the past. They are unable to make a decision on many issues and therefore the state legislature is not acting on several issues that have been brought before it. Fortunately, the US Congress may force the issue and create laws that will force issues to be settled at the state level and create funding problems for those states choosing not to act. Again, patients are being caught in the middle and are the ones that will suffer.

This article is important and does need to be quoted for several issues. “Consider these facts:

• More than five million Americans had their medical images read remotely last year;
• Approximately 10% of all the intensive care unit beds in the U.S. use telemedicine;
• According to MobiHealthNews, there are more than 13,000 consumer health applications for the iPhone;
• One million Americans benefit from remote cardiac monitoring for implantable devices or for checking on a suspected cardiac arrhythmia; and
• The American Telemedicine Association estimates that more than 10 million Americans have directly benefited from some sort of telemedicine service this past year, probably double from just three years ago.

The American Telemedicine Association (ATA) was established in 1993. The ATA says the leading barriers to the development of telemedicine in the USA have been government policies. The Centers for Medicare and Medicaid Services (CMS) is very hesitant to reimburse for telemedicine. Then the ATA lists state-based standards of care and professional licensing as blocking much of what it needed for the advancement of telemedicine. And the list goes on to the FCC and FDA for their dragging of action.

Please take time to read the article in the link above.  It explains what is happening to telemedicine and the reasons they feel that 2013 will be the year of change.

Endocrinology Absent in Choosing Wisely

When I read articles and press releases, I read with a concern or jaundiced eye to the factual information and what the strengths and weaknesses may be and may mean to the value of the information published. This is sometimes impossible or nearly so because of the information released. What is being hidden behind the pay wall and how accessible is a contact to receive a copy. As a patient, sometimes the information is easily available and at other times, extensive research is required. I don't mind the research, but at times, I find it a complete waste of time, as the full information is just as poor as the press release.

That is why when I read this; I almost did not believe what I was reading. A doctor writing an article about endocrinology that was not a study, but in fact was his opinion. The topic is well chosen and his observation is great, until he writes his list. I will not begrudge most of his efforts since he has chosen the low-tech side of the issue. Choosing wisely has for the most part been on the high tech side and is very interesting in the tests that we need to be watchful of letting our doctors and hospitals do too many of these tests when simpler or less expensive procedures will yield the same results.

I can agree with most of his low-tech reductions for cost savings. I will list his points and comment where I disagree – which I do on one item and I hope you will agree.

I would encourage you to read the entire article as Dr. Plotzker has some solid points.

My Top 5 List of Excessive Practices

1. Any test of any type that is already in an accessible record does not need to be repeated unless something has happened to that patient that might alter his or her medical status.

2. When a person comes in with weight loss and palpitations, a TSH should be measured before going on a tumor hunt or doing sophisticated cardiac studies.

3. A hemoglobin A1c measured a day or two after a packed red blood cell (RBC) transfusion misleads more than it contributes.

4. Many patients with diabetes test their blood glucose excessively, leading to overuse and unnecessary costs of test strips.

5. Finally, there's a phenomenon that I like to call consultorrhea, or excessive consulting.

I could nit-pick some points in all of Dr. Plotzker's points above, but the one that I feel he is wrong about is number 4. He does have a decent grasp on the topic, but with the problems many people with all types of diabetes encounter in obtaining a sufficient number of test strips, he should not be another one. I feel this doctor is one more obstacle to overcome by patients that should be allowed more test strips.

The example he chooses to use may be true, but there are those people in the early months following diagnosis that need to be able to test, test, and maybe retest quite often. I finally located my testing records from the first year, and I was a little shocked at how often I did test. The first four months I averaged eight tests per day on two oral medications. And yes, when I transferred to insulin, I continued but my average increased to 10 times per day. Then in the fifth month of using insulin, my average decreased to eight times and then I leveled off at about five times per day. I had several times a month that I would be at 10 or more in a day and I was happy to see my notes. A couple of times when I knew I would have a low because of a mistake, either in over estimating carbs, or injecting too much insulin. Other times the extra testing was because I added a new to me food and wanted to check my results for several days to be confident in the quantity I was eating. Thankfully, I had my food logs as well.

Because of Medicare and their testing strip limit, many type 2 patients cannot obtain extra test strips when they need them and most insurance companies follow the lead of Medicare. Our own American Diabetes Association and Joslin Diabetes Center may have much to do with the limits on test strips when they state that certain type 2 patients probably don't need to test. They ignore the fact that most oral medications can cause hypoglycemia and that is when extra test strips become invaluable. I don't have that many episodes of hypoglycemia, but I can use a lot of test strips when I do have an episode, especially on insulin.

I have no evidence and only speculation, when I say that it is possible that many elderly deaths may be caused by hypoglycemic episodes. Because these elderly often live alone, their deaths are listed as heart failure and no mention is made for secondary causes.

Recently, a ten member panel of “experts” in different aspects of hypoglycemia, five from the ADA and five from The Endocrine Society. I have not finished my blog on this yet, but it does recognize hypoglycemia from oral medications. It also has advice for clinical use.

Patient Privacy in Telemedicine

Using telemedicine, especially video-based communications is not difficult for me. I do not have a doctor that will use it. Fortunately, there are doctors that can and do use this form of communications in some areas of the USA. I admit that I wish I could and maybe someday, as telemedicine becomes more acceptable and the Centers for Medicare and Medicaid Services (CMS) decides that it is worth reimbursing for and less of a problem than they currently envision. I am hoping congressional action will light a fire under CMS.

This is one reason I try to research about telemedicine more frequently. Diabetes still is my main concern, but I am finding more regular sources of information and don't have to look as hard for good information. Now the information comes to me and allows me to research more for topics in telemedicine, mHealth, telehealth, and other topics of interest.

As telemedicine comes into its own, one Silicon Valley firm has stepped up and has a product that consumers may desire because of its availability. Granted, presently it is only for iPad owners and not those of us with desktop computers. Vsee, a Silicon Valley-based company that's created the first iPad telehealth app that is FDA-registered and HIPAA-compliant. It's also free to download and free for patients to use the base-level service. This is the great part and makes it desirable.

When will it be available for desktop computers, and other tablets? This is unknown at this time. Further down it does say computers or tablets, so apparently they are available. The big feature is Vsee uses end-to-end encryption. The drawback is finding doctors that will use this under current conditions. I can envision contract physicians using this. I discuss contract medicine in a blog of mine here.

Vsee CEO Milton Chen says that last year in the USA, there was more than 900 million doctor visits. He estimates that half those would have been suitable for handling remotely, especially for things like follow-ups, discussion of lab results, psychiatric visits, and certain types of counseling.

Another feature that Vsee promotes is document sharing and the use of an electronic pen to mark up the document. This means test results and other reports important to the patient. Vsee does charge $9 per user per month for the document-sharing feature and collects a usage fee from the participating doctor. A patient would pay the healthcare provider directly for the telemedicine visit.

Make CMS Audits Less Burdensome

Healthcare providers are urging lawmakers to make CMS audits less burdensome. The Centers for Medicare and Medicaid Services is coming under fire for some of their audits. Knowing that they are vigilant for fraud, makes me wonder what healthcare providers are attempting to hide. A bipartisan group of six senators on the Finance Committee solicited the white papers from providers, insurers, contractors, and suppliers in May 2012.

In April 2013, the group issued a report based on the white papers received. There are some revealing facts that did come to light and many of these do need fixing. The biggest that I see is CMS auditor education and communication between CMS and the provider on a timely basis to resolve issues and let the providers continue operations in an efficient and effective manner. Many providers are upset with the education of auditors, particularly on medical necessity criteria.

Taking the last item, I do wonder how much agreement could be reached among providers on medical necessity criteria. This looks like an area for discussion and standardization by the professional medical associations before CMS auditors are educated on this. Two other areas received prominent support and I would agree that simplification could very well be a top priority. However, realize that when dealing with the government, simplification may not be in your best interest. You never want to have it come down to you against the government when papers turn up missing. The next problem is too common in dealing with the government. Duplication and even as high as five times the amount of paperwork has to be generated when often two copies should be enough. But for those of us outside the government, we should have gotten used to the saying that the right hand does not know what the left hand is doing. How else are they able to claim they don't know anything else about it. No one is willing to take ownership or responsibility for anything.

Now that I have given some sympathy to providers, I will take the other side. How many times has the item been billed to upscale it to a more expensive bill? How many times has something been billed multiple times? I know this is common practice by providers especially after done accidentally once and they have gotten by with it. This is very commonly done by most providers and especially by hospitals. The more labor they can cover many times the greater the chances of it being done. I have seen one nurse's half hour appear as many as seven times for the same patient and the nurse was only present in the room for 20 minutes. Since that nurse was only on that floor one time in three days, how was her time billed for three and one-half hours. It is little things like this that add up and hospitals love to do.

Another goodie that is profitable is a box of kleenex. I have seen the same box (distinctively marked by the way) billed on 19 patients and the box was never opened and always returned to the same recovery room. This $0.86 box of kleenex was billed 19 times over the course of five days for $18.00 on each bill. Did Medicare discover this? Did Medicaid discover this? Did other insurance companies discover this? The answer is no, and they just processed this through without question. Even after they had been told by auditors this was happening.

It takes too much manpower to dispute items like this, and hospitals make use of this knowledge to the extreme to over bill and overcharge on items unlikely to be questioned. We as patients are powerless to stop this and this goes on.

Debate On Labels for Patients

This doctor is very conscious of labeling patients. Contrary to many doctors that don't mind stereotyping us, it is refreshing to read a doctor that is concerned. I am surprised that different groups are so eager to put labels on us and this label is unacceptable or should be to most people.

I am very appreciative about Dr. Wen's discussion and her distinctions about labeling us as healthcare consumers. We do consume healthcare, but not in the traditional sense. As Dr. Wen explains, we should not be healthcare consumers this way as it could be very unhealthy to postpone receiving healthcare the way consumers do when purchasing consumer goods.

I have blogged about the types of patients here, here, and here. I feel that we should remain patients, but know there are different types of patients. I do feel that as we move away from some of us older patients, many of whom are passive patients, the term patient will gain in respectability and the patient will gain in knowledge about health and especially the health issues they may have.

Dr. Wen correctly states the following, “I also worry about effects of rebranding on the physician-patient relationship. What happens when the doctor becomes the hired consultant of the savvy shopper patient? Perhaps the doctor will be more responsive to consumer demands—but perhaps this doctor will also feel more obligated to give the consumer exactly what he wants, including unnecessary tests and harmful procedures. And will these physicians still retain their sense of social responsibility, when healthcare is reduced from societal obligation to personal choice?”

Her statement, I feel, states the crux of many of the problems we are facing now with the advertising of new drugs. Then as patients, we are now facing stereotyping and labeling under the “Patient Activation Measure” (PAM). This was not the original intent, but in large part has been bastardized to what the doctors want it to be. Originally it was as a measure to determine how educated we were and if we would use this education to make our health better. Now, unfortunately, many physicians use this to help them determine how compliant we are or will be.

Dr. Wen's last paragraph states some good points. I do not believe we need to change the meaning of patient like she states, but to classify patients at types. We can have the normal patient that we have now. There is the passive patient of which there are far too many. The proactive patient is becoming more in number, but they are still trying out their wings and learning to apply what they are learning. Then we come to the empowered patient that knows how to learn and apply the information to various medical situations. The e-patient is an advanced empowered patient and in addition to having learned about the medical situation that he or she is involved in, knows how to apply this knowledge across a broad spectrum.

A special status called patient advocate applies to people that have likely received education in advocacy and they are trained to provide guidance to the other types of patients. Some will be very specialized in billing, others in medical procedures affecting patients and how physicians and surgeons avoid raising certain issues to not alarm patients and have them consider alternatives to their condition which may be just as effective, but less profitable for the physician or surgeon.

Dr. Wen is also another doctor that is concerned about the consumerism already in place where many believe more is better. She is another that believes healthcare is not a limitless commodity. This is a good thing for many doctors to be concerned about, but we do need to be cautious about unbridled rationing. This is just as dangerous and will often shorten the lifespan of many innocent people. Finding that delicate balance is not for the faint of heart.