Telemedicine promises better access to health care for heretofore underserved populations. Telemedicine has been around since the late 1950s and has been used successfully in rural areas, in prisons, and by the military, but technological advances and rapidly rising medical costs are hastening its widespread implementation.17 The possibilities of telemedicine seem limitless and the potential cost savings are staggering (by one estimate, $36 billion a year).18 The technology includes devices that can be implanted in a patient's chest to collect heart and blood pressure data and transmit it to a doctor's office over the Internet. Similar devices can monitor patients with diabetes and other chronic conditions, saving the elderly and afflicted a trip to the doctor's office. "Smart toilets" can do a urinalysis and transmit the results for study. The list goes on.
Technological advances like these are challenging the longstanding belief that doctors must interact with patients one-on-one. The big questions now are: Who will pay for telemedicine and how is it to be regulated? Recognizing the cost savings promised by telemedicine, Medicare and insurance companies slowly started coming around in the late 1990s. For example, First Health Group will pay doctors $25 for Internet consultations with patients. The 1997 Balanced Budget Act included the first Medicare telemedicine payment provisions. By September 30, 2000, Medicare had reimbursed a rather unimpressive $20,000 for 301 teleconsultation claims, but at least the debate had changed from whether Medicare should pay to how Medicare should pay (Pushkin).19
Telemedicine has raised concerns about the practice of medicine across state lines (some states require doctors to be licensed in every state where they provide telemedicine consulting). Proposed national licensure of physicians is opposed by the American Medical Association and others who see licensing as a states' rights issue. Other concerns involve record keeping and confidentiality. While the establishment debates these issues, contemplate the future as imagined by Maryann Karinch (Telemedicine: What the Future Holds When You're Ill): "Robots performing complex surgical procedures directed by medical specialists at major hospitals continents away. Dark, bubbling aquariums where babies born too soon breathe special liquids that allow their premature lungs to develop. Pocket-sized computers programming new nerve networks, so people with spinal cord injuries can walk again." And maybe, no more long hours spent sitting in waiting rooms.
Sources: Chart: Agency for Healthcare Research and Quality, Telemedicine for the Medicare Population, http://www.ahcpr.gov/. Maryann Karinch, Telemedicine: What the Future Holds When You're Ill," http://www.karinch.com/Telemedicine.html.. Nancy Brown, "What is Telemedicine?," May 3, 2002, http://trc.telemed.org/. Tom Sanders, "Virtual Doctors," April 2002, http://www.doctorandpharmacy.com/. Blanton, Thomas, et al., "Telemedicine: The Health System of Tomorrow, Futurist, Sept/Oct 1995. Dena S. Pushkin, "Telemedicine: Follow the Money," Online Journal of Issues in Nursing, September 30, 2001, http://www.nursingworld.org/. Information retrieved October 2, 2002.
1 Cetron, Marvin J. and Owen Davies, "Trends Now changing the world: Technology, the Workplace,…" Futurist, March/April 2001, p27-42.
2 Health, United States, 1998; see source notes.
3 According to Cancerweb. See http://cancerweb.ncl.ac.uk/
4 See http://www.bphc.hrsa.gov. A detailed listing of HPSAs is published in the Federal Register; see http://www.access.gpo.gov/su_docs/aces/aces140.html.
5 Figures cited by Vanselow; see Source notes.
6 For those who do not live on the East Coast, it may be comforting to know that life expectancy is no greater in regions that have more specialists, and Medicare surveys find that the quality of care is no better. (Gina Kolata; see Sources)
7 Medical specialties include: Allergy & immunology, cardiovascular diseases, dermatology, family practice subspecialties, gastroenterology, internal medicine subspecialties, pediatric allergy, pediatric cardiology, other pediatric subspecialties, and pulmonary diseases. Surgical specialties include: colon/rectal surgery, general surgery, neurological surgery, obstetrics and gynecology, ophthalmology, orthopedic surgery, otolaryngology, plastic surgery, thoracic surgery, and urology. Other specialties include: aerospace medicine, anesthesiology, child psychiatry, diagnostic radiology, emergency medicine, general preventive medicine, medical genetics, neurology, nuclear medicine, occupational medicine, pathology and forensic pathology, physical medicine and rehabilitation, psychiatry, public health, radiology, radiation oncology, and other and unspecified.
8 An International Medical Graduate (IMG) is a person who has graduated from a medical school in an international state (outside the United States, Canada, and Puerto Rico) or who is otherwise qualified to practice medicine in an international state. IMGs must complete an accredited residency or fellowship program in the United States. These foreign-born physicians usually enter the country under an exchange visitor program administered by the U.S. Information Agency (USIA). Their visas (called J-1 visas) require them to leave the country when their medical training is done, but this requirement can be waived at the request of a federal agency or a state. This waiver generally requires that the physician practice for a specified period in an underserved area. The program often became a stepping stone to immigration.
9 A pre-September 11 analysis by GAO and the Appalachian Regional Commission's Inspector General found instances in which foreign physicians were not practicing at the facility where agencies believed them to be or were not practicing full-time in the underserved areas for which their waivers were granted.
10 See the American Medical Association's Web site for litigation updates (http://www.ama-assn.org/ama/pub/category/8100.html) or call Medical Society of the State of NY (516-488-6100, ext. 320).
11 A 500-page study formally titled Nursing and Nursing Education in the United States.
12 Effective with the passage of Public Law 105-33 (effective Jan 1, 1998). See http://www.nursing world.org/gova/medreimb.htm
13 They are called licensed vocational nurses in California and Texas.
14 An interesting history of the use of radiation technology can be found at http://www.asrt.org/other_categories/about_asrt/history.htm.
15 The Association of Telehealth Service Providers (ATSP) reported 206 telemedicine programs in 2000, up 724% over the 25 projects identified in 1995 and up 21% over the 170 identified in 1999. ATSP describes itself as "an international membership-based organization dedicated to improving health care through growth of the telehealth industry. See http://www.atsp.org/.
16 Merriam-Webster online defines triage as "the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximize the number of survivors."
17 Florida was moved to initiate a prison telemedicine program in 1990 after a prison inmate sued the state over inadequate health care and won a $1 million settlement (Blanton and Balch; see Source notes).
18 According to the consulting firm of Arthur D. Little, cited in Futurist (see Source notes).
19 As of September 2002 the U.S. Congress had not yet acted on proposed legislation (Medicare Remote Monitoring Services Coverage Act) to require Medicare to pay physicians the same amount for remote monitoring of patients' conditions as they are paid for face-to-face consultations.
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